FRACTURES OF THE UPPER EXTREMITY AND CLAVICLE*

J. J. KIRSCHENMANN, M.D.

BROOKLYN, N. Y.

T HIS is a study of 182 consecutive fractures of the upper extremity. These fractures are seen by our

internes on the ambuIance or in the first aid department and are reduced by them immediateIy. The case is then referred back to the hospita1 for x-ray and further reduction if necessary.

Our internes are taught to paIpate the bones by gentIy running their fingers over them to note any change in the contour. This can be deveIoped to a surprising degree of accuracy and it is indeed en- couraging to see how few fractures need further reduction after the x-ray is taken.

In a11 of our fractures we strive for perfect x-ray aIignment pIus a normal contour of the part. We often have cases with perfect x-ray aIignment but in which there is considerabIe bowing of the part. In this event we correct the bowing and try to maintain the aIignment. It is usuaIIy tweIve to twenty-four hours from the time of the fracture before the case is seen by me. At this time foIIowing the x-ray the fracture is further reduced unti1 the x-ray and physica examination are satis- factory. By satisfactory we mean a reduc- tion of 90 per cent or better.

Anesthesia is rarely used for reducing these fractures. We find that if the fracture is gentIy reduced after a few minutes of traction to reIax the muscIes that the discomfort is not as severe as the taking of an anesthetic. When anesthesia is used we usuaIIy find it necessary because the chiId is unruIy or we fee1 that we can not reduce the fracture at the first attempt. Out of this series of 182 cases, 49 needed fur- ther reduction and onIy 9 were given anesthetics.

CLAVICLE

There were 18 cases of fracture of the cIavicIe. The youngest patient was two and one-haIf years oId and the oIdest fifty-six. The cause of the fracture in most cases was an indirect force appIied through the shouIder. Sixteen of the 18 cases (88 per cent) were fractures of the middIe third of the cIavicIe, showing that this is the point of greatest strain and most IiabIe to fracture. Fractures of the cIavicIe are fractures characteristic of ,vouth or before complete ossification takes pIace.

In treating these cases I use a dressing which I fee1 is an improvement on others that I have seen described or used. A 3 inch strip of adhesive is applied to the arm on the fractured side, but not compIeteIy encircIing the arm. It is started on the anterior surface of the humerus from the insertion of the deItoid upward. It is then carried across the back and around the chest anteriorIy to the nippIe line on the side of the fracture, bringing the shouIder in extreme extension. The purpose of the adhesive being carried across the chest is to immobiIize the skin anteriorIy. A pressure pad is then appIiec1 over the fracture by anchoring a 2 inch strip of adhesive to the adhesive across the back, carrying it over the fracture and down over the strip of adhesi\-e across the anterior chest. It is impossibIe to bring the forearm across the chest with this type of dressing. Therefore I put the forearm in a sIing at the side of the body. Any dressing that aIIows the forearm to be pIaced on the chest defeats its purpose as this brings the shouIder forward. This dressing is usuaIIy changed at weekIg

* From the out-patient sugica1 department of the Norwegian llospital, Brooklyn.

297

298 American JournaI of Surgery Kirchenmann-Fractures AUGUST, 1934

intervaIs. At the end of the first week there of fracture of the shaft the youngest was is ample caIIus to prevent the fracture six years of age and the oIdest fifteen.CaIIus from slipping, and at the end of the second was present in most of these cases at the

FIG. IA. Before reduction.

week it is quite firm.

HUMERUS

In our series there were 33 fractures of the humerus; 6 fractures above the neck, 7 fractures of the shaft, 7 supracondyIoid fractures, 13 fractures of the condyIes or the Iower end.

Of the 6 cases of fracture above the neck, 4 cases were fractures of the surgica1 neck. Three of these patients were over fifty years of age. Fractures in this part of the bone are usuaIIy due to direct force. These cases were treated by simpIe immobiIiza- tion and an axiIIary pad. Passive motion was started in 5 of these cases at the end of one week. At the end of the second week the arm is compIeteIy extended and active motion is aIIowed at the end of the third week. OnIy a sIing being used at this time, the patient is aIIowed to take his arm out for this purpose. One arm had to be put in an airpIane spIint for reduction. This patient was not given active or passive motion for three weeks. CompIete function was obtained at the end of five weeks. (Fig. I.)

Fractures of the shaft seem to occur more frequentIy in young peopIe. Of the 7 cases

FIG. IB. After reduction.

end of one week, but passive motion was no started unti1 the end of the second or third week 4s there is no supporting bone and the strain at the point of fracture is great. CompIete function was obtained between the fourth and fifth week without the aid of baking or massage.

Fractures of the lower end of the humerus are divided into supracondyIoid, condyIar, or Iower end of humerus proper. There were 20 cases in aII, of which 90 per cent of the patients were Iess than tweIve years of age. Most of these fractures are caused by direct force appIied to the eIbow. We try to give these patients passive motion at the end of three or four days unIess the fracture is such that manipuIation wiI1 disIodge it. This is foIIowed by active motion during the second or third week. Most patients had compIete function at the end of the fourth week, the severer supracondyIoid fractures taking six weeks. Three of these fractures were not seen unti1 the end of the third week from the time of injury. AI1 of them had very Iimited motion at the eIbow. Active and passive motion was instituted immediateIy but the disabiIity Iasted forty- four days on an average. Cases of a simiIar type which were seen from the start and

\I-u SLHIIS \‘<>I. NSV. No. z Kirchenmann--Fractures .4nlcl-,r:ill Jwrual or SurL’r. \ 299

gi\-en acti\.e motion between the seventh Colles’ Fractures. True Colles’ fractures and fourteenth day had a tota disability are fractures limited to the distal inch of of twentv-six days. With fractures of the the radius. Often this fracture is com-

condyIes we fee1 that a sIing is a11 that is necessary and active motion should be started as soon as the sweIIing recedes. None of these patients was given baking or massage. (Fig. 2.)

FIG. 2.4. Before reduction.

FOREARM

In considering the forearm I shal1 divide the cases into fractures of the radius, uIna or both. Each bone wil1 be further divided into Iower, middle or upper portion. Ninety-nine of this series of fractures ~54 per cent) were in the forearm, whiIe sevent?- (38 per cent) were in the lower end of the radius, ulna or both.

Epiphyseal fractures of the lower end of the radius are not true fractures, but separations at the epiphysea1 Iine, due to the fact that compIete ossification has not taken place. Therefore this condition must be Iimited to youth. In our series there were 4 cases a11 of which occurred at the age of puberty. Three of these cases were treated as CoIIes fractures with a moIded anterior cock down spIint with uIna deviation of the hand. The fourth patient was admitted to the hospita1 and not seen again. In separat- ing the epiphysis remains firmIy attached to the wrist whiIe the shaft of the radius is cIispIaced: Passive motion was started on :tbout the sixth day and active motion on the tenth day.

FIG. ZB. After reduction.

pIicated by fracture of the styIoid process of the uIna aIso. Under this heading I wiI1 consider both types of CoIIes’ fracture. In this group there were 30 true CoIIes’ fractures and 8 compIicated by fracture of the styIoid process of the uIna also. Twenty- one of these fractures were in patients under twenty years of age while 17 were over twenty years of age. Of these I-, I I

were over fift;v >-ears of age. This series seems to point to the fact that CoIIes’ fractures are not characteristic of the age as formerI? taught, although a complicnt- ing fracture of the styIoid. process of the ulna is.

In treating these fractures we like to pIace them after reduction in an anterior moIded cock down spIint so as to keep the hand in flexion and uIna deviation. This type of splint aIIows motion to be started at the end of three or four days with Iittle discomfort to the patient. At the end of one week active motion is aIlowed at the wrist, the patient raising the hand from the spIint fifteen or twenty times daily. In addition to this compIete extension, prona- tion and supination are obtained by passi\-e motion at each visit after the third day. Anesthesia was used in onIy one fracture of this group. The average disability in these cases was onIy twenty-nine days. In patients under twenty years the average disability was twenty-eqht days and in

300 American Journal of Surgery Kirchenmann-Fractures AUGUST. 1934

those over twenty it was thirty days. This in chiIdren. Passive motion was started is much Iess than what is usuaIIy considered Iate. This was not from choice except in to be the disabiIity in CoIIes’ fractures. One one case where union did not take place

FIG. 3~. Before reduction.

of these patients was given baking and massage. He was not seen unti1 the ninth day after injury with a resulting tota disabiIity of thirty-three days. OnIy 2

patients under twenty years of age had an impacted fracture, whiIe g of those over twenty had impacted fractures.

Fractures of the lower end of the radius are far enough away from the wrist joint to be considered as a fracture of the shaft. In this group are incIuded a11 fractures in the Iower one third of the radius that are above the IeveI aIIotted to CoIIes’ fractures. There are 8 cases in this group. The youngest patient was twenty months and the oIdest thirty-seven years. They were a11 treated by immobiIization in anterior and posterior bass wood spIints in compIete supination. Passive motion was started at about the seventh day. Active motion was aIIowed at the end of three weeks. The shortest disabiIity was twenty days and the Iongest forty days. The average Iength of disabiIity unti1 compIete function returned was twenty-six days. Baking or massage was not used in any case.

The fractures of the middle third of the radius, a smaI1 group of 5 cases, a11 occurred

FIG. 38. After reduction.

for fifteen days. In the other cases the patients did not return when instructed to. The tota disabiIity in this group was twenty-six days, there being no proIonga- tion due to the Iate date of starting passive motion. This was due to the fact that the fracture was not near a joint.

Fractures of the Upper Third of the Radius. In this group there are 7 cases in aI1. Two were in the shaft proper whiIe five were in the head. Fractures of the head of the radius were at one time considered rare, but with better diagnosis and the x-ray it is found to be a not uncommon fracture. None of these fractures of the head of the radius was dispIaced and there- fore operative interference was not neces- sary. We fee1 that earIy motion is very essentia1 in these cases. After the second or third day when the sweIIing is gone we pIace the forearm in a sIing and start active motion.

Fractures of the ulna when not com- pIicated by fractures of the radius are rather rare. In this series there are onIy 5 fractures of the ulna aIone as compared to 54 fractures of the radius onIy. This shows that the radius absorbs the shock

NE= SERIES Var. XXV, No. z Kirchenmann-Fractures American Journal OI Surgery 301

before it is transmitted to the &a. that is not displaced act as a splint and Fractures of the ulna are usuaIIy due to hoId both bones in position after reduction, direct trauma to the bone and are more whereas if an anesthetic is given the muscIes

FIG. 4A. Before reduction.

prone to occur in oIder peopIe. (Fig. 3.) Fractures of both bones of the forearm

offer a more serious probIem than that of fractures of one bone. The characteristic thing about fractures of the Iower third of the radius and uIna is that they are aImost a11 transverse and within 2 inches of the epiphyseal line. The age group in this cIass is we11 defined. The youngest patient was four and the oIdest tweIve years. Fourteen of the 21 cases in this group occurred between the ages of seven and ten years.

Fractures of the middIe third of the radius and uIna or the upper third occurred in the same age group as those of the Iower third. In grouping a11 fractures of both bones there are 33 in a11 of which the youngest patient was four and the oIdest tweIve. In treating these fractures onIy 2 patients were given anesthetics to aid in reduction. If onIy one of the two bones are dispIaced we fee1 that it is better not to use an anesthetic. The muscIes about the bone

FIG. 4~. After reduction.

are reIaxed and it is not uncommon to find that the fracture has again slipped in appIying the splints. In adults or very muscuIar subjects an anesthetic wouId of course be necessary. In reducing these fractures traction should be appIied pro- gressiveIy for five minutes or unti1 the muscIes reIax. There is no pain connected with this. Then the dispIaced fragment can be manipuIated into position and heId without diffkuIty. In immobiIizing we use an anterior or anterior and posterior moIded spIint with the arm in compIete supination. The forearm is pIaced in a sIing and to this extent onIy is the elbow immobilized. We have not had any dif- ficuIty from not immobiIizing the elbow and fee1 that it is not necessary in most cases. The patient shouId be instructed, however, not to put his injured arm through the sIeeves of any of his garments. Motion shouId be started earIy in this group as the caIIus has a tendency to bridge across the

302 American Journal of Surgery Kirchenmann-Fractures AUGUST, 1934

two bones. This is impossibIe, however, if a this group onIy one fracture was such that satisfactory reduction was obtained. The average tota disabiIity in this group was

it couId not be easiIy reduced and heId in position. A banjo spIint was used in this

FIG. 3~. Before reduction.

twenty-eight days. Baking and massage were not found necessary. (Figs. 4 and 5.)

FRACTURES OF THE CARPAL BONES

These are rare fractures that are usuaIIy produced by faIIing on the extended hand. The diagnosis cannot be made positiveIy unIess a11 sprained and contused wrists are x-rayed routineIy. Active motion in these cases shouId be earIy or Iimitation of motion and pain wiI1 be sure to foIIow.

FRACTURES OF THE METACARPAL BONES .

There were 8 fractures of the metacarpa1 bones (4.9 per cent of this series). These fractures occur during the active years of Iife and are the resuIt of direct pressure as in striking an object or faIIing on the knuckIe. In treating these fractures it is essentia1 to maintain the paImar arch. It is unfortunate that haIf of our patients did not return for treatment. I have found the banjo spIint of considerabIe vaIue in reducing these fractures.

FRACTURES OF THE PHALANGES

Fractures of the phaIanges are mostIy due to crushing injuries or direct force. In

FIG. jiB. After reduction.

case. There were 4 compound fractures in this group, 3 of which heaIed compIeteIy without any Iimitation of motion. The fourth patient deveIoped an OsteomyeIitis in the dista1 phaIanx of the fifth finger. It is interesting to note that the index finger which we consider so important is rareIy injured. Early motion in these cases is very essentia1 as Iimitation sets in earIy and is diffLzuIt to remedy. The bones unite readiIy and are not easiIy dispIaced.

RESULTS

Our patients are discharged when they have compIete function and soIid union. By soIid union we mean that the fragments cannot be moved when grasped at the site of fracture and forcibIy manipuIated. X-ray pictures may show ampIe caIIus and yet the union may not be firm. It is for this reason that we reIy upon the foregoing procedure. In spite of this we have had 5 fractures which recurred through the origina site of fracture. AI1 of these were caused by the patient faIIing on the previously fractured part:

A &?e Time of (l’rs.) Site of Fracture Refracture

II Shaft of humerus After 60 days

3o CoIIes’ After 3 weeks

9 Lower % of radius and ulna After 3 weeks

9 Middle $$ of radius and uIna After 50 days

‘9 Middle 2; of radius and uIna After 90 days

Any patient not throwing out palpabIe callus about the fracture at the end of two weeks, or not showing definite signs of union is asked to take two teaspoonsfu1 of cod Iiver oil with \-iosterol after meaIs. We feel that this is of decided benefit in hasten- ing firm union and usuaIIy after one week of this caIIus is paIpabIe. There was no case of non-union.

This series of cases was conducted with- out the aid of physica therapy except in one case, as I have feIt for some time that the \-aIue of this agent is far overestimated except as a paIIiative. We have used passive motion earIy and carefuIIy as we fee1 that a properIy reduced fracture wiI1 not be dis-

placed by gentle motion. Where limitation of motion has set in at the end of two weeks we do not hesitate to secure complete function by rather strenuous passive mo- tion with the patient’s cooperation. This is foIIowed by frequent active and passive motion. We do not fee1 that passive motion tears and injures the muscIes if performed gently and graduaIIy.

CONCLUSION

I. Fractures of the upper extremities are more common in chiIdren.

2. A good reduction is essential for perfect function.

3. Early passive and active motion shorten the disabiIity.

4. Passive motion”is not injurious. 3. Baking and massage are not necessar)

for restoration of function in fractures 4 the upper extremities.

REFERENCES OF DR. SALTZSTEIN”

1. RICPHEETEKS, H. O., and RICE, C. 0. Varicose veins, 4. HARRINGTON, S. VV’. Diagnosis and treatment ot comphcations direct and associated following lesions of the breast. A. J. Cancer, 19: 3664 injection treatment. J. A. ibf. A., 91: 1090, 1928. (Sept.) 1933.

2. SC&, J. W. Chronic ulcer of the leg, report of 300 cases treated with modification of original Unna’s paste. J. A. hf. A., 92: I r57 (April 6) 1929.

3. IIERTZL.ER, A. E. Surgical pathology of skin, fascia, muscles, tendons, blood, and lymph vessels. Phila., Lippincott, 193 I.

5. CUTLER, E. C., and ZOLLINGER, R. Use of sclerosing soIutions in the treatment of cysts and fistulae. AM. J. SLRG., n.s. 19: 41 r-418 (blar.) 1933.

6. BRAUY, L. Cervical cauteriLntion under parametrial anesthesia. Am. J. Ohst. (3’ Gynec,., 26: 421 (Sept.j

‘933.

+ Continued from p. 2H-.