I 8 inches above the epiphyseal cartilage, with lateral shifting of

COMPLETE FRACTURE OF THE LOWER THIRD OF THERADIUS IN CHILDHOOD, WITH GREENSTICK FRAC-TURE OF THE ULNA *

BY PENN G. SKILERN, JR., M.D.OF PHIIADUI'HqIA

INSTRUCTOR IN ANATOMY AND SURGERY, UIVEUITY O PENNSYLVANA

WHILE fractures of both bones of the forearm in childhood arefrequent and well-recognized, there is one variety that, in its mechanism,site, and characteristics, is as definite a clinical entity as is Colles's frac-ture, and yet it has not been differentiated in the text-books or in theliterature from the other indifferent fractures of the forearm. I referto complete fracture of the radius with incomplete greenstick fractureof the ulna in the lower third of their shafts (Fig. I). The cause isquite constantly a fall while in motion, most commonly either off skatesor a bicycle. The deformity consists of displacement of the lower frag-ment of the radius to the dorsum and laterally, and bending of the ulnawith concavity toward the radius, the radial portion of the fibres of theulna at its site of fracture being compressed but not torn asunder, theinner fibres only being separated. I shall endeavor to show that aboutthis peculiar and characteristic incomplete greenstick fracture of theulna hinges the maintenance of the displacement, and also the correctmethod of reduction. The following two cases are typical:

CASE I.-H. H., male, aged fourteen years, school-boy, white,presented at the Surgical Out-patient Department of the Univer-sity Hospital (Case record 40,201) on April 2, I9I4, with the his-tory of having fallen two days previously, while skating, upon theoutstretched right forearm.

Clinical Diagnosis.-Fracture of radius and ulna shafts, lowerthirds, that of the radius being complete and with displacement,and that of the ulna being incomplete and with diminution of thenormal external concave curve. Skiagram showed for the radiusin the anteroposterior view a transverse dentate line of fractureI 8 inches above the epiphyseal cartilage, with lateral shifting ofthe distal fragment, one-third diameter; and in the lateral view,displacement of the same fragment dorsally, two-thirds diameter;and for the ulna a transverse greenstick line incomplete externally,at a higher level (Y8 inch) than that of the radius, and withbowing of the ulna concave externally (Figs. I and 2).* Read before the Philadelphia Academy of Surgery, October 5, 1914.14 209

PENN G. SKILLERN, JR.

A study of this fracture in the skiagram not only reveals the mechan-ism of production, but also furnishes a clue to the mechanism of reduc-tion. The deformity leads one to anticipate difficulties in completereduction, but it is very simple. In the first instance, it is evident thatthe brunt of the vulnerating force was borne by the radius, whose frac-ture is complete, and that there was sufficient force remaining to producethe greenstick fracture of the ulna. The inner fibres of the ulna wereruptured by tensile stress, whilst the outer fibres underwent compressivestress, the force thus stopping short of causing a complete fracture ofthis bone. These intact outer fibres of the ulna maintained the positionthe bones were in when the force ceased to act, and therefore presentedthe chief obstacle to reduction. It is patent that in order to reduce thefracture, attention must be directed chiefly toward overcoming thevicious bouring of the ulna, and that this can be accomplished only byrupturing the still intact outer fibres, so that alignment of the innerborder of the ulna may be restored, which means conversion of thegreenstick into a complete fracture. This having been done, the radialfragmens, aided by a little pressure, will reduce themselves auto-matically. Acting upon this analysis of the fracture, the complete re-duction of the fragments, as shown in the second skiagram (Figs. 3 and4), was attained. The criterion of reduction, then, must be the restora-tion of the alignment of the inner border of the ulna.

CASE II.-H. M., male, aged thirteen years, school-boy, white,presented at the Surgical Out-patient Department of the Hospitalof the University of Pennsylvania (Case Record 4I,22I) onJuly 22, I914, with the history of having tripped five days pre-viously down three steps, turning a somersault, and landing uponright forearm.

Clinical Diagnosis.-Complete fracture in lower third of radiuswith displacement, and greenstick fracture of ulna at a slightlyhigher level. Skiagram showed for the radius in the antero-posterior view (Fig. 5) a transverse dentate line one inch abovethe epiphyseal cartilage, with displacement of upper end of distalfragment laterally, one-third diameter, and in the lateral view(Fig. 6) displacement of upper end of distal fragment dorsallyone-half diameter. The ulna showed in the anteroposterior viewa transverse greenstick line iY2 inches above the epiphyseal carti-lage, incomplete externally, and slight bowing of distal fragmentwith concavity toward radius. In the lateral view there is no dis-placement.

Under nitrous oxide gas anaesthesia the greenstick fracture ofthe ulna was made complete, the outer, unbroken fibres rupturing

210

FIG. I.-Type of "special" fracture of radius FIG. 2.-Lateral view of rad-and ulna (anteroposterior view). The radius is in- ius and ulna in Case I. Thevolved by a transverse dentate line, IS inches distal fragment of the radius isabove the epiphyseal cartilage. The distal frag- displaced dorsally, two-thirdsment is shifted laterally, one-third diameter. The diameter. There is slight dor-ulna is involved by a transverse greenstick line, sal displacement of the ulna.incomplete externally, at a higher level (X4 inch)than that of the radius, and with bowing concaveexternally. See Case I.

FIG. 3.-After reduction (anteroposterior FIG. 4.-After reductionview). Note complete rupture of outer fibres (lateral view). Fragments re-of ulnar fracture, with consequent straight- duced to their normal position.ening of inner border of ulna and automatic Compare with Fig. 2.shifting of displaced distal fragment of radiusinto good position. Compare with Fig. I.

FIG. S.-A second typical case of FIG. 6.-Lateral view"special" fracture of radius and ulna (an- of radius and ulna interoposterior view). The description cor- Case II. Note dorsalresponds to that of Fig. i, although both displacement of distalbones are fractured at a more distal fragment of radius, 2 di-('8 inch) level. By placing a ruler along ameter, with greater an-the inner border of the ulna the outward gulation than in Fig. 2.bowing of this bone, distal to the seat of No displacement of ulna.fracture, is accentuated. See Case IL.

FIG. 7.-After reduction ; anteroposterior FIG. 8.-After reduction;view. Again the outer fibres of the ulnar fract- lateral view. Distal frag-ure have been completely ruptured with the re- ment of radius still angulatessult that the alignment of the inner border of the slightly backward, but thisulna has been restored and the displaced radial was corrected with ease atfragment shifted into place. Restoration of align- the next dressing. Comparement of inner border of ulna may be demonstrated with Fig. 6.by a ruler. Compare with Fig. 5.

FOREARM FRACTURES IN CHILDHOOD

with an audible snap. The fragments of the radius adjusted them-selves automatically into place. Two splints were applied, avolar bond and a dorsal straight, and the forearm was placed ina triangular sling. Skiagram (Figs. 7 and 8) showed that reduc-tion was complete, the alignment of the inner border of the ulnahaving been restored.

This case was so similar to the first case in the mechanism of pro-duction, the findings, and the mechanism of reduction, that I lookedover our records to gauge its frequency. A study of these previouscases, together with a closer investigation of cases reporting subse-quently forced me to the conclusion that here we are dealing with afracture fully as characteristic and significant as Colles's fracture inadults. In other words, this fracture is to childhood what Colles's frac-ture is to adults. Colles's fracture is comparatively rare in childhood,having been found in but four per cent. of cases in this series, and occursat an older age than fracture of both bones in their lower third.

Malgaigne recognized that greenstick fractures are more common inthe forearm than elsewhere, and are usually due to a fall upon the hand.The importance of reduction is exceptionally great, not only from thestand-point of epiphyseal growth, but also from that of rotation of theradius, which may be easily destroyed by displacement or non-union.The teaching that a bad anatomical result does not always imply a badfunctional result is baneful, for it furnishes an excuse to be satisfied withinferior anatomical reduction. On the contrary, the idea expressed byMr. Robert Jones, of Liverpool, that a bad anatomical result gives goodfunctioning in only 29.7 per cent., but that a good anatomical resultgives good functioning in 90.7 per cent. of cases, is to be endorsed. Thesame authority also advises that, in addition, the bones be restored totheir normal curve. Despite these strong arguments in favor of com-pleting incomnplete fractures so as to restore proper alignment, there aresome, Cotton among others, who consider it unnecessary, and that itmakes it harder to maintain the fragments in the correct position. Tothis there may be added the theoretical objection that the periosteummight be ruptured or torn up, and that osteoblasts might grow alongthe blood clot out into the muscles, produce exuberant callus, and subse-quently interfere with function. These objections may be met with theobservations that many fractures are complete from the beginning, andoften showv considerable displacement, as in the radius in my case, yethealing without exuberant callus results; that in childhood the perios-teum is thicker and tougher than in adults, and hence less liable to betorn; and that, when properly reduced, it is not hard to maintain the

211


fragments in the correct position-not even so hard as when the frac-tures are complete from the beginning, since the grip of the greenstickfracture, together with the unruptured periosteum, tends to preventwide excursion of the fragments from each other during reduction. Ofcourse, in fractures as well as in luxations, it is inadvisable to use anundue amount of force in the act of reduction, for extensive damagemight be done.

ANALYSIS OF CAsEs.-One hundred cases of fractures of the radiusand ulna in childhood in which the histories were carefully kept wereselected from the records of the Surgical Out-patient Department of theUniversity Hospital between January i, I9I2, and September I, I914,and afford a fairly rich assortment for study.

Season.-Sixty per cent. occurred in the summer months, fromMay to August, inclusive. In the Spring, bicycles, skating and runningbecome popular. In June and July young human beings revert to thetype of their arboreal ancestors coincident with the appearance ofluscious cherries upon trees. With the opening of public playgroundsfalls from swings furnish many cases. Twenty per cent. occurred ineach of the remaining periods of four months, sledding being a contribu-tory factor.

TABLE ITABLE SHOWING FREQUENCY ACCORDING TO MONTHS AND SEASONS

January ............. 3 May ... io September...... 8February ............ 6 June ... io October...... 6March .............. 5 July ... 28 November...... 4April .............. 6 August .... 2 December...... 2

Total. 20 6o 20

Age.-More than two-thirds occurred from nine to fourteen yearsof age, inclusive. This is the period of greatest and roughest activity inchildhood. Both bones and the ulna alone were broken in youngerchildren, while fractures of the radius alone or disjunction of its lowerepiphysis occurred on an average in older ones.

TABLE IITABLE SHOWING FREQUENCY ACCORDING TO AGES

2 ................... I 9.. I3 15 ...-...-....... 43.3 10................ 7 i6 ..-.-........... 34 ... 3 II.II 17 ...................... 45 ................... I 12 . 3 I8...................... 06 ...................5 13 . II I9...................... I

7 ................... 4 14 . 148 .2

Total.19 69 I2

212


Sex.-Four-fifths of the cases occurred in boys, in keeping with theirrougher methods of play.

TABLE IIITABLE SHOWING FREQUENCY ACCORDING TO SEX

Males ... 8iFemales ... I9

Cause.-Fract.ures of the upper extremity in general and the fore-arm in particular are the penalty of the erect attitude, and of atrophy ofthe prehensile function of the forelimb. It seems best to distinguishtwo classes of falls, those with which momentum is strongly associated,and those in which it is an insignificant factor, the attraction of gravitypredominating. In the latter class falls from a height may be givenspecial prominence. A study of these cases shows that the specialfracture of the lower third of the radius and ulna, the basis of thispaper, is particularly associated with the momentum gained by bicycling,skating, swinging, running, horseback-riding, motoring, and pole-vault-ing. Those in which the force is more purely the attraction of gravityare falls from steps, porch or fence rail, chair, bed, high-jump, or merelyslipping and falling upon hyperextended, less often hyperflexed, hand.Falls from a height include those from a tree, pole, ladder, or haystack.

Site.-As in adults, the lower third of the radius is most frequentlyfractured. In this series the lower third of both bones or of the radiusalone comprised 70 per cent. of the fractures. This circumstance andthe fact that the radius in childhood is usually fractured above Colles'ssite (which is usually taken at from one to one and one-half inchesabove the lower articular surface of the bone) may be explained in partby the statement of Rixford (Jour. A. M. A., I913, lxi, 9I6), that inthe long bones of children the medullary canal is smaller than in adultsand is especially undeveloped toward the ends, and that the compactbone of the shaft becomes thin much farther from the ends than inadult bones and the cancellous bone extends correspondingly fartherfrom the epiphyses. The following table has been compiled to show themechanism according to the site of fracture.

The most significant feature of this table is the frequency with whichthe radius and ulna are both fractured in their lower third, this sitebeing involved in 32, or almost one-third of the cases. Of these 32cases, thirteen, or almost 50 per cent., conform to the type to whichspecial attention is called in this paper, namely, complete fracture of thelower third of the radius with dorsal and lateral displacement and green-stick fracture of the ulna incomplete on its radial side and with bowing

213


TABLE IVTABLE SHOWING MECHANISM ACCORDING TO SITE OF FRACTURE (See Figs. 9-13)

NO. Gravity Gravity Falls Prom Cause Notcases site Without With Height GivenMomentum Momentum

4 Both bones, upper third......... 3 I 0 014 Both bones, middle third ....... . 7 6 0 x32 Both bones, lower third .5....... 1 ISIX 6 06 Radius, lower third, and ulna,

styloid ...................... 2 2 0 23 Radius, upper third (neck 2,

shaft I) ........................ 2 0 0 I3 Radius, middle third.I 2 0 0I6 Radius, lower third ............ 9 4 2 II6 Radius, disjunction of lower epi-

physis, and fracture of ulna,styloid tip (2) ................. 5 4 3 4

6 Ulna. ........................ 4 Ix 0

100 48 31 12 9

of the lower fragment of the ulna over toward the radius, the displace-ment of whose lower fragment it thus maintains. In fact, this specialfracture comprises I3 per cent. of all fractures of the radius and uln4

FIG. 9.-Fractures of radiusulna (thirds).

and FIG. IO.-Fractureof radius (lower third)and ulna (styloid proc.es).

}3

.34/6

FIG. II..-Fractures of radius(thirds).

in this series. Of these thirteen special fractures at least eight, or almost66 per cent., were caused by gravity with momentum. In the remainingfive the nature of the fall unfortunately is not stated in two, was direct

214


violence in two others, and a fall from a ten-foot ladder in the remainingcase. Hence, it may be stated that this special fracture is typically theresultant of the action of gravity with momentum. A study of the non-typical fractures at this site shows in a general way that falls upon thehyperflexed hand are apt to result in " buckling " fracture of both bones,by which is meant telescoping of cancelli with bulging about the circum-ference of the fracture and without displacement; that falls upon thehyperextended hand are apt to result in ordinary greenstick fracturesof both bones with angulation, and that falls from a height are apt toproduce complete fractures of both bones with greater displacement.

FIG. 12.-Epiphyseal disjunction, FIG. 13.-Fractures of ulna.lower en of radius.

Hence, knozwing the mechanism of the fall enables one to predict witha fair degree of certainty the nature of the injury to the bones, and Ihave thus diagnosed the injury in many cases from the history alone. Inthe smaller number of cases in which the radius is fractured in its lowerthird alone or in conjunction with separation of the tip of the ulnarstyloid the same rules of cause and effect hold good. In the last analysisthe extent of fracture hinges upon the intensity of the vulneratingforce, and it must be borne in mind that minuter details of mechanismcould be elicited if the observer were to see the patients actually falling.

In the sixteen cases of disjunction of the lower epiphysis of theradius all these mechanisms were exemplified. This injury occurs on anaverage at a later age than the fractures we have been discussing. It isdiagnosed clinically by the site of the displacement, if any exist. There

215


may have been displacement which was reduced by the patient, in whichcase the history is of great diagnostic importance, and the skiagrambeing negative is really of positive value. In two of these cases thetip of the styloid process of the ulna was avulsed. There was one caseof para-epiphyseal strain, in which injury the epiphysis is partially sepa-rated, and one of para-epiphyseal sprain, in which the epiphysis iscompletely separated but not displaced. These types of injuries conformwith the well-known classification of Ollier, and may be diagnosed bythe site of " wincing " tenderness, the absence of deformity or of historyof deformity, and the skiagram, which shows a widening of theepiphysis, and later on callus formation about the site of injury.Epiphyseal injuries must always be suspected in children and adolescentsand carefully reduced and treated just as a fracture, lest there arisedeformity in the growth of the bone.

The diagnosis of an injury to the forearm should always be made bycareful clinical investigation. It is a great mistake in more than oneway to depend exclusively upon the skiagram. A skiagram must be con-sidered merely as one of the many signs of fracture. There are twofactors which will diagnose go per cent. of fractures of the forearmclinically. One is a thorough understanding of the mechanism obtainedfrom a careful history, and the other, " wincing " tenderness. It hasbeen shown that a given mechanism is apt to produce a certain fracture.This, in turn, indicates where to examine for " wincing " tenderness. Iuse the term " wincing " because more expressive than the adjective " lo-calized." When the site of fracture is reached moderate pressure witha finger tip causes the patient to wince: he screws his face up and invol-untarily withdraws his arm. This is almost pathognomonic of fracture.

There is another feature to which I believe attention has not hithertobeen called. I have recently seen several cases of fracture in childhoodin which I was positive of the existence of a fracture on clinical grounds,but in which skiagrams taken from all aspects were apparently negative.Not having been satisfied I decided to await the usual period of callusformation and then have other skiagrams taken, in the meantime treatingthe cases as fractures. In these several cases I had the satisfaction ofseeing typical callus produced. In the first case I wondered if this werea traumatic osteoperiostitis, but my doubts were allayed by the secondcase, in which there was a complete fracture with callus in the lowerthird of the radius while the ulnar callus showed only along the radialborder of this bone, at a location where it is obvious that traumatic osteo-periostitis could not occur, especially seeing that the injury was pro-duced by indirect violence. Minute scrutiny of the skiagrams now

216

FIG. I4.-The method of diagnosing "first degree" greenstick fractures, patent clinically butobscure in skiagram, by awaiting callus formation. The radial border of the ulna, between thetwo arrows, shows a strip of callus formation, the lower arrow showing, on close scrutiny, a green-stick fracture. Note callus on radius. Skiagram taken 40 days after injury.


revealed a very faint transverse line, perhaps only a few torn cancelli,whose site corresponded exactly to that of the clinically-elicited " winc-ing" tenderness (Fig. I4). In interpreting this faint line defects inthe plate were carefully excluded. I believe that here we are dealingwith the first degree of a greenstick fracture-a degree attained by thevulnerating force ceasing to act after it had torn a few cancelli, whereasfurther action of this vulnerating force wcould have produced the typicalbending greenstick fracture. These cases also emphasize the accuracy of"wincing ' tenderness, and its value as an indicator of where to look onthe skiagram for a fracture. I believe I present good reasons for consid-ering a skiagram a secondary signi of fracture that is surpassed in valueby a careful history and the eliciting of " wincing " tenderness.

I believe that fractures of the radius and ulna or of either alone inchildhood are best treated according to the following plan. If reduc-tion be indicated, nitrous oxide gas should be administered for reasonsstated above. Attempts at reduction must be repeated until the skiagramshows a' satisfactory result. The criterion of reduction of a Colles'sfracture or an epiphyseal disjunction is the restoration of the carpalarticular surface of the radius to a plane that lies at right angles with thelong axis of the forearm. Spiints of the proper size are fashionedfor the individual case from stout pine board. It is my custom to haveat hand for this purpose a stock of boards in lengths and a sharp car-penter's saw. The splints are well padded with non-absorbent cotton,which is retained by a muslin bandage secured by a pin. The paddedsplint is applied to the forearm and retained, not by plaster, but bya muslin bandage. In applying this bandage the first turns are theloosest and the final turns the tightest. The bandage is secured by pinsor adhesive strips. The forearm is always bandaged at right anglesto the upper arm, lest the upper edge of the bandage cut into the ante-cubital fossa. A triangular sling is then applied. For fractures of bothbones in the upper two-thirds the mid-prone position is liable to resultin sagging of the fragments toward the ulnar side, an undesirable cir-cumstance that may be obviated by the position of full supination. Thepatient reports the next day to insure against ischaemic contracture, andthe parent is directed to watch the circulation of the limb by notingthe color, temperature, and occurrence of pain, and bring the childaround immediately upon the appearance of these disturbances, for it isknown that ischaemic contracture may develop within a very few hours.Massage and passive motion are prescribed for the individual case, andthe splints removed as soon as firm union is present.

CONCLUSIONS.-(i) There is a fracture of the lower third of the217


IaU

0

*

ia aA

bO._d

000d

0 01. r.

*ci

0O

0

a 0 a

tlO g .04 o

U

a am

0 p|a+ :++:Nto0

3 ;h + :++

o0

54~~~~~~~~-0 .0

. . .

0

. '..4.Oa ...-~~~ .254. ..

* *bA eq rpo

43 1 j :-+ ++jrf'04364d.ltU)>3)

z U U)'00

.a.

.a da

of a6

°e o i A f00

C3.20O

gX . e f

m aS .E S._04 H

0 0

U ~~~~~,01" 0*0

+ O cn~~~~~zCe G

S coP 0+ +.C<a3~~~~~~~3 + + + +

a

0 + :: :: :+:

4- X0 c

.0 .. .

.~ . ~..@ . . .. .....~

W . . .. . - .~~~~~ok - V

d :+ +~~~~~:++

a a ... . .

0 ' ++++ :: + :+ +

G)c0 ' g 3

I +:1:: ++ :+:.

X I2 ++ ++ + +:++

°\@ 0b w %0a o NOe co rxinU z_ _ _ _ _ _ _ _ _ _ _ _

U2)218

in N0 a%0 fto) 1*o rFoomf o

§

U)

40M545

co

0 0

54

0

'3

o8co

Ia N (q(3)

k

11

VI

70

I.-

r

11

p

c


.a a0_3 9

- A

2 tI. CU-DA '

+ ++ : foo

++ :+

+ Ht

+ :+ 0a

+ :+ o

a 0

co d.W m

0 0k w

P84 C4)

+ :H+ + :+rO in '00 In

0)In '0 1' 0

60 0 . - In

C4 8 8 8

In' I'

UC'

*-

U)

0

to)

04Ca

* @

Oa,4 * 84S

:::: : t0: : 9

.]{it * W- -l

.o6o cot n om@* .. . . * * *

*8 . i .. C.... ......... .* .4488444 C .. 8. *............

CUt0.:! .8000g00d 0 0 0 00 00

on>+ nu An

8 0o +:++ ++ :++ :++ :++ :++++ + :+::

a +++ ++++ :+ :+++++ ++ ++ :++ ,

U| n~~~~~~~~~~~~~~~~~~~~~~~~~~~~~C

* :+:: :+: :+: :+: :+:: :+ :++

3

4A

i t + :++ ++++++: :+++: :+:+ ++ :++4__

.4L5i... .... R ... .O . .

* * aa*.*****. ag m .gIag..,0...........(No moo NO ......" ............NO.... )o G "l... ...t...............o ............" ..m

Z_ __ o om~~

..,.--_. ae,4

0% ;&g08tC'0084t -]0i0|xg;g'0<g;X

00cnC 'Ocf0C++++0+++++++++ 084+ +++ :+ 8CoO00Co08@ nC..-088484n84 In4~c-n .

fi N "tZ ^ " H " b" H " Ce0 8 C01C0C8)C00845In'o600808404In'02.60 0084CI"o

0 219""*M . . . .. . MMM aoMMC219

I 11 I~~~~~~~~~~~

i4-4

t

OF3

Olb

I01-4

a

LI

314


.o .0.a.0Go

000++ ++ 00

a°t1+++++ 1

0 aco

+: :+ :+

4 I 1++++++

Id

.0 I L ..

to - l *- C4 m -

*U *. )

a~~~a

- ~j :+::+::j

0 X I+ :++ :++

0ae I t"o"8qM" 1z CO)"^944 C

0 °-0 )

4)

4)

£0a

i

%o

3.

IS

4

;a

U

C.,

0Q

4p

320

CU

W4

6 i

S.a.0

a e.a 0E0 : .

4

aw 0

2 .A 3'NZq: C.)9,

4)

* +:+ :+:c

4a

0

co0

:+ :+ :+C1

+ :++ +:

:+:: :+CU

** *

a 00 * *l*.4

:+:.+0+.+.+: H

r X*N ~~~~t)U

zo,')'Wt Cnf )

a0ICl " * on,*

11_ *

(3

co

-4u904


A4)4 $ >a

a4 4P eria0 3 I

0. 4)

if

+ +:

+ 4

o~~~~~~~c

4) 0 C

0 0 .0

Z Zto

44

~ co

0

0 * 0

m

. +

44 U 0

00

0

4) 44jI+ :+ 1i

fi~~ ~~~c ci

44S0:+c;5)o

I oO 0.in in in

V

uX

'40

E4)0

4

64+4

' 4

04

'40

21)

0

94

gi06)

00,

,o

43

40 .01.

o a

4)

+ .4

:++

0

4)

.4

.++

44

z

4 o

0 o0

an -4 + ++

04

. . C

cU ._.

.i . .0 * .o.. .

mC) '86.444NO laf

I

4)

4:

+4

04-

04

I

II

I I


Isa

0

mo . mm 0J.9 .4 . '.

-1 A 0

cis. 20 fr2A:3

A~:3: )D

42 0:2 0° j-44 *.4.d 4

0'

0 0

>~~~~~~~~~~~c ._.

020202 4) 4D 4

00++ 44+ ++ + + ++

0 0 000 > + "

4)~~~~~~~~~~~~~~~~4

+ ++:++ +

04)~ ~~~ ~ ~ ~~~~~~~~4

co

0 ~~ ~ ~ ~ ~ ~ 0

. * - g * -, .4-a U .a 4) 04*4

a 4: co: : E

t 4, 0 0I

d - . d * * *t

s 0 3t0

s s .1k $4 64 44

bD NOUO * m M 00tOlle M0W rW*H io

++ :+ +++ ++ + + + + ++:0~ ~~~~~~~~~ in

00 0 0 0 0 0 i0n4 0 a " o

U V -~~~~' £'00 04 - 2Q 14 "*04Z ~ 02Pt 2 2 q2 24)

M 1* ooo1- o0 H " m lq in2% 2'N t-oON o 44 421-

412

222

O'0000'. 0. t4

3

4L)cn

0

0

.0

*s

91.:3

U


.

is~~~~~~~~~~~~~~C*64A% 144

A4

4a04

to'.

. I+ :+ re

d .+

CIO~

. : ::+

r +:: ~+: :-+: + :+::+ to

a:4

0 + 0

g * j * . * - *4

is4a 43 0 4244

4 ot t "ot of vo 4a

IX+++++++ ++++

o oOao^ tq o tH bt w nHnON~~~~~~t- oo0 ooween aO lq to 0H o oo 0 mEN oam

10 : 9ztn qt m t-X in m Mt-"

d C00 MMo 0no2 030 ao -

o ,

223

*.3

cG

.4.

0

*R

04

(1

0.

0


Mto

4

a

4)

lYa00

42

q

C)4)0

d w44

00

O S..

al 9o O

wo

C3.

+:

14.

AA

.0

A~~~~

_b e

*2 I+ +cq

o .24) :

4 i)g4 0

A 4

Cl) X + I

* . d 0 '

tau I e +0 C

In oot0

0C%co(d.

..4A

*a

Ce

I0$-4

o

O"Il0

'4-

04

224

"4

P4

.0

42042

0 I0A54 so

00 O..1,0 .

). aCZ;'3

.0 ' " $

D44d..

4)

4) I ++00

o + I 4

4)b

%4

a

4) +co

'o + ++: reI : :: +

0~~~~

oo4) - ____ _ _ _

en ++

0 f. 4' 0

* 0*Z.L.

"&oo so

COa)w

co

'4

.e v

CP

0

0

.r.

I . copESO4m

os)

0


radius and ulna peculiar to childhood and which constitutes aboutI3 per cent. of fractures of the forearm. This fracture commonly occursbefore the age of puberty, is most frequently encountered during thesummer months, and is caused usually by the effects of gravity plusmomentum. It is characterized by complete fracture of the radius withdorsal and lateral displacement of the lower fragment and by incompletegreenstick fracture of the inner half of the ulna, usually at a higher level,the outer half remaining intact and maintaining the deformity of theulna, which is a bowing of the lower fragment toward the radial sideand which, in turn, maintains the displacement of the distal fragmentof the radius. In reducing this fracture the aim must be to convert theincomplete greenstick into a complete fracture by forcibly rupturing thestill intact outer fibres, thereby enabling restoration of alignment of thedistal fragment tf the ulna with that of the axis of the bone, the distalfragment of the radius coincidentally shifting itself automatically intoposition. The criterion of reduction is the restoration of the normalalignment of the inner border of the ulna.

(2) Fracture of the lower third of both bones and of the radiusalone comprise 70 per cent. of fractures of the forearm in childhood.The site of the fracture and its variety may often be predicted by aknowledge of the history and mechanism of the fall.

(3) Injuries to epiphyses, whether strain, sprain, or disjunction,should be recognized and treated as fractures because of their im-portance in the growth of the bones and because epiphyseal injuriesoften predetermine infections, typically tuberculous.

(4) Diagnosis may be established clinically by the mechanism and" wincing" tenderness. If deformity exist it is unjustifiable to elicitfurther signs of fracture. Skiagrams are of corroborative value, butby no means the final arbiters. Their chief value is in showing thedegree of deformity and its presence after reduction.

(5) Owing to the delicacy of the radius and ulna in childhood frac-ture is the rule, while contusion and sprain are the exceptions.

(6) Treatment is begun by the administration of an anaesthetic ifdeformity exist. Otherwise a carefully prepared and padded splint (orsplints) is applied firmly and without undue pressure. Skiagraphic con-trol of reduction is important. Massage and passive motion areadapted to the individual case. The splints must be removed as soonas there is firm union.

(7) Operation is indicated only when conservative treatment isadmittedly a failure. It will seldom be necessary. The inlay methodof Albee should be used instead of an array of metal fixtures.

15 225

I 8 inches above the epiphyseal cartilage, with lateral shifting of

Documents

Transcript of I 8 inches above the epiphyseal cartilage, with lateral shifting of