Separation of the Superior Epiphysis of the Humerus.
Selected writings of A. Jackson Howe.
This paper is a sample of the numerous surgical articles by Dr. Howe printed in the Eclectic Medical Journal as a leader. It discusses clearly this interesting and often undetected form of injury. Professor Howe excelled in bone surgery, and wrote "Fractures and Dislocations," one of the best treatises of its day. This book is not often seen nowadays except in the libraries of the older Eclectic physicians. The wonderful advances made in the surgery of bones necessitates the frequent purchase of up-to-date works, and of necessity this book is valued only relatively at the present day.—Ed. Gleaner.
SEPARATION OF THE SUPERIOR EPIPHYSIS OF THE HUMERUS.—Between the anatomical and surgical necks of the humerus there exists in young subjects a lamina of cartilage that divides the head of the bone and a part of the tuberosities from the shaft. In an adult subject there may be fracture at either of the two necks, i. e., above or below the tuberosities, but in juveniles the separation is along the plane of the cartilaginous septum which is through the tuberosities, and not above nor below them. The age of the patient is to aid in the diagnosis—an adult sustains a fracture at one of the cervices of the humerus—a young person sustains diastasis or separation of the epiphysis from the shaft along the line or plane of the cartilaginous interlayer.
The deformity appears somewhat like a sub-coracoid dislocation of the humerus, yet the displacement inwards is not so pronounced as in luxation. The glenoid cavity is not made empty as in dislocation, but presents some depression in the outer portion of the space. The epiphysis (head of the humerus and part of the tuberosities) stays in place, while the upper end of the shaft takes a position an inch or so inwards. The arm is neither lengthened nor shortened, for parts of the fractured surfaces rest in contact with each other. A portion of the broken surface of the lower and long fragment extends under the coracoid process. The displaced shaft is near the skin on the inner aspect of the arm. A fullness is apparent on the inner aspect of the scapulo-humeral articulation. Crepitation on imparted motion is not readily obtained in all cases, but an abnormal sound can be obtained. It may be that of rubbing or rocking. The injury is likely to deceive the inexperienced and the unwary—it is oftenest produced by direct violence, the shoulder receiving the force of a fall of several feet, as when a young person is thrown from a horse or carriage.
The diastasis is to be treated as if it were a fracture, and, as follows: A strip of rubber adhesive plaster four inches wide and a yard long is to be split in the middle a few inches from one end, and a loop made by passing the end through the slit and sticking it to the strip, adhesive surfaces coming in contact. The hand and forearm are sent through the loop, and also the upper arm to a point a little below the fracture. Then the long end of the adhesive strip is carried across the back and made to adhere to the skin at a time when the upper end of the long fragment is pressed outward. The loop and adhesive strip are to act as a fulcrum, while the humerus is converted into a lever as the elbow is pulled inward so the open hand shall cover the opposite axilla. It is well to hold the elbow in the inwardly pulled position by using another strip of rubber plaster to cover the olecranon and the outer aspect of the forearm, and then reach the opposite shoulder. This dressing will prevent deformity, and secure osseous union of the broken cartilaginous surfaces. No other dressing will secure a satisfactory result. It is to be borne in mind, too, that this is the best dressing for treating fracture of the clavicle.—HOWE, Eclectic Medical Journal, 1885.