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There is a preponderance of literature regarding various types of fractures about the elbow joint, and our routine treatment of fresh fractures and dislocations of this region is clearly defined by standard text books, but very little attention seems to be given impaired fractures and disabilities as a sequence of such injuries, the occurrence of which is by no means infrequent.

Undoubtedly a majority of deformed or impaired joints following trauma are due to failure in securing accurate reduction; the old adage, "to place the arm and forearm at right angles the most useful position in ankylosis," is responsible for many defective members, however, unsatisfactory results are, at times, unavoidable even in the hands of the most skillful surgeon-which is due 10:

1. The complex mechanical construction with practically no loss of motion in a normal elbow-a very slight irregu larity may obviously inhibit action. However, in individuals with lax joints gross irregularities may occur with practically perfect function.

2. The interference with growth and development by trauma to one or more epiphyses.

3. Callous formation may block joint action.

4. Muscular relations are such that periosteal tears may cause myositis ossi

ficans, notably in the brachialis anticus muscle.

5. Cartilaginous outgrowths or multiple chondroma may encase the joint "en bloc" or materially interfere with the range of motion.

6. The slightest irregularity may produce a traumatic arthritis, progressive in nature, a vicious cycle, until joint action may be materially reduced.

7. Loose bodies occasionally occur but far less frequently than in the knee.

8. Slight lateral or backward dislocations may easily be overlooked but may cause serious impairment-external lateral displacement often occurs associated with fractures of the head of the radius.

When we weigh these facts, one is not surprised that even mild injuries about the elbow joint are often attended by a prolonged convalescense, regardless of the type of treatment employed, consequently trauma, as well as fractures and dislocations are considered, the latter

being so frequently associated with frac

tures that a discussion in this connection is warranted. No attempt is made to discuss every type of impaired elbow, but only such as have come under my personal observation. Detailed case report is omitted, only group analysis being considered for the sake of brevity. In order to demonstrate more closely, operative measures employed are des

is stripped anteriorly and posteriorly. The relation of the transverse axis of the transverse axis of the lower fragment to the axis of the shaft, (rotation of the lower fragment) is restored by simple manipulation or by heavy bone holding forceps. If the impairment in motion. is in flexion the joint is placed in acute flexion (Jones Position) the ulnar side of the hand opposite the tip of the acromion. Internal fixation is unnecessary. If motion is impaired in extension, as is seen when the lower fragment is displaced forward, which occured in one case, the line of osteotomy follows the old fracture, which is well defined by union with the anterior aspect of the shaft. Complete extension reduces, but care must be taken to prevent posterior dislocation of the joint, which occurred in one case-hence after ten days or two weeks the elbow is flexed fifteen or twenty degrees or as far as possible without displacing fragment. Of the ten, nine obtained perfect results, one unimproved all were in children.

Of the three condylar fractures, two were ununited, one of the external, one

(Fig. 2 (Case 2) A-Fracture of the head of the radius; B-after reduction by open operation.)

of the internal condyle. In the former I freshened the edges and used an auTogenous bone peg from the tibia with failure to produce union. In the latter I excised the fragment with internal condyle and portion of the trochlear surface with success, except that slight laxity prevailed but motion war nor mal. Both were in children about ten years of age. The third, an adult, had a fracture of the external condyle, with small fragment obstructing extension at ninety degrees. A number of roentgengrams, at various angles, of both elbows were necessary before the exact rature of the block could be determined. On incision the displaced fragment was found within the radio humeral articulation, but united to the external condyle-the head of the radius and capitellum were normal except that the orbicular ligament required repair. The offending particle was removed, within three weeks motion was practically normal.

In two the capetillum had united in an eccentric position with limited motion and impaired function. This was removed with rapid restoration to nor mal.

sue, callous and fractured particles are then excised. Reduction is accomplished without difficulty, only a very few minutes being required to complete the operation. The ulna nerve is located and if in danger from pressure by fibrous tissue or exposure, restored to a protected position. The periosteum is now closed posteriorly and the tendon of the triceps sutured into position with some tension, but it is never possible or essential to replace to the former attachment above-fascia and skin are closed in the routine manner. The elbow is then placed in sixty degrees flexion.

This incision gives perfect access to the joint with minimum trauma. Dissection of the triceps tendon allows lengthening which facilitates reduction, as does the subperiosteal removal of the lower contracted structures. After the tissues have been replaced, joint motion is free with stability. Arthroplasties and excisions of the elbow, which were formerly done because of great difficulty in reduction, are avoided by this new method of approach to the clbow. With this procedure the entire joint is conserved, provided the articular cartilages are intact. In all, from forty to one hundred per cent free motion was secured-one was complieated by vicious union of the upper third of the ulna, which made reduction impossible until refracture.

employed, these consist of the same technique as used in dislocations, with the exception that the joint surfaces are remodeled, after which the fibres of the triceps and adjacent fascia are sewed about the lower extremity of the humerus, completely separating the radius and ulna by a mass of soft tissue which is viable and healthy. Of the three arthroplasties, two were successful-one too early to conclude results.

In one, a girl of fourteen, following slight trauma, chondromita developed about the joint, through the muscles, and fascia gradually encroaching upon joint action until only twenty degrees motion was possible. By external examination and repeated roentgenograms it was possible to determine the true nature of the obstruction. On incising posteriorly, many large and small rounded and irregular cartilaginous masses were removed with material improvement, but the condition rapidly recurred with calcification and a second operation was required.

Considering the cases as a whole, of the thirty-nine, thirty-four were successful, increasing function from forty to a hundred per cent, in two there was no improvement-in three sufficient time has not elapsed to determine the result. In no case was the patient rendered more disabled or impairment of funetion increased-consequently I feel that we are justified in assuring this type of case that operative measures give an excellent chance of restoration of function and should be more generally employed.

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