The great danger of fractures round the elbow-joint, with the exception of olecranon fractures, is the subsequent formation of an excess of callus. In children this particularly applies, and all these fractures are best left alone to nature and splintage unless the danger is fully appreciated. Then, and then only, can mobilisation and massage help. The mobilisation of shoulder, wrist, and hand may be freely given. If, however, mobilisation and massage are ordered from the outset, movement may be administered to the elbow with advantage, but only if two rules are scrupulously obeyed. The first is that massage throughout the early stages should be limited to the easing of pain, and the second that mobilisation for the first two weeks must consist only of relaxed movements given very sparingly. In children this may mean that massage is reduced almost to zero from the second or third day; in adults it will require a longer dose at each sitting, and it may be necessary to continue massage for two or three weeks. After the first week, in an adult case, it will be necessary to commence gentle kneading for oedema, but great care must be taken to avoid the area of injury and to proceed so gently that not a trace of movement takes place between the fragments. Gentle frictions over the lower part of the brachialis anticus should be used whenever any effusion can be felt in this situation. Skill is required to perform the manipulation with a minimum of movement in the direction of extension. The limb will almost certainly be kept in a position that is a shade short of full flexion. It is meant to be in full flexion, but this is a very painfully cramped position and is equally difficult to secure permanently. Taking the position in which the limb is fixed as about 300, the angle is increased by about 10° and then decreased again to the original 30°. This movement is performed once, and of course only after complete relaxation has been secured. Next day perhaps an extra 5° of extension is performed once only, and by the end of the week the angle to which the limb is extended should only reach about 6o°. By the end of the next week it may perhaps reach 150°, and during the following week full extension may be given except for the last few degrees of movement. It is probable that the elbow will not be completely straightened till the end of the fourth week, or even later. It may prove necessary to apply a straight splint before the last few degrees of extension are secured at the end of six weeks. The patient may be allowed to assist flexion from the end of the second week, and to perform it voluntarily some time during the third week of treatment. Throughout the treatment of these injuries a careful watch must be kept for any increase of pain or of sensitiveness. In the event of either being detected, the indication is that the callus is "irritable," and it should therefore be regarded as an absolute contra-indication to further mobilisation until it is relieved. Rest in flexion followed by a more gradual increase in the range of movement is then undertaken.

Fig. 76. - To illustrate the application of one type of "cuff and collar." The straps passing over the shoulder are shortened day by day as flexion increases. Full flexion is maintained till the patient can, after loosening the straps, raise his forearm to the full extent without pain. Then the "cuff" is allowed to drop a little each day.

If surgeons would only recognise the importance of bearing in mind the existence of the "carrying angle," when reducing fractures of the lower end of the humerus, many a patient would escape permanent deformity and resulting loss of function.

Except in cases of fracture of the head of the radius, rotation may be commenced early, pronation being added to the extension from about the end of the first week, with supination to assist the restoration of flexion. If the head of the radius is involved, rotation must be performed very tentatively with one exception, namely, when a fragment is broken completely off and is really little more than a loose foreign body. In this case free mobilisation is safe, but all other cases, for no very apparent reason, tend to throw out an excess of callus more readily than perhaps any other fracture in the body, not even excluding fracture of the ribs and the so-called separation of the lower epiphysis of the humerus. Rotation is a comparatively small movement, and if we secure 25 per cent. by the end of the first week, 50 per cent. by the end of the second, and 75 per cent. by the end of the third week, progress will have erred on the side of recklessness. And for this reason: no guide - absolutely none - will serve to show the gravity of the situation until the damage is done. Everything may seem to be going on splendidly for about eighteen days, then the patient may begin to complain of pain, and, do what we may, another week will see a heart-rending reduction in movement, which may lead to permanent loss of mobility and power. Absolute rest and hot-air baths for three to six weeks will, however, occasionally avert complete disaster. The cases in which this excess of callus is most usually seen are those in which faulty diagnosis has been made. The patient has a fall, is shaken up, has some pain in his elbow (not a great deal), does his work, goes to bed and then has a bad night. Next morning there is some swelling, a medical man is consulted, movement is found to be a little painful but perfect, and there is no crepitus. Diagnosis of "sprain" is made. Hot fomentations or a liniment "to be well rubbed in" are ordered, and the patient is often advised "to keep the elbow from getting stiff." It is swollen, so he expects some pain, and it is only when he finds that the pain persists that he seeks advice again. Even the movement involved in the changing of fomentations is enough to cause an enormous outpouring of callus, so it is easy to imagine the parlous state of many of these patients. If the patient has used the arm at all after the accident, or if fomentations or "rubbing" have been advised, there is only one safe treatment - absolute rest in flexion and hot-air baths from the outset (see Figs. 76, 77, and 78). The fixation prevents the further dissemination of osteogenetic cells, the flexion ensures that any ossification that may follow will not impede flexion, while the heat causes a local hyperaemia which tends to hasten the absorption of exudate, and so reduces the amount of pathological material in which ossification can take place.

Fig. 77. - To show flexion by a sling.

Fig. 78. - To show how flexion may be relaxed.