INTER- MUSCULAR SEPTUM
RADIAL NE
A.
RADIUS
4
Rt. Ant.View
Fractures of the Humerus with Radial-Nerve
1382 THF: JOURNAl. oil. BONE ANI) J(iIN’I’ SURGERY
Paralysis
*BY ARTHUR HOLSTEIN, M.I).’f’, ANI) G\\’ILi’M B. LEWIS, M.D.t, BF:ItKELEY, CALIFORNIA
In our experience when paralysis of the radial nerve complicates fractures of
the shaft. of the hunierus, a specific situation usua.lly exists. The fracture is in the
distal third of the humerus, it. is spiral in type, the (listal bone fragniemit is always
displa(’ed proximally w’ith its proximal end deviated radialwam’d, the radial nerve
is caught in the fracture site, and, if there is a coniminuted fragment, it is the oblique
surface (If the distal end of the proximal fragment that damages the nerve. \Vhen
fr;uetul’es in t.his area occur and the initial trauma does not. Pmo(lu(’e gross displ;tce-
nient (If the type described, theum i’adial-mierve paralysis may not occur (Fig. I).
Fin. I
I)rawing showing relationship of nerve to frat’t tirt.’ Iielore (left )amid alter disl)hao’emllelit (right ).
With radial disphat’ement and overridimig of til(’ distal lragmeiit tliemiervo’, fixed to) tho’ liroxirnal il’agnio’mlt.l)y t.ht’ ilit(’l’IiitiSt’tllaI’ s(’pttin), is tl’apl)t’tl h)o’t tho’ fm’act tilt’ sulfates.
To understand the mechamii(’s of this fracture syndi’(Ime, the follow’iiig anatomi-
cal factors are pertinent.
As Whitsoui (Ieniouistrated, contrary to tli(’ deseriptiomms iii standard anatomical
textbooks 1,2, the radial nerve does iiot travel along the so-called spiral groove of the
* Hea(l at tiio’ AmimiuahMeeting oil Tlit’ Anienio’aii Ao’ado’niy oil(lithiol)aetlio’ Siim’geoimis,Chicago,
Ilhinoiis, January 28, 1962.
t:3011 Telegraph Avenue, Berkelt’’ 5, California.
Fin. 2
F1IACTURES OF THE HUMERUS 1383
Vol.. 45-A, NO. 7, OCTOBER 1963
humerus ;instead, alomig InoIst of its course, it is sepalate(l fromii the humerus by from
one to five cent.inieters of niuscle, the a\’eIage thiickmiess of the muscle beiiig 3.4
centimeters. The nerve lies close to the inferior lip of the spiral graove, i)ut not in the
groove. l’or (lilly a short dist.mtmice near the lateral supracondylar ridge is the nerve
iii direct contact with the humerus, and it is in this au’ea that the nerve pierces the
lateral int.ermusculau’ septum before passimig On to the surface of the brachialis
niuscle. Froni our anat(Iniical dissections, the nerve has least ni(Ibihity at this point,
amid, in our opinion, it is this lack of niohility that is a prime factor contrihuitiuig to
the nerve imijuu’y in fractures of the hunierus at this level.
The following case reports are recorded to call attemition to the importance of
u’ecognizimmg this fracture syndronie taxi the mieed for open reduction to avoid further rlmini’ige to the nerve.
Case 1. Lateral 9.11(1 amit(’m’t)posterior roemltgemmogranls slmo t’pit’al lrao’t tire. Note t’hiarao’to’ristic features: its locat.ioui in the distal omi(’-t.hird, its spiral t’oiltour, an(! tiio’ radial (leviatioin oil the 1)roximnal eli(1 of the (listal lragnemit.
Seveui typical fractures vei’.’ collected, four tu’e;uted by us and three seeui in
consultat.ioui for the Uuiited States Navy (A.Il.). Iii an eflolrt to determuitie the
frequency of this particular syndrome, 341 coiisecuiti\’e fractures of the shaft. (If the
hunierus at one private hospital weu’e also reviewed. ( )f these, 1 93 weme in the proxi-
mal third of the shaft of the humerus, sixty-three iii the niid-port ion of the humerus,
aiid eighty-five iii the distal portion of the humuerus. Of this ‘hole group, six had
associated radial-imerve illvolvememlt, mm incidemice of 1.8 per (emit. Five of the six
‘ere displaced fract tires (If the type w’e are describing. The other ‘as a fracture iii
the niiddle third of the humerus. This case is presented here merely to illustrate
how’ this fracture differs froni the symidrome we are describing (Case 8). The low’
incidence of radial-nerve involvenient in this series is of interest in view of the receuit
study by t.he Pennsylvamiia Orthopedic Society, iii w’hich radial-nerve imivolhvememmt.
Fw. 3
1384 AII’rHITR HOLSTEIN AN1) G. B. LEWIS
THF: JOURNAL OF B0NF: ANI) JOINT SURGERY
w’as found iii 12 1e1’ ccitt. of a large series of mid-shaft hutueral f’i’act.ures.
Case Presentations
CASE 1. A. P., a woman fifty years old, was thnowmi against the side of the can imi an automobile
accidemit and expeniellced su(Ideli severe pain in the night arm. On admissiomi, a diagnosis of fracture
the humerus with nadial-uienve paralysis was made.
At operation, tue distal fnagmeuit of the humerus had impaled the radial mienve omiit.s shiarp tip at the 1)oint. where the nerve passes from the I)ostcnior comnpantmemit., through the intermuscular
septum, into the antenion compartment (Fig. 2). The nerve was freed from the b)one fragment and
displaced laterally to this distal lnagmeuit.. The fracture was reduced and fixed with two screws
placed transversely across the fracture line. A palm-to-axilla plaster cast was applied. Alter dis-
charge from thie hospital, t.he patient transferred to another area for follow-up cane. No further
imifonniation isavailable.
(;tst 2. Failuro’ t.ti achieve l)roP(’r aligmimuent muui (‘omit.at’t. (if the frao’t.um’o’ surf;u’es liv O’l(ist’d ml’i;Lmiil)tllat.iO)mi suggo’st 5 iuit.enl)osit.ion oil the l’aolial no’rv(’ nut! m’o.’lat.ed soft. tissomo’s.
C.sE 2. (;. \\‘., a miitili, thirty-six years old, \.(5 injuro(1 wla’mi his oar strtick a tree. lit’ llad
i1llIlie(iitt(’ 1)ttimi iii Ins left. arm above the elbow’, nianked paimi in thie left pant of his chest amid b)ack,
i100l 1)aIl ill thit’ right shioiui(ler area. I’hi(’atlmnittimig diagmioaoes Opeli o’oll’imllinut(’(! lrao’ture of the
distal t’mid of t.hio’ loft litllllerus with ntdial-mierve l)aresis ; lract.urt’s of the s(’t’on(I thirough tue eighth ribs ott t.ii(.’ right. ; amid (‘OIliflhillute(! frao’tures of the t.hir(l through eighth ribs 0)11 the left with a Ilitil o’hest. ali(l IL lnao’tum’eo! right s(’apula.
Imiit.ialiy, there s’as oiily slight restriction of extension 0)1 the fingers at the mfl(’ta(’arpophlalami-
goal jo)ilit.s amitl oil the wrist. on the left with (liffuse hypesthesia to light. touch throughout. the left
hamiol, especially on its (lonsonadial aspect. Since the chest injury took l)reo’(’denco’, at first omily
ol#{233}linitlememit. 0)1 the wound in the arm was done with immliol)ilizatioli of the hitimeral fracture imi a
iialmii-t.o-axilla plaster tast. Re(’hleck of the fingen-wnist movements less thian tweuity-foun holuns after injury showed complete loss of do)rsiflexion of 1)0th the wrist and the fingers.
At operationi filt4’eii days after the injury the proximal portion of the radial nerve was freed and traced (‘aro’lullv int.oI the distal pant of thio’ arm. The mit’rve was completely enmeshieti in the fibrous
tissue around the fracture. The nervo’ was in c’omitinuitv :amioi, alter hit’imlg disset.’tt’oi free from its
fihrouis tissue 1)001, it. was displat’ed laterally aual the fracture of the hiumo’rus was reduced and
fixed by means of a plate and four screws.
FRACTURES OF THE HUMERUS 1385
One of the factons to note here was the failure to obtain apposition of the fragments after initial
d#{233}bnidement and immobilization in a plaster cast (Fig. 3). This should have suggested that the
nerve was interposed between the fragments as was also the situation in Case 5. Three months
after operation activity of the extensor carpi returned and five months after operation full finger
extension was noted. Full return of powerful finger and wrist motion was noted at eight months.
The only residuum at one year was slight hypesthesia in the anatomical snuff box.
CASE 3. M.W., a woman, fifty years old, fell in hen bathtub, landing on hen left arm. She reported immediate pain and gross deformity of the left arm, but remained at home for twenty-
four hours. At that time examination revealed a spiral fracture of the shaft of the distal part of
the humerus with complete paralysis of motor and sensory components of the radial nerve. At
operation forty-eight hours after the injury, the distal humeral fragment was immediately visible
in the proximal end of the wound. The tip of this fragment had pierced the muscle and come out
through a rent in the fascia into the subcutaneous tissue. Immediately in evidence, just medial
to the distal fragment and lateral to the proximal fragment, was the radial nerve. A definite con- tusion of the nerve at the level of the fracture line was visible. The nerve was resting between the two fragments of bone at the point where it would normally have pierced the lateral septum.
The nerve was removed from its position between the two ends of the fracture and was displaced
to the radial side of the distal fragment. The fracture was then reduced and held by two screws.
There was return of muscle function in the fingers and wrist five months after surgery, with
persistent hypesthesia in the anatomical snuff box and a tingling sensation in the same area.
CASE 4. LW., a man, thirty-three years old, was working on a scaffold on a bridge when he fell twenty feet, sustaining an open comminuted fracture of the left humerus with complete
radial-nerve paralysis. He also fractured his night clavicle. Initially the wound was debrided and
a light plaster cast was applied. The wound became infected and drained. Exploration of the
fracture site was delayed for three months.
At operation it was found that the nerve was severed and displaced to the medial side of
the distal humeral fragment, where it was bound down in marked scar tissue. The nerve ends
were identified and repaired by end-to-end suture after cutting back the nerve ends to satisfactory
nerve tissue. This repair was done under moderate tension.
The return of some dorsiflexion power of the wrist and sensation was first not(’(! seven months following the nerve repair.
CASE 5*#{149}C.G. (U.S.N.), a man, twenty years old, broke his left arm while plmLying football.
The extremity was immobilized in a splint and two days later he was transferred from a naval
dispensary to a hospital. On admission there was barely demonstrable weakness of wrist and
finger extension on the left side. There was hypesthesia in the distribution of the radial nerve.
The fracture of the humerus was manipulated and held in a plaster sugar-tong splint. l)uring the
next ten days, while the arm was immobilized in this splint, the radial-nerve weakness gradually
increased, and numbness in the region of the anatomical snuff box in the left hand developed.
At operation the radial nerve was traced upward and found, with mu l)Ortion of muscle, to
rummi right through the proximal portion of the fracture cleft. The nerve wmt.s freed up to the point
where it passed through the intermusculan septum, then the hole through this was enlarged to
let the nerve slide free. The intenl)osed tissue was removed from the fracture site, and the fracture
w’as reduced anatomically and held by means of two screws and a plaster cast.
CASE 6. C.K. (U.S.N.), a man, twent.--three years old, while working mtboand a tug, stis-
tahied a comminuted fracture of the distal third of the shaft of the humerus when he fell into the
water (Fig. 4). Wrist-drop was noted on admission to the hospital on the day of the accident.
A Kirschnen wine was placed through the olecranon, and the arm was then placed in balanced
traction. Electromyognaphic studies done six days later showed no activity in motor units sup-
plied by the radial nerve.
On the ninth day after the injury the fracture in the distal part of the night humerus was
explored and the radial nerve was found to be contused over a distance of about one and one-half
inches at the level of the fracture site but to be grossly intact. Injecting sterile saline solution
into the nerve revealed the neunilemmal sheath to be intact. Accordingly the nerve was removed
from the fracture site, and the fracture was reduced and held with two screws. Muscle tissue was
placed between the radial nerve and the fracture site. An axilla-to-palm plaster cast was applied
after wound closure.
CASE 7. W.B. (U.S.N.), a boy eighteen years old, in an automol)ile accident, sustained mm.
* Navy personnel transfer to their home area and we are unable to obtain follow-up.
VOL. 45-A, NO. 7, OCTOBER 1963
1386 ARThUR HOLSTEIN ANI) G. B. LEWIS
THI’ JOURNAl. OF BONE AN1) Jt)INT SURGERY
cOI’i’illiimititt’t! lrat’t tir(’ oil the shalt of the right hunerus in the (listal tliirol with t’omplete loss of
nali:tl-mio’rvo’ lumictiomi, ami oien (‘omillfliliut(’(I fracture of thio’ left tibia, :011(1 a closo’d fnacturo’ of the
night littoral niallo’olus. Initially a plaster sI)hint. was used for the lrat’ttired humerus. This was
t’hangt’ol to a hamigimig plasto’r cast. Hot’mitgetiograms thit’n revo’alo’d that, thit’ bone cIldS w’o’rt’ mioit in o’oimitact. Tho’ro’ \VIO5 110 retunmi oil radial-mierve lunt’t ion olurimlg t he first loitir vo’o’ks afto’r Iract tire.
.-t opo’rat ion twentv-nimie olays alter illjtu’v, the mio’rve was found to lit’ approxinlatt’ly 90
iier tent. st’vo’ro’ol at t he frao’t uro’ site wit hi omd’ a t hiin tenuous I iamid o’omlne(’ting the two ends.
‘iho’ no’m’ve (‘miols t.raiipo’tI in tho’ fibrous callus at t ho’ fracture sito’. The emitls of t ho’ miervo’wore
lreshio’no’ol amiol ai iliroximnato’o! wit hi (100000 silk stit uro’s.
The fract tilt’ \V’IS iIlillloiliiliZt’Ol imi a plaster cast. ()ne muointh lato’m’ tlie tiatiemit fell wit 11ro’(’un- rent’t’ oil pain at the lracttmi’o’ sito’, mit. miti o’hiango’ imi 1ioisititill of the li’ao’t.tire. Cont.imiuo’d illimo- bilizatioii nesult(’ol in bono’ umiitin. When the patio’nt was l:tst seen, t hero’ bat.! Iit’en miti rt’turn oil nerve ftmnctiomi. Noi follow-imp was possihilo’.
Fit;. 4 Fin. 5 Fit;. (1
l”iti . 4 :(:tso’ 6. (‘OimliIliiillite(l fract uro’ with t lIe thiird lragmiit’mit o!isplat’t’t! nlo’(iiallv and the (list mol fragnit’mit ill tlie t’li:tm’:tct.t’ristic lioisit.ioin ‘it Ii o)v(’rnithng amid ratlial (1o’viatioiml oil its tiroximal end.
Fig. 5: ( )l 34 1 frao’t tires of the humno’ral shalt this was thit’ oimily fracture unit imi the distal omie-tliind vliio’li assoo’iato’o.l ‘it h .iar’sis oil tlie radial nerve.
Fig. 6: Fixation oil a sinil)le sPinal lrao’turt’ with twoi so’ro’ws alto’r r(’nioival oil t he mio’rve from the lrao’turo’ sito’.
( ASE S. ‘1. \Io’L., a hot’ filteemi old, stist :i.imiod a spil’al fr:n’t out’ in the’ mnioldlo’ oiie-third oil the hiunio’rus \it hi inj um’y to t.hi(’ radial mio’rve causimig loss of semisatioml (iii the (lorsum of the hiamio! betwt’ Ii t lit’ first and secoii(! illt’taca.m’lials l)ut no mtmst’lo’ weakmiess (Fig.5). A hanging plaster cast was applied. ( )mi t lit’ follolwing t!av, it \s.:ls mlote(! t hat t hio’patient was timial ile to extemiol thie thiumiib amid thit’ fimigers fulls’ at thit’ mo’tao’arioiphalamigeal joiints. ( )mi the tenth day folloiw’ing the inj un’, with mioi ao!o!itional treatmemit , tho’ro’ was o’vio!(’mi(’e 0)1 ro’ttmrmi of rao!ial-mio’rvo’ luma-tion. The pat io’nt condo! again t’xto’nd t ho’ thunili ant! fingers, am! semisatioin ha! m’o’ttmrno’t!. ‘1 here was liii!
ret urn oil rao!ial-nem’vo’ ltimit’tiomi o!um’ing immiiobilizat loin ill tilt’ iilast en cast.
Ihis ease is mnemiti(Ined merely to illustrate w’hat is hot fliemtiit hW t.hie syndrome
lihi(I(I (‘0)iisi(l(’i’ltiOu 1. Aliioiig 34 1 humueral fract tires this was the ooily (nie wit in the
distal oiie-thiird which ‘as associ:tt(’ol w’ith imijuirv tti thie radial iierve,
FRACTURES OF TFIE HUMERUS 1387
VOL. 45-A, Nt). 7, O(’TOBER 1963
Discussion
Iii this fracture syndronie, there are certain factors which do iiot vary. Ihe
fracti.ire is always in the distal one-third of t.he humerus; it is spiral with radial mtiiguiatioii mit. the fi’acture site and overriding of the distal fragmeiit; and there is
involvement, of the radial nerve, both sensory and niotor coinipomiemits. The (lilly part
(If the symidromue that varies is the degree of involvement of the nerve; t.his involve-
nieiit varies from contusiolil to colmplete severance. The degree of traumua must. be
melutively violent, and thiere must l)e definite displacement (.)fthe fragments of the
shaft. of the humuerus as a result of the iiijum’y ifmierve damage is to occur.
In a nun’li)er of these fractures, an initial closed re(luctiomi was attempted ; iii
t.w’o, muniore profi lund radial-nerve pai’alysis resulted. Iloen t genograms, made after
Fmt;. 7
Fixat ioimi (if It im’ao’t tilt’ it hi a plato’ a mioI loutim’ so’m’t’vs. Hem’o’ t’OIl’in)imlut iou mli:tt!(’ st’t’tirt’ strew’ fixat ioin imiil)ti)’sililt’.
IliuiiipIilmtti()hi, revemtle(1 that the frmtgmuents \veme beimig held apmimt )i’e5uflimth)ly by
iiitei’positioii (If Soft tissue. All the fractures -ere eveiitually treated surgically,
amid the interl)ose(l soft tissu(’ w’as imivarimibly fouiid to imichide the ra(hmil nerve, sonietimues toi the extent thmit the mierve ‘as surrounded h)V early callus h)etweeii the bone (‘lids.
On the basis of uur experience, we strongly advise mtgmuimst attempted closed
reduction of fractures ouf the distal one-third (If the hunierus with (lemiiomistrable
radial-nerve p:u’esis. \Ve reeonimiiemid primary open reduction throughi miii muit ero-
lmuteral approach. The mierve should be located, dissected free, mlii(l displmtced lmit.ermilly
to the distmil frmignient. The fracture should then be reduced; and, because of its
spirmil ehmurmtcter, it cmiii usumully be satisfactorily fixed by two screws plmuced acm’ss the
frm.ucture. When there is sufhciemit coiiimiiinution to iuake simple screw fixmut ion not
satisfactory, a light btliie plate with four screws can be used. A very light, pmulm-to-
1388 ARTHUR HOLSTEIN AND G. B. LEWIS
axilla hanging plaster cast is used for external immobilization (Figs. 6 and 7). The
optimum time for nerve repair, the best method for repairing the radial nerve, and
the treatment of permanent weakness of the wrist and finger extensors are not the
concern of this paper. We wish only to emphasize that the rmtdial nerve is frequently caught between the fracture surfaces in this readily recognized fracture muiid hence
likely to be damaged either at the time of imijury or during treatment.
Summary
This paper presents seven cases illustrating a humeral-fracture syndrome corn-
plicated by radial-nerve paralysis. The fracture occurs in the distal one-third of the
humerus at a point where the radial nerve comes through the lateral int.ermuscular
septum and is in contact with the bone. Due to the force of the injury, the proximal
fragment is displaced distally, carrying with it the intermuscular septum and the
rmudimtl nerve contained within its foramen in the septum. At the same time the apex
of the distal fragment is moved proximally and radially, lacerating or trapping the
radial nerve between the bone fragments. Primary open reduction is the treatment
of choice for this injury. Closed maiiipulation is contra-indicated when the criteria of the syndrome are present.
References
1. CUNNINGHAM’S Text-Book of Anatomnv. Ed. 9, pp. 253, 490, 1081. Edited by J. C. Brash, New
York, Oxford University Press, 1951.
2. MoRRIS’ Human Anatomy. A Complete Systematic Treatise. Ed. 10, lP 198, 440, 1 106. Edited
by J. P. Schaeffen. Philadelphia, The Blakiston Co., 1942.
3. 1ENNSYLVANIA ORTHOPEDIC SoCIETY, SCIENTIFIC RESEARCH COMMITTEE: Fresh Midshaft
Fnmm.ct.ures of the Humerus in Adults. Evaluation of Treatment during 1952-1956. Pennsylvania Med. J., 62: 848-850, 1959.
4. \VHITSoN, R. 0. : Relation of the Radial Nerve to the Shaft of the Humerus. J. Bone amitl Joint
Sung., 36-A : 85-88, Jan. 1954.
DISCUSSION
l)mu. BLAND W. CANNON, MEMPHIS, TENNESSEE: Discussion of this presentation from a
neurological surgeon necessitates the assumption that the method of treatment of fracture of the
humerus, with radial-nerve impairment, depends on the integrity of the nerve. We accept this
compliment, for we know that you, as onthopaedsts, are aware of singularities of this nerve
vhiich allows mm.favorable result ultimately, regardless of the method of treatment.
Fortunately, the usual sequelae of trmm.umatic neuritis and other painful syndromes in nerve
injury are esemupeol because of the insignificant sensory component of the radial nerve. Repair of
this lacerated or divided nerve usually yields retunni of function to all muscles of its domain.
Not infrequently, near normal neurological status is obtained.
The crucial anatomical location for radial-nerve injury in fracture of the humnerus is mis I )n.
Holstein alld Dr. Lewis have designated. However, the decision to effect prompt opemi reductiomi
should not be based on the existence of nerve paralysis. If severance of the nerve has occurred,
the immediate post-injury period is not the optimum time for nerve repair. If contusion, without
laceration, is found on inspection of the nerve, only limited constructive information has been
gained. A lapse of time is almost necessary in evaluating the functioning status of the nerve. The
application of our neurophysiological on electrodiagnostic aids, such as electromyognaphy, is
usually impractical during the two weeks immediately following this type of traumatic nerve
paralysis. The significant exception to our advised delay is illustrated by two of I)n. Holstein
and Dr. Lewis’ cases, in which a more profound paralysis followed closed reduction.
If you produce or increase paralysis by manipulation, proceeding with surgical visualization
and decompression of the nerve is wise.
Of the three cases depicting severance of the nerve, the lapse of fifteen days, twenty-nine
days, and three months, respectively, before surgical attack probably improved t.he chance of
successful nerve repair and neurological recovery.
A delay in nerve repair of approximately fifteen days fmtcilitates mt more accurate determina- tion of the area of viable nerve in the contused mind damaged proximal and distal trunks. Also,
a suitable bed for protection of the sutured nerve can be assured. Such factors are of primary
importance in obtaining the best results. Otherwise, evidence favors the assumption that the
(Continued on paqe 1484)
THE JOURNAL OF BONE AND JOINT SURGERY
1484 H. S. UNGER, L. H. SCHNEIDER, AND JOANNA SHER
2. HINES, L. E.: Compression Myelitis Secondary to Echinococcus Disease of Vertebrae and
Kidney. Arch. Pathol. and Lab. Med., 1: 180-181, 1926.
3. HOWORTH, iI. B.: Echinococcosis of Bone. J. Bone and Joint Simng., 27 :401-41 1, July 1945.
4. HUTCHISON, W. F.; THOMPSON, W. B.; and DERIAN, P. 5.: Osseous Hydatid (Echinococcus)
I)isease: Report of an Indigenous Case. J. Am. Med. Assn., 182 : 81-83, 1962.
5. MILLS, T. J.: Paraplegia Due to Hydatid 1)isease. J. Bone and Joint Surg., 38-B : 884-89 1,
Nov. 1956.
6. RoBINsoN, R. G.: Hydatid Disease of the Spine and Its Neurological Complicmotions. British
J. Sung., 47: 301-306, 1959.
DISCUSSION
FRACTURES OF THE HUMERUS
(Continuedfrom page 1388)
degree mond rate of mmenve recovery after sutunimug is moot influemoced by lemigth of time between
iiijilry 1010(1 operation.
We know of no cmose of fracture of the humerus imu whuich reai)pnoximation of a severed radial muenve could not be effected, providing no avulsion or tissue loss occurred.
Thus, a neurosurgeon might suggest postponement of the chosen open reduction for at
hemost that period of time necessary to create a more desirable approach to correcting nerve dys- fulictiolu.
REFERENCES
01-1-oSITI0N OF THE THUMB AN1) ITS RESToRATIoN
(Continued front page 1396)
9. NICULAYSEN, JOHAN: Tramusplant:otion des M. abductor (jig. V. bei Fehiender ()ppositioio F’bhig-
keit des I)aumens. l)eutsche Zeit.schn. f. Chin., 168 :133-135, 1922.
10. ROWNTREE, ToM: Anomalous Innervation of the Hand Muscles. J. Bomie timidJoint Sung., 31-B:
505-510, Nov. 1949.
11. SABATIER, R. B.: Trait#{233} d’Anatomie. Paris, 1764.
12. ScHorrsTAEoT, E. It.; LARSEN, L. J.; and BOST, F. C.: Complete Muscle Transpositiomu. J.
Bone amid Joint Sting., 37-A :897-919, Oct. 1955.
13. SUNDERLAND, S., and HUGHES, E. S. It. : Metrical and Nomu-Metnical Fetotunes of the Muscular
Branches of the Ulnar Nerve. J. Comnp. Neunol., 85 :1 13-123, 1946.
14. THOMPSON, T. C.:A Modified Operatioli for Oppomoens Paralysis. J. Bomie 911(1 Joint Sung., 24:
632-640, July 1942.
REFERENCES
THE Os ODONTOIDUEM
(Continuedfrom page 1471)
13. PENnERGRAsS, E. P.; SCHAEFFER, J. P.; and HODES, P. J.: The Head arid Neck in Roentgeli
l)iagmuosis. Ed. 2, pp. 1529-1530. Spnimugfield, Illinois, Charles C. Thomas, 1956.
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Neighbourhood of the Foramen Magnum with a Note on Surgical Approach. Brain, 60 : 52-84, 1937.
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THE JOURNAL OF BONE AND JOINT SURGERY
