439

The Role of Stretch VARUS DEFORMITY OF THE ELBOW

I do not intend to suggest that stretch plays no part in FOLLOWING SUPRACONDYLAR FRACTURES OF
the production of strise gravidarum. It does. The best THE HUMERUS IN CHILDREN
evidence for this is the unilateral appearance of strise
P. R. FRENCH
around previous F.R.C.S.
gridiron abdom- FIRST ASSISTANT, DEPARTMENT OF ORTHOPÆDICS,
inal incisions. ST. GEORGE’S HOSPITAL, LONDON, S.W.1
Primigravidse who A GUNSTOCK or varus elbow is the commonest late
have such scars,
deformity in supracondylar fractures of the humerus
and who are des-
(fig. 1). It is usually caused by failure to correct the rota-
tined to develop
tional displacement of the distal fragment. Madsen
strix, always get
their earliest strix (1955) has again emphasised the need for exact reduction
in the treatment of these fractures, and has reiterated the
near the scar, al-
views of Windfeld (1948) and others of the importance of
Fig. 5-Early striae gravidarum appearing though it may be rotational
at each end of an appendicectomy scar 2 or more weeks displacement as a cause of late deformity. That
(primigravid pregnancy of 30 weeks). internal rotation is part of the established deformity is
before symmetri-
shown by the fact that a gunstock elbow is almost always
cal strix appear.
This observation accompanied by an apparent increase in internal rotation
of the shoulder when the flexed elbow is used as a lever.
suggests strongly As Madsen says, internal rotation is the most difficult
that the distorted
skin tensions displacement to reduce and to hold reduced.
around the scar Correction of the Fracture
play their part in Internal rotation of the distal fragment may be recog-
the formation of nised radiologically when it is not apparent on clinical
strise (figs. 5 and examination. The anteroposterior radiograph very fre-
6). Many women,
Fig. 6-Striae gravidarum alongside an not destined to
appendicectomy scar in a primigravid
pregnancy of 34 weeks. Note absence of
develop strix, go
striae the left. At 38 weeks, in this
on to term without
case, there were extensive bilateral strie. strix despite their
scars.
It seems reasonable to suggest, therefore, that skin
stretch and the " striae factor " are both required for the
production of strix, and without the latter no degree of
stretch will produce striae.
Summary
Striae gravidarum should no longer be considered as
" stretch marks ". There is strong evidence that they are
closely related to adrenal cortical hyperactivity.
In a study of 116 primigravid pregnancies it was shown
that: quently shows that the supracondylar ridges on the upper
The formation of strix gravidarum does not depend directly
fragment are of unequal length, the internal ridge com-
upon skin stretching; this only influences the production of
monly being longer than the external (figs. 2 and 3). The
"
strix in the presence of a striae factor ".
lateral radiograph then shows that the longer spike of
There is a close relation between lowered glucose tolerance in the upper fragment is pointed forwards (figs. 2 and 3).
late pregnancy and the development of strix gravidarum. Provided that the lateral radiograph is correctly centred
There is a close relation between acne, a sign of adrenal on the elbow-joint, the forward direction of the spike of
cortical hyperactivity, and breast striae, particularly as regards the medial supracondylar ridge indicates that the shaft
time of onset. of the humerus is externally rotated, and this results in a
Several other clinical findings all lend support to an relative internal rotation of the lower fragment.
association between strise gravidarum and adrenal cortical
Fig. 3 illustrates how the persistence of internal
hyperactivity. rotation gives rise to the gunstock deformity; the lateral
Olive-oil massage does not prevent strise gravidarum.
The substance of this paper was included in a thesis accepted by part of the lower fragment becomes hitched and reduced,
the University of Adelaide for the degree of M.D.
I am grateful to Sandoz Ltd., Australia, for defraying the total DR POIDEVIN: REFERENCES—continued
expenses of this study. Greenhill, J. P. (1955) Obstetrics. Philadelphia.
Holland, E., Bourne, A. W. (1955) British Obstetric and Gynæcological
REFERENCES Practice. London.
Albright, F. (1943) Harvey Lect. 38, 123. Jailer, J. W. (1956) Bull. Sloane Hosp. Women, 3, 82.
Appel, S. B., Gluck, J. L., Schlecker, A. A., Miller, A., Reichman, S., Jeffcoate, T. N. A. (1957) Principles of Gynæcology. London.
Springer, C., Goldman, A., Rosenbluth, M., Kupperman, H. S. (1953) Migeon, C J., Bertrand, J., Wall, P. F. (1957) J. clin. Invest. 36, 1350.
Acta endocr., Copenhagen, 14, 99. Moore, F. C. (1908) Practitioner, 81, 397.
Browne, F.J., Browne, J.C.M. (1955) Antenatal and Postnatal Care. London. Parkes Weber, F. (1905) Med. Pr. 130, 261.
Burns, T. W., Engel, F. L., Viau, A., Scott, J. L., Hollingsworth, D. R., Persky, M., Linsk. J., Isaacs, M., Jenkins, J. P., Rosenbluth, M., Kupper-
Werk, E. (1953) J. clin. Invest. 32, 781. man, H. S. (1955) J. clin. Endocrin. 15, 1247.
Conn, J. W., Louis, L. H., Wheeler, C E. (1948) J. Lab. clin. Med. 33, 651. Robinson, H. J., Bernhard, W. G, Grubin, H., Wanner, H., Sewekow,
Eastman, N.J. (1956) Williams’ Obstetrics. New York. G. W., Silber, R. H. (1955) ibid.p.317
Evans, E.L. (1915) Proc. R. Soc. Med. 8, 230. Rolleston, H. D. (1908) Brit. med. J i,494.
Forsham, P. H.,Thorn, G.W., Prunty, F. T. G., Hills, A. G.(1948) [Link]. Selye, H. (1946) J. clin. Endocrin. 6, 117.
Endocrin. 8, 15. Sibley, W. K. (1923) Proc. R Soc. Med. 17, 44.
Gold, J. J. (1957) ibid. 17, 296 Sisson, W. R. (1954) J. Pediat. 45, 520
Venning, E. H. (1946) Endocrinology, 39, 203.
References continued at foot ofnext column Wilks (1861) Guy’s Hosp. Rep. 7, 297.
440

ported by the other hand. Moreover this position may pre-

dispose to redisplacement after reduction, and the corrected
deformity would therefore seem to be more easily maintained
at extreme flexion. Sir Robert Jones’ principle was to put up
the elbow "at five minutes past the hour ", or as much flexed
as was consistent with an easily palpable pulse. One disad-

vantage of this is the delay in attaining full extension of the

while the medial end remains behind the long spike of

the medial supracondylar ridge. This rotational dis-
placement further accentuates the varus deformity, for
the inner border of the humerus is now shorter than the
outer.
Manipulative correction may be modified on the basis
of this observation.
The fracture should be reduced under radiographic control;
elbow, so that the varus deformity may not be appreciated
once it has been found that the fracture requires reduction the
child may be spared the discomfort of much radiography until for six months or a year. The presence of varus may be sus-
anaesthetised. Traction is applied with the elbow flexed and the pected, however, if radiography shows that the internal
forearm pronated, countertraction being supplied by an rotation has not been corrected or maintained.
assistant holding the upper arm and attempting to keep the Late Correction of the Deformity
humerus in neutral rotation. Lateral shift of the distal frag-
ment is first corrected, and then rotation of the lower fragment,
Once fully developed the gunstock deformity does not
using the forearm as a lever. Posterior angulation is then improve. Although, as Attenborough (1953) points out,
abolished by pressure of a thumb on the olecranon and considerable remodelling of the lower end of the humerus
increasing the flexion of the elbow. Fig. 4 shows how it is takes place, this af-
possible to overcorrect the angulation; the longer spike of fects the anteropos-
the medial supracon- terior displacements
dylar ridge is now point- and angulations
ing backwards, indicat- without altering the
ing that the lower frag- varus angulation or
ment is externally rota-
the internal rota-
ted, for the radiograph
is still correctly centred tion. The deform-
on the elbow joint. ity is very unsightly,
Fig. 5 shows the same and, although joint
elbow after correction function may not be
of the external greatly impaired,
rotation. the child’s parents
The internal rota-
tion may be caused im-
usually request an
mediately by the nature
operation, if mainly
for cosmetic rea-
of the fall, and perpet-
sons.
uated by the position in
which the arm is held The correction is
after the injury-i.e., done by means of
a wedge osteotomy,
acrosstheabdomensup-
 441

My thanks are due to Mr. B. H. Burns and Mr. R. H. Young for

permission to use their cases and for their help and encouragement.
I am also grateful to the photographic department of St. George’s
Hospital for the clinical photographs and reproductions of the
radiographs.
REFERENCES
Attenborough, C. G. (1953) J. Bone Jt Surg. 35-B, 386.
Jones, R. (1904) Clin. J. 25, 17.
Madsen, E. (1955) J. Bone Jt Surg. 37-B, 241.
Windfeld, P. (1948) Ugeskr. Lœg. 110, 370.

ATROPINE IN MONGOLISM
J. M. BERG M. W. GILLIAN BRANDON
M.B. W’srand, [Link]. Cape Town B.A. Lond., [Link].
CLINICAL RESEARCH FELLOW RESEARCH PSYCHOLOGIST

BRIAN H. KIRMAN
M.D. Lond., D.P.M.
CONSULTANT PSYCHIATRIST

FOUNTAIN HOSPITAL, LONDON, S.W.17

McKusick (1957), writing on genetically determined
"
drug idiosyncrasy, posed the question: What is the basis
for the not infrequently fatal idiosyncrasy of mongoloid
idiots to agents of the atropine group ? " Professor
McKusick tells us that this knowledge of the sensitivity of
mongol children to atropine is a " local pearl " at the
Johns Hopkins Hospital, and that he has been unable to
find a published reference to it. We have from time to
time used atropine as preoperative medication in mon-
golism, and we have found no ill effects. Nevertheless, in
view of its potential importance, we investigated the
reaction of mongol children to atropine.
Method
the triangular wedge having its base on the lateral supra- Two trials made; in each there was a group of
were
condylar ridge. In the past the operation has been not ten mongols and of ten mentally defective controls,
without hazard, and the osteotomy has been found diffi- matched for age, mental level, mobility, and general
cult to control. The following procedure gives a good health. Cripples and children with obvious motor lesions
, exposure, robs the operation of some of its dangers, were excluded. All the children were inpatients at the
provides a method for satisfactory control of the osteo- Fountain Hospital. Different patients were used in the
tomy, and allows of earlier mobilisation of the elbow: two trials.
The lower end of the humerus is approached from the back One drop of atropine 1 % was instilled into the right
through an incision splitting the triceps. The lateral half of eye of each child. The eyes were examined in natural
the triceps is detached from its insertion and reflected upward.
By this means, the posterior surface and lateral border of the
daylight 15 minutes later, and then daily until the pupils
humerus can be seen. The ulnar nerve can also be displayed became equal in size. Any difference in dilatation of the
on the medial side. Two drills are inserted which can act as pupils was scored on a three-point scale, + + + repre-
guide to the plane of the desired osteotomy and their position senting a maximal difference.
is checked by radiography (figs. 6-8). Before the bone is cut Permission for the trial was sought from the mothers of
across, two screws are inserted above and below the guides the controls. It was pointed out that the drop of atropine
and parallel to them.
The wedge is then excised: the bone is cut across with a TABLE I-DEGREE OF DILATATION OF THE PUPIL 15 MINUTES AFTER
INSTALLATION OF ATROPINE
mechanical saw as far as possible, but the inner periosteum is
left intact as a hinge. The cut surfaces are then approximated
by tightening a wire connecting the heads of the two screws
(figs. 8 and 9). This may be done most easily by threading
the wire through a small hole in the neck of one of the screws
before full insertion, and round the neck of the other screw.
Further insertion of the first screw will then tighten the wire.
The rotational deformity is corrected at the same time by
placing the screws in different positions in the coronal plane
(figs. 8 and 9).
Summary
Cubitus varus following supracondylar fractures of
the humerus in children is usually caused by internal
rotation of the distal fragment.
This displacement may be recognised radiologically
and can be treated by manipulative reduction under
radiological control.
The established gunstock deformity may be corrected
by a wedge osteotomy with internal fixation by screws.