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Pediatric Hand Therapy, 1e 1st Edition Joshua M. Abzug
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Preface
Fractures about the elbow are extremely common in the pediatric and adolescent populations. However, many clinicians find them to be quite challenging to diagnose and accurately treat due to the complex nature of the elbow as well as the developmental anatomy of a child’s elbow. The aim of this comprehensive book focused on pediatric elbow trauma is to provide the clinician with an understanding of the developmental anatomy of the child’s elbow as well as to familiarize the clinician with the various injuries that occur.
Each chapter highlighted in this book covers the necessary information to accurately diagnose and treat pediatric elbow fractures. Numerous radiographic images will aid the reader in familiarizing themselves with the specifics of each fracture, while the indications for the various treatment modalities will aid in determining the appropriate treatment.
Baltimore, MD, USA
Joshua M. Abzug, MD Philadelphia, PA, USA Martin J. Herman, MD Philadelphia, PA, USA Scott Kozin, MD
Julio J. Jauregui and Joshua M. Abzug
2 Physical Examination of the Pediatric Elbow
Matthew Varacallo, Kush S. Mody, Darshan Parikh, and Martin J. Herman
3 Radiographic Evaluation of the Pediatric Elbow
Ryan Hoffman, John Prodromo, and Martin J. Herman
A. Russo and Joshua M. Abzug
Jonathan Klaucke and Joshua M. Abzug
Sania Mahmood, Karan Dua, and Joshua M. Abzug
7 Medial Epicondyle Fractures
Randle W. Ramsey and Martin J. Herman
Richard Chen, Michael Kwon, and Martin J. Herman
Scott H. Kozin 10 Proximal
Arun Hariharan and Joshua M. Abzug
Nicholas Grimm and Martin J. Herman
12 Pediatric Elbow Dislocations: Acute
Matthew Varacallo, Darshan Parikh, Kush Mody, and Martin J. Herman
William P. Hennrikus (Son), David G. Fanelli, Zachary P. Winthrop, and William L. Hennrikus (Father)
Francisco Soldado and Scott H. Kozin
Scott H. Kozin
Scott H. Kozin
Elbow Stiffness
Scott H. Kozin
Scott H. Kozin
Contributors
Joshua M. Abzug, MD Departments of Orthopedics and Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
Richard Chen, BA Drexel University College of Medicine, Philadelphia, PA, USA
Karan Dua, MD Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
David G. Fanelli, MD Geisinger Health Systems, Danville, PA, USA
Nicholas Grimm, DO Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
Arun Hariharan, MD, MS University of Maryland Medical Center, Baltimore, MD, USA
William L. Hennrikus (Father), MD Division of Gastrointestinal Surgery, Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
William P. Hennrikus (Son), BA Division of Gastrointestinal Surgery, Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
Martin J. Herman, MD Drexel University College of Medicine, St Christopher’s Hospital for Children, Philadelphia, PA, USA
Ryan Hoffman, BS, MD Department of Orthopedic Surgery, Albert Einstein Medical Center, Philadelphia, PA, USA
Julio J. Jauregui, MD Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, USA
Jonathan Klaucke, MD Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
Scott H. Kozin, MD Shriners Hospital for Children—Philadelphia, Philadelphia, PA, USA
Michael Kwon, MD Drexel University College of Medicine, St. Christopher’s Hospital for Children, Philadelphia, PA, USA
Kush S. Mody, BS Drexel University College of Medicine, Philadelphia, PA, USA
Darshan Parikh, BS Drexel University College of Medicine, Philadelphia, PA, USA
John Prodromo, MD Department of Orthopedic Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
Randle Ramsey, DO Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
Stephanie A. Russo, MD, PhD Department of Orthopaedic Surgery, University of Pittsburgh Medical Center—Hamot, Erie, PA, USA
Francisco Soldado, MD, PhD Hospital Sant Joan de Deu, Barcelona, Spain
Matthew Varacallo, MD Department of Orthopedic Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
Zachary P. Winthrop, BS Penn State College of Medicine, Hershey, PA, USA
Part I
Anatomy, Examination and Imaging of the Pediatric Elbow
Anatomy and Development of the Pediatric Elbow
Julio J. Jauregui and Joshua M. Abzug
Introduction
Trauma and injury to skeletally immature patients represent a common challenge to the orthopedic surgeon. Of these, injuries to the pediatric elbow are extremely common in children, representing from 15 to over 40% of all fractures observed in children [1]. Although relatively common, these injuries can be one of the most elusive to detect. Therefore, understanding the anatomy and development of the pediatric elbow will aid in the detection of fractures, even in their subtle form [2]. This chapter will discuss the anatomy of the pediatric elbow as well as its ossification development.
Background: Elbow Development
The elbow joint includes three types of articulations making it a complex joint. These are the ulnohumeral articulation providing a hinge-type
J.J. Jauregui, M.D.
Department of Orthopaedics, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 300, Baltimore, MD 21201, USA
e-mail: JJauregui@umoa.umm.edu
J.M. Abzug, M.D. (*)
Departments of Orthopedics and Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
movement, the radiohumeral articulation providing a pivoting movement, and the proximal radioulnar joint providing a rotational movement (Fig. 1.1). As opposed to simple joints, a complex joint, such as the elbow, can give way to more stress being placed on adjacent joints. While variations are seen in timing for every individual due to gender/race, etc., there is an
Fig. 1.1 Lateral radiograph of an elbow depicting the various motions about the elbow including flexionextension through the ulnohumeral articulation and forearm rotation through the proximal radioulnar articulation (Courtesy of Joshua M. Abzug, MD)
J.M. Abzug et al. (eds.), Pediatric Elbow Fractures, https://doi.org/10.1007/978-3-319-68004-0_1
J.J. Jauregui and J.M. Abzug
overall predictable pattern of ossification in the pediatric elbow [3, 4]. Between the ages of 6 and 12 months, the capitellum ossification center is visible on plain radiographs. Girls tend to have their ossification centers visible earlier than boys, and their physes may close anytime up to 2 years sooner than in boys. Although there is up to a 2-year disparity between males and females, the elbow ossification patterns are well known and follow the mnemonics described by Hansman, Garn, and Girdany [5–7]. The sequence of ossification follows the mnemonic word CRITOE, in which the first center to ossify is the Capitellum at a mean of 3 months, then the Radial head at 5 years, the Internal (medial) epicondyle at 7 years, the Trochlea at 9 years, the Olecranon at 11 years, and the External (lateral) epicondyle at 13 years (Table 1.1). In general it is thought that the fusion of the elbow growth centers is complete by 13 years of age in girls and 15 years of age in boys [8] (Figs. 1.2 and 1.3).
There are subtle variations by gender in which these ossification centers develop, whereas they typically develop sequentially in boys and more often do not develop simultaneously in girls. The capitellum fuses first with the trochlea and lateral condyle. Later in development, there is fusing of
the olecranon, radial head, and lastly the medial epicondyle. The closure of the medial epicondyle apophysis is the final growth center about the pediatric elbow to fuse, which typically occurs between 15 and 20 years of age, marking skeletal maturity of the elbow [3] (Table 1.1).
Motion
There are many studies evaluating the range of motion in pediatric patients with acquired or genetic conditions, but only a paucity of studies have described elbow range of motion in the nonpathologic pediatric elbow. A recent study by Barad et al. [9] recorded motion data on 1361 normal pediatric elbows. These patients had a mean age of 4.9 years (range, 1–16 years; SD, 2.6 years), with a mean weight of 47.5 lb (range, 12–183 lb; SD, 19.8 lb). The mean amount of flexion was 142° (range, 125°–155°; SD: 4.0°), and the mean extension was 11° (range, 35° to 0°; SD, 4.3°). The mean total arc of motion was 153° (range, 127°–175°; SD, 6.0°).
When stratified by gender, boys had a mean amount of flexion, extension, and total arc of motion of 141°, 11°, and 152°, respectively. Table 1.1
Fig. 1.2 Radiographs at various developmental ages demonstrating the progression of ossification. (a) AP and (b) lateral elbow radiographs of an 18-month-old child. (c) AP and (d) lateral elbow radiographs of a 3-year-old child. (e) AP and (f) lateral elbow radiographs of a 6-year-
old child. (g) AP and (h) lateral elbow radiographs of a 9-year-old child. (i) AP and (j) lateral elbow radiographs of a 12-year-old child. (k) AP and (l) lateral elbow radiographs of a 15-year-old child (Courtesy of Joshua M. Abzug, MD)
Fig. 1.2 (continued)
J.J. Jauregui and J.M. Abzug
Fig. 1.2 (continued)
Fig. 1.3 Schematic showing the various ossification centers about the elbow and their average age of appearance on plain radiographs (Courtesy of Joshua M. Abzug, MD)
Age for Ossification Pediatric Elbow
Medial epicondyle 6–7 years
Olecranon 10 years
Trochlea 8–10 years
Lateral epicondyle 11–12 years
Capitellum 1 year
Radial head 4 years
In girls, the mean amount of elbow flexion, extension, and arc of motion was higher, at 143°, 12°, and 154°, respectively (p < 0.01). Although significantly different, the authors concluded that these differences were not clinically relevant as they are all under 2°. The authors also described that the range of motion when plotted by age increased until 6 years for boys and until 8 years for girls; however these findings were not statistically significant. In contrast, a study by Golden et al. [10] analyzed the measurements of range of motion of 600 elbows from 300 children and concluded that the amount of elbow flexion correlated positively with age, whereas the amount of elbow extension did not.
Specific Development and Anatomy
Bony Anatomy
Three articulations make up the elbow joint. First, the distal humerus articulates with the ulna at the trochlea. The trochlea groove of the ulna articulates at the distal humerus’ medial articular end and is characterized by its rounded and grooved appearance. The trochlea groove of the ulna is composed of articular cartilage and is bounded proximally by the olecranon process and distally by the coronoid process. Flexion and extension of the elbow occur through this ulnohumeral or ulnotrochlear
J.J. Jauregui and J.M. Abzug
joint. This motion occurs in a single plane due to this hinged articulation. It is noteworthy to point out that the ulna fractures in a different pattern than many other pediatric and adolescent bones about the elbow, with fractures occurring in the metaphysis as opposed to about a physis [ 2 ].
The next articulation is the capitellum met by the radius’ concave head. The capitellum forms the distal humerus’ convex lateral articular surface. In this articulation, the proximal radius moves in relation to the distal humerus by a paired concavity and convexity, thus permitting a pivoting motion. The last articulation about the elbow is the proximal radioulnar joint, where the radial head articulates with the proximal ulna. This permits rotation of the forearm with the aid of the interosseous membrane and distal radioulnar joint [ 11 ] (Fig. 1.1 ).
Anatomy: Muscles and Ligaments
Integrated stabilization is provided to the elbow joint when muscles of the arm and forearm transverse the elbow. Stemming from the medial epicondyle is the flexor-pronator muscle group, which aids in resisting valgus stress. Static stability of the elbow is accomplished by
the bony and ligamentous structures about the elbow (Fig. 1.4 ). This stability primarily comes from the ulnohumeral articulation and the medial and lateral collateral ligaments. At 90° of flexion, approximately 55% of the valgus stability of the elbow occurs due to the ulnar collateral ligament (UCL). This ligament originates from the medial epicondyle and is composed of three main elements; the anterior, posterior, and transverse bundles. The main valgus stabilizing bundle of the elbow is the anterior bundle of the UCL, which is distinctly separate from the anterior joint capsule. The anterior bundle of the UCL is comprised of anterior and posterior bands that function separately. While the tightness and stability in extension is due to the anterior band, as the elbow is flexed, there is increasing stability provided by the fan- shaped posterior band [ 3 ] (Fig. 1.4 ).
In contrast, varus stress is resisted mainly by the bony articulation of the radiocapitellar joint in flexion and extension, as the lateral collateral ligament (LCL) only contributes a minimal amount of stability (9–14%). The lateral collateral ligament complex originates from the lateral epicondyle and is comprised of the radial collateral ligament, lateral ulnar collateral ligament, accessory lateral collateral ligament, and annular ligament [3] (Fig. 1.4).
Ligaments of the Pediatric Elbow
Anterior capsule
Radial collateral ligament
Annular ligament
Transverse ligament
Posterior capsule
Anterior bundle (MCL)
Annular ligament
Transverse bundle (MCL)
Posterior bundle (MCL)
Fig. 1.4 Schematic of the elbow depicting the ligamentous structures. The drawing on the left is looking at the lateral structures, and the drawing on the right depicts the medial structures (Courtesy of Joshua M. Abzug, MD)
Centers of Ossification
Many studies have evaluated the formation of the growth centers within the pediatric elbow [4, 12]. Of these, a recent study by Dwek utilized pediatric elbow images to evaluate multiple growth centers about the elbow. There are four secondary ossification centers seen in the distal humerus: (1) the capitellum, (2) the trochlea, (3) the medial epicondyle, and (4) the lateral epicondyle. It is worth pointing out that at birth, not one of these centers is ossified [5, 6]. In terms of laterality, studies describe no difference in timing or ossification pattern between the right and left elbow [4].
A single smooth center is how the capitellum develops with ossification. A jagged and nonregular appearance is seen in the trochlear ossification. A single center is seen in development for the medial epicondyle; however, this physis is a spherical growth plate that engulfs the whole medial epicondyle, which allows for the normal circumferential growth to take place [12]. A single elongated center or even multiple centers can be seen in the ossification of the lateral epicondyle. The ossification center of the radial head starts out oval and later becomes disk shape and flat. The olecranon commonly starts as two secondary centers which ossify into the olecranon but can also start as multiple centers which should not be mistaken for fracture fragments [4, 11] (Figs. 1.2 and 1.3).
The lateral condyle forms from the fusion of the lateral epicondyle to the distal humeral epiphysis, which then later fuses to the metaphysis. The fusion of the epiphysis and metaphysis is the last step of the lateral epicondyle’s ossification, which is a peripheral process. This forms a large gap between the lateral epicondyle ossification center and the lateral condyle, with the former having a linear pattern and the latter often mistaken for an avulsion fracture.
Soft Tissue
Multiple fat pads exist about the elbow and are typically located within bony fossae that exist to permit flexion and extension of the elbow.
J.J. Jauregui and J.M. Abzug
These fat pads can be pushed up and outward from the fossae when the joint space is filled with fluid, such as blood following a fracture. There are many studies that have evaluated this finding and have described that the posterior fat pad sign could be predictive of an occult fracture of the elbow following trauma. Skaggs and Mirzayan described this fat pad sign in a prospective series of 45 children with a traumatic history about the elbow who had an elevated posterior fat pad and had no other radiographic evidence of fracture. The authors reimaged the elbows in these children and noted that periosteal reaction from an occult fracture was present in 76% of patients [13].
Nerve Anatomy
The nerve anatomy of the pediatric elbow is similar to that of the adult counterpart. In pediatric patients, the ulnar nerve crosses the elbow posterior to the medial epicondyle, the median nerve crosses the elbow with the brachial artery, and the radial nerve runs between the brachialis and brachioradialis muscles before crossing the elbow and penetrating the supinator muscle. The radial and median nerves are vulnerable to injury following supracondylar humerus fractures which occur after an elbow hyperextension injury. In contrast, the ulnar nerve is vulnerable to injury after a supracondylar fracture with elbow hyperflexion or when a direct blow to the posterior aspect of the elbow occurs.
Pediatric patients may have instability of the ulnar nerve, which is important to recognize due to the potential risk for nerve injury during medial percutaneous pinning of supracondylar humerus fractures. Zaltz et al. [14] evaluated 328 ulnar nerves (164 children) and noted that 17.7% of children between the ages of 0–5 had ulnar nerve instability. 7.7% of the children between 6 and 10 years of age and 5.7% of the children between 11 and 18 years of age had ulnar nerve instability. The rate of ulnar nerve instability is significantly increased in children with ligamentous laxity.
Vascular Anatomy
The brachial artery runs superficial to the brachialis muscle along the anteromedial aspect of the humerus. Subsequently, this artery passes anterior to the distal humerus while an extensive collateral circulation develops. As the artery extends into the forearm, it splits into the radial and ulnar arteries. Following a supracondylar humerus fracture, the brachial artery is especially prone to injury. The distal extent of the proximal bony fragment may cause intimal damage to the vessel leading to subsequent thrombosis and vascular insufficiency. Due to the extensive collateral circulation present at the elbow, arm ischemia caused by complete occlusion of the brachial artery is infrequent.
Conclusion
Knowledge of the development of the pediatric elbow is necessary for the proper management of children with an elbow fracture.
References
1. Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am. 2008;39(2):163–71, v.
2. John SD, Wherry K, Swischuk LE, Phillips WA. Improving detection of pediatric elbow fractures by understanding their mechanics. Radiographics. 1996;16(6):1443–60; quiz 63–4.
3. Tisano BK, Estes AR. Overuse injuries of the pediatric and adolescent throwing athlete. Med Sci Sports Exerc. 2016;48(10):1898–905.
4. Cheng JC, Wing-Man K, Shen WY, Yurianto H, Xia G, Lau JT, et al. A new look at the sequential development of elbow-ossification centers in children. J Pediatr Orthop. 1998;18(2):161–7.
5. McCarthy SM, Ogden JA. Radiology of postnatal skeletal development. VI. Elbow joint, proximal radius, and ulna. Skeletal Radiol. 1982;9(1):17–26.
6. McCarthy SM, Ogden JA. Radiology of postnatal skeletal development. V. Distal humerus. Skeletal Radiol. 1982;7(4):239–49.
7. Garn SM, Rohmann CG, Silverman FN. Radiographic standards for postnatal ossification and tooth calcification. Med Radiogr Photogr. 1967;43(2):45–66.
8. Dimeglio A, Charles YP, Daures JP, de Rosa V, Kabore B. Accuracy of the Sauvegrain method in determining skeletal age during puberty. J Bone Joint Surg Am. 2005;87(8):1689–96.
9. Barad JH, Kim RS, Ebramzadeh E, Silva M. Range of motion of the healthy pediatric elbow: cross-sectional study of a large population. J Pediatr Orthop B. 2013;22(2):117–22.
10. Golden DW, Jhee JT, Gilpin SP, Sawyer JR. Elbow range of motion and clinical carrying angle in a healthy pediatric population. J Pediatr Orthop B. 2007;16(2):144–9.
12. Dwek JR. A segmental approach to imaging of sportsrelated injuries of the pediatric elbow. Sports Health. 2012;4(5):442–52.
13. Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999;81(10):1429–33.
14. Zaltz I, Waters PM, Kasser JR. Ulnar nerve instability in children. J Pediatr Orthop. 1996;16(5):567–9.
Physical Examination of the Pediatric Elbow
Matthew Varacallo, Kush S. Mody, Darshan Parikh, and Martin J. Herman
Pediatric Elbow Injuries
The pediatric and adolescent elbow is subject to both acute and chronic injuries. In general, the injury patterns seen are related to the relative weakness of the developing physes in comparison to the surrounding soft tissue stabilizers [1, 2] and the rapid turnover of the bone in the metaphysis of the distal humerus, proximal radius, and proximal ulna that particularly make the elbow susceptible to fracture. Overall, elbow injuries account for 1–3% of all pediatric and adolescent emergency department (ED) visits [3]. These numbers are expected to increase with increasing participation in youth sports as well as the advent of extreme sports [4]. Competitive sports participation with younger athletes is estimated at seven million in the United States alone,
and year-round sport participation has generated substantial increases of certain types of chronic overuse injuries [5, 6]. The annual incidence of elbow pain in youths playing baseball, aged 9–12 years old, is approximately 50–70% [7]. High rates of pediatric elbow injuries also occur in tennis and gymnastics [4].
Elbow fractures are among the most common injuries seen in pediatrics, second only to fractures of the distal forearm [8–10]. Fractures of the elbow comprise 5–10% of all fractures in the pediatric population, and they account for up to 85% of the operatively treated pediatric injuries in some series [11]. Supracondylar humerus (SCH) fractures account for the majority of pediatric elbow fractures and in total account for around 3% of all pediatric fractures [12, 13]. Lateral condyle and medial epicondyle fractures make up the second and third most common types of pediatric elbow fractures, respectively [14].
M. Varacallo, M.D.
Department of Orthopedic Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
e-mail: Born2run.4@gmail.com
K.S. Mody, B.S. • D. Parikh, B.S. Drexel University College of Medicine, Philadelphia, PA, USA
e-mail: Ksmody2255@gmail.com; Djp337@drexel.edu
M.J. Herman, M.D. (*) Drexel University College of Medicine, St. Christopher’s Hospital for Children, 3601 A Street, Philadelphia, PA 19134, USA
e-mail: MARTIN1.Herman@tenethealth.com
Pediatric elbow injuries often present a diagnostic dilemma for the treating physician. The unique anatomy of the elbow in the growing child along with the narrow therapeutic window and relatively high complication rates associated with certain types of fracture patterns creates a challenging diagnostic environment for the clinician. Moreover, injury patterns change with the growth and development of the elbow into adolescence and young adulthood [15]. Understanding the context and chronicity of the injury helps guide
J.M. Abzug et al. (eds.), Pediatric Elbow Fractures, https://doi.org/10.1007/978-3-319-68004-0_2
the clinician through a comprehensive physical examination and establishes the appropriate diagnostic framework to successfully treat pediatric and adolescent patients presenting with a wide variety of elbow pathology.
Clinical Assessment
The History
Acute Injury
The initial approach to the pediatric or adolescent patient with a suspected injury or fracture about the elbow follows a standard approach to assessing any type of musculoskeletal pathology. An accurate and complete history should be obtained from the patient if possible. The wide variety of potential injuries, in addition to the potential difficulty with radiographic interpretation, makes obtaining an accurate and comprehensive history imperative.
The location, quality, and duration of the pain, if any, should be elicited as best as possible. Time of onset as well as any history of similar episodes or injuries helps guide the working differential diagnosis. Any previous interventions or associated injuries or symptoms should be taken into consideration as well [4]. Finally, referred pain from the cervical spine, shoulder, hand, and/or wrist should be ruled out by asking specifically about limitation of motion or pain in these other areas, radiation of pain, and sensory and motor changes in the extremity [2, 16].
For acute fractures about the elbow, the history is usually indicative of a high-energy trauma or a fall from height on an outstretched hand with the elbow extended [11, 17–19]. In these situations, it is important to consider a complex fracture dislocation or associated neurovascular injuries, which may complicate the overall management, although the majority of injuries are isolated elbow fractures [20]. The age of the patient and their degree of skeletal maturity also influence the type of fracture pattern sustained. Knowledge of the normal growth pattern and expected ages of reference for sequential ossification center appearance, development,
and fusion is critical for appropriate evaluation and management of these injuries.
In general, the younger the child at the time of the injury, the more difficult the assessment can be in many cases. In younger patients or patients with developmental delays in which the clinician must rely solely on the parents and/or caregivers, child abuse must be in the working differential diagnosis. Although beyond the scope of this chapter, all health providers taking care of children should be able to distinguish between abusive and accidental injury in settings when the stated cause is not consistent with the injury [21, 22].
Chronic Injury
In chronic overuse injuries, asking about sports participation is critical [2, 23]. This includes an accurate description with respect to seasonal activity, duration of play, year-round schedules, and any periods of rest from participation. A careful assessment of the overall effect on the child and the importance of sports in his or her daily life can influence potential overreporting or underreporting of symptoms [2]. Little league baseball pitchers and other overhead athletes most commonly present with medial elbow pain, which can be either constant or intermittent with increasing activity [24]. The age of the patient helps provide clues for the potential diagnosis. Patients in early childhood and in whom the secondary ossification centers have yet to appear have pain likely from repetitive injury to the ossification center and apophysis of the medial epicondyle. In adolescents, however, the pain is more likely from the muscle attachments pulling on the medial epicondyle repetitively and eventually resulting in a medial epicondyle avulsion injury [25] or ulnar collateral ligament incompetence, a much less common scenario in children younger than 12 years of age.
Physical Examination of the Injured Arm
Observation and Inspection
Observation is a key component when examining younger patients and should not be overlooked.
2 Physical Examination of the Pediatric Elbow
Assessing the child’s demeanor and if he or she is able to use the extremity adds to the clinical picture and suspected diagnostic considerations. In addition, comparing how the child is using the injured side to the contralateral, uninjured side can help provide an appropriate frame of reference. During the inspection, the skin should be checked for any ecchymosis, abrasions, tissue loss, or swelling indicating an acute injury. Signs of an open fracture such as small puncture sites, intermittent oozing of blood or frank bleeding, and exposed bone must also be assessed. In patients with chronic symptoms, more longstanding changes such as hypertrophy or atrophy of the surrounding musculature and joint contractures should also be noted.
For patients able to comfortably extend the elbow, the overall axial alignment of the limb at the elbow, also known as the carrying angle (Fig. 2.1), is assessed and compared to the
contralateral side. The carrying angle is determined clinically by the angle formed between the long axis of the humerus and forearm at the elbow joint itself [ 26 , 27 ]. Typically, the carrying angle measures between 11° and 14° of valgus; overhead throwers often demonstrate an increased carrying angle secondary to repetitive valgus stresses, which can cause medial epicondyle hypertrophy [ 27 , 28 ]. Variations in the carrying angle may also be secondary to previous trauma, the most common of which is cubitus varus or “gunstock” deformity, the result of varus malunion of a supracondylar humerus fracture. Genetic syndromes that are associated with congenital abnormalities of the elbow, such as a congenital radial head dislocation causing cubitus valgus, as well as ligamentous hyperlaxity, and neuromuscular diseases, among other etiologies, are associated with abnormal carrying angles.
Fig. 2.1 Carrying angle. (a) Normal carrying angle. The carrying angle is defined as an angle made by the axes of the arm and the forearm, with the elbow in full extension and the palm facing anteriorly. In most children and adults, the normal angle varies between 5° and 15° of valgus (distal segment pointing away from the midline). Females generally have an increased carrying angle compared to males. (b) Cubitus varus. A child with cubitus
varus, also known as “gunstock deformity,” has less than 0° of valgus. It is usually the most common complication following a supracondylar fracture. (c) Asymmetric carrying angle. This child had two supracondylar fractures of the left elbow and now has asymmetry of the carrying angle with more valgus on the left than the right but has no functional deficits. Cubitus valgus is usually greater than 15° from the midline
Palpation
The next component of the physical exam involves palpating the anatomic landmarks about the elbow, starting first with the asymptomatic areas and progressing toward the symptomatic ones. Bony landmarks that can be palpated at the elbow include the distal humeral metaphysis, the medial and lateral epicondyles, the olecranon process and proximal ulna, and the radial head and capitellum at the radiocapitellar articulation. The osseous points from the epicondyles form a triangle with equal lengths to each side connecting the olecranon inferiorly. Palpation in the lateral soft spot between the capitellum, radial head, and olecranon may demonstrate soft tissue fullness indicating a possible joint effusion. Focal areas of tenderness may be indicative of fracture or other acute injuries and warrant further investigation.
Palpation of the soft tissues of the upper arm and forearm is useful if severe trauma or the development of compartment syndrome is of concern. The volar upper arm, and in particular the biceps muscle, is rarely the site of compartment syndrome but, in our experience, may occur. The volar forearm, however, is the most common site of compartment syndrome development after supracondylar fractures and other severe injuries of the elbow. While subjective, tenderness along the muscle of the arm and foreman as well as tenseness of the compartments must be included in the initial examination and afterward if the suspicion for the diagnosis is raised. This part of the exam is often coupled with assessment of pain when passively stretching the fingers of the affected arm. While pain with passive stretch is a potential sign of compartment syndrome, in children this determination may be unreliable because of anxiety and preexisting discomfort from the fracture and subjective, similar to the determination of the “tenseness” of compartments.
Provocative Maneuvers
Provocative maneuvers can also be combined with palpation to aid in diagnosis. Pain caused by
pressure directly over the radiocapitellar joint combined with axial loading and forearm pronation and supination can be indicative of Panner’s disease, an osteochondrosis of the capitellar ossification center in preadolescent children; once adolescence is reached, similar findings more often correlate with a capitellar OCD lesion [25, 29, 30]. Palpation of the radial head while pronating and supinating the forearm may also elicit a sensation of radial head instability in patients with a missed radial head dislocation or missed Monteggia fracture.
Tenderness to palpation at or around the lateral epicondyle may be indicative of lateral epicondylitis or apophysitis, depending on the age of the patient; resisted wrist extension, which puts on stretch the wrist extensors which originate from the lateral epicondyle, provokes the patient’s pain. A similar approach is applied on medial palpation. Tenderness can be elicited around the medial epicondyle secondary to apophysitis (chronic medial epicondylitis) or ulnar collateral injury depending on the age of the patient; resisted wrist flexion may illicit pain because the flexor-pronator mass originates at the medial epicondyle. While skeletally immature patients may have a combination of apophysitis and ligament tenderness, which is difficult to determine on exam alone, older patients with a completely fused medial epicondyle are more likely to have pathology related strictly to the ulnar collateral ligament.
The Posterior Elbow
To exam for posterior pathology, the elbow is positioned in 25°–30° of flexion to “unlock” the olecranon from the humerus and relax the triceps. The posteromedial and posterolateral aspects of the olecranon fossa are then palpated for fullness or tenderness; adolescent overhand throwers can present with pain posteriorly secondary to valgus extension overload, termed posterior impingement. Olecranon apophysitis and proximal ulna stress reactions may also be
seen in the scenario of overuse, signaled by point tenderness at the olecranon process and along the triceps insertion. In older adolescents, repetitive stresses posteriorly can result in osteophyte formation in the olecranon fossa, causing a painful mechanical block to full elbow extension [27].
Range of Motion and Stability
Normal range of motion (ROM) is defined as unopposed motion of the forearm with flexion, extension, supination, and pronation at the elbow joint, with all four types of motions ideally evaluated both actively and passively. Although normal range values exist to describe range of motion with respect to the skeletally mature elbow, normative data for healthy pediatric patients is somewhat lacking and controversial [ 25 , 31 ] . Several recent studies have been conflicting regarding age and gender-specific differences with respect to flexion at the elbow in particular [ 30 , 32 ] . Despite these minor discrepancies, normal ROM in the flexion-extension plane is generally described as 140° of flexion to extension of 0 to 10° of hyperextension, with the assessment made with the patient holding the forearm supinated. Normal forearm pronation and supination are typically 75° and 85°, respectively [ 33 ]. Passive rotation of the forearm is best determined by grasping the distal forearm and rotating it into supination and pronation, thereby eliminating carpal rotation; active measures of forearm rotation that use the hand or thumb position to assess motion may lead to overestimation of true forearm rotation because of carpal mobility.
In patients with acute injuries, assessing active motion first assures that the examiner does not cause discomfort by attempting to passively move an injured arm; lack of full active motion after an injury is an indication for elbow imagining. For patients with chronic complaints of elbow pain, flexion contracture is a common presentation for many overuse
pathologies. It is important to compare elbow extension to that of the contralateral extremity because subtle loss of extension may not be appreciated without direct comparison; an asymptomatic 10°–15° flexion contracture may be a sign of early apophysitis, OCD lesion of the capitellum, or posterior impingement syndrome.
Stability Tests
Elbow instability can be difficult to determine in the younger patient while in the office, while adolescents tend to be more cooperative with certain types of provocative exam maneuvers. In the setting of acute injury, these are especially difficult for patients to tolerate and, in our practice, rarely applied in this scenario. To test the lateral ligamentous complex, slight varus stress and internal rotation are applied to the elbow with the joint positioned in about 25°–35° of flexion. In a similar fashion, the medial complex is tested by applying a valgus moment combined with an external rotational stress with the elbow held at 25°–35° of flexion [27]. The posterolateral pivot shift test, a provocative maneuver used to assess stability of the posterolateral ligamentous complex of the elbow, is performed by applying a valgus and axial load to the elbow while flexing the elbow with the forearm held in supination and the arm positioned overhead; the test is most reliable when performed with anesthesia. A positive test demonstrates a clunk with greater than 40° of flexion [34].
These examination maneuvers can be helpful in evaluating certain types of chronic elbow pathologies. For example, valgus instability may develop secondary to nonunion or malunion of a previous medial epicondyle fracture or avulsion injury. Posterolateral rotatory instability (PLRI), diagnosed by the posterolateral pivot shift test, may be seen in patients sustaining an elbow dislocation who develop secondary lateral collateral ligament deficiency or in adults who have residual cubitus varus after a supracondylar fracture sustained as child.
Neurovascular Assessment
A thorough neurovascular examination of the upper extremity must be performed for patients with both acute and chronic complaints. In the setting of a high-energy injury especially, but even after isolated elbow trauma, immediate assessment of the neurovascular structures to the limb is imperative and helps guide the short-term management of the injury. Assessment of younger patients in the setting of acute trauma may be a difficult task secondary to pain and anxiety [35]. Using a gentle approach and starting with the uninjured side help reassure the patient that cooperating with the exam will not be painful. A systematic approach to the motor and sensory function of the nerves (median, ulnar, and radial nerves) of the arm should be undertaken.
Motor Testing
A simple way to assess the motor function of the anterior interosseous nerve, a segment of the
M. Varacallo et al.
median nerve that has no sensory component and is the most commonly injured nerve when extension supracondylar fractures occur, is to ask the child to make an “ok” sign [36]; this movement requires both flexion of the second finger DIP joint and the IP joint of the thumb that are powered by this nerve. Ulnar nerve motor function can be tested by having the child “claw” the ring and little fingers or to ask the child to flex the fifth finger while holding the PIP joint extended, effecting isolating FDP function powered by the ulnar nerve. The posterior interosseous nerve, a segment of the radial nerve with no sensory component, is tested by asking the child to give a “thumbs up” or having the child extend the MCP joints of the fingers while holding the PIP and DIP joints flexed. Having the child play rock-paper-scissors (Fig. 2.2) is another classic method that is often used to adequately assess motor function in pediatric patients [37]. Forming the “paper” tests radial nerve motor function, cutting with “scissors” tests ulnar nerve motor function, and making the “rock” tests median nerve motor function.
Fig. 2.2 The physical exam of the injured upper extremity includes a motor examination of the hand by individually testing median, ulnar, and radial nerve function. Playing the children’s game “rock-paper-scissors” is one method of examining the younger child. (a) Median nerve function: “rock”. “Rock” (making a fist) grossly tests the median nerve, which innervates the finger and forearm flexors. Injury to the median nerve can decrease flexor
function and affect the thenar muscles of the thumb. (b) Radial nerve function: “paper”. “Paper” (finger extension) grossly tests the radial nerve, which innervates the finger and forearm extensors. (c) Ulnar nerve function: “scissors”. “Scissors” (actively spreading the extended index and middle fingers) tests the ulnar nerve, which innervates the intrinsic hand muscles, such as the interossei and lumbricals
Sensory Exam
The sensory examination should be performed in all three nerve distributions: median, ulnar, and radial nerves (Fig. 2.3). Light touch is primarily tested in the setting of acute injury by gently stroking the skin; two-point discrimination testing and pinprick are not tested routinely except in the setting of chronic nerve injury or in the setting of surgical nerve repair and recovery. The median nerve is best tested by stroking the palmar index middle fingers. The ulnar nerve is best tested along the lateral (ulnar) border of the fifth finger. Radial nerve sensation is assessed by stroking the skin of the first dorsal web space and lateral (radial) thumb. Most children younger than 3–4 years of age are able to participate in the exam without difficulty and are able to verbalize and distinguish differences between the injured and non-injured limbs. Younger patients and patients with developmental delays present more of a challenge but can be examined by observing them doing activities, participating in games, or presenting them objects to grasp or giving them tasks such as holding a pencil that require different motor and sensory input. Pinching or applying noxious stimuli along the nerve distribution may bring about a withdrawal response and is suggestive of normal sensation [8] but is sometimes
difficult to ascertain and may lead to discomfort which makes the remainder of the exam more difficult.
Vascular Exam
Finally, the vascular exam is an essential component of the examination (Fig. 2.4). The exam starts by assessing the color of the extremity, noting a normal pink tone of the palmar hand and fingers as opposed to the whitish or pale appearance of the dysvascular limb. Feeling the fingertips of the affected limb and comparing the general sense of warmth compared to the uninvolved limb is another way of determining flow but may be influenced by the method of immobilization, the ambient temperature, and other factors, making this assessment especially subjective. Palpation of the radial pulse is the most common way to assess flow and is easier to find compared to the ulnar pulse in many children. A rich collateral circulation that takes its origin proximal to the elbow provides adequate perfusion, however, for many children even if the brachial artery is in spasm or is disrupted yielding no palpable distal pulses, such as after a supracondylar fracture. Doppler studies are not routinely used but are helpful when the limb is severely swollen and difficult to assess or the physical exam is equivocal. The vascular status is generally reported as in the table.
Fig. 2.3 The sensory examination of the hand assesses areas that are innervated by a single nerve. Light touch can be assessed even in young children, while two-point discrimination is more difficult to assess. (a) Median nerve innervation. Sensation in the palmar index finger at the level of the distal phalanx shows innervation by the
median nerve. (b) Radial nerve innervation. Sensation on the dorsum of the thumb in the first web space can measure innervation by the radial nerve. (c) Ulnar nerve innervation. Sensation in the palmar and lateral small finger at the level of the distal phalanx shows innervation by the ulnar nerve
Fig. 2.4 Vascular assessment of the upper extremity. (a) Distal blood flow. The vascular assessment includes palpating for the radial pulse. Doppler ultrasound may also be used to assess distal flow. (b) Capillary refill. Normal capillary refill is less than 3 s in children in normal ambient room temperature; it is used to indicate adequate hydration and distal blood perfusion to tissues. (c) Vascular status. The vascular assessment is generally classified into three broad types for children with a supra-
Summary
A careful assessment of the injured limb includes observation and assessment of deformity, palpation for tenderness and signs of severe swelling in the compartments, and elbow range of motion assessment actively and passively when tolerated by the patient. A thorough motor and sensory examination should focus on the median, ulnar, and radial nerves. Vascular assessment is critical to distinguish between the normal exam, the limb that has perfusion but is pulseless, and the dysvascular hand.
condylar fracture based on the examination. The radial pulse is determined by palpation but may also be assessed by Doppler ultrasound; comparison of the result to the uninjured limb is useful for separating flow patterns that result from collateral circulation versus normal radial artery flow. The finger perfusion is considered normal if the capillary refill is normal and the palmar digits and nail beds are pink. Temperature is determined by comparing the injured limb to the uninjured limb and is subjective
References
1. Malanga GA, Ramirez JA. Common injuries of the foot and ankle in the child and adolescent athlete. Phys Med Rehabil Clin N Am. 2008;19:347–71.
2. Miller MD, Thompson SR, DeLee J, Drez D. DeLee & Drez’s orthopaedic sports medicine. 4th ed. Elsevier/ Saunders; 2015.
3. Freed GL, Gafforini S, Carson N. Age distribution of emergency department presentations in Victoria. Emerg Med Australas. 2015;27(2):102–7.
4. Arora R, Fichadia U, Hartwig E, Kannikeswaran N. Pediatric upper-extremity fractures. Pediatr Ann. 2014;43(5):196–204.
5. McLeod TCV, Decoster LC, Loud KJ, Micheli LJ, Parker JT, Sandrey MA, White C. National Athletic Trainers’
M. Varacallo et al.
2 Physical Examination of the Pediatric Elbow
Association position statement: prevention of pediatric overuse injuries. J Athl Train. 2011;46(2):206–20.
6. Dizdarevic I, Low S, Curie DW, Comstock RD, Hammoud S, Atanda A Jr. Epidemiology of elbow dislocations in high school athletes. Am J Sports Med. 2016;44(1):202–8.
7. Ireland ML, Hutchinson MR. Upper extremity injuries in young athletes. Clin Sports Med. 1995;14(3):533–69.
8. Wingfield JJ, Ho CA, Abzug JM, et al. Open reduction techniques for supracondylar fractures in children. J Am Acad Orthop Surg. 2015;23(12):e72–80.
9. Simanovsky N, Lamdan R, Mosheiff R, Simanovsky N. Underreduced supracondylar fracture of the humerus in children: clinical significance at skeletal maturity. J Pediatr Orthop. 2007;27(7):733–8.
10. Lanson AN, Garg S, Weller A, et al. Operative treatment of type II supracondylar humerus fractures: does time to surgery affect complications? J Pediatr Orthop. 2014;34(4):382–7.
11. Badkoobehi H, Choi PD, Bae DS, Skaggs DL. Management of the pulseless pediatric supracondylar humeral fracture. J Bone Joint Surg Am. 2015 Jun 3;97(11):937–43.
12. Cheng JC, Lam TP, Maffuli N. Epidemiological features of supracondylar fractures of the humerus in Chinese children. J Pediatr Orthop B. 2001;10(1):63–7.
13. Scanell BP, Jackson JB 3rd, Bray C, et al. The perfused, pulseless supracondylar humeral fracture: intermediate-term follow-up of vascular status and function. J Bone Joint Surg Am. 2013;95(21):1913–9.
14. Landin LA, Danielesson LG. Elbow fractures in children: an epidemiological analysis of 589 cases. Acta Orthop Scand. 1986;57:309–12.
15. Crowther M. Elbow pain in pediatrics. Curr Rev Musculoskelet Med. 2009;2(2):83–7.
16. Goldberg C. Musculoskeletal examination general principles and detailed evaluation of the knee & shoulder. The Regents of the University of California; 2011.
17. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90(5):1121–32.
18. Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22(4):440–3.
20. Kazakos CJ, Galanis VG, Verettas DJ, Dimitrakopoulou A, Polychronidis A, Simopoloulos C. Unusual patterns of Monteggia fracture-dislocation. J Orthop Surg. 2006;1:12.
21. Swoboda SL, Feldman KW. Skeletal trauma in child abuse. Pediatr Ann. 2013;42(11):236–43.
22. Flaherty EM, Perez-Rossello JM, Levine MA, Hennrikus WL. Evaluating children with fractures for child physical abuse. Am Acad Pediatr. 2014;133:2.
23. Difiori P, Benjamin HJ, Brenner J, Gregory A, Jayanthi N, Landry GL, Luke A. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Clin J Sport Med. 2014;24:3–20.
24. Kramer DE. Elbow pain and injury in young athletes. J Pediatr Orthop. 2010;30:S7–S12.
25. Dwek JR. A structural and mechanism-based perspective toward understanding pediatric and adult sports injuries. AJR Am J Roentgenol. 2016;206(5):980–6.
26. Golden DW, Jhee JT, Gilpin SP, Sawyer JR. Elbow range of motion and clinical carrying angle in a healthy pediatric population. J Pediatr Orthop B. 2007;16(2):144–9.
27. Hsu SH, Moen TC, Levine WN, Ahmad CS. Physical examination of the Athlete’s elbow. Am J Sports Med. 2012;40:699.
28. O’Holleran JD, Altchek DW. The Thrower’s elbow: arthroscopic treatment of valgus extension overload syndrome. HSS J. 2006;2(1):83–93.
29. Kramer DE, Yen YM, Simoni MK, Miller PE, Micheli LJ, Kocher MS, Heyworth BE. Surgical management of osteochondritis dissecans lesions of the patella and trochlea in the pediatric and adolescent population. Am J Sports Med. 2015;43(3):654–62.
30. Chen NC. Osteochondritis dissecans of the elbow. J Hand Surg Am. 2010;35(7):1188–9.
31. Barad JH, Kim RS, Ebramzadeh E, Silva M. Range of motion of the healthy pediatric elbow: cross-sectional study of a large population. J Pediatr Orthop B. 2013;22(2):117–22.
32. Da Paz SN, Stalder A, Berger S, Ziebarth K. Range of motion of the upper extremity in a healthy pediatric population: introduction to normative data. Eur J Pediatr Surg. 2016;26(5):454–61.
33. Berme N, Engin AE, Correia da Silva KM Biomechanics of normal and pathological human articulating joints. NATO ASI Series. 1985;3:123.
34. Fedorka CJ, Oh LS. Posterolateral rotatory instability of the elbow. Curr Rev Musculoskelet Med. 2016;9(2):240–6.
35. Shrader MW. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am. 2008;39(2):163–71.
36. Robertson JS, Marsh AG, Huntley JS. Neurological status in paediatric upper limb injuries in the emergency department current practice. BMC Res Notes. 2012;5:324.
Pediatric elbow fractures are difficult clinical challenges to manage for many reasons. For the inexperienced surgeon, however, interpretation of x-rays of the injured child’s elbow is perhaps the most daunting of tasks. The elbow is a complex joint with three articulations that allow flexion-extension of the elbow joint as well as pronation-supination of the forearm. The developmental bony anatomy is also complex, as ossification centers form sequentially over time. Starting out as cartilaginous anlagen, the distal humerus, proximal radius, and proximal ulna progress through skeletal maturity via a predictable pattern of ossification. These sequential bony changes make the radiographic appearance of the pediatric elbow appear differently
R. Hoffman, B.S., M.D.
Department of Orthopedic Surgery, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, USA
e-mail: Rah94@drexel.edu
J. Prodromo, M.D.
Department of Orthopedic Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
e-mail: prodromo.john@gmail.com
M.J. Herman, M.D. (*)
Drexel University College of Medicine, St. Christopher’s Hospital for Children, 3601 A Street, Philadelphia, PA 19134, USA
e-mail: MARTIN1.Herman@tenethealth.com
year-to-year, making x-ray interpretation complicated and fraught with errors of both underand overdiagnosis of injuries.
Mastery of the radiographic assessment of the pediatric elbow is critical to success of care of pediatric elbow trauma and an important goal for the young surgeon [1].
Basic Anatomy
Bony Anatomy
The elbow is a ginglymus joint—a stabilized articulation providing motion strictly in a single plane—resembling that of a hinge. This joint is primarily responsible for flexion, supination, and pronation of the forearm relative to the arm. The elbow is constructed on a foundation of three articulations—the humeroradial, humeroulnar, and radioulnar. The humerus distally transitions from the diaphyseal shaft into two columns of metaphyseal bone that are separated by the olecranon fossa, an oval depression in the posterior surface of the bone where the tip of the olecranon fits when the elbow is extended. Distal to this, these separate bony columns coalesce and terminate in the distal humeral articulation, two convex surfaces of bone covered with hyaline cartilage separated in the middle by a shallow cleft that creates a spool-like appearance to the bone’s end. The
J.M. Abzug et al. (eds.), Pediatric Elbow Fractures, https://doi.org/10.1007/978-3-319-68004-0_3
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Project Gutenberg eBook of George Bernard Shaw: His Plays
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Title: George Bernard Shaw: His Plays
Author: H. L. Mencken
Release date: May 31, 2022 [eBook #68209]
Language: English
Original publication: United States: John W. Luce & Co, 1905
Credits: Emmanuel Ackerman, Charlie Howard, and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)
*** START OF THE PROJECT GUTENBERG EBOOK GEORGE BERNARD SHAW: HIS PLAYS ***
George Bernard Shaw his plays
BY HENRY L. MENCKEN
BOSTON AND LONDON
JOHN W. LUCE & CO.
1905
C o p y r i g h t , 1 9 0 5 , b y J W L C
B o s t o n , M a s s . , U . S . A .
The Plimpton Press Norwood Mass. U.S.A.
CONTENTS
P .
B W I .
T S P : Mrs. Warren’s Profession. Arms and the Man. The Devil’s Disciple. Widowers’ Houses. The Philanderer.
Captain Brassbound’s Conversion. Cæsar and Cleopatra.
A Man of Destiny.
The Admirable Bashville. Candida.
How He Lied to Her Husband. You Never Can Tell. Man and Superman. John Bull’s Other Island.
Major Barbara.
T N O W :
The Irrational Knot, Love Among the Artists, Cashel Byron’s Profession, An Unsocial Socialist, On
Going to Church, The Quintessence of Ibsenism, etc.
B S
S S .
PREFACE
T is a little handbook for the reading tables of Americans interested enough in the drama of the day to have some curiosity regarding the plays of George Bernard Shaw, but too busy to give them careful personal study or to read the vast mass of reviews, magazine articles, letters to the editor, newspaper paragraphs and reports of debates that deal with them. Every habitual writer now before the public, from William Archer and James Huneker to “Vox Populi” and “An Old Subscriber” has had his say about Shaw. In the pages following there is no attempt to formulate a new theory of his purposes or a novel interpretation of his philosophies. Instead, the object of this modest book is to bring all of the Shaw commentators together upon the common ground of admitted fact, to exhibit the Shaw plays as dramas rather than as transcendental treatises, and to describe their plots, characters, and general plans simply and calmly, and without reading into them anything invisible to the naked eye.
The order in which the plays are considered is not the chronological one, and some readers may think that it is not the logical one. Inasmuch as an exposition of the reasons that urged its adoption would waste a great deal of space, the point will not be argued. The brief biography of the dramatist is based upon the most accurate available eulogies, denunciations, reminiscences, and manuscripts. So, too, the historical data regarding the plays and other publications.
The reputation of Mr. Shaw as a playwright has so far exceeded his renown as a novelist, a socialist, a cart-tail orator, a journeyman reformer, a vegetarian, and a critic of literature and the arts, that his novels and other minor works have been noticed but briefly. But this
is not to be taken as evidence that they do not merit acquaintance. Even the worst of Shaw is well worth study.
BY WAY OF INTRODUCTION
What else is talent but a name for experience, practice, appropriation, incorporation, from the times of our forefathers?
F N .
A is a mere clock-tick in eternity, but measured by human events it is a hundred long years. Napoleon Bonaparte, born in 1768, became an officer of artillery and gravedigger for an epoch. Born in 1868, he might have become a journeyman genius of the boulevards, a Franco-Yankee trust magnate, or the democratic boss of Kansas City. And so, contrariwise, George Bernard Shaw, born in 1756 instead of 1856, might have become a gold-stick-in-waiting at the Court of St. James or Archbishop of Canterbury. The accident that made him what he is was one of time. He saw the light after, instead of before Charles Darwin.
Darwin is dead now, and the public that reads the newspapers remembers him only as the person who first publicly noted the fact that men look a great deal like monkeys. But his soul goes marching on. Thomas Huxley and Herbert Spencer, like a new Ham and a new Shem, spent their lives seeing to that. From him, through Huxley, we have appendicitis, the seedless orange, and our affable indifference to hell. Through Spencer, in like manner, we have Nietzsche, Sudermann, Hauptmann, Ibsen, our annual carnivals of catechetical revision, the stampede for church union, and the aforesaid George Bernard Shaw. Each and all of these men and things, it is true, might have appeared if Darwin were yet unborn. Ibsen might have written “A Doll’s House,” and a rash synod or two might have turned impertinent search-lights upon the doctrine of infant damnation. It is possible, certainly, but it is supremely, colossally, and overwhelmingly improbable.
Why? Simply because before Darwin gave the world “The Origin of Species” the fight against orthodoxy, custom, and authority was perennially and necessarily a losing one. On the side of the defense were ignorance, antiquity, piety, organization, and respectability— twelve-inch, wire-wound, rapid-fire guns, all of them. In the hands of the scattered, half-hearted, unorganized attacking parties there were but two weapons—the blowpipe of impious doubt and the bludgeon of sacrilege. Neither, unsupported, was very effective. Voltaire, who tried both, scared the defenders a bit and for a while there was a great pother and scurrying about, but when the smoke cleared away the walls were just as strong as before and the drawbridge was still up. One had to believe or be damned. There was no compromise and no middle ground.
And so, when Darwin bobbed up, armed with a new-fangled dynamite gun that hurled shells charged with a new shrapnel—facts —the defenders laughed at the novel weapon and looked forward to slaying its bearer. Spencer, because he ventured to question Genesis, lost his best friend. Huxley, for an incautious utterance, was barred from the University of Oxford. And then of a sudden, there was a deafening roar and a blinding flash—and down went the walls. Ramparts of authority that had resisted doubts fell like hedge-rows before facts, and there began an intellectual reign of terror that swept like a whirlwind through Europe, America, Asia, Africa, and Oceania. For six thousand years it had been necessary, in defending a doctrine, to show only that it was respectable or sacred. Since 1859, it has been needful to prove its truth.
It will take the perspective of centuries to reveal to us the exact metes and bounds of Darwin’s influence. He himself probably gave little thought to it. His own business in life was the investigation of biological phenomena and he was too busy at that to take an interest in politics or ethics. But his new method of assailing tradition appealed to men laboring in far distant vineyards, and soon there was in progress a grand assault-at-arms that left orthodoxy and custom dying on the field. Huxley led the physicians and Spencer the metaphysicians. Every time the former overturned an old theory of matter, the latter pricked an old maxim of ethics. And so the search
for the ultimate verities, which had been a pariah hiding in cellars, like anarchism or polygamy, became the spirit of the times. Whenever custom or tradition reared one of its hydra-heads, there was a champion ready to strike it down.
The practical result of this was that seekers after the truth, growing bold with success, began attacking virtues as well as vices. And herein you will find the fundamental difference between the philosophers before Darwin and those after him. The Spectator, in the ’teens of the eighteenth century, inveighed against marital infidelity—an amusement counted among the scarlet sins since the days of Moses. Ibsen, a century and a half later, asked if there might not be evil, too, in unreasoning fidelity. If you pursue this little inquiry to its close, you will observe that George Bernard Shaw, in nearly all of his plays and novels, follows Ibsen rather than Addison. Sometimes he lends his ear to one of the two classes of pioneers he mentions in “The Quintessence of Ibsen,” and sometimes to the other, but it is always to the pioneers. Either he is exhibiting a virtue as a vice in disguise, or exhibiting a vice as a virtue in vice’s clothing. In this fact lies the excuse for considering him a world-figure. He stands in a sense as an embodiment of the welt-geist, which is a word invented by the Germans to designate world-spirit or tendency of the times.
II
Popular opinion and himself to the contrary notwithstanding, Shaw is not a mere preacher The function of the dramatist is not that of the village pastor. He has no need to exhort, nor to call upon his hearers to come to the mourners’ bench. All the world expects him to do is to picture human life as he sees it, as accurately and effectively as he can. Like the artist in color, form, or tone, his business is with impressions. A man painting an Alpine scene endeavors to produce, not a mere record of each rock and tree, but an impression upon the observer like that he would experience were
he to stand in the artist’s place and look upon the snow-capped crags. In music it is the same. Beethoven set out, with melody and harmony, to arouse the emotions that stir us upon pondering the triumphs of a great conqueror. Hence the Eroica Symphony. Likewise, with curves and color, Millet tried to awaken the soft content that falls upon us when we gaze across the fields at eventide and hear the distant vesper-bell—and we have “The Angelus.”
The purpose of the dramatist is identical. If he shows us a drunken man on the stage it is because he wants us to experience the disgust or amusement or envy that wells up in us on contemplating such a person in real life. He concerns himself, in brief, with things as he sees them. The preacher deals with things as he thinks they ought to be. Sometimes the line of demarcation between the two purposes may be but dimly seen, but it is there all the same. If a play has what is known as a moral, it is the audience and not the playwright that formulates and voices it. A sermon without an obvious moral, well rubbed in, would be no sermon at all.
And so, if we divest ourselves of the idea that Shaw is trying to preach some rock-ribbed doctrine in each of his plays, instead of merely setting forth human events as he sees them, we may find his dramas much easier of comprehension. True enough, in his prefaces and stage directions, he delivers himself of many wise saws and elaborate theories. But upon the stage, fortunately, prefaces and stage directions are no longer read to audiences, as they were in Shakespeare’s time, and so, if they are ever to discharge their natural functions, the Shaw dramas must stand as simple plays. Some of them, alackaday! bear this test rather badly. Others, such as “Mrs. Warren’s Profession” and “Candida,” bear it supremely well.
It is the dramatist’s business, then, to record the facts of life as he sees them, that philosophers and moralists (by which is meant the public in meditative mood) may deduce therefrom new rules of human conduct, or observe and analyze old rules as they are exhibited in the light of practice. That the average playwright does not always do so with absolute accuracy is due to the fact that he is merely a human being. No two men see the same thing in exactly
the same way, and there are no fixed standards whereby we may decide whether one or the other or neither is right.
Herein we find the element of individual color, which makes one man’s play differ from another man’s, just as one artist’s picture of a stretch of beach would differ from another’s. A romancist, essaying to draw a soldier, gave the world Don Cesar de Bazan. George Bernard Shaw, at the same task, produced Captain Bluntschli. Don Cesar is an idealist and a hero; Bluntschli is a sort of refined day laborer, bent upon earning his pay at the least possible expenditure of blood and perspiration. Inasmuch as no mere man—not even the soldier under analysis himself—could ever hope to pry into a fighting man’s mind and define and label his innermost shadows of thought and motive with absolute accuracy, there is no reason why we should hold Don Cesar to be a more natural figure than Captain Bluntschli. All that we can demand of a dramatist is that he make his creation consistent and logical and, as far as he can see to it, true. If we examine Bluntschli we will find that he answers these requirements. There may be a good deal of Shaw in him, but there is also some of Kitchener and more of Tommy Atkins.
This is one of the chief things to remember in studying the characters in the Shaw plays. Some of them are not obvious types, but a little inspection will show that most of them are old friends, simply viewed from a new angle. This personal angle is the possession that makes one dramatist differ from all others.
III
Sarcey, the great French critic, has shown us that the essence of dramatic action is conflict. Every principal character in a play must have a complement, or as it is commonly expressed, a foil. In the most primitive type of melodrama, there is a villain to battle with the hero and a comic servant to stand in contrast with the tearful heroine. As we go up the scale, the types are less strongly marked, but in every play that, in the true sense, is dramatic, there is this
same balancing of characters and action. Comic scenes are contrasted with serious ones and for every Hamlet you will find a gravedigger.
In the dramas of George Bernard Shaw, which deal almost wholly with the current conflict between orthodoxy and heterodoxy, it is but natural that the characters should fall broadly into two general classes—the ordinary folks who represent the great majority, and the iconoclasts, or idol-smashers. Darwin made this war between the faithful and the scoffers the chief concern of the time, and the shamsmashing that is now going on, in all the fields of human inquiry, might be compared to the crusades that engrossed the world in the middle ages. Everyone, consciously or unconsciously, is more or less directly engaged in it, and so, when Shaw chooses conspicuous fighters in this war as the chief characters of his plays, he is but demonstrating his comprehension of human nature as it is manifested to-day. In “Man and Superman,” for instance, he makes John Tanner, the chief personage of the drama, a rabid adherent of certain very advanced theories in social philosophy, and to accentuate these theories and contrast them strongly with the more old-fashioned ideas of the majority of persons, he places Tanner among men and women who belong to this majority. The effect of this is that the old notions and the new—orthodoxy and heterodoxy —are brought sharply face to face, and there is much opportunity for what theater goers call “scenes”—i. e. clashes of purpose and will.
In all of the Shaw plays—including even the farces, though here to a less degree—this conflict between the worshipers of old idols and the iconoclasts, or idol-smashers, is the author’s chief concern. In “The Devil’s Disciple” he puts the scene back a century and a half because he wants to exhibit his hero’s doings against a background of particularly rigid and uncompromising orthodoxy, and the world has moved so fast since Darwin’s time that such orthodoxy scarcely exists to-day. Were it pictured as actually so existing the public would think the picture false and the playwright would fail in the first business of a maker of plays, which is to give an air of reality to his creations. So Dick Dudgeon, in “The Devil’s Disciple” is made a
contemporary of George Washington, and the tradition against which he struggles seems fairly real.
In each of the Shaw plays you will find a sham-smasher like Dick. In “Mrs. Warren’s Profession,” there are three of them—Mrs. Warren herself, her daughter Vivie and Frank Gardner. In “You Never Can Tell” there are the Clandons; in “Arms and the Man” there is Bluntschli, and in “Man and Superman” there are John Tanner and Mendoza, the brigand chief, who appears in the Hell scene as the Devil. In “Candida” and certain other of the plays it is somewhat difficult to label each character distinctly, because there is less definition in the outlines and the people of the play are first on one side and then on the other, much after the fashion of people in real life. But in all of the Shaw plays the necessary conflict is essentially one between old notions of conduct and new ones.
Dramatists of other days, before the world became engaged in its crusade against error and sham, depicted battles of other sorts. In “Hamlet” Shakespeare showed the prince in conflict with himself, and in “The Merchant of Venice” he showed Shylock combatting Antonio, or, in other words, the ideals of the Jew at strife with Christian ideals of charity and mercy. Of late, the most important plays have much resembled those of Shaw. Ibsen, except in his early poetical dramas, deals chiefly with the war between new schemes of human happiness and old rules of conduct. Nora Helmer fights the ancient idea that a married woman should love, honor and obey her husband, no matter what the provocation to do otherwise, just as Mrs. Warren defies the mandate that a woman should preserve her virtue, no matter how much she may suffer thereby. Sudermann, in “Magda,” shows his heroine in revolt against the patriarchal German doctrine that a father’s authority over his children is without limit, and Hauptmann, another German of rare talents, depicts his chief characters in similar situations. Shaw is frankly a disciple of Ibsen, but he is far more than a mere imitator. In some things, indeed—such, for instance, as in fertility of wit and invention —he very greatly exceeds the Norwegian.
IV
As long as a dramatist is faithful to his task of depicting human life as he sees it, it is of small consequence whether the victory, in the dramatic conflict, goes to the one side or the other. In Pinero’s play, “The Second Mrs. Tanqueray,” the heroine loses her battle with convention and her life pays the forfeit. In Ibsen’s “Ghosts,” the contest ends with the destruction of all concerned; in Hauptmann’s “Friedensfest” there is no conclusion at all, and in Sudermann’s “Johnnisfeuer,” orthodox virtue triumphs. The dramatist, properly speaking, is not concerned about the outcome of the struggle. All he is required to do is to draw the two sides accurately and understandingly and to show the conflict naturally. In other words, it is not his business to decide the matter for his audience, but to make those who see his play think it out for themselves.
“Here,” he says, as it were, “I have set down certain human transactions and depicted certain human beings brought face to face with definite conditions, and I have tried to show them meeting these conditions as persons of their sort would meet them in real life. I have endeavored, in brief, to exhibit a scene from life as real people live it. Doubtless, there are lessons to be learned from this scene— lessons that may benefit real men and women if they are ever confronted with the conditions I have described. It is for you, my friends, to work out these lessons for yourselves, each according to his ideas of right and wrong.”
That Shaw makes such an invitation in each of his plays is very plain. The proof lies in the fact that they have, as a matter of common knowledge, caused the public to do more thinking than the dramas of any other contemporary dramatist, with the sole exception of Ibsen. Pick up any of the literary monthlies and you will find a disquisition upon his technique, glance through the dramatic column of your favorite newspaper and you will find some reference to his plays. Go to your woman’s club, O gentle reader! and you will hear your neighbor, Mrs. McGinnis, deliver her views upon “Candida.” Pass among any collection of human beings accustomed to even rudimentary mental activity—and you will hear some mention, direct
or indirect, and some opinion, original or cribbed, of or about the wild Irishman. All of this presupposes thinking, somewhere and by somebody. Mrs. McGinnis’ analysis of Candida’s soul may be plagiarized and in error, but it takes thinking to make errors, and the existence of a plagiarist always proves the existence of a plagiaree. Even the writers of reviews in the literary monthlies, and the press agents who provide discourses upon “You Never Can Tell” for the provincial dailies are thinkers, strange as the idea, at first sight, may seem. And so we may take it for granted that Shaw tries to make us think and that he succeeds.
V“My task,” said Joseph Conrad the other day, in discussing the aims of the novelist, “is, by the power of the written word, to make you hear, to make you feel—it is, before all, to make you see. That— and no more....”
“All that I have composed,” said Hendrik Ibsen, in an address to the Ladies’ Club of Christiania, “has not proceeded from a conscious tendency. I have been more the poet and less the social philosopher than has been believed.... Not alone those who write, but also those who read, compose, and very often they are more full of poetry than the poet himself....”
“The poet,” said Schopenhauer, “brings pictures of life and human character and situations before the imagination, sets everything in motion and leaves it to everyone to think into these pictures as much as his intellectual power will find for him therein.”
Let us suppose, for instance, that “Mrs. Warren’s Profession” is given a performance and that 2000 average citizens pay to see it. Of the 2000 it is probable that 1900 will be persons who accept unquestioningly and without even a passing doubt the legal and ecclesiastical maxim that the Magdalen was a sinner, whom mercy might save from her punishment but not from her sin. A thousand,
perhaps, will sit through the play without progressing any further; it will appeal to them merely as an entertainment and those who are not vastly delighted by its salaciousness, will condemn its immorality. But the 900, let us say, will slowly awaken to the strange fact that there is something to be said against as well as for the ancient maxim. Eight hundred of them, perhaps, after debating the matter in their minds, will decide that the arguments for it overwhelm those against it, and one hundred will leave the playhouse convinced to the contrary or in more or less doubt. But the eight hundred, though they have left harboring the same opinion that was theirs before they came, will have made an infinite step forward. Instead of being unthinking endorsers of a doctrine they have never even examined, they will have become, in the true sense, original thinkers. Thereafter, when they condemn the Magdalen, it will be, not because a hundred popes did so before them, but because on hearing her defense, they found it unconvincing.
In this will be seen the truth of the statement purposely reiterated: that Shaw is in no sense a preacher. His private opinions, very naturally, greatly color his plays, but his true purpose, like that of every dramatist worth while, is to give a more or less accurate and unbiased picture of some phase of human life, that persons observing it may be led to speculate and meditate upon it. In “Widowers’ Houses” he attempts, by setting forth a series of transactions between a given group of familiar Englishmen, to show that capitalism, as a social force, is responsible for the oppression that slum landlords heap upon their tenants, and that, in consequence, every other man of the capitalistic class, no matter what his own particular investments and activities may be, shares, to a greater or less extent, in the landlords’ offense. A capitalist reading this play may conclude with some justice that the merit of husbanding money—or, as Adam Smith calls it, the virtue of abstinence—outweighs his portion of the burden of this sin, or that it is, in a sense, inevitable and so not properly a sin at all; but whatever his conclusion, if he has honestly come to it after a consideration of the facts, he is a far better man than when he accepted the maxims of the majority unquestioningly and without analysis.
