Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

. (page 12 of 100)
Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 12 of 100)
Font size
QR-code for this ebook

alveoli, but also those teeth which are firm.' Vulcanized rubber might
be substituted for the silver in this apparatus.

Wiseman having been summoned to a child with his whole upper
jaw forced in by the kick of a horse, "beating the ethmoides quite in
from the os cribriforme," and forcing the palate bone against the back
of the pharynx, found great difficulty in securing a permanent read-
justment. At first he attempted to introduce his finger back of the
bone, but failing in this, he bent an instrument into the form of a hook,
and passing it between the bone and the pharynx, he easily replaced
the fragments. But, on removing the instrument, they were again
displaced. Immediately he had constructed an instrument by which
the bones could be not only easily reduced, but also retained in place,
extension being made by the hands of the child, his mother, and others,
alternately. In this way the reunion was finally effected, and " the
face restored to a good shape, better than could have been hoped for,"*

Harris, of New York, mentions a case in which a child, two years
old, having fallen from a height of fifty feet upon the pavement, was
found to have a diastasis of both the superior maxillary and palate

> Boston Hed. and Surg. Jonm., vol. Ui. p. 878.

' Report on Deformities after Fracture. Trans. Amer. Med. Association, vol. yiii.
p. 875, Case IV.
3 Traits des Frac., etc., par L. F. Malgaigne, p. 878.
« Chirurgical Treatises, hj Richard Wiseman, 1734, p. 443.

Digitized by



bones; the separation being sufficient to admit the little finger, and
extending from between the alveoli which supported the central in-
cisors, to the soft palate. It is not said whether any efibrts were made
to reduce the bones, but six weeks after the injury was received they
were still open, and it was proposed to close the space by a plastic
operation as soon as the condition of the patient would warrant such
a procedure.^

I suspect that in this example, as in my experiments referred to
under fracture of the malar bone, it was found impossible to adjust
the bones and close the intermaxillary suture, and for the same

If, in consequence of a blow received upon the ossa nasi, the nasal
processes of the superior maxillaa are broken down, they may be lifted
and adjusted in the same manner as the ossa nasi.

I have seen several examples of this accident, and I have in my
cabinet a specimen, in which the nasal bones being driven in by the
kick of a horse, the nasal process upon the left side is broken off just
above the root of the cuspid tooth, and its upper end inclined inward
toward the nasal passage and backward, until it is completely buried.
In this situation it has become firmly united to the bony and soft
tissues into which it was brought in contact.

The following example will illustrate some of the complications
and difficulties connected with a depression of the malar bone, and
consequent fracture of the antrum raaxillare.

M. P., of Colesville, aged about 84 years, was thrown from a height,
striking upon his face, forcing the right malar bone down upon the
antrum of the superior maxilla. Dr. L. Potter, of Yarysburg, and
myself were called.

The deformity produced by the sinking of the malar bone was
very striking, and both the patient and myself were very anxious to
have it remedied, if possible. We found some of the teeth upon the
side of the fracture loose, and we determined to extract them, and
press up the bone with an instrument introduced through the empty
sockets. The first attempt to extract a molar tooth, however, brought
down several teeth, and the whole floor of the antrum. The detach-
ment of this fragment was also now so complete that we believed it
necessary to remove it entirely, a labor which was accomplished with
infinite difficulty, and with no little hazard to the patient, as dissec-
tion had to be extended very far back into the throat, and in the end
it was not effected without bringing out, attached to the fragment of
maxillary bone, a considerable portion of the pyramidal process of
the OS palati.

The time occupied in this operation was at least one hour, during
which we were every moment in the most painful apprehensions lest
we should reach and wound the internal carotid, which lay in such
close juxtaposition to the knife that we could distinctly feel its pulsa-
tion. After its removal, the hemorrhage was for an hour or more

> New York Joum. Med., vol. xiil., 2d ser., p. 214.

Digitized by



qaiie profuse, and could only be restrained by sponge compresses
pressed firmly back into the month and antrum.

When the hemorrhage was sufficiently controlled, we proceeded to
examine the antrum, the Boor of which being removed entire, per>
mitted the finger to enter freely. The restoration of the malar bone
was now accomplished without much difficulty, and with only mode-
rate force.

Two years after the accident the face presented, externally, no
traces of the original injury. The malar bone seemed to be as promi-
nent as upon the opposite side, and there was no perceptible falling
in where the teeth and alveoli were removed. During several months
after the removal of the bone, the antrum continued to discharge pus,
but at length a semi-cartilaginous structure closed in the cavity
below, entirely reconstructing its floor, and the discharge ceased.
Since then he has experienced no further inconvenience.

I wish to propose two or three expedients for lifting the malar bone
when it has been thrust down, which may in certain cases be substi-
tuted for the mode which has been heretofore generally adopted.

In many instances no difficulty will be experienced in resorting to
the usual method. The recent loss of one or more teeth opposite the
floor of the broken antrum, or the complete displacement of a tooth
by the accident itself, will give an opportunity for the perforation of
the antrum through the open socket, and for the introduction of a
suitable instrument for lifting the depressed bone. Unless, however,
the opening is quite large, the instrument employed must be so small,
such as a straight steel sound or a female catheter, as to expose the
parts against which its end is made to pres^ to some risk of being
broken and penetrated. It is even possible in this way to penetrate
the socket of the eye, and thus inflict serious injury upon the eye
itself. Yet, with some care, such accidents may be avoided, and it it»
probable that in the cases supposed, where the sockets of the teeth
opposite the base of the antrum are open, this method will continue
to h^ve the preference.

But if the teeth remain firm in their places, or if they have been
some time removed, and the sockets are filled up, and we wish to enter
the antrum at its base, we must either drill through its anterior wall
above the roots of the teeth, or we must proceed to extract a tooth.
The first method gives an inconvenient opening, and one through
which it will be necessary to use a curved instrument ; but yet it is a
method far less objectionable than the extraction of a tooth which is
firm, or which is even tolerably firm, in its socket^ and which may
require the forceps for its removal. The objections to this latter pro-
cedure were suggested by the tedious and painful operation already
detailed. The first attempt to extract a tooth brought down the whole
floor of the antrum, with all its corresponding teeth, and the pyramidal
process of the palate bone. The tooth was already loose, and we
thought it might easily be taken out, but it had not occurred to us
that it was loosened by the comminuted condition of the walls of the
antrum, and of the dental arcade. The experiments made upon the
dead subject would seem to show that this fracture and comminution

Digitized by



of the alveoli is not a very frequent result of a fracture of the antrann
produced by a blow upon the malar bone, yet it may happen, and
whenever it does, the attempt to extract a tooth must always expose
the patient to the same hazards. Certainly it is no trifling matter to
pull away all of a man's upper teeth upon one side, and to open freely
into a broad cavity which might never close again, and which, ia
this event, must always serve as a place of lodgement for particles of
food, and for foul secretions, to say nothing of the external deformity
which it is likely to produce, and of the severity and even danger of
the operation.

I wish, then, to suggest certain procedures, the value of which I
have been able to determine by experiment upon the living subject
in two or three cases, and which I have carefully and frequently
tested upon the cadaver.

First we ought to attempt to lift the bone by putting the thumb
under its zygomatic process and body within the mouth. If the bone
is thrown directly downward, or downward and backward, this
method can scarcely fail ; and even when it is thrown downward and
forward so as to press into the antrum, it is likely to succeed. If,
however, for any reason, the thumb cannot be brought to bear upon
its under surface, we may make a small incision upon the cheek over
the anterior margin of the masseter muscle, where its insertion into
the malar bone terminates, and pushing a strong blunt hook under
the bone, we may lift it with ease.

Where the depression of the malar bone is in the direction of the
anterior and superior angle these means may not be found available,
and we may then employ a screw elevator, an instrument which I find
already constructed in a case of trephining instruments made for me
by Mr.-Liier, of Paris, and which I have often used, and constantly
recommended to my pupils, in certain cases of fractures of the skull.
The instrument ought to be made of the best steel, and with a broad,
sharp-cutting thread. A slight incision being made through the skin,
and down to the centre of the malar bone, the elevator is then screwed
firmly into its structure, and now its elevation and adjustment may be
accomplished with the greatest ease.

Malgaigne remarks: "In all complicated fractures of the upper
jaw, there is one principle which surgeons cannot too much study,,
namely, that all fragments, however slightly adherent they may be,
ought to be most carefully preserved, and they will be found to unite
with wonderful ease. This remark had already been made by Saviard,
Larrey insists strongly upon it, and we have seen that M. Baudens,
so great an advocate for the removal of loose fragments, has declared
for these fractures a special exemption."*

Malgaigne has here especial reference to fractures of the dental
arcade, and to fractures implicating the alveoli and extending more or
less into the body of the bone.

It would be an error, however, to suppose that a reunion will in

• Op. cit., vol. I. p. 376. Paris cd.

Digitized by



these cases uniformly take place. Exceptions have occurred in my
own practice, the fragments becoming loosened and completely de-
tached after the lapse of several weeks. In the case related by Miller,
the whole floor of the antrum having been broken oflF, in an unskilful
attempt to extract the second right upper molar, it was found impos-
sible to make it unite, and it was subsequently removed.^ Such
unfortunate results certainly may sometimes be reasonably anticipated.
Yet they occur so seldom as to justify the opinions and practice
advocated by Malgaigne.

In some instances, where fragments are displaced, carrying with
them several teeth, while others in the same row remain firm, it will
be sufficient to close the mouth and apply a bandage as for fracture of
the inferior maxilla; in others, the teeth and their alveoli ought to be
fastened with silk, or gold or silver thread ; gold, silver, gutta-percha,
or vulcanite clasps may be applied to the teeth and jaw.

In a case of fracture of the right superior maxilla, reported by
Baker, of Norwich, N. Y., complicated with a fracture of the inferior
maxilla, the alveoli were retained in place very perfectly by a mould
of gutta percha.' Neill, of Philadelphia, has also reported three cases
of fracture of the bones of the face, involving the superior maxilla,
in two of which the eyes were made to protrude more or less from
their sockets.' The loosened alveoli were made fast by wire. The
subsequent deformity was inconsiderable, yet in no instance was the
restoration complete.* The same method was adopted successfully by
a surgeon in Virginia, in the case of a negro fifty years old, where most
of the teeth of the left upper jaw were forced into the mouth, carrying
with them their corresponding alveolar processes. The teeth remained
firm in their sockets, but the separation of the bone was complete, the
fragment being held in place only by the raucous membrane of the
moQth. On the eighth day the surgeon found that the negro had
removed the wire, and also the cork from between his teeth, and the
maxillary bandage: but the soft parts had already united, and the
bones showed no tendency to displacement. His recovery was speedy,
and it was accomplished without any farther treatment.^

Oar experience during the war of the rebellion in this country con-
firms most of the observations heretofore made in relation to these
fractures. Owing to the extreme vascularity of bones composing the
upper jaw, the fragments have been found to unite, after the most
severe gunshot injuries, with surprising rapidity; the amount of
necrosis and caries being usually inconsiderable, compared with
the amount of comminution. The same anatomical circumstance,
namely, the vascularity, has rendered these accidents peculiarly liable
to troublesome hemorrhages, both primary and secondary.
The Surgeon-General reports that of 4167 wounds of the face tran-

< News Letter, April, 1854. Also, Boat. Med. and Surg. Joum., vol. 11. p. 264.
« New York Joum. of Med., vol. i., 8d ser., p. 862.

* Bee '* Observations,'* under Fractures of the Malar Bone ; in which the orbital
plate of the malar bone was pushed into the sockets.

• Phil. Med. Exam., vol. x., new ser., pp. 455-8.
' Amer. Med. Gazette, vol. viii., new ser., p. 106.


Digitized by



Bcribed from the reports from the beginDing of the war to October, 1864,
there were 1579 fractures of the facial bones, and of these 891 re-
covered, 107 died— the terminations are still to be ascertained in 581
cases. He farther remarks that secondary hemorrhage has been the
principal source of fatality in these cases, and that frequent recourse
has been had to ligation of the carotid, with the result of postponing-
for a time the fatal event.^



The zygoma, strictly speaking, is formed in a great measure by th#
body of the malar bone, and it is broken whenever the malar bone is
completely separated through any portion of its body ; but I propose
to confine my remarks to that portion only which is composed of the
two processes, called respectively the zygomatic processes of the malar
and temporal bone.

Duverney relates a case in which a young child, having in his
mouth the end of a lace-spindle, fell forwards and thrust the spindle
through the mopth from within outwards, breaking the zygoma in the
same direction, and leaving the fragments salient outwards.' To which
case of outward displacement Packard, in a note to Malgaigne's work
on fractures, &c., has added a second.^

I know of no other examples in which the fragments have been
thrust outwards. A reference to my experiments upon the naked
skull will, however, show that the zygoma may be broken and dis-
placed in the same direction, by any force which shall fracture the
superior maxilla, and depress the anterior margin of the malar bone.
In my experiments this has happened three times, and always at the
same point, viz., a little beyond the middle of the zygoma, near where
the suture which joins the two processes terminates below. The
fractures were always transverse, and not in the line of the suture.
They were therefore fractures of that portion of the zygoma which
belongs to the temporal bone.

I suspect, also, that to this class of cases belongs the example re-
lated by Dupuy tren, in which the patient having died on the fifth day,
from the effects of the cerebral concussion, the autopsy disclosed " a
fracture through the zygomatic arch ; and that part of the superior
maxillary bone which constitutes the antrum was driven in."^

In another case mentioned by Dupuytren, produced by a direct
blow, the fracture was compound and comminuted, and although the

< Circular No. 6, Washington, Nov. 1, 1865, p. 20.

* fialletin de la Society Anatomiqae, p. 188, 1810.
» Op. cit., p. 2«9, vol. i.

* Injuries and Diseases of Bones, by Baron Dapnytren. 8yd. cd., London, 1847,
p. 830.

Digitized by



fragments were raised easily by an elevator, suppuration ensued be-
neath, and the matter was discharged within the mouth.^

Tavignot reports a case of fracture of this arch which was not dis-
covered until after death, the fragments not being at all displaced.'

Dr. John Boardman, one of the surgeons to the Buffalo Hospital of
the Sisters of Charity, informs me that he has met with a fracture of
the zygoma in a man about thirty years of age, occasioned by a blow
from a cricket ball. Dr. Boardman saw him on the fourth day, and
ascertained that immediately on the receipt of the injury he felt
slightly stunned, and that he'soon recovered from this, but was unable
to open his mouth except by pulling it open with his hand; neither
could he close it except in the same manner. This immobility of the
jaw continued several days with only very slight improvement; at
the end of five weeks, however, when last seen, the mobility was
nearly, but not quite, restored. The depression, a little in front of
the centre of the zygoma, was discovered by the patient himself im-
mediately after the receipt of the injury, and he says he tried at once
to ascertain whether he could not push the fragments back by moving
the jaw. He was unable to make any impression upon them by this
manoeuvre. The depression still remains, but it is not so distinct as
it was when first seen.

Symptoms. — An irregular projection or depression of the fragments
is the only sign which can be relied upon to indicate the existence of
this accident; and this must often be concealed by the swelling which
follows so rapidly wherever the integuments are severely bruised over
a superficial bone. This displacement can scarcely occur in but two
directions, either outwards or inwards ; since the attachments of the
temporal aponeurosis above, and of the masseter muscle below, must
effectually prevent its descent or ascent.

Neither motion nor crepitus will often be present. In some few
cases the difBiculty in opening or shutting the mouth, occasioned by
the projection of the fragments towards or into the tendon of the tem-
poral muscle, may assist in the diagnosis.

Prognosis. — ^If the fracture has been produced indirectly by a de-
pression of the malar bone, the prognosis must depend upon the
amount of injury done to the other bones of the face; in itself, the
fracture of the zygoma cannot be a matter of any moment. The same
remark might apply also to any fracture of the zygoma in which the
angles were salient outwards. If, on the contrary, the angle is salient
inwards, the fracture having been produced by a blow inflicted directly
upon the zygomatic arch, from without, or by a blow upon the outer
portion of the malar bone, it may, perhaps, occasion some embarrass-
ment to the action of the temporal muscles.

If the force which produces the fracture has acted more upon the
temporal portion of tne arch, near where the process arises from the
temporal bone, it may be accompanied with a fracture of the skull,
and with serious cerebral lesions, as in one of the cases already alluded
to as having been noticed by Dupuytren.

I Op. cit., p. 885. > Bunetin de la Soc. Anat., 1810, p. 138.

Digitized by



The abscess which followed in the case of the compouDd, commi-
nuted fracture, quoted from the same author, indicates the danger of
this complication ; biit it must be noticed that its evacuation resulted
in a rapid cure, and that no deformity or diiBculty in moving the jaw

Treatment. — A fracture, accompanied with an outward displacement,
and occasioned by a depression of the malar bone, will be adjusted
by a restoration of the malar bone in the manner already described,
when speaking of fractures of the superior maxillary, &c. If the
fragments are displaced outwards, in consequence of a direct blow
from within, then they may be replaced by pressing upon the project-
ing angle. In this way Duverney easily reduced the bones in the
case which I have cited.

When the fragments, in consequence of a direct blow from with-
out, have been driven inwards, and, as a consequence, serious embar-
rassment to the motions of the temporal muscle ensues, an attempt
ought to be made at once to replace them ; if, however, no impedi-
ment to the action of the muscle exists, it is scarcely necessary to say
that no surgical interference will be required. It is quite probable,
indeed, that a slight amount of embarrassment may be the result of
the direct injury to the muscle inflicted by the blow, without reference
to the displacement of the bone, and that a few days will suffice to
remedy this evil entirely ; and, moreover, experience teaches that in
the case of a fracture in other bones, where the fragments actually
penetrate the muscles and remain thus displaced, the. points are gradu-
ally absorbed, and rounded, so that after a time they constitute no
impediment to the action of the muscles. It is proper to infer that
the same thing will occur here. The surgeon may be reminded, also,
that it is not the muscle but only its tendon which is liable to be
penetrated, and that even this is usually protected somewhat by a
plate of soft adipose tissue lying between the tendon and the arch.

If to these considerations we add the difficulties which we shall be
likely to encounter in the reduction, we shall expect to find but few
cases in which a resort to surgical interference will be necessary.

Duverney says that he restored a fracture of this arch, accompanied
with depression, by pressing against the zygoma from within the
mouth; but an examination of the interior of the buccal cavity will
convince us that this is impossible when the fracture is at any point
near the middle of the zygoma, and that it can be only when the frac-
ture is at or near the junction of the zygoma with the body of the
malar bone that any effective pressure can be made from this direction.
In such a case, we may, perhaps, lift the portion of the zygoma re-
maining attached to the malar bone, by the same means which have
already been suggested for lifting the bone itself.

If the bone is driven toward the tendon of the temporal muscle at
or near its centre, as happens almost always, then if its restoration be-
comes necessary, it can be accomplished only by approaching the bone
from without.

Dupuytren found an external wound through which, by the aid of
a levator, he easily restored the fragments to place.

Digitized by



M. Ferrier, however, of the Hospital of Aries, in a case brought
before him, made an incision through the integuments down to the
bone, and then attempted to slide underneath the small extremity of
a spatula; but the aponeurosis would not yield, and he was obliged
to cut it also. He was now able to lift the fragments easily. The
wound healed rapidly, and the patient was dismissed without any de-



Division. — Of 43 examples of fracture of this bone which have
come under my observation and been recorded by me, not including
gunshot fractures, 40 were broken through some portion of the body.

Having made an analysis of 83 of the above examples, I find that
13 were broken completely asunder at two or more points, consti-
tuting double and triple fractures; and of the remaining 20, 5 were
accompanied with detachment of portions of the alveoli, and 1 with
detachment of a considerable frag-

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 12 of 100)