Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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ment from the body. Fig. 25.

19 of the 33 were comminuted
fractures. 12 were compound; not
including in this enumeration sev-
eral examples in which the partial
or complete dislodgement of a tooth
might entitle them to be called com-
poand.

Four fractures through or near
the symphysis were nearly or quite
vertical, and 18 of the remainder

were known to be oblique. Malgaigne has remarked, also, that in
fractures of the body of the bone the direction of the obliquity is
generally such that the anterior fragment is made at the expense of
the internal face of the bone, and the posterior fragment at the ex-
pense of the external face; this latter overriding the former. Buck,
of New York, has seen the fragments in an opposite condition, requir-
ing the use of the knife and the saw for their extrication.' I have
myself recorded one similar example, but in which the fragments
were easily replaced.

In twenty examples of fractures through the body, not including
fractures of the symphysis, the line of fracture has been observed to be
fourteen times at or very near the mental foramen ; twice between the

* Balletin dcs Sciences M6d., torn. x. p. 160.

« New York Joum. Med., March, 1847. Proceedings of N. Y. Med. and Surg.
Boc., Sept. 19, 1846.



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110 FRACTUBES OF THE LOWEB JAW.

first and second incisor; three times behind the last molar, and once
between the last two molars.

Syme, Liston, and Miller have remarked, also, the greater fre-
quency of fracture near this foramen, but Mr. Erichsen thinks he has
seen it most frequently broken near the symphysis, between the lateral
incisors or between these teeth and the canine. Boyer observes that
it is generally somewhat in front of the foramen; for which reason, as
he thinks, the dental nerve is rarely torn.

Says Boyer, in his Traili des Maladies Ohirurgtcales, "A fracture
never takes place in the central point of the length of the jaw, called
the symphysis of the chin ; but when the solution of continuity occurs
towards the middle of the bone, it is upon one or the other side of the
symphysis, which remains always upon one of the fragments." An
opinion which, however, he does not seem always to have entertained,
since Richerand, in a report of his lectures, has made him say that a
fracture sometimes takes place " near the chin, but seldom so as to
produce the division of th^ symphysis of that part, though it be not
impossible." But many surgeons since his time have noticed this
fracture, and Malgaigne assures us that J. Cloquet has demonstrated
its existence upon an anatomical specimen.

Stephen Smith, of New York, has seen two examples,* Lonsdale
mentions three,* and Gibson has seen one,' and I have met with two,
both of which are recorded in the early editions of this book.

Velpeau, Fergusson, Gibson, Henry Smith, and others, have re-
marked that a separation at the symphysis takes place usually in in-
fancy or childhood. But in the eight examples in which I find the
ages reported, only one, a case mentioned by Lonsdale, occurred in a
person as young as ten years; in one of the cases seen by myself the
patient was seventeen years old, and the remainder have ranged from
twenty-five years to sixty ; and the average age of all is thirty-two
years.

I have seen one example of a fracture of the ramus, in a man twenty-
three years old, who had been struck by a wooden block on the side
of his face. The ramus was broken just above the angle, and the
body was broken, also, obliquely near the symphysis. The intercepted
fragment was carried inwards:^ and in May, 1869, 1 met with another
similar case at Bellevue Hospital, in a woman ; a pharyngeal abscess
resulted, threatening suflEbcation ; for which my house surgeon. Dr.
Frank Bosworth, performed tracheotomy successfully. Ledran men-
tions the case of a child, ten or twelve years old, in whom the fracture
was double also; one fracture having taken place through the bo3y,
and one extending obliquely from the root or the coronoid process to
the neck of the condyle. The intercepted fragment was, however, so
little displaced that the fracture of the ramus was not discovered until
after death.* Malgaigne refers to this as the only example recorded ;

> New York Jonm. Med., Jan. 1857, Hospital Reports.

« Practical Treatise on Fractures. By Edward F. Lonsdale. London, 1888, p. 286.

s Institutes and Practice of Surg. By Wm. Gibson. Philadelphia, 1841, p. 261.

* Trans. Amer. Med. Assoc. Report on *^ Deformities after Fractures,'* vol. viU.
p. 885, Case 17.

* Malgaigne, op. cit., p. 837, from Ledran, Observ. Chirurg., torn. i. obs. viii.



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rRAOTURES OF THE LOWER JAW. Ill

but Stephen Smith, of the Bellevue Hospital, has met with it four
times : in one case the ramus was broken on both sides; in two cases
one ramus only was broken ; and in one the body was broken on the
right side and the ramus on the left.^ In two of these examples the
fragments were not displaced.

The coronoid process is so well protected by muscles and by the
surrounding bony projections, that it is very rarely broken.

Houzelot mentions a case in which a fall from a height produced
at the same time a fracture of both condyles, of both coronoid pro-
cesses, and of the symphysis.^

With this single exception, I am not able to find a recorded exam-
ple of a fracture of this process.

At least nine cases have been reported of fracture of the condyles,
in all of which the separation occurred through the neck, viz., three
by Ribes, two by Desault, one by B^rard, one by Houzelot, one bv
Bichat, one by Packard, of Philadelphia, and two by Watson, of K. Y.
The fracture always occurring through the neck and just below the
insertion of the external pterygoid muscle.

According to Malgaigne, the analysis of these cases, excepting those
mentioned by Packard and Watson, shows two classes of examples :
the one occasioned by falls or blows upon the chin, and producing a
simple fracture of the neck of the condyle ; the other occasioned by
injuries inflicted upon the side of the face, and producing a fracture
of the neck on the side corresponding to that upon which the injuries
are received, and at the same time a fracture of the body upon the
opposite side. These two varieties seem to be about equally common.

In the case mentioned by Houzelot, and already cited, there existed
at the same time a fracture of both condyles, of both coronoid pro-
cesses, and at the symphysis. The man also whom Watson saw in
the New York Hospital, had fallen from the yard-arm of a vessel,
breaking his thigh and arm bones and both condyles of the lower jaw.
" His face was somewhat deformed by the retraction of the chin ; the
mouth could not be opened so as to protrude the tongue to any great
extent beyond the teeth, and the teeth of the upper and lower jaws
could not be brought into contact. Id attempting to move the jaw,
the patient experienced pain and crepitation just in front of the ears;
the crepitation could easily be felt by placing the fingers over tlfe
fractured condyles. Nothing was done for the fractures of the jaw.
In a few weeks the rubbing of the broken surfaces and attendant sore-
ness ceased to trouble him ; but the shape of the jaw, and difficulty of
opening the mouth to any great extent, still remained unaltered."^

Miology. — ^The causes, in such cases as I have myself investigated,
seem generally to have been direct blows, in most instances inflicted
by a club, or by the kick of a horse; in two examples the blow was
inflicted by the fist. I have also seen a fracture immediately in front
of the right cuspid, in a lad eight years of age, produced by being
pressed between two wagons, the pressure being made upon the two

' New York Journ. of Med., Jan. 1857. Bellevue Hosp. Reports.

' Malgaiffne, op. cit., p. 400.

* New York Journ. of Med., Oct. 1840. Hospital Reports.



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112 . PBACTURES OP THE LOWER JAW.

angles of tbe jaw. In ten of eleven cases mentioned by Stephen Smitb,
the causes were direct blows. Examples of fracture of the inferior
maxilla from indirect blows have, however, been mentioned by other
surgeons, the angles of the bone being pressed together by the pas-
sage of a wheel, and the fracture taking place usually towards the
symphysis.

We have already alluded to the observation of Malgaigne, that frac-
tures of the condyles belong to two classes; the one being occasioned
by falls upon the chin, and the other by blows upon the side of the
face; the former acting as a counter force, and the latter as a direct.

The coronoid process can only be broken by a direct blow.

Symptoms, — Fractures of the body of the bone are characterized by
the usual signs of fracture elsewhere, namely, displacement, mobility,
crepitus, and pain.

The displacement is generally present; but its direction and amount
vary according to tbe situation and course of the fracture, and also
according to the violence and direction of the force producing the
fracture. I have seen several cases unaccompanied with displacement^
and one of these I think ought to be regarded as an example of a
partial fracture.

A lad, aet. 9, was kicked by a horse on the 22d of June, 1858, the
blow being received on the right side of the jaw. I saw him very
soon after the accident, but could not detect any fracture, only the
body of the jaw seemed to be bent in. On the third day, however,
while endeavoring to straighten the jaw by violent pressure from
within outwards, I detected a feeble crepitus, which on more careful
examination proved to be opposite the second incisor of the right
side. I was also able to detect a slight motion at the same point. It
was found impossible to rectify the bending, and no farther eflforts
were employed. At this moment, after a lapse of nearly a year, the
natural curve is partially but not completely restored.

Ledran and other surgeons have also seen examples where neither
the periosteum nor mucous membrane was torn.

Generally, in fractures of the body, the anterior fragment is de-
pressed; and Malgaigne affirms that where an overlapping occurs, the
anterior fragment lies, generally, within the posterior ; a fact which
he explains by the direction which the line of fracture usually takes,
namely, from without, inwards and backwards, as we have already
mentioned. In one instance, reported by me to the Amer. Med. Assoc.,
where the jaw was broken at the symphysis and also on both sides
through the body, the central fragments were found, after about four
weeks, lifted two lines above the lateral fragments, and also slightly
carried backwards.^ I have twice also met with examples in which
the posterior fragments were inclined to fall inwards toward the mouth,
acircumstance which seemed to indicate that the course of the obliquity
was in a direction opposite to that which Malgaigne has observed to
be most frequent. In each of these examples the jaw was broken
upon both sides, by blows inflicted with a club, and the fractures were

> Trans. Amer. Med. Assoc, vol. viii. p. 880, 1855, Case 6.



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FRACTURES OF THE LOWER JAW. 118

situated well back.^ It is possible, however, that the position of the
fragments was dae rather to the direction and foroe of the impression
than to the direction of the line of fractare.

As to the action of the muscles in the production of displacement,
Boyer, S. Cooper, Erichsen, and Malgaigne have observed that their
action upon the anterior fragment is greater in proportion as the frac*
ture is nearer the symphysis, and less in proportion as it approaches
the angle. So that in the former case the attempt to close the mouth
is sometimes attended with a depression of the anterior fragment,
causing a separation of the fragments at their alveolar margins ; while
in the latter case the attempt to close the mouth forcibly is occasion-
ally attended with separation of the fragments along the line of the
base;

While I am not prepared to deny the accuracy of these observations,
it is proper to notice that Liston finds the greatest displacement when
the fracture is opposite the first molar, and I must confess that the fact,
as stated by Boyer and others, does not seem to admit of a satisfactory
explanation; since the number, and consequently the power, of the
muscles which act upon the anterior fragment from below is greater
in proportion as the line of fracture is farther back. These muscles,
namely, the digastricus, the genio-hyo-glossus, and the mylo-hyoideus,
with several other muscles which act less directly, all tend to depress
the anterior fragment, and in some slight degree to carry it backwards,
a direction which, indeed, it usually takes, and which it would pro*
bably always take if left alone to the action of the muscles. If the
fracture has occurred through the angle, or at any point within the
attachments of the masseter muscle, the action of those fibres of this
muscle which remain connected with the anterior fragment will suffi*
ciently explain the fact that it is not now so easily depressed below
the level of the posterior fragment ; while the separation of the frag-
ments along the line of the base when an attempt is made to close
the jaw forcibly, is probably due to the loosening and partial dislodge-
ment of some of the molars, which, being pressed upwards, act as a
pivot upon which the fragments are made to bend.

Boyer affirms, also, that "the fractured portions are never deranged
so as that one passes on the other, or in the direction of their length ;
for the action of none of the muscles of the lower jaw is parallel to
the axis of that bone ; besides, its extremities are retained in the
glenoidal cavities of the temporal bones." But this theory is too ex-
clusive, since the fragments may have become displaced in any direc-
tion independently of the muscular action. Moreover, the action of
the muscles attached to the anterior fragment, although not parallel to
the axis of the bone, does somewhat favor a displacement in this
direction; and the action of the pterygoid muscles upon the posterior
fragment still farther favors this form of displacement.

An overlapping of the fragments in the direction of the axis is, in
simple fractures, no doubt, exceptional, and in such examples as I have
seen, it was very trivial. It occurred in case "three" of my "Report,"

> Ibid., Cases 1 and 10.



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114 FRACTURES OP THE LOWER JAW.

the fracture beiag near the raeatal foramen ; in case "two," the frac-
ture being just anterior to the last molar; and also in case '^ six,'^
where the bone had been broken through the centre of the body oq
both sides and through the symphysis; but in neither case did the
overlapping exceed two or three lines, and it was always easily over-
come.

The mobility of the fragments is not so striking in these accidents
as in fractures of the long bones, yet it is generally sufficiently marked,
and especially where the bone is broken upon both sides at the same
time. If 'only one side is broken, both motion and crepitus will be
most easily detected by lateral pressure upon the posterior fragment,
which, being the smallest and the least supported by antagonizing
muscles, will be found to be the most movable. If the fracture is
upon both sides, mobility and crepitus will be most readily developed
by seizing upon the anterior fragment and moving it gently up and
down, while the finger rests upon the alveolus within the mouth.

Sometimes a slight swelling or tenderness at some point of the
dental arcade, or the loosening or complete dislodgement of a tootb,
will indicate the point of fracture.

Pain, especially when the fragments are moved, is here more con-
stant than in most other fractures, owing perhaps, in part, to the
superficijal position of the bone, which renders the soft parts lying over
it more liable to injury from the causes of fracture ; but also, in part,
to the lesions which the inferior dental nerve may have suffered. It
is, indeed, a matter of surprise that injury to this nerve does not
oflener seriously complicate these accidents, coursing, as it does,
through so large a portion of the angle and body of the bone. One
might naturally suppose that its complete disruption would often
occasion paralysis of those portions of the face to which it is finally
distributed, and that its partial lesions and contusions would create,
in many cases, the most acute and constant suffering. It is rare, how-
ever, that we have present an amount of pain which might not be
attributed to a severe shock, or a slight strain upon its fibres. I have
myself never seen any extraordinary suffering distinctly attributable
to an injury of the dental nerve after fracture, nor any degree of fajcial
paralysis. Bossi relates a case in which convulsions followed this
accident, and in which, as a final remedy, he proposed to expose and
bisect the nerve; and Flajani saw a patient, whose jaw had been
broken, die in convulsions on the tenth day, the muscular contractions
having commenced as early as the fourth day after the accident. The
autopsy disclosed a rupture of the dental nerve, but no injury to the
brain.

These two examples are, as far as I know, all which our records
supply, in which grave results have been attributed to lesions of this
nerve ; and even here some doubt must remain whether the symptoms
were not quite as much due to the immediate injury done to the brain
as to the nerve.

Boyer explained the infrequency of severe injury to the dental
nerve by the supposition that the " greater part of these fractures take
place between the symphysis and the foramen by which this nerve



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FRACTURES OF THE LOWER JAW. 115

comes out.'' An opinion which may be correct, but needs confirma-
tion. I have seen the body or angle broken at points posterior to the
mental foramen, and where the nerve lies within its bony canal,
twelve times, and in front of the mental foramen eight times; at
other times the point of fractare has not been noted with such accu-
racy as to enable me to say whether it was in front or behind the
foramen.

I suspect that a better explanation may be found in the fact that the
fragments seldom overlap, to any appreciable extent, and that even
the displacement in the direction of the diameters of the bone is gene-
rally inconsiderable ; or if it does exist, the fragments are easily and
promptly replaced.

If the displacement is sufficient to occasion a complete disruption
of the nerve, some degree of temporary paralysis in the portions of
the face supplied by it must be inevitable; and, perhaps, this occurs
oflener than it has been noticed, since, during the confinement of the
jaw by dressings, it is not likely to be observed, and after the lapse of
a few weeks it will probably cease altogether.

Boyer remarks that when it is torn, " the square and triangular
muscles of the chin are paralyzed. The skin of that part and the in-
ternal membrane of the under lip preserve their sensibility, which it
appears they owe to some threads of the portio dura of the seventh
pair; but the paralysis of these muscles does not prove of itself that
the jaw is fractured." Boyer has, however, noticed this result but
once, and then in a case where the bone was broken upon both sides
and the soft parts greatly contused. The triangular and square mus-
cles were paralyzed, in consequence of which there was a slight con-
tortion of the mouth. A. B^rard has also mentioned a case of vertical
fracture occurring between the second and third molars, without dis-
placement, which was accompanied with complete insensibility of the
lip on the same side throughout the space comprised between the
commissure and the median line, and between the free border of the
lip and the chin. The paralysis disappeared after a few days.^

To these signs now enumerated, we may add as occasional com-
plicationsy rather than as diagnostic symptoms, salivation, swelling of
the submaxillary and sublingual glands, abscesses, necrosis, &c. If
the blow has been vertical upon the chin, and the direction of its
force has been towards the articulations, the bony structure of the
ear, and even the brain, may have suffered serious lesions, which may
be indicated by a deafness or a roaring in the ears, by bleeding from
the external meatus, and by fatal coma. Tessier saw a man who had
received the kick of a horse exactly upon the centre of the chin,
breaking the bone on both sides, and who, in consequence, bled freely
from his ears;' and Alix relates the case of a young man who, fall-
ing from a height and striking upon his chiu, had broken his jaw.
Insensibility immediately followed ; convulsions also ensued upon the
fourth day, and he died upon the sixth.^

> Malgaigne, from Gazette des Hdpitaux, 10 AoOt, 1841.
Malgaigne, pp. 888 and 886, from Joum. de M^d., 1789, tom. Ixxiz. p. 246.
Ibid., p. 886, from Alix, Obseryata Chir., fascic. 1, ob&. 10.



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116 FRACTURES OP THB LOWER JAW.

If the fracture is at the symphysis, it is generally vertical, and either
fragment may be found slightly displaced upwards or downwards.
In one of the examples seen by myself, the left fragment fell three
lines below the right, and in another the right side had fallen about
one line. In a case mentioned by Syme there was scarcely any dis-*
placement.^ Liston remarks that it is usually slight Erichsen and
B. Cooper have observed the same.

Signs which indicate a fracture through the angle have already
been sufficiently considered when speaking of fractures of the body ;
from which it only differs in the less degree of displacement, and ia
the fact that the posterior fragments are a little more prone to fall in-
wards towards the mouth. I have noticed, also, that, owing probably
to the loosening and partial dislodgement of the last molar^ it is some-
times difficult to close the mouth, the same as in the fractures a little
farther forwards.

In each of the two examples of fracture of the ascending ramus
which I have seen, the bone being broken also through its body, the
fracture of the ramus was recognized by both crepitus and mobility.

As to the signs which indicate a fracture of the coronoid process, I
am only able to infer them from its anatomical relations. There must
be some embarrassment in the motions of the jaw, occasioned by the
detachment of a portion of the fibres of the temporal muscle ; and
it is probable that an examination by the finger within the mouth
would readily detect mobility and displacement.

A fracture through the neck of the condyle is characterized by pain
at the seat of fracture, especially recognized when an attempt is made
to open or shut the mouth, by embarrassment in the motions of the
jaw, by crepitus. Which may usually be felt or heard by the patient
himself, by mobility and displacement.

The upper fragmient, if disengaged from the lower, is drawn for-
wards, upwards, and inwards, by the action of the pterygoideus exter-
nus ; and it is felt not to accompany the movements of the lower
fragment.

The lower fragment is at the same time drawn upwards, in conse-
quence of which the lower part of the face is distorteds'; a circum-
stance first noticed by Bibes, and which supplies an important diag-
nostic mark between a fracture of one condyle and a dislocation. In
dislocation, the chin is commonly thrown to one side, but it is to the
side opposite that on which the dislocation has occurred, while in frac-
ture the chin is drawn to the same side.

Prognosis. — Physick, of Philadelphia, saw a case of non-union of
the body of this bone, which had existed nine months.* Dupuytren
mentions a case which had existed three years." Stephen Smith, of
New York, reports a case of fracture of both the body and the ramus,
in a man forty-five years old. The severity of the injury, with the
supervention of delirium tremens, prevented the application of dress-
ings until the thirteenth day. On the twentieth day about a pint of
blood was lost by hemorrhage from the seat of fracture. He re-

> Amer. Joum. Med. Sci., vol. xvlii. p. 348.

• Phila. Med. and Surg. Joum., voL v. • Lemons Orales.



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PBACTURBS OF THE LOWER JAW. 117

mained in the hospital one hundred and thirty-seven days, and was
finally discharged, the fragments not having yet united.' I have
seen one example of fibrous union in the case of a man who broke
the body of the jaw by a fall upon his chin. Malgaigne says that
Boyer has seen several examples, but I know of no other cases, unless



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 13 of 100)