Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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toid ligaments, and a dislocation of the atlas backwards.^

South says there is a specimen in the museum of St. Thomas's Hos-
pital, showing this double fracture. The man had received bis injury
only a few hours before admission to the hospital, and died on the
fifth day. On examination, the atlas was founa to be broken in two
places, and the odontoid process of the axis at its root. The fifth ver-
tebra was also broken through its body. With neither fracture was
there sufficient displacement to produce pressure, but a small quantity
of extravasated blood lay in the substance of the spinal marrow, and
its tissue was at one point broken down and disorganized.*

Mr. Phillips relates that a man fell from a hay-rick, striking upon
the occiput ; after which, although momentarily stunned, he walked
half a mile to the parish surgeon, and in two days more he returned
to his occupation. About four weeks after the accident he was seen
by Mr. Phillips, who discovered a small tumor over the second cervi-
cal vertebra, pressure upon which caused a slight pain. He com-
plained also that his neck was stiff, and that he was unable to rotate
it. No other disturbance of the functions of the body could be dis-
covered. After a time the tonsils became swollen, and the patient
experienced some difficnlty in deglutition, and, upon examining the
throat, a slight projection or fulness was discovered at the back of
the larynx, opposite the second cervical vertebra. Subsequently he
became affected with general anasarca and pleuritic effusions, of which
he finally died. Up to the last week of his life he was able to walk
about his bedroom, and his condition presented no other evidence
than has been mentioned, that he was suffering from an injury of the
spine. He died forty-seven weeks after the receipt of the injury.

The autopsy disclosed a fracture with displacement of the atlas, and
a fracture of the odontoid process of the axis. The two vertebrsa
were united to each other firmly by complete bony callus.^



CHAPTER XVI.

FRACTURES OF THE STERNUM.

Fbactubss of the sternum are of rare occurrence, owing, probably,
to the elasticity of the ribs and their cartilages, upon which it mainly
rests, and also, in part, to the softness of its structure. In advanced
life, the ossification and fusion of all of its several portions becoming
more complete, and the cartilages of the ribs also becoming more or
less ossified, its fracture is relatively more frequent.



> Malffaiffne, op. dt., torn. ii. p. 888.

* GheuoB^ Surgery, note by South, yol. i. p. 688.

• Phillips, Mel-Chir. Trans., vol. zx. 1887, p. 884.



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166 TRACTUBES OP THE STEBNUM.

Ckvxses. — They are generally the result of direct blows inflicted upon
the part, such as the passage of a loaded vehicle across the chest, the
fall of a tree or of some heavy •timber upon the body ; the fracture
implying always that great force has been applied.

Indirect blows, and voluntary muscular action alone have been
known also occasionally to produce this fracture.

David, in his Mimoire sur les Contrecoups, published as a prize
essay by the Academy of Medicine, mentions the case of a mason, who,
in falling from a great height^ struck upon his back against a cross-
bar which intercepted his fall, in consequence of which the abdominal
and sterno-cleido-mastoidean muscles were so stretched that the ster-
num broke asunder between its upper and middle portions.^ Sabatier
reports another case of fracture at the same point, produced in a simi-
lar manner f and Roland has described a third example in a woman
sixty-three years old, who, falling from a height backwards and strik-
ing upon her back, broke the sternum near its centre.*

Gruveilhier saw a man who, having fallen from a height of twenty
feet upon his nates, was found to have a fracture of the sternum/
Cussan saw the same result in a person who fell from a third story,
striking first upon his feet and then pitching over upon his back.'
Maunoury and Thore have reported an analogous case, where a man
fell from a height of twelve or fifteen mkres, first striking upon his
feet and then falling over upon his back and head.' Mr. Johnson,
late editor of the London Med.-Ghir. Bev., reports a case of this kind,
also, as having been received into St. George's Hospital, in London ;
the man, a health v laborer from the country, had fallen from the top
of a hay-cart, striking only upon his head. He walked with his head
much bent forwards, and was incapable of either flexing, extending,
or rotating it any &rther. The fracture was transverse, and about
three inches below the top of the sternum, opposite the centre of the
third rib, the lower fragment projecting in front of the upper. The
fragments were easily replaced by simply throwing the head back,
and fell into place with an audible snap, but immediately resumed
their unnatural position when the head was flexed. They finally
united, but with a slight projection and overlapping.' Gross has
reported one more example.*

Malgaigne expresses a doubt whether all these can be considered
as the results of muscular action, since, in a certain number of the
examples cited, the head seems to have been thrown forwards by the
concussion, and in others, also, there is no evidence that the muscles
attached to the sternum were put upon the stretch. The only remain-
ing explanation is that in such cases the sternum has been broken by
the violent shock, or corUrecoup.

> Boyer on Bones, p. 67.

* Malgaigne, from Sabatier, M6m. sur la Fract. du Sternum,
s Ibid., from Bull, de Th^rap., torn. vi. p. 288.

« Ibid., from BuU. de la Soc. Anat., Jain, 1826.

• Ibid., from Atchiy. de MM., Jany. 1827.
c Ibid., from Qaz. M6d., 1842, p. 861.

7 London Med.-Chir. Rev., vol. xTii., new series, p. 586, 1882.
» Gross, System of Surg., vol. ii. p. 167.



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FBACTtXBBS OF THE STEBNUM.



167




ra/irely unite ,



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year
I toon after j9uhertf

j^rtly cariHa^iTmus /»

advaofied life

SterQQiD, Bbowlng the periods at wMoh its several
parts anlte by bone. (From Gray.)



Seal and Direction of Fracture. — The sternum is separated most fre*
quently either ia the long cen-
tral portion, or at the junction
of this with the upper portion,
where the bohe is weakest. In
fact, a separation at this latter
point may be regarded fre-
quently as a diastasis or dislo-
cation rather than as a fracture,
since the two portions do not
become firmly united by bone
until late in life. The very late
ossification and fusion of the
xiphoid cartilage with the cen-
tral piece, also, will explain the
infrequency of its fracture.

Boj^er believed that the xi«
phoid cartilage was not suscepti-
ble of being permanently dis-
placed backwards, except in
aged persons, after it had become ossified, " for," he says, '' though
violently struck and driven backwards by a blow on what is vulgarly
termed the pit of the stomach, yet it restores itself by its own elas-
ticity."^

The following case, however, which has come under my own ob-
servation, is conclusive as to the possibility of this accident : —

A man, twenty -eight years old, fell forwards, striking the lower end
of his sternum upon the top of a candlestick, breaking in the xiphoid
cartilage. During two years following the accident he had frequent
attacks of vomiting, which were excessively violent and distressing;
the paroxysms occurring ev^ry five or six days. Both Dr. Green,
of Albany, and Dr. White, of Cherry Valley, upon whom he called for
relief, recommended excision of the cartilage, but the patient would
not submit to the operation. Twelve years after the accident, in the
year 1848, while he was an inmate of the Buffalo Hospital of the
Sisters of Charity, I examined his chest, and found the xiphoid carti-
lage bent at right angles with the sternum, pointing directly towards
the spine. He now suffered no inconvenience from it, except that it
hurt him occasionally when he coughed.'

The upper portion of the sternum is rarely broken, unless at the
same time the central portion is broken also.

The direction of these fractures is generally transverse, or nearly
so ; occasionally a slight obliquity is found in the direction of the
thickness of the bone. In three or four examples upon record, the
direction of the fracture was longitudinal. It is not so unfrequent,
however, to find the bone comminuted. Compound fractures are
exceedingly rare.

1 Boyer on Diseases of Bones, p. 60.

< Buffalo Med. Joum., yol. zii. p. 282, Gases of Fractures of the Sternum.



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168 FBACTUBES OF THE STSBNUK.

When tbe fracture is transverae, the lower fragment is almost
always displaced forwards^ and sometimes it slightly overlaps the
upper fragment.

In one idstance mentioned by Sabatier, where the separation bad
taken place at the point of junction between the fir^t and fiecond
pieces, the lower fragment was displaced backwards, and was also car-
ried upwards under the upper fragment to the extent of twenty -eight
milliinStres,

I have seen a remarkable case of separation of the manubrium
from the gladiolus, accompanied with a true fracture and otber
complications.

Louis Wilson, »t. 60, was admitted into the Long Island College
Hospital, April 4, 1866, having just fallen through the hatchway of a
vessel. He had a compound comminuted fracture of the right leg ;
a fracture of the four first ribs on each side at their necks ; a dislo-
cation of the sternum from the cartilages of both second ribs; a
dislocation of the left third cartilage from its rib ; a dislocation of the
first from the second boue of the sternum ; and a transverse fracture
of the sternum three-quarters of an inch below the top of the gladiolus.
The dislocation of tbe manubrium was complete, and it was thrust
behipd the upper end of the gladiolus, underlapping it half an inch.
The transverse fracture three-quarters of an inch lower down was
also con>plete, and the fragment thus separated was divided into two,
namely, an anterior and a posterior fragment, by a transverse splitting;
the anterior moiety retaining its attachment to the periosteum below,
and not being displaced, while the posterior moiety retained its
attachment to the periosteum both above and below, and was pushed
downwards by the descent of the manubrium. His mind was clear,
but he had paralysis of the bladder, and was breathing wiih some
embarrassment. I had no difficulty in diagnosticating the dislocation
of the third cartilage, and of the manuljrium. There was no swelling
or discoloration on the front of the chest, but it was quite tender. His
head was not thrown forward. He complained of some soreness on
the back of his head. His general condition was such that I did not
attempt reduction. The following day he expectorated blood, and on
the third day he died. The autopsy revealed some effusions of blood
underneath the pleura, but n<^ lesions of the heart or lungs. The
evidence is in this case conclusive that he struck upon his back and
head, in fact that it was a fracture from counter-stroke, by which the
head, neck, and three or four upper vertebraB were bent forward with
great force, thus doubling forward the top of the sternum.

Dr. Robert Watts, Jr., of this city, has reported a very similar case,
in which death occurred on the same day. The fragments of the
sternum were not displaced, but the ribs had suffered similar lesions.^

DiagTiosis, — In a few cases the patients have felt tbe bone break at
the moment of the accident. When displacement exists, it may gene-
rally be easily recognized, and the lower fragment will often be seen
to move forwards and backwards at each inspiration and expiration.

" WattB, Am. Med. Times, vol. ui. p. 55.



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FRACTURES OF THE STERNUM. 169

Crepitus may also be detected in some of these examples, but it is less
ofteD present where no displacement exists. To determine the exist-
ence of crepitus, the hand should be placed over the supposed seat of
fracture, while the patient is directed to make forced inspirations and
expirations, or the ear may be applied directly to the chest.

Emphysema has, also, occasionally been noticed, indicating usually
that the lungs have been penetrated by the broken fragments.

The frequent occurrence of congenital malformations of the sternum
should warn us to exercise great care in our examinations, lest we
mistake these natural irregularities for fractures. Bransby Cooper
mentions a remarkable instance of malformation of the xiphoid car-
tilage which he at first suspected to be a fracture. It was so much
carved backwards that, as Mr. Cooper thinks, its pressure upon the
stomach produced a constant disposition to vomit whenever he had
taken a full meal, or had taken a draught of water .^

Prognosis. — In simple fracture of this bone, uncomplicated with
lesions of the subjacent viscera, and especially when the fracture is
the result of muscular action or of a counter-stroke, no serious con-
sequences are to be apprehended. The bone unites promptly even
where it is found impossible to bring its broken edges into appo-
sition. Indeed, generally, where the fragments have been once com-
pletely displaced, although it is not difficult to replace them momen-
tarily, a re-displacement soon occurs, and they are found finally to
have united by overlapping ; but no evil consequences usually result
from this malposition. In nearly all of the cases reported in which
palpitations, difficult breathing, &c., have been charged to the persist-
ence of the displacement) the injuries were of such a character as to
furnish for these unfortunate results other and much more adequate
explanations. In one instance only, already mentioned, serious incon-
veniences followed from a displacement of the cartilage backwards.

In other cases, however, where the fracture is the result of a direct
blow, constituting a large majority of the whole number, the prognosis
is often very grave ; a conclusion to which one would naturally ar-
rive from the fact already stated, that the fracture of the sternum thus
produced, in itself implies the application of great force.

An abscess occurring in the anterior mediastinum, and caries or
necrosis of the bone, are among the most common results of a blow
delivered directly upon the sternum ; complications which generally
end sooner or later in death. Blood may be also extensively effused
into the anterior mediastinum.

A remarkable case of recovery after gunshot injury of the sternum
is reported by the U. S. Medical Bureau : —

Private C. Betts, 26th N. J. Vols., aet. 22, was struck by a three-
ounce grape-shot, May 3, 1863, in the charge upon the heights at
Fredericksburg, Va. The ball comminuted the sternum, opposite the
third rib on the left side, penetrating the costal pleura. The patient
removed the ball from the wound himself. On the following day he
was admitted to the hospital of the second division of the sixth corps.

> B. Cooper, Princ. and Pract. of Surg., p. 359.
12



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170 FRACTURES OF THE STERNUM.

Through the wound the arch of the aorta waa distinctly visible, and
its pulsations could be counted. The left lung was collapsed ; when
sitting up, there was but slight dyspnoea. Several fragments of the
sternum were removed. The wound soon began to heal, and he made
a complete recovery.*

Where emphysema is present, we may anticipate inflammation of
the pleura and of the lungs.

In several instances, where death has occurred speedily after the
injury, the heart has been found penetrated and torn by the fragments.
Sanson and Dupuytren have each reported one example of this kind.
Duverney has mentioned two, and Samuel Cooper sfiys there is a
specimen in the museum of the University College, exhibiting a lace-
ration of the right ventricle of the heart by a portion of fractured
sternum. Watson mentions a case in which the pericardium was
torn, but the heart was only contused.*

Treatment, — When the fragments are not displaced, the only indi-
cations of treatment are to immobilize the chest, and to allay the in-
flammation, pain, &c., consequent upon the injury to the viscera of the
chest. The first of these indications is accomplished, at least in some
, degree, by inclosing the body, from the armpits down to the margin
of the floating ribs, with a broad cotton or flannel band. A single
band, neatly and snugly secured, and made fast with pins, is preferable
to, because it is more easily applied than, the roller which surgeons
have generally employed ; it is also much less liable to become dis-
arranged. It should be pinned while the patient is making a full
expiration. To prevent its sliding down, two strips of bandage should
be attached to its upper margin, and crossed over the shoulders in the
form of suspenders.

Generally the patients prefer the half-sitting posture, with the head
and shoulders thrown a little backwards; and this is the position
which will be most likely to maintain the fragments in place, and also
to secure immobility to the external thoracic muscles, while it leaves
the diaphragm and the abdominal muscles free to act.

The second indication may demand the use of the lancet ; but more
often it will be found necessary to allay the pain and disposition to
cough by the use of opium.

If, however, the fragments are displaced, it is proper flrst to attempt
their reduction ; which, as we have already intimated, is generally
more easy of accomplishment than is the maintepance of them in place
until a cure is effected.

The upper fragment may be thrown forwards, and made to resume
its position sometimes by a single full inspiration ; but then it usually
falls back during expiration ; or it may be reduced by straightening
the spine forcibly, and at the same time drawing the shoulders back.

Yerduc and Petit proposed, in those cases in which it was found
impossible to reduce the fragments by these simple means, to cut
down and lift the depressed bone. N^Iaton suggests the use of a blunt

» Circular No. 6, Washington, D. C, Nov. 1, 1865, p. 28.
* New York Journ. Med., vol. iii. p. 861.



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FRACTURES OP THE STERNUM. 171

crotchet introduced through a narrow incision ; and Malgaigne has
thought of another plan, which is, to penetrate the skin with a punch,
and directing it to the broken margin, to push the fragment into its
place, but which he does not himself regard as a suggestion of much
value, since the bone is too soft to afford the necessary resistance ; and,
moreover, this, in common with all of the other similar methods, is
liable, in some degree, to the objection that it may increase the ten-
dency to caries and suppuration, already imminent. If reduced, the
fragments will probably immediately again become displaced ; and
more than all, it still remains to be proven conclusively that the mere
riding of the fragments is in itself ever a cause of subsequent suffering,
or even of inconvenience.

When an abscess has formed in the anterior mediastinum, surgeons
have occasionally recommended the use of the trephine. Gibson has
twice operated in this manner at the Philadelphia Hospital, but in
each case the caries continued to extend, and the patient died ; an
experience which has inclined him latterly to discountenance the
operation.*

There are other considerations mentioned by Lonsdale, which ought
to decide us never to use the trephine in these cases. " For the symp-
toms denoting the presence of the abscess, when completely confined
to the under surface of the bone, will be very uncertain ; and when
the matter collects in large quantities, it will show itself at the margin
of the 'Sternum, between the ribs; when it can be let out by making
a puncture with the point of a lancet, without the necessity of remov-
ing a portion of the bone."* Ashhurst, referring to the same point,
remarks : " The fact that the mediastinal space can be cut into with-
out injury to the pleura is shown by many cases, among others by
one which came under my own observation."*

We have already said that a separation of the first from the second
piece of the sternum, occurring before ossific union had taken place,,
might with some propriety be regarded as a diastasis, or as a dislo-
cation even. Maisonneuve, Vidal (de Oasis), Malgaigne, and other
French surgeons speak of it as a dislocation, and Yidal has collected
five examples, in all of which the lower bone occupied a position in
front of the upper. Malgaigne enumerates ten examples. The points
of difference between the dislocation and the true fracture are too
small, however, to demand of us especial attention.

> Gibson, Institutes and Practice of Surgery, vol. i. p. 269.

> Lonsdale, Practical Treatise on Fractures, London, 1838, p. 242.
s Ashhurst, Am. Joum. Med. Sci., Jan. and Oct. 1862.



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172 FRACTURES OP THE RIBS AND THEIR CARTILAGES.



CHAPTER XVII.

FRACTURES OF THE RIBS AND THEIR CARTILAGES.
§ 1. Fractures of the Ribs.

Fractures of the ribs, observed more often than fractures of the
sternum, are rare as compared with fractures of other long bones.

In my records, not including fractures from gunshot injuries, only
twenty-five patients are reported as having had broken ribs ; but as
in several of the cases two or more ribs were broken at the same time,
the total number of fractures is about fifty-eight. If, however, I had
always accepted the diagnosis made by other surgeons, the number
would have been much greater, since I have been repeatedly assured
that the ribs were broken when, upon the most rigid examination, no
evidence, beyond the existence of a severe pain and of difficult res-
piration, has been presented to me.

Etiology. — The force requisite to break the ribs is scarcely less than
what is requisite to break the sternum; and in childhood and infancy
it is sometimes almost impossible to break them, so that children and
even adults are often crushed and killed outright, where, although the
pressure has been directly upon the thorax, the ribs have resumed
their positions, and have been found not to be broken. I have met
with several examples of this kind.

In old age, the cartilages ossify and the ribs themselves suflfer a
gradual atrophy, which renders them much more liable to break.

The most common causes are direct blows, of very great force, in
consequence of which sometimes the fragments are not only broken,
but more or less forced inwards ; occasionally they are the result of
counter-strokes, and then the fragments, if they deviate at all from
their natural position, are salient outwards; a species of fracture
which I have not met with so often.

Malgaigne has collected eight examples of fractures of the ribs pro-
duced by muscular action, by the beating of the heart, &c., all of which
occurred upon the left side. It is believed, however, that in all of
these cases the ribs had previously become atrophied, and perhaps
undergone other changes in their structure, rendering them liable to
fracture from the action of trivial causes.

Pathology, Seat, Ac. — The fourth, fifth, sixth, and seventh ribs are
most liable to be broken ; the upper ribs, and especially the first rib,
being so well protected in various ways as to greatly diminish their
liability, while the loose and floating condition of the last two ribs
gives them an almost complete exemption.

In my own cases I have found the first, second, and third ribs each
broken four times; the fourth, six times; the fifth, twelve times ; the



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FRACTURES OF THE RIBS. 173

sixth, twelve timas; the seventh, nine times; the eighth, ninth, and
tenth, twice each.

Twenty-one were broken through their anterior thirds, generally at
or near the junction of the cartilages with the ribs ; ten through their
middle thirds; and twenty through their posterior thirds. Mai-
gaigne has noticed, also, contrary to the general opinion of surgeons,
that the ribs are most often broken in their anterior thirds, whether
the cause has been a direct or a counter blow.

The direction of the fracture is generally transverse or slightly ob-
liqae; sometimes it is quite oblique. It is often compound ; and in
a few instances I have found it comminuted or multiple. Where the
fracture is compound, it is rendered so generally by the fragments
having penetrated the lungs, and not by a tegumentary wound. In
only twelve of the twenty-five cases recorded by me, has the fracture



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 20 of 100)