Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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been uncomplicated with fractures or dislocations of other bones.

Displacement cannot occur in the direction of the axis of the bone
unless several ribs are broken at the same time. The fragments are
therefore either not at all displaced, or they fall inwards toward the
cavity of the chest, or outwards, or very slightly downwards, in the
direction of the intercostal spaces. Sometimes the rib moves a little
upon its own axis.

Prognosis. — Death occurs sooner or later in a pretty large propor-
tion of the cases in which the ribs have been broken ; yet not often
as a direct consequence of the fracture, but only as a result of the
injury inflicted upon the viscera of the chest, or of other injuries re-
ceived at the same moment. The violent compression of the heart
and lungs has frequently produced death, and sometimes, as I have
more than once seen, almost immediately ; or the patients have suc-
cumbed at a later period to acute pneumonitis.

Lonsdale saw a case in which the body of a man having been tra-
versed by the wheel of a wagon, eight ribs were broken, and death
having followed almost immediately, the autopsy disclosed a rent in
the left auricle of the heart, produced by one of the broken ribs.^
South says there is such a specimen at St. Thomas's Hospital.'

Dupuytren reports a similar case. The same surgeon has also seen
several deaths produced by the emphysema, independent of the frac-
ture, two of which are particularly described in his Clinical Lectures.'
Amesbury has seen a case of death from rupture of the intercostal
artery, where there was no injury of the lungs.*

In several instances observed by me, patients have suffered from
pains in the side, occasionally from cough, &c., after the lapse of two
or more years, and I suspect it is no uncommon thing for these injuries
to entail some such permanent disability, but which is a consequence
rather of the injury to the viscera of the chest, than of any condition
of the broken ribs themselves.

In general, simple fractures of the ribs unite in from twenty-five to
thirty days. Malgaigne has seen one case of non-union ; Huguier met

» Lonsdale on Fractores, p. 258. « Chelius's Surgery, by South, vol. i. p. 599
' Dupuytren, op. cit., p. 79. * Amesbury on Fractures, vol. ii. 612.



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17i FRACTURES OP THE RIBS AND THEIR CARTILAGES.

with another upon the cadaver, in which a complete false joint existed,
furnished with a capsule and lined with synovial membrane ;* Eve, of
Nashville, Tenn., saw a case of non-union occasioned, probably, by a
caries or necrosis of the bone, since it was accompanied with a dis-
charge of matter, and in which a removal of the ends of the fragments
resulted promptly in a cure of the sinus ;* and Samuel Cooper says
there is a specimen in the Museum of the University College, of a
fracture of six ribs, where the fragments are only connected by a
fibrous or ligamentous tissue.'

The union generally occurs with only a slight degree of displace-
ment.

After the union is completed, even where there is no displacement,
a certain amount of ensheathing callus may generally be felt at the
point of fracture. Of five cases which I have carefully examined after
recovery, in only one instance was I unable to detect any irregularity
at this point. I have in my cabinet nine specimens of fractured ribs,

in four of which the en-
Fig. 89. sheathing callus is com-
pletely formed, but the
fragments are in perfect
apposition: in one, ap-
position is preserved, but
there is no ensheathing
callus ; and the remain-
ing four, all occurring
in the same person, are
united with displace-
ment, but without a pro-
per ensheathing callus.
In some specimens I
have observed sharp spiculee, in others broader sheets, of bone ex-
tending along the course of the intercostal muscles from one rib to
the other, forming a species of anchylosis between their adjacent mar-
gins.

Symptomatology, — Acute pain, referred especially to the point of
fracture, sometimes producing great embarrassment in the respiration,
and crepitus, are the most common indications of a fracture. The
pain and embarrassed respiration are, however, far from being diag-
nostic, since they are often present in an equal degree when the walls
of the chest have only been severely contused.

The crepitus, also, is often difl5cult to detect, owing to the thickness
of the muscular coverings, or to the amount of fat upon the body, or
to the fracture having occurred perhaps directly underneath the mam-
mae in the female. In three instances, where the presence of emphy-
sema rendered the existence of a fracture quite certain, I have been
unable immediately after the accident to discover crepitus.
The crepitus may be discovered sometimes by pressing gently upon

> Malgalgne, op. cit., p. 485. « Eve, N. Y. Joum. Med., vol. xv. p. 186.

» 8. Cooper's Surg., vol. ii. p. 321.




Fimetnred ribs Joined to each other bj osseous matter.
Dr. Gross's cabinet.)



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FRACTURES OF THE RIBS. 175

the seat of fracture, or by applying the ear or the stethoscope over
this point while the patient attempts a full inspiration, or coughs ; or
we may press upon the front of the chest with one hand, while the
fingers of the other hand rest upon the fracture.

Occasionally the patient has felt the bone break, and very often he
feels or hears the crepitus after it is broken, and will himself indicate
very clearly the point of fracture.

At the same time that we detect crepitus we are able also to discover
motion in the fragments, but I have once or twice discovered preter-
natural mobility without crepitus.

Emphysema, which is almost certainly indicative of a fracture, is
present in a pretty large proportion of cases. It has been observed by
me in eleven ou-t of twenty-five cases ; generally it did not extend
over more than two or three square feet of surface ; but in one instance
it finally extended over nearly the whole body. It is remarkable,
however, that in only four of these eleven cases did the patients ex-
pectorate blood, and* then in a very small quantity, and not until the
second or third day.

Desault observes that emphysema rarely succeeds to fractures of
the ribs ; an observation which, as will be seen, my experience does
not confirm.

li'eatinenL — In simple fractures, where there is no displacement, or
where the displacement is only moderate, the chest may be inclosed
with a broad belt or band, as we have already directed in case of frac-
ture of the sternum ; provided always that it is not found to increase
instead of diminishing the patient's sufferings. Some patients cannot
tolerate this confinement at all ; while with a majority, although it is
at first uncomfortable and oppressive, after an hour or two it affords
great relief from the distressing pain, and they will not consent to
have it removed even for a moment In nearly all cases of commi-
nuted fracture it is inadmissible, on account of its tendency to force
the pieces inwards.

Hannay, of England, has suggested the use of adhesive strips as a
substitute for the cotton or flannel band ; the several successive pieces
being imbricated upon each other until the whole chest is covered.'
The same objection holds to this mode of dressing as to a similar mode
of dressing a broken clavicle, which has been recently recommended.
It will certainly become loosened after a few hours, by the slight but
uninterrupted play of the ribs.

The forearm ought also to be brought across the chest at a right
angle with the arm, and secured in this position with a moderately
tight bandage or sling, so as to prevent any motion in the pectoral
muscles.

As to position, the patient generally prefers to sit up, or he chooses
a position only partly reclining upon his back ; but there is no posiftive
rule to be observed in this matter, except that such a position shall
be chosen as shall prove most comfortable to the patient.

1 American Joom. Med. Sci., vol. xxxix. p. 198. From Lond. Med. Gaz., Nov.
1845.



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176 FRACTURES OF THE RIBS AND THEIR CARTILAQSS.

If the fragments are salient outwards, tbe fracture having been pro-
duced by a counter-stroke, they may be reduced by pressing gently
upon them from without. If, on the contrary, the fragments are salient
inwards, they will be found, in a great majority of cases, to have re-
sumed their positions spontaneously or through the natural actions of
respiration ; but if they have not, it will be exceedingly difficult to
restore them. Possibly it may be accomplished by pressing forcibly
upon the front of the chest, or upon the anterior extremity of the
broken rib ; yet if the fragments are comminuted, and the ends are
much driven in, this method will avail little or nothing. In such cases
several surgeons have recommended that we should cut down to tbe
bone and elevate the fragments, but Bossi alone claims to have actu-
ally put the suggestion into practice.

No doubt, if the necessity was urgent, this method might be suc-
cessfully adopted ; or, instead of cutting down to the broken rib, we
might even seize the fragment with a hook, as suggested by Malgai^e,
or, what in some cases might be even more convenient, with a pair of
forceps constructed with long teeth, obliquely set upon a firm shaft.
Yet the exigency which will demand a resort to any of these measures
will be exceedingly rare. In gunshot fractures, which are nearly all
compound and comminuted, the loosened or detached fragments should
be at once removed.

In no case do I attach any value or importance to the advice given
by Petit, that we shall place a compress upon the front of the chest,
underneath the bandage, in order to reduce the fragments, or to retain
them in place after reduction. Lisfranc, who advocated this method,
claimed that its advantage consisted in the increased length which
was thus given to the antero-posterior diameter of the chest, and the
consequent accumulation of pressure from the encircling band, in this
direction.' The mechanical law is no doubt correctly stated, but its
value in practice is too inconsiderable to deserve consideration.

The emphysema generally demands no especial attention, since it is
usually too limited to occasion inconvenience; and when more exten-
sive, it generally disappears spontaneously after a few days, or a few
weeks at most. The advice given by some surgeons, that we ought
in these cases to cut down to the pleural cavity so as to allow the air
to escape freely through the incision, seems thus far to have rested its
reputation upon a more than doubtful theory rather than upon any
testimony of experience. Abernethy alone, so far as I know, has
actually made the experiment, and his patient died.

Dupuytren, in the two cases already alluded to, bled the patients
and applied resolvent liquids, with rollers; he also made incisions
with the lancet at various points of the body, more or less remote from
the seat of fracture, a practice, however, in which he confesses he has
no confidence whatever. These patients both died.

Dr. Stedman, of the Massachusetts General Hospital, has reported the
case of a man aged sixty-nine, of intemperate habits, who, in addition to
a fracture of one of his ribs, had also a dislocation of the outer end of

1 Banking's Abstract, vol. ii. p. 204, from Gaz. des Hdpitaux, July 8, 1845.



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PBACTURBS OF THE CARTILAGES OF THE RIBS. 177

the clavicle. The emphysema commenced immediately, and reached
its acme on the twenty-second day. At this time it bad extended
over his whole body : his eyes were closed, and he breathed with great
difiBcuIty; but on the forty-fifth day the emphysema had entirely dis-
appeared, and he was dismissed cured. The treatment consisted
cbiefly in the free internal use of stimulants, and in the application of
bandages ; but the bandages soon became disarranged, and after a few
days they were entirely laid aside.^

In the case of my own patient, where the emphysema was almost
equally extensive, the patient recovered after a few weeks, under the
use of a simple diet, and without any special medication whatever.
ISTor have I ever met with a case which demanded interference of any
kind.

§ 2. Fraotubes or the Cabtilaoes or the Bibs.

Boyer was incorrect when he said that the cartilages of the ribs
could not be broken until they were ossified. They are often broken
when there is no ossification, at the same time that the ribs themselves
are broken. Sometimes they are broken alone. Not unfrequently,
also, the separation takes place at the precise point of junction between
the cartilage and the bone.

Pyper relates a case in which the sternum was broken in a man
aged twenty-five years, and also the cartilages of the sixth, seventh,
and eighth ribs of the right side, as was proven by the autopsy, yet
the cartilages were not ossified. The vena cava ascendens was also
ruptured by the force of the compression.* The reader is referred
also to my own and Dr. Watts' cases reported in the chapter on Frac-
tures of the Sternum.

Etiology. — The causes are the same as those which produce fractures
of the ribs, yet it is generally understood that it will require greater
force, and that consequently the injury done to the viscera of the
thorax will be more complicated and intense.

In the reports of the Massachusetts General Hospital an account is
given of the case of a man aged thirty, who was crushed by the fall
of a heavy weight upon his body, and who died after about sixty
hours. An examination after death revealed a fracture of the car-
tilages of the third and fourth ribs, with a laceration of the intercostal
muscles to such an extent that a hernia of the lungs had occurred at
this point. This hernia had been discovered and recognized by Dr.
Warren soon aft»r the accident occurred ; the protrusion being at
that time as large as the clenched fist, and regularly rising and falling
with each movement of respiration. It was accompanied, also, with a
moderate emphysema.

Pathology. — The fracture is clean and vertical, or transverse ; never
irregular or oblique. The direction of the displacement varies as in
fractures of the ribs, but the anterior or sternal fragment is generally
found in front of the posterior or spinal.

' Boston Med. and Surg. Jonm., vol. Hi. p. 810.

« Banking's Abstract, vol. i. p. 147, from the Lancet, Oct. 1S44.



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178 FRACTURES OF THE CLAVICLE.

Union takes place in these fractures, not through the medium of
cartilage, but of bone. Sometimes the new bone being deposited only
between the ends of the fragments, in the form of a thin plate, and at
other times it is formed around the fragments as well as between
them. The latter of these two processes has been most frequently
observed. The ensheathing callus appears to be supplied by the peri-
chondrium, while the experiments of Dr. Redfern render it probable
that the intermediate callus may result from a conversion or trans-
formation of the adjacent cartilaginous surfaces. Paget remarks, also,
that the ossification extends to the parts of the cartilage immediately
adjacent to the fracture.

I have seen one example, in the person of Hiram Leech, set. 38,
which, after the expiration of more than one year, had not united.
The fracture had occurred in the united cartilages of the tenth and
eleventh ribs. The posterior fragment overlapped the anterior, and
they played freely upon each other at each act of inspiration and
expiration.

I do not know that any observations have been made upon the
repair of these cartilages in very early life, and it is possible that the
process may differ from this, which has been described as it has been
observed in the adult.

Treatment. — The treatment need not differ from that already recom-
mended for fractured ribs.



CHAPTER XVIII.

FRACTURES OF THE CLAVICLE.

For the sake of convenience, I shall divide fractures of the clavicle
into those occurring through the inner, middle, and outer thirds. By
the "outer third" is meant all that portion of the clavicle included
between its scapular extremity and the internal margin of the conoid
ligament. The remaining portion is intended to be divided equally
into two separate thirds. The peculiarities of these several portions,
in respect to anatomical relations, liability to fracture, results, etc.,
will explain the propriety of the divisions.

Caitses. — If we except gunshot fractures, the clavicle is broken, in
a large majority of cases, by a counter-stroke, such as a fall, or a blow
upon the extremity of the shoulder.

Occasionally it is broken by a direct stroke, as when a blow aimed
at the head is received upon the shoulder ; it is broken sometimes by
the recoil of an overloaded gun, especially when the person lies upon
the ground, with the butt of the gun resting against the clavicle.

Gibson has seen a case in which it was broken in a child at birth,



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FRACTUBES OP THE CLAVICLE. 179

by an ignorant midwife pulling at the arm,* and Dr. Atkinson has re-
ported an example of intra-uterine fracture of the clavicle.*

I have once seen the clavicle broken by muscular action alone. A
large, well-built, and healthy man, aged thirty-seven, standing upon
the ground, attempted to secure the braces of his carriage-top with
his right arm, when he felt a sudden snap, as if something about his
shoulder had given way. He did not, however, suspect the nature of
the injury, and did not consult any surgeon until eight days after, at
'which time I found the right clavicle broken near its centre, but
rather nearer the sternal than scapular extremity. The fragments
i^ere but slightly, if at all, displaced, but motion and crepitus at the
point of fracture were distinct. The usual node-like swelling was
also present, indicating the existence of a considerable amount of en-
sheathing callus. He had been unable to raise the arm to a right
angle with the body since it was broken^ but he had suffered no other
inconvenience from it.

A similar case is reported in the number for January, 1843, of the
American Journal of Medical Sciences, copied from the Bevista Medica.
The subject of this case was a colonel of cavalry, about sixty years of
age. In mounting his horse, he experienced a sensation as if some-
thing had broken, followed by acute pain in his left shoulder, and, on
examination, it was found that the clavicle was fractured in the mid-
dle. The health of this gentleman had been impaired, it is further
stated, by repeated attacks of syphilis.

Malgaigne has recorded three other examples of fracture of this
bone from muscular action ; and Parker saw a case which was pro-
duced by striking at a dog with a whip ; the bone had been previously
somewhat diseased, yet it united favorably.*

Of these six cases, five occurred on the right side, and always near
the middle of the bone, if we except one case reported by Malgaigne,
in which the point of fracture is not mentioned. In neither case did
the fragments become displaced, only as they were found, in some of
the examples, inclined slightly forwards.

Pathology, — It has already been observed, in speaking of partial
fractures, that this bone suffers an incomplete fracture more often
than any other, and that in such cases the lesion occurs generally in
the middle third, or rather to the sternal side of the centre, and in a
direction nearly or quite transverse. They are not usually accom-
panied with much displacement; but if a displacement exists, it is a
slight forward inclination of the fragments.

Fractures which are complete occur mostly after the bones have
become firm and unyielding. They are also generally oblique, seldom
comminuted, still more rarely compound. The point of the clavicle
at which a complete fracture usually occurs is at or near the outer
end of the middle third, and a little to the sternal side of the coraco-
clavicular ligaments, near where the trapezius and deltoid cease their
attachments. It might be more exact to say that the fracture extends

1 Gibson, Principles of Surg., sixth ed., vol. i. p. 273.
« Atkinson, Bost. Med. and Surg. Joum., July 26, 1860.
» Parker, N. Y. Joum. Med., July, 1852.



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180 FRACTURES OF THE CLAVICLE,

from this point downwards and inwards, toward the sternum, em-
bracing one inch or less of its entire length. In some cases the obli-
quity is greater, and the amount of bone involved is much more
considerable.

Why the bone should break more frequently at this point, espe-
cially in the adult and in the male, it is not difficult to understand.
It is smaller here than elsewhere, and less supported by muscular aad.
ligamentous attachments. At this point, also, the axis of the boae
begins pretty abruptly to curve forwards, and more abruptly in the
adult and male than in the child and female. When, therefore, the
clavicle is broken, as it usually is, by a counter-stroke, the force of
the blow, conveyed from the shoulder through the outer portion of the
bone, is suddenly arrested, and expends itself upon the point where
the direction of the axis is changed.

In a record of one hundred and five fractures, including partial and
comminuted, and not including gunshot fractures, eighty-eight have

occurred through the middle
Fig. 40. third ; and, with the exception of

the partial fractures, the fracture
has in nearly all of the cases
taken place near the outer end of
this third. Four have occurred
through the inner third, three of
which were within one inch of the
sternum ; and thirteen through
the outer third.

A more practical analysis can
be based, however, upon the point
of fracture with reference to its
cause; and I have never, but
once, seen a complete fracture of
this bone produced clearly by a
counter-stroke, which was not
near the outer end of the middle
third.

When the fracture is at this
point, or in any portion of the
middle third, the direction of the
displacement is almost uniformly

Complete oblique fracture of claricle. thcsamC. The Stcmal fragment

is slightly lifted by the action of
the clavicular portion of the sterno-cleido-mastoid muscle, not-
withstanding the resistance of the rhomboid ligament, and the sub-
clavian muscle. On the other hand, the acromial fragment is
dragged downwards by the weight of the arm, aided by the con-
joined action of a portion of the pectoralis major and the latissi-
mus dorsi, feebly resisted by the trapezius and other muscles from
above ; by the action of the same muscles, aided by the pectoralis
minor, and perhaps by some portion of the subclavius, it is drawn
toward the body, diminishing thereby the axillary space ; while by
the preponderating strength of the pectoralis major and minor, the



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FRACTURES OF THE CLAVICLE. 181

acromial end of the fragment, with the shoulder, is drawn forwards;
the sternal end of the same fragment being rather displaced back-
vrards, and at the same time resting at a point somewhat elevated
above the acromial end.

Desault has recorded one example of an overlapping by the eleva-
tion of the acromial fragment over the sternal ;^ and Bichat remarks
that Hippocrates speaks of the phenomenon as a thing which was
familiar to him. Syme has mentioned a .case of this kind which he
had seen.* Gu^retin, Malgaigne,* and Stephen Smith have each re-
ported an example.^ In Stephen Smith's case the fracture occurred
in a man thirty-eight years old. The bone was broken through the
outer third, and transversely. He was treated at the Bellevue Hos-
pital, but the overlapping, to the extent of one inch, remained after
the cure was completed.

In nearly all the cases of oblique fractures occurring through the
middle third there follows immediately an overlapping, varying from
one-quarter of an inch to an inch, and sometimes, though very rarely,
exceeding this. There is a specimen in the Dupuytren Museum, in
which the shortening equals one-third of its entire length.

Transverse fractures, wherever they may occur, are not so constantly
foOnd displaced, at least in the direction of the axis of the bone, as the
following examples will illustrate: —

An old lady, aged eighty years, fell down a flight of stairs, break-
ing the right clavicle transversely, about one inch from the sternum.
I saw her, with Dr. Trowbridge, on the day following the accident.
Motion and crepitus were distinct, but there was scarcely any dis-
placement. No dressings were applied, but she was directed to keep



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 21 of 100)