Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

. (page 25 of 100)
Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 25 of 100)
Font size
QR-code for this ebook

rare. Indeed, the existence of this fracture, uncomplicated with a
comminuted fracture of the glenoid cavity, is denied by Sir Astley
Cooper, South, Erichsen, and others. Mr. South says there is no such
specimen in any of the museums in London ; and I have not been able
to find one in any of the American cabinets. Dr. Mott has said tome

Digitized by



tbat he had never seen a specimen, and that in the natural condition
of the bone he regards its occurrence as impossible. Such, I confess,
also is ray own conviction.

If, however, it is intended, in speaking of fractures of the neck of
the scapula, to refer, as Sir Astley Cooper has done, only to fractures
extending through the semilunar notch behind the root of the cora-
coid process, then its existence is certain; yet the fracture is not com-
mon. Duverney has reported one example, the existence of which he
established by a dissection. The coracoid process was broken at the
same time, but the fracture through what was called the neck, was
distinct from this; and Sir Astley has recorded three examples in

Fig. 55. Fig. 56.

Commlnated fracture of the glemoid Fracture of the neck of the » capula ; according to

cavitf. . 8ir Astlef Cooper.

which the diagnosis was very clearly made out, yet not actually proven
by an autopsy.

Symptoms. — Sir Astley justly remarks that " the degree of deformity

{)roduced by this accident depends upon the extent of laceration of a
igament which passes from the under part of the spine of the scapula
to the glenoid cavity. If this be torn" (and to this we ought to add
the ligaments passing from the coracoid process to the clavicle and
acromion process), " the glenoid cavity and the head of the os humeri
fall deeply into the axilla, but the displacement is much less if this
remains whole."

The usual signs are, a depression under the acromion process, the
same as in dislocation of the head of the humerus downwards, but not
so deep ; the head of the humerus felt, perhaps, in the axilla ; crepitus,
and the immediate recurrence of the displacement whenever, after the
reduction has been fairly accomplished, the arm is left unsupported.
The crepitus is best discovered by resting one hand upon the top of
the shoulder in such a manner as that a finger shall touch the point
of the process, while the arm is rotated and moved up and down by
the opposite hand. It may also be easily ascertained that the cora-

Digitized by



coid process moves with the humerus instead of the scapula. Occa-
sionally, the accident is accompanied with paralysis of the arm, from
pressure upon the axillary nerves, and a rupture of the axillary arterjr
is also mentioned by Dugas.^

Treatment. — The indications of treatment are three, namely, to carry
the head of the humerus, with the glenoid cavity, &o., up, to carry it
out, and to confine the body of the scapula. The first is accomplished
by a sling, the second by a pad in the axilla, and the third by a broad
roller carried repeatedly around the arm and chest and across the

§ 3. Fractures of the Acromion Process.

Examples of fracture of the acromion process have been reported
by Duverney, Bichat, Avrard, A. Cooper, Desault, Sanson, N^laton,
Malgaigne, West,* Brainard,' Stephen Smith,* and others. I have
myself reported three examples ;* and one more example has come
under my notice since the date of that report.

In the case seen by Cooper it entered the articulation of the clavicle,
and produced at the same moment a dislocation. Malgaigne says it
occurs generally farther up, and posterior to the attachments of the
clavicle, "near the junction of the diaphysis with the epiphysis," and
that the fracture is in most cases transverse and vertical ; but N^laton
saw a case in which the fracture was oblique. In the case reported
by C. West, of Hagerstown, Md., the fracture was through the base
of the process. In two of the examples seen by me the fracture was
in front of the clavicle ; in the third, occasioned by the fall of a barrel
of flour upon the shoulder, the fracture occurred at the acromio-clavi-
cular articulation, and was accompanied with an upward dislocation
of the outer end of the clavicle ; and in the fourth the fracture occurred
at the same point, but there was neither displacement of the clavicle
or of the process, the fracture being only recognized by the crepitus
and motion.

There is some reason to believe, I think, that a true fracture of the
acromion process is much more rare than surgeons have supposed,
and that in a considerable number of the cases reported there was
merely a separation of the epiphysis ; the bony union having never
been completed. If such fractures or separations occurred only in
children, very little doubt might remain as to the general character
of the accident ; but the specimens which I have found in the mu-
seums, and the cases reported in the books, have been mostly from
adults. It is more difficult, therefore, to suppose these to be examples
of separation of epiphyses, but I am inclined to think that in a
majority of instances such has been the fact. It is very probable,
also, that in the case of many of the specimens found in the museums,
called fractures, the histories of which are unknown, they were united

" Remarks on Frac. of Scapula, by L. A. Dugas, Georgia. Am. Journ. Med. 8d.,
Jan. 1858.
« West, Penln. Joum. of Med., vol. v. p. 254.
' Brainard, Bost. Med. and Surg. Journ., vol. xxxi. p. 501.
« 8. Smith. Hamilton, Report on Deform., op. cit.

Digitized by

Go ogle


originally by cartilage, and that in the process of boiling, or of mace-
ration, the disjunction has been completed. The narrow crest of
elevated bone which frequently surrounds the process at the point of
separation, and which Malgaigne may have mistaken for callus, is
found upon very many examples of undoubted epiphyseal separations
which I have examined ; and this circumstance, no doubt, has tended
to strengthen the suspicion that these were cases of fracture.

This opinion is confirmed by the remark of Mr. Fergusson, that a
fracture of this process is an accident "of rare occurrence." "I have
dissected," he adds, "a number of examples of apparent fracture of
the end of this proceas ; but in such instances it is doubtful if the
movable portion had ever been fixed to the rest of the bone." Dr.
Jackson says there are four specimens in the museum of the Massa-
chusetts Medical College, and in the museum of the Boston Society
for Medical Improvement, which might easily be mistaken for frac-
tures, but which only illustrate to how late a period the bony union
is sometimes delayed. In one specimen the patient could not have
been less than forty years of age; "the acromial process of each
scapula was fully formed, but having no. bony union whatever with
the bone itself. The union was ligamentous, but strong and close."

To the same class belong several specimens in my own collection ;
specimens 163 and 997 in Dr. March's collection ; 707 in the Albany
CJollege collection ; two specimens in the Mutter, and one in the Jef-
ferson Medical College museums.

I wish to mention,. also, that in the case of my own specimens of
epiphyseal separation, as well as most of the specimens which I have
examined, the ends of the fragments were closed with a compact bony

The mode of development of the scapula will explain these cases.
The scapula is formed from seven centres ; namely, one for the body,
one for its posterior border, one for its inferior border, two for the
acromion process, and two for the coracoid. Ossification of the body
exists to a certain extent at or near the period of birth. It commences
in one of the centres of the coracoid process, about one year after
birth, and unites to the body at about the fifteenth year. .All the
other centres remain cartilaginous until from the fifteenth to the sev-
enteenth year, when ossification commences, and is completed by
a commqn union among all parts, usually between the twenty-second
and twenty-fifth years.

No doubt, however, a fracture of this process does occasionally take
place. In addition to my own, I have already mentioned several
other examples, some of which have been confirmed by dissection ;
and in the case mentioned by Stephen Smith, an autopsy, made three
weeks after the accident, showed a fracture without displacement, the
periosteum covering its upper surface not being torn ; the fragment
could be turned back as upon a hinge.

Prognosis. — The process generally unites with a slight downward
displacement. This occurred in at least two of the examples seen by
me ; but in such cases the motions of the arm are not in consequence
much, if at all, embarrassed ; unless, indeed, it is so much depressed

Digitized by



Fig. 67.

Bcapala, with epiphyses. (From Gny.)

as to interfere with the upward movements of the arm; a result which
Heister erroneously supposed was inevitable.

Sir Astley Cooper says that a true bony union is rare in these frac-
tures, and that there generally results a false joint, the fragments uniting
by a fibrous tissue ; but sometimes the surfaces, instead of uniting
either by bone or ligament, become polished, and even eburnated.

Malgaigne has noticed, also, in a specimen contained in theDupuy-
tren museum, a hypertrophy of the lower fragment, this portion having
a diameter nearly twice as great as that of the portion from which it
was detached.

Symptoms. — Where no displacement exists, the diagnosis must
always be difficult, if not impossible. In such a case we could only
be instruated by the manner in which the injury had been received,
by the contusion, and by the presence of mobility or crepitus.

In examples attended with displacement, if no swelling is present,
the finger carried along the spine of the scapula to its extremity, will
easily detect the fracture by the abrupt termination of the process, or
by the presence of a fissure, or a depression ; but as to the other symp-
toms, they must depend very much upon the point at which the
fracture has taken place. If in front of the acromioclavicular articu-
lation, the position of the arm in its relations to the body Will not be
changed ; but if the fracture is through the articulation, and a dis-

Digitized by



location of tbe olavicle results, or if it is behind the acromio-clavicular
articulation, the arm, having in either case lost the support of the cla-
vicle, will assume the same position that it does in a fracture of the cla-
vicle; that is, the shoulder will fall downwards, inwards, and forwards.

Treatment. — If the fracture has taken place in front of the acromio-
clavicular articulation, no doubt the most rational plan of treatment
is that recommended by Delpech ; that is, placing the patient in bed,
upon his back, and carrying the arm out from the body nearly to a
right angle ; since by this method the fragment is not only lifted, but
the deltoid muscle is relaxed, and, consequently, the fragment is no
longer forcibly drawn away from the spine of the scapula. If, there-
fore, the patient will submit to this treatment for a sufficient length of
time, the union must be accomplished with the least possible amount
of displacement. In case he will not consent to such confiuement, I
am confident no other plan which has been recommended merits a
trial, unless it be simply to place the arm in a sling until the union is

If, however, the fracture has taken place at or behind the junction
of the clavicle with the process, the indications of treatment must be
in all respects the same as in a fracture of the clavicle.

§ 4. Fractures of the Coracoid Process.

" The coracoid process," says Mr. Lizars, " is said to be broken off,
but this I question very much; it must be along with the glenoid
cavity, or there must be a fracture of the neck of the scapula."

Dr. Neill, of Philadelphia, has in his cabinet a specimen of separa-
tion of this process at about one inch from its extremity. The line of
separation is somewhat irregular ; there is no callus, but it is united
to the upper portion by a dried tissue, half an inch in length, and con-
tinuous with the periosteum. This has been regarded as an example
of fracture ; but although the scapula is large, and evidently belongs to
an adult, the fact that the acromion process is not yet united by bone
renders it probable that this, also, is an epiphyseal separation. Prof.
Charles Gibson, of Richmond, Ya., has informed me also that be has in
his cabinet a dried specimen, from an adult, which has been broken
obliquely near the end, but which is now united by a ligamentous or
fibrous tissue of one line and a half in length. The fragment is dis-
placed a little forwards, as well as downwards. Reuben D. Mussey,
of Cincinnati, possessed a very remarkable and conclusive example
of this fracture. The humerus is dislocated forwards, the head and
neck being firmly united to the neck and venter of the scapula, while
at the same time the coracoid process is broken and displaced. Dr.
Jackson, of Boston, says that specimen No. 453 in the museum of the
Massachusetts Medical College seems clearly to have been a fracture
involving the base of the coracoid process, and which, having taken
place somewhere within a year of the death of the person, had become
united by bone, and that just before death the process had broken ofl^
and so completely, as to involve a portion of the glenoid cavity.^

1 The author's Report on Deformities, op. cit.

Digitized by



Bransby Cooper relates a case of fracture through the base, which
after eight weeks, when the patient died, was found to be united bj a
ligament. The acromion process was broken at the same time, and
had united in the same manner. The head of the humerus was also
broken and partly united.^ One example is said to have occurred in
the practice of Dr. Arnott, at the Middlesex Hospital, London, in
consequence of which the patient died, when a dissection disclosed
the true nature of the accident.' Mr. South has also reported a case
resembling somewhat Mussey's, but much more complicated. The
humerus was partially dislocated forwards, the clavicle, acromion pro-
cess, and the olecranon were broken as well as the coracoid process.
Neither the fracture of the clavicle nor of the coracoid process was
made out until after the patient died, which was on the fourth daj ;
the fact of the existence of these fractures being then ascertained by
dissection.* Erichsen says there is in the museum of the University
College a preparation showing a fracture at the base of this process,
the line of fracture extending across the glenoid cavity.* Duverney,
Boyer, and Malgaigne have also reported four additional examples
confirmed by dissections.*

The existence of this form of fracture, established by at least nine
or ten dissections, can no longer be denied; yet it is usually accom-
panied with serious complications, such as must in most cases prove

fatal. In the only two cases, how-
Fig. 5S. ever, in which I have had reason to
believe that I had to deal with a frac-
ture of this kind, the symptoms and
termination were less grave, although
they were both complicated with an
upward dislocation of the outer end
of the clavicle. A gentleman resid-
ing in the country was struck by a
board which fell edgewise upon his
shoulder. The fracture of the cora-
coid process does not seem to have
been recognized by his su rgeon. An
apparatus was applied to retain the
clavicle in its place, but after three

Fracture of the coracoid prooeM. mOUths, whcU he Called UpOU me, it

still remained displaced as at first.
During all of this time the apparatus had been steadily kept on. On lay-
ing off the dressing, I discovered that the coracoid process was de-
tached, obeying constantly the movements of the head of the humerus,
but being not at all subject to the movements of the scapula. Some
months later I examined the arm again, and found the parts in the
same condition as before, but the functions of the arm were not im-
paired. A girl was admitted to Bellevue Hospital in November, 1868,

> B. Cooper, edition of Sir Astleyon Prac. and Disloc., Amer. ed., p. 880.

« Amott, Fereusson's Surg., p. 213.

» South, Lond. Med.-Chir. Rev., 1840, vol. xxxii., new series, p. 41.

* Erichsen, Surgery, p. 207. * Malgaigne, op. cit., p. 512.

Digitized by



having fallen upon her lefl shoalder^and having sustained a complete
lazation of the acromial end of the clavicle, upwards and outwards.
Upon careful examination, a fracture of the coracoid process was also
diagnosticated, indicated by both mobility and crepitus.

It has been generally stated that when this process is broken off, it
will be carried downwards by the united action of the pectoralis minor,
the short head of the biceps, and the coraco-brachialis muscles; but
this will depend upon whether the coraco-clavicular ligaments are
ruptured also; a circumstance which is not very likely to occur, at
least to any great extent ; and in fact not one of the well-attested ex-
amples of this fracture has ever been accompanied with any consider-
able displacement in this direction.

2V€aiment.—In a case of simple fracture of the process, unattended
with any other lesions, it has been recommended to place the arm in
a sling, with the elbow advanced as much as possible upon the front
of the chest, as by this position we relax somewhat all of the three
muscles having attachments to this process, and then to confine the
scapula by a few turns of a roller. It is not probable, however, that
by these measures we should accomplish enough to justify their con-
tinuance if they were found to be painful, or even exceedingly irk-
some. Patients under my observation have generally complained
very much of the pain and discomfort attending this position of ex-
treme flexion of the arm and forearm, first employed by Velpeau for
fractures of the clavicle. Moreover, I do not think the fragments are
generally displaced : and if they were, and the final union were to be
accomplished solely by ligament, I think the usefulness of the arm
would not be at all impaired. Such, at least, has been my experience
in the two cases above recorded, and in both of which no bony union

In the graver forms of the accident, where other bones about the
shoulder are broken or dislocated, which, as we have seen, constitute
the larger proportion of the whole number, the treatment must gene-
rally have little or no regard to this particular injury.



It is not sufficient to consider fractures of this bone as occurring
through the shaft and its two extremities, as some systematic writers
have done; since upon this simple arrangement it is impossible to base
a natural division of their causes, symptoms, prognosis, and treatment.

We shall find it necessarv to consider —

1. Fractures of the head and anatomical neck. (Intra-capsular;
non impacted and impacted.)

2. Fractures through the tubercles. (Extracapsular; non-impacted
and impacted.)

Digitized by



3. Longitadinal fractures of the head and neck, or splitting off of
the greater tubercle.

4. Fractures of the surgical neck. (Including separations at the
upper epiphysis.)

5. Fractures through the body of the shaft, or of the shaft below
the surgical neck and above the base of the condyles.

6. Fractures at the base of the condyles. (Including separation at
the lower epiphysis.)

7. Fractures at the base, complicated with fractures between the
condyles, extending into the joint.

8. Fractures or separations of the internal epioondyle.

9. Fractures or separations of the external epicondyle.

10. Fractures of the internal condyle.

11. Fractures of the external condyle.

Of 118 fractures of the humerus examined by me, 25 occurred
through the upper third, 17 through the middle third, and 71 through
the lower third. An observation which is in contrast with the state-
ment made by Amesbury, and which has been repeated by Lizars, B.
Cooper, Fergusson, Gibson, and others, that this bone is most often
broken in its middle third.

Of the fractures belonging to the upper third, one was a separation
at the junction of the epiphysis with the shaft, one was probably a
fracture at or near the anatomical neck, with impaction and splitting
of the tubercles, one was a fracture of the greater tubercle alone, and
16 were fractures of the surgical neck.

Of the fractures belonging to the lower third, 15 were through the
internal condyle and epicondyle, 18 through the external condyle, 16
were at the base of the condyles, 6 through the condyles and across
the base at the same time. The remainder, 16, being through the
shaft, but above the base.

Unfortunately, surgical writers have not been agreed in the use and
application of the terms " head," '^neck," " anatomical neck," and "sur-
gical neck" of the humerus ; and, as a consequence, their meaning is
often obscure, and their teachings are sometimes contradictory and
absurd.^ It is necessary, therefore, that we should define them more

The head of the humerus is that smooth, elliptical surface, covered
by cartilage and synovial membrane, which articulates with, and is
received into, the glenoid cavity of the scapula.

The anatomical neck is the narrow line immediately encircling the
head, and which receives the insertion of the capsular ligament.

The surgical neck is that portion which commences at the lower
margin of the tubercles, or at the point of junction between the epi-
physis and the diaphysis, and which terminates at the insertion of the
pectoralis major and latissimus dorsi.

The neck is all of that portion included between the head and the
insertion of the pectoralis major and latissimus dorsi, comprising not
only the anatomical and surgical necks, but also the tubercles, which
occupy the triangular space between these two.

^ Boston Med. and Surg. Joum., June 24, 1868, p. 410.

Digitized by VjOOQIC


§ 1. Fraotubxs of the Head and Anatobhcal Negk. {Intra-Capsular;
Non-impacted and Impacted.)

CaiLses, — The causes which have been found competent to produce
fractures of the head and anatomical neck are^ the penetration of balls
or of other missiles directly into the joint, producing thus a compound,
and generally comminuted, fracture of the head ; and falls, or direct
blows upon the shoulder, without penetration.

PcUhology, Results, (to. — When the fracture results from the direct
penetration of some foreign body into the joint, it is not only a com-
pound fracture, but the head of the bone is almost necessarily broken
into fragments. If the patients recover, sooner or later the fragments
have generally to be removed.

Fractures of the anatomical neck, produced by falls upon the
shoulder, without penetration, are, however, usually neither compound
nor comminuted, but they often follow, with a remarkable degree of
accuracy, the line of the insertion of the capsular ligament, being
always, according to Bobert Smith, within the inferior or outer mar-
gin of this insertion. He calls them, therefore, intra-capsular. It is
probable, however — since, as we shall presently see, bony union is not
denied to this fracture — that the line of separation is not always, or
generally, perhaps, completely within the insertion of the ligament,
but that it is in some degree extra-articular, if not extra-capsular. If
it is entirely intra-articular, no doubt union of the fragments can never
take place, and generally suppuration will ensue, demanding, at a
period not very remote, an operation for their removal, the same as
in compound fractures.

Gibson, however, thinks that the fragment occasionally remains,
being gradually absorbed and changed in figure. He says that his
museum contains three or four well-marked cases of this kind, in all
of which the head has lost its spherical form, and
is very much diminished, and rough and flattened Fig. 69.

next to the scapula.^ Other cabinets contain simi- ~

lar specimens.

The displacements to which the upper fragment,
or the head of the bone, is subject, are remarkable,
and some of them do not seem to be satisfactorily

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 25 of 100)