Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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explained. Frequently, indeed, its position is not
sensibly disturbed, but at other times it is found
impacted, or driven into the cancellous structure
of the inferior fragment^ in consequence of which
one or both of the tubercles are frequently broken

Bobert Smith relates the following case as having
afibrded him his first opportunity of ascertaining
by post-mortem examination the exact nature of
this form of displacement : —

"A female, set. 47, was admitted into the Rich- p^ture of the anato-
mond Hospital, under the care of the late Dr. Mc- mieai neck.

> Gibson, Elements of Surgery, vol. i. p. 279.

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Dowell, for an injury to the humerus, the result of a fall upon the
shoulder. Five years afterwards^ the woman was again admitted,
under the care of Mr. Adams, with an extra-capsular fracture of the
neck of the femur, one month after the occurrence of which she died,
in consequence of an attack of diarrhoea.

" The shoulder was of course carefully examined ; the arm was
slightly shortened, the contour of the shoulder was not as full or
round as that of its fellow, and the acromion process was more promi-
nent than natural. Upon opening the capsular ligament, the head of
the humerus was found to have been driven into the cancellated tissue
of the shafty between the tuberosities, so deeply as to be below the
level of the summit of the greater tubercle; this process had been
split ofif, and displaced outward ; it formed an obtuse angle with the
outer surface of the shaft of the bone."'

The description is accompanied with two excellent drawings of the
specimen, showing the distance to which the superior fragment had
penetrated the inferior, and showing also complete union by bone.

I believe, alsb, that in the following example there was a fracture
at or near the anatomical neck, with impaction, and splitting of the
tubercles : —

January 12, 1858, a young man, aged about sixteen years, fell from
a height in a gymnasium, severely injuring his left shoulder. I saw
him, with Dr. Boardman, soon after the accident, and found him com-
plaining very much of the shoulder, which was some swollen and
tender. He could not tell us how he fell, nor could we discover any
contusions by which to determine the point where the blow was re-
ceived. All motions of the shoulder-joint were painful ; and there
was a remarkable fulness in front of the joint, feeling like the head of
the bone, yet not such as is usually present in a forward luxation.
To determine this more positively, however, the limb was manipulated
as for the reduction of a dislocation. Once during the manipulation
a feeble but distinct crepitus was detected ; yet the position of the
bone remained unchanged. The head was found to be in the socket^
but the precise nature of the injury was not made out.

Fifteen days later, when the swelling had completely subsided, a
careful e2camination was again made by Dr. Boardman and myself,
when we arrived at the conclusion that it was a fracture through the
bicipital groove, and that the lesser tubercle was carried forward half
an inch or more from its fellow, while the head and the greater
tubercle occupied their natural positions opposite the socket. The
fragment projecting in front presented a sharp point, and could not be
confounded with any swelling of the soft parts. There was a distinct
space between the tubercles, into which the finger could be laid. No
depression existed under the acromion process behind, but, on mea-
surement, the head of this humerus was found to be half an inch wider
in its antero-posterior diameter than the opposite.

That this fracture was accompanied with impaction was rendered

1 South, Fractures in Vicinity of Joints, pp. 101-^.

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certain by the repeated and carefal measurements of the length of the
hamerus, which constantly showed a shortening of half an inch.

Under these circumstances union generally takes place; but it is
usually accompanied with the formation of an irregular mass of osteo-
phytes, which encircle the head like a coronet; presenting in this
respect again a remarkable resemblance to extra-capsular fractures of
the neck of the femur. This ensheathing callus, as it may be called,
is an outgrowth from the inferior fragment, and it sometimes incloses
the upper fragment as the case of a watch incloses the crysttil, only in
a manner much more irregular, thus retaining it steadily in its pface,
although very little direct union has occurred. The cancellous tissue,
nevertheless, is occasionally found united completely by a new and
intermediate bony tissue, and at other times by a fibrous tissue, or by
both fibrous and bony tissue.

In some cases a perfect false joint has been Ibrmed between the
opposing surfaces, while in a few unfortunate examples the head not
only refuses to unite, but by its presence, as we have already remarked,
produces inflammation and suppuration, resulting in itd final extrusion
from the joint.

At other times the upper fragment turns upon its own axis, and is
found more or less tilted or completely rotatea in the socket ; so that
its cartilaginous or articulating surface rests upon the broken surface
of the lower fragment, and its own broken surface presents toward
the glenoid cavitv.

Bobert Smith has described a specimen of this kind which he re-
moved from the body of a woman, aged forty, who many years pre-
vious to her death fell down a flight of stairs, and struck her shoulder
with great violence against the edge of ope of the steps. Whether
she applied to a surgeon or not at the time of the accident, Mr. Smith
was not able to ascertain. After death the shoulder looked somewhat
as if there was a dislocation of the humerus into the axilla, there being
a marked depression under the acromion process, but the shaft of the
humerus was drawn upwards and inwards toward the ooracoid pro-

When the capsular ligament was opened, the head of the bone was
found to have been broken from the shaft through the line of the ana-
tomical neck, and to have completely turned upon itself; and the
cartilaginous surface was actually driven one inch into the cancellated
structure of the shaft, so as to split off the lesser tubercle with a por-
tion of the greater. Only one-half of the upper fragment was thus
impacted, the other half projecting beyond the margin of the lower
fragment. Between the cartilaginous surface and the shaft no union
had occurred ; but there was complete bony union between the upper
and lower fragments, beyond the limits of the cartilage.

The upper surface of the superior fragment rested in part against
the inner half of the glenoid cavity and upon its inner margin, and in
part it rested against the neck of the scapula in the direction of the
coracoid process.^

> R. Smith, op. clt., pp. 198-6.

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Fig. 60. Fig. 61. N^laton saw a similar specimen in

the possession of M. Dabled, the revo-
lution of the upper fragment being
complete ; but there was no later dis-
placement, and the union had been
accomplished in a manner similar to
that which is seen after intra-capsu-
lar, impacted fractures, without re-

I have also been permitted to ex-
amine a specimen belonging to Dr.
Charles A. Pope, of St. Louis, Mo.,
which seems to have been broken
not only through the line of the
anatomical neck, but also through the
surgical neck. Both fragments are
united by bone, the lower fragment
being carried in the direction of the
coracoid process, while the upper
fragment appears to be reversea, so
that its articular surface is directed
toward the shaft, and its broken sur-
face articulates with the glenoid cavity.
The history of this specimen is un-

It is possible, we think, that these
extraordinary changes of position were
not the direct result of the accident
which broke the bone, but that they
had been taking place gradually and
through a long period. It is certainly quite as probable that the
constant motions of the arm should accomplish these displacements,
as that they should be produced by a direct blow ; indeed, the former
supposition appears to us much the most probable.

There is another supposition which, in my opinion, is capable of
explaining most of the phenomena usually present in these cases,
and which, if admitted, renders the supposition of a fracture unne-
cessary. It is, that these are all of them examples of softening of
the neck of the bone, as a result of chronic inflammation, ulceration
&c.; and that the changed position of the head is due to pressure
alone, being acted upon by the muscles which surround the joint,
and which act all the more vigorously because they partake also of
the inflammation which has invaded the bone. This view of these
specimens, which had already more than once suggested itself to me,
was very strongly confirmed by its having occupied the mind also of
Dr. Neill, of Philadelphia, and who at his own instance stated to me
that he believed this was their true explanation. We were, at the
time, examining Dr. Pope's specimen, already alluded to, and, on com-

' N^laton, El^mente de Pathol. Chirar., torn. prem. p. 807.

Db. Pope's Spbciukv.
Front view. side Tlew.

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paring it with a specimen of dislocation and partial absorption of the
head of the humerus contained in Dr. NeilPs museum, the points of
resemblance were so numerous and striking that we felt compelled to
doubt whether Dr. Pope's specimen, together with those seen by Smith
and N^laton, did not belong to the same class with this of Neill's.

In a case of fracture of the " cervix humeri within the capsular liga-
ment," examined by Sir Astley Cooper, there was also a complete
forward luxation of the head ; but ligamentous union had occurred
between the fragments.* Many similar cases have been reported by
other surgeons.

§ 2- Pbaotures through thb TUBEKGLE& (Extra-capsular; Non-impacted

and Impacted.)

Under this division we intend to speak of all fractures traversing
the upper end of the humerus, and involving the tubercles, or of all
those which occur between the anatomical neck on the one hand, and
the epiphyseal junction, or surgical neck, on the other hand, and which
iriay be more or less oblique as well as transverse. Fractures of the
greater or lesser tubercles are of course excepted, since they are more
properly longitudinal fractures, and do not completely traverse the
diameter of the bone. Nor do we intend to include those fractures
which occur at the epiphyseal junction, since, being below the princi-
pal insertioq of those muscles which are attached to the tubercles, they
present very peculiar and distinctive features which will demand fox
them a separate classification.

Gatises, Pathology, and Results, — Fractures through the tubercles,
like fractures through the anatomical neck, are the results generally
of direct blows received upon the shoulder. They are not usually
accompanied with much lateral displacement at the point of fracture ;
a circumstance which finds a partial explanation in the fact that the
line of fracture is through the insertions of the muscles converging
upon the tubercles, and not entirely above or below them, so that they
continue to act nearly equally upon both fragments ; but it is also
sometimes due in a measure to impaction : the head being forced
downwards toward the axilla, and upon the shaft until it is made to
ride upon its inner or axillary wall like a cap ; the compact bony
tissue of the shaft penetrating the reticular structure of the head.
These fractures generally unite by bone; yet more or less impairment
of the motions of the limb results from the inflammation which occurs
in and about the joint, or from the irregular deposits of callus in the
vicinity of the fracture.

§ 3. Longitudinal Fractures of the Head and Neck ; or Splitting off
OF the Greater Tubercle.

Causes, Pathology, Symptoms, and Results. — Mr. Guthrie seems to
have been the first to call attention to this peculiar injury of the
shoulder. In a lecture delivered in November, 1833, he described

> A. Cooper on Dislocations, &c., p. 873.

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four cases which had come under his observation, and which he re-
garded as examples of separation of the small tuberosity, accompanied
with more or less of the head, the fracture extending along a portion
of the bicipital groove.^

Sobert Smith, however, believes that it was the greater and not the
lesser tuberosity which was thus detached in the cases mentioned by
Mr. Guthrie, since the external signs were so nearly like those which
were present in a woman seen by himself, and in whom an autopsy
enabled him to verify his diagnosis. The following is the case as
related by Mr. Smith : —

" In July, 1844, 1 was requested to examine the body of Julia Darby,
0et. 80, w&o had died of chronic pulmonary disease. Upon entering
the room, the appearances of the left shoulder-joint at once attracted
my attention, and struck me as being different from those which attend
the more common injuries of this articulation.

" The shoulder had lost, to a certain extent, its natural rounded
form ; the acromion process, although unusually prominent, did not
project as much as in cases of dislocation of the head of the humerus.
The breadth of the articulation was greatly increased, and, upon press-
ing beneath the acromion, an osseous tumor could be distinctly felt,
occupying the greater part of the glenoid cavity ; it formed a promi-
nence which was perceptible through the soft parts; it moved along
with the shaft of the humerus, but was manifestly not the head of the

"A second and larger tumor, presenting the rounded form of the
head of the humerus, lay beneath the base of, and internal to, the cora-
coid process, and between the two the finger could be sunk into a deep
sulcus, placed immediately below the coracoid process. The elbow
could be brought into contact with the side, and there was no appre-
ciable alteration in the length of the arm.

" Upon removing the soft parts, the head of the bone presented itself,
lying partly beneath and partly internal to the coracoid process. The
greater tuberosity, together with a very small portion of the outer
part of the head of the bone, had been completely separated from the
shaft of the humerus. This portion of the bone occupied the glenoid
cavity, the head of the humerus having been drawn inwards so as to
project upon the inner side of the coracoid process; it was still, how-
ever, contained within the capsular ligament.

" The fracture traversed the upper part of the bicipital groove,
which, in consequence of the displacement which the heaa of the bone
had suffered, was situated exactlv below the summit of the coracoid
process. A new and shallow socket had been formed upon the costal
surface of the neck of the scapula, below the root of the coracoid pro-
cess, and the inner edge of the glenoid cavity corresponded to the pos-
terior part of the sulcus, which separated the head of the bone from
the detached tuberosity. The latter was united to the shaft only by

" The capsule had not been injured, but was thickened and en-

' Robert Smith, p. 181, from Lond. Med. and Phys. Journal.

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larged, and the bone had been deposited in its tissue. The injury had
evidently occurred raany years before the death of the patient, but
the history connected with il could not be precisely ascertained."*

Mr. Smith relates one other case, in the living subject, which he
saw in connection with Mr. Adams, at the Richmond Hospital, and
he adds that " numerous" other living examples have fallen under his

Sir Astley Cooper has also published the particulars of a case of
fracture of the greater tubercle, which was communicated to him by
Mr. Herbert Mayo.'

The following I believe also to have been an example of this rare
accident : —

John Hill, »t. 78, fell upon the side-walk, striking upon his right
shoulder. The physician to whom he was sent thought the humerus
was dislocated, and directed him to the Buffalo Hospital of the Sisters
of Charity, but he did not apply for admission until eight days after,
Oct. 14, 1857, when Dr. Boardman and myself examined the limb

Although we placed him under the influence of chloroform, the
diagnosis was not satisfactorily made out. We inclined, however, to
the opinion that it was a fracture of the greater tubercle. The antero-
posterior diameter of the upper end of the bone was greatly increased ;
there was occasional distinct crepitus, but the limb was not shortened.

Subsequently, the examinations were repeated many times, and the
depression between the fragments becoming rhore palpable, the diag-
nosis was at length confirmed.

No treatment was adopted, except confinement in bed, and stimu-
lating embrocations. Two months after the accident he still remained
an inmate of the hospital, his shoulder being quite stiff, and the pro-
jection continuing in front.

Mr. Bobert Smith thinks that when the displacement is considerable,
the fragments generally unite by ligament, rather than by bone.

§ 4. Fhaotubes through the Subqioal Neok. (Including SeparoHona at
the Upper JSpiphysia,)

I have already defined the " Surgical Neck" as all of that narrow
portion commencing at the upper epiphysis and terminating at the
insertion of the pectoralis major ana latissimus dorsi. It seems
proper, therefore, that we should include under this division both
fractures, and separations occurring at the epiphysis, especially since,
owing to their anatomical relations, they are subject to the same dis-

?lacements as fractures occurring half an inch or one inch lower down,
'he capsular muscles, with the exception of the teres minor, having
no more influence over the lower fragment when a separation occurs
at the epiphysis, than when a separation occurs at any other point of
the surgical neck.

> Robert Smith, op. dt., p. 17S.

« A. Cooper, on Dislocations and Fractures of the Joints. Edited by B. Cooper.
American edition, p. 384.

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Fig^62. A brief description of the plan of development of

the humerus will enable the reader better to ander-
stand the occasional separation of the epiphysis, both
at the upper and lower ends of the bone.

The humerus is originally formed from seven car-
tilaginous centres, namely, one for the shaft, one for
the head, one for the greater tuberosity, one for each
epicondyle, and two for the lower, articulating end
of the bone. At birth the shaft is ossified in nearly
its whole length. Between the first and fourth years
ossification commences in the several centres com-
posing the upper end of the bone, and they coalesce
by the end of the fifth year, so as to form a single
epiphysis, which finally unites with the shaft at
about the twentieth year. At the lower end of the
bone, ossification commences in the radial portion of
the articular surface at the end of two years, in the
trochlear portion at twelve years, in the internal epi-
condyle at the fifth year, and in the external epicon-
dyle at the thirteenth or fourteenth. At the sixteenth
or seventeenth year all the centres are joined to each
other, and to the shaft, except the inner epicondyle,
which does not unite by bone until about the eighteenth
year. It will be observed, therefore, that sJtfaough
Hnmernt, with ossificBtiou commeuccs iu the upper epiphysis first, it
6piph3r««. (Prom jg ^j,q j^g^ ^ f^^^^ y^^y ^^iou with thc shaft.

^^' The following is an account of a case of separation

at the upper epiphysis which came under my notice in 1855 : —

Mike Bovin, »t. 18 months, fell sideways from his cradle, causing
some injury to his arm near the shoulder. He was taken' to an em-
piric, who called it a sprain, and applied liniments. Three weeks
after the accident he was brought to me, and I found the arm hanging
beside the body, with little or no power on the part of the child to
move it. There was a slight depression below the acromion process,
and considerable tenderness about the joint; but the shoulaer was
not swollen, nor had it been at any time. The line of the axis of
the bone, as it hung by the side, was directed a little in front of the

On moving the elbow backwards and forwards, the upper end of
the shaft moved in the opposite directions with great freedom, and
could be distinctly felt under the skin and muscles. This motion was
accompanied with a slight sound, or sensation, a sensation not like
the grating of broken bone, but much less rough. There was no
shortening of the limb. When the elbow was carried a little forwards
upon the chest, the fragments seemed to be restored to complete coap-
tation ; and of this I judged by the restoration of the line of the axis
of the shaft to the centre of the socket, and by the complete disappear-
ance of the depression under the point of the acromion process.

I applied suitable dressings to retain the arm in this position ; but
five months after the injury was received the fragments had not

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tinited, and the child was still unable to lift the arm, although the
forearm and hand retained their usual strength and freedom of motion.
The same crepitus could occasionally be felt in the shoulder, and the
same preternatural mobility. The shoulder was at this time neither
swollen nor tender. I have since this time met with three more ex-
amples, occurring in young men who were respectively 18, 16, and
19 years of age, all of which were unreduced, the patients having
been brought to me as examples of unreduced dislocations.

^bert Smith and Sir Astley Cooper both speak of it as a frequent
accident in early life, but the recorded cases are very few. The case
mentioned by Mr. Smith has been given very much at length, and, as
a characteristic example, deserves to be repeated : —

" During the early part of last year, a boy, eight years of age, was
admitted to the Richmond Hospital, under the care of Dr. McDowell.
About a week previous to his admission he had fallen upon the
shoulder, and at once lost the power of using his arm.

" It was at first sight evident that there did not exist any luxation
of the head of the humerus, and it was equally obvious that the case
was not an example of any of the ordinary fractures to which the neck
of the bone is liable. There was no diminution of the natural rotun-
dity of the shoulder, nor any unusual prominence of the acromion
process ; the head of the bone could be distinctly felt in the glenoid
cavity, and it remained motionless when the arm was rotated ; there
was very little separation t>f the elbow from the side, but it was di-
rected slightly backwards.

"About three-quarters of an inch below the coracoid process there
existed a remarkable and abrupt projection, manifestly formed by the
upper extremity of the shaft of the humerus, every motion imparted
to which it followed. Its superior surface, which could be distinctly
felt, was slightly convex, and its margin had nothing of the sharpness
which the edge of a recently broken bone presents in ordinary

" When this projecting portion of the bone was pushed outwards, so
as to bring it in contact with the under surface of the head of the
humerus (previously fixed as far as it was possible to do so), a crepitus
was produced by rotating the shaft of the bone. It did not, however,
resemble the ordinary crepitus of fracture, but it would be extremely
difficult, by any description, to convey a clear idea of what the differ-
ence consisted in.

" From a careful consideration of the symptoms and appearances
above mentioned (taking into account also the age of the patient), the
diagnosis was formed, that the injury consisted in a separation of the
superior epiphysis of the humerus from the shaft of tne bone. Va-
rious mechanical contrivances were employed in this case, but all
proved ineffectual in maintaining the fragments in their proper rela-
tive position."^

Sir Astley Cooper has also briefly described one example.

» Robert Smith, op. cit., p. 201.

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" Its age was ten years. The symptoms of the injury were, inability

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 26 of 100)