Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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of moving the elbow from the side, or of supporting the arm, unless

by the aid of the other hand, without great
^S' ^' pain. The tension which succeeded filled

up the hollow which was at first produced
by the fall of the deltoid muscle. When
the head of the bone was fixed, the frac-
tured extremity of the humerus could be
tilted under the deltoid muscle, so as tp be
felt, and even shown, by raising the arm at
the elbow. Crepitus could be perceived,
not by rotating the arm, but by raising the
bone and pushing it outward. The cause
of the fracture was a fall upon the shoulder
into a saw-pit of the depth of eight feet"^
It will be necessary, in order to a full
understanding of the various aspects of this
fracture — a fracture of the surgical neck —
to relate several illustrative examples.

Fracture of the .nrglcal neck of the 9^SE 1 Simpk/rOCture, nCOer displaced;

bmnenii. (From Gray.) umon without deformity, — Alcx. Balcntine,

S8t. 62 ; admitted to the Buffalo Hospital of
the Sisters of Charity, December 19, 1851. He had fallen upon the
side-walk, striking upon his right arm. Dr. Johnson, of Buffalo, had
reduced the fracture and applied appropriate dressings. No union of
the fragments had yet occurred ; but as the surfaces were in appo-
sition, it was only after considerable manipulation, and not until we
bent the forearm upon the arm, and rotated the humerus by means of
the forearm, that the crepitus became distinct, and gave unequivocal
evidence of the existence of a fracture, and of its situation.

The treatment, after admission, consisted in the application of one
gutta-percha splint, accurately moulded, and extending from above the
shoulder to below the elbow, and encircling one-half the circumference
of the arm ; the splint being secured with the usual bandages, &c.

The result is a perfect limb.

Case 2. Simple fracture ; union with displacement and deformity, —
White, of Buffalo, set. 12, fell fourteen feet, striking on the front and
outside of the left shoulder. Dr. P., of Erie County, saw the lad within
three hours (July 19, 1858). He was brought to me on the fourth day
after the accident. The upper part of the arm was then very much
swollen. I found- the arm dressed as for a fracture of the middle or
lower third of the humerus. It was shortened one inch. The elbow
was inclined backwards, and there was a remarkable projection in front
of the joint, feeling like the head of the bone. The hand and arm
were powerless. I suspected a dislocation of the head of the humerus
forwards ; and, having administered chloroform, I attempted its reduc-
tion with my heel in the axilla. While making extension, I felt a
sudden sensation like the slipping of the bone into its socket, but on

1 A. Cooper, op. cit., 882.

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examination I found the projection continued as before. I then re-
peated the eflFort, with precisely the same result.

I now applied an arm sling, and directed leeches and cold evapo-
rating lotions.

On the 25th, five days after the accident, it was examined by Drs.
Mixer, McGregor, Joseph Smith, with myself. We still believed it
was a dislocation, and, having administered chloroform, we again
attempted its reduction. The same slipping sensation was produced
as before, and the deformity was repeatedly made to disappear; but,
on suspending the extension, it as often reappeared.

The character of the accident was now made apparent, and we pro-
ceeded at once to apply the splint and bandages suitable for a fracture
of the surgical neck of the humerus, namely, a gutta-percha splint,
extending, on the outside, from the top of the shoulder to below the
elbow, with an arm and body roller secured with flour paste.

On the 81st, twelve days after the accident^ Dr. Wilcox, Marine Sur-
geon at Buffalo, saw the arm with me. The fragments were displaced
the same as when I first saw it, and the same as when no apparatus
was applied. We examined it again carefully, and attempted to make
the fragments remain in place, but we were unable to do so, except
while holding them and making extension.

August 9 (twenty -first day). I removed all the dressings. Motion
between the fragments had ceased, but the projection and shortening
remained as before ; now, also, the irregular projections of the fractured
bones were more distinctly felt. The dressings were never reapplied.
Three months later no change had occurred. He could carry the
elbow forwards freely, as well as backwards, the motions of the shoul-
der-joint being unimpaired.

Case 8. Simple fraclure^ with displacement; resulting in deformity
and non-union, — L. B., of Lockport, aet. 43, was thrown from his horse
in February, 1854, striking upon his right elbow.

Dr. Maxwell, an experienced surgeon of Lockport, examined and
dressed the fracture. * Dr. Fassett was present and assisted at a subse-
quent dressing. Three surgeons who examined the arm before Dr.
M., called it a dislocation.

Twelve weeks after the accident, Mr. B. called upon me. The right
arm was shortened one inch ; the elbow hung off slightly from the
body ; the upper end of the lower fragment was distinctly felt in front
of the shoulder-joint, under the clavicle, feeling very much like the
head of the bone. The fragments were not united, but they could be
seized easily, and made to move separately and freely. He stated to
me that he was subject to rheumatism, and especially in the shoulder
and arm of the side injured. He wished to know whether it could
not be " re-set."

Two years after, I found the bone still ununited. He was, however,
able to write with that hand, having first lifted his arm with the other
hand and laid it upon the table.

Cass 4. Simple fracture, probably impacted: resulting in deformity, —
Wm. A., of Buffalo, est, 15, fell backwards, June 4, 1855, striking on
his back and left shoulder. Dr. L. saw it immediately, and, regarding

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it as a dislocation, attempted its reduction. He subsequently repeated
the attempt. I saw the patient with Dr. L. on the tenth day. The
arm was shortened one inch and a half. The fragments were displaced
forwards, projecting in front of and a little below the joint. As in
Case 3, it might easily be mistaken for the head of the bone ; bat the
difficulty of diagnosis had been very much lessened by the subsidence
of the swelling. There was no motion between the fragments ; nor
could the deformity, by any manipulation or extension, be made to
disappear. It was probably in^pacted.

March 23, 1856, nearly ten months after the accident, I found tbe
fragments remaining as when I first examined the limb, and the arm
shortened one inch and a half. The elbow hung a very little back
from the line of the body. The upper end of the lower fragment was
lifted to within one inch of the head of the humerus ; the upper frag*
ment having its head in the socket, with its lower end downwards and
forwards. The arm was, however, in every respect as useful as before
it was broken. It was equally strong, and he could raise his arm as
high, and move it in every direction as freely, as he could the other.

Causes. — Epiphyseal separations belong almost exclusively to the
periods of youth and childhood, but true fractures at the surgical neck
occur most often in adult life ; with the exception of one girl and two
lads, aged, respectively, eleven, twelve, and fifteen years, all of the
examples of this latter accident recorded by me occurred in adults,
and of twenty-eight cases in which I find the ages recorded, the
average age is about forty-three years ; yet Sir A. Cooper declares
these fractures to be most common in infancy, while Malgaigne has
never seen a case in a person under fifty-three years.

Both epiphyseal separations and fractures at this point are occa-
sioned, in most cases, by direct blows or falls upon the shoulder. Of
twenty-seven examples in which I find the cause recorded, eighteen
were from direct blows, eight from indirect blows, and one from mus-
cular action, as in throwing a ball. Of the eight resulting from indi-
rect blows, one was from a fall upon the hand; seen by Desaulty and
seven were from falls upon the elbow, of which two were seen by
Desault, and five by myself.

Pathology. — I have found the fragments sensibly displaced in ten
cases out of fifteen ; a proportion much greater than has been observed
by Malgaigne, who has only seen a displacement twice in more than
twenty cases. It is certain, however, that complete or sensible dis-
placement is less common in this fracture than in most other fractures,
the broken ends being retained in place, probably, by the long tendon
of the biceps.

As to the direction of the displacement, I have seen the upper end
of the lower fragment drawn forwards and upwards toward the cora-
coid process four times, in one of which examples the upper ^fragment
plainly followed in the same direction. Sir Astley Cooper declares
that with infants this direction is constant, and in museum specimens
I have seen but one exception. In the specimens of fracture of the
surgical neck, with also aisplacement of the head, belonging to Dr.
Pope, this direction of the fragments is plainly seen, as also in a spe-

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cimen belonging to Dr. Neill, of the Pennsylvania Medical College,
where the lower fragment almost reaches the coracoid process, and in
a specimen contained in one of the cabinets of the University of
Pennsylvania, where the upper end of the lower fragment has become
united by bone to the coracoid process.

The only exception which I have met with is in the possession of
Dr. Neill. In this example the two ends are tilted toward the axilla.
In the recorded examples, also, I find the displacement forwards men-
tioned four times, and the displacement toward the axilla but once. I
am compelled, therefore, to doubt the accuracy of Malgaigne's obser-
vations, who thinks he has seen the lower fragment most often drawn
toward the axilla, as well as the observations of those who think that
the upper fragment is generally displaced outwards ; yet, no doubt,
they do sometimes assume this position. Desault has seen them both
thrown backwards ; while Dupuytren, Paletta, and others have seen
them pushed outwards ; 'and I have in my cabinet th^ copy of a speci-
men in which both fragments are drawn outwards, but the lower frag-
ment is to the inner side of the upper.

' When the fracture occurs at or near the epiphysis, it is sometimes
accompanied with impaction, of the same character as we have already
described when speaking of fractures through the tubercles. Bobert
Smith has given, in his treatise, an engraving intended to illustrate
the relative position of the fragments in extra-capsular impacted frac-
tures, and the line of separation very nearly corresponds to the line of
JQDCtion of the epiphysis with the shaft.

Bat in a majority of cases no impaction occurs. Dr. Charles A.
Pope, of St. Louis, Mo., has two specimens of this kind, in which no
union has taken place, nor is there any evidence that impaction had
ever occurred. In one case the line of fracture commences at the
junction of the head with the shaft, and extends thence irregularly
across to a point half an inch below the greater tuberosity. In the
second specimen the fracture commences at the same point, and ter-
minates three-quarters of an inch below the greater tuberosity. In
relation to these bones, Dr. Pope remarks : "These are not cases of
detachment of the epiphyses, as the bones are evidently those of adults,
and there is, at their lower extremities above the condyles, no trace of
an epiphyseal line."

BesuUs. — Eight of the examples of fracture of the surgical neck
recorded by me are known to have resulted in perfect limbs, and three
are more or less deformed. In one of these no bony union has taken
place after the lapse of two years or more. It is satisfactory, however,
to know that, with the exception of this last (Case 3), all the patients
have recovered the free and complete use of their arms.

Symptoms, w Differerdial Diagnosis of Accidents about the Shoulder-
joirU, — ^No place could be more appropriate than this to call attention
to the difficulty of diagnosis in the case of accidents about the shoul-
der-joint, a difficulty which surgeons have constantly recognized, and
which has sometimes rendered diagnosis impossible.
Let us first study the ordinary signs of a dislocation at the shoulder-

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joint, regarding this as the type with which the other accidents are to
be compared,

a. Signs of a Dislocation, ((7a?i56, generally a fall upon the elbow or
hand, yet not very unfrequently a direct blow.)

1. Preternatural immobility.

2. Absence of crepitus.

8. When the bone is brought to its place, it will usually remain
without the employment of force.

These three are common signs, which apply to any other joint as
well as to the shoulder.

4. Inability to place the hand upon the opposite shoulder, or to
have it placed there by an assistant, while at the same time the elbow
touches the breast. This is a sign common to all of the dislocations
of the shoulder.^

The following are special signs, or such a§ belong only to particular
dislocations of tne shoulder.

5. Depression under the acromion process ; always greatest under-
neath the outer extremity, but more or less in front or behind, accord-
ing as the dislocation may be into the axilla, forwards or backwards.

6. Round, smooth head of the bone sometimes felt in its new situa-
tion, and very plainly removed from its socket ; moving with the shaft.
Absence of the head of the bone from the socket.

7. Elbow carried outwards, and in certain cases forwards or back-
wards, and not easily pressed to the side of the body.

8. Arm shortened in the dislocation forwards, and slightly length-
ened or its length not changed, when in the axilla.

b. Signs of a Fracture of the Neck of the Scapula. {Cause, generally
a direct blow.)

1. Preternatural mobility.

2. Crepitus, generally detected by placing the finger on the coracoid
process and the opposite hand upon the back of the scapula, while the
head of the humerus is pushed outwards and rotated.

8. When reduced, it will not remain in place.

4. The hand may generally, but with difficulty, be placed upon the
opposite shoulder, with the elbow resting upon the front of the chest.

5. Depression under the acromion process, but not so marked as in

6. Head of the bone may be felt in the axilla, but less distinctly than
in dislocation. Never much forwards or backwards. Head of the bone
moves with the shaft. Head of the bone not to be felt under the acro-
mion process, although it has not leR; its socket.

7. Elbow carried a little outwards, but not so much as in dislocation.
Easily brought against the side of the body.

8. Arm lengthened.

9. The coracoid process carried a little toward the sternum, and

1 Report on a New Principle of Diagnosis in Dislocations of the Shoulder-joint,

L. A. Dugas, Prof, of Sui '^ " "^ * *"

!ed. Assoc., vol. x. p. 175.

by L. A. Dugas, Prof, of Surgery in the Medical College of Georgia. Trans. Amer.

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10. Pressing upon the coracoid process, it is found to be movable,
and it is also observed that it obeys the motions of the arm.

c. Signs of Fracture of the Anatomical Neck of the ffumerus. Intra-
capsular. {Cause, a direct blow; generally opening to the joint, but
not always.)

1. Mobility not increased, nor diminished.

2. Crepitus, generally discovered by pressing up the head of the
bone into its socket and rotating; or, when the tubercles are also
broken, by grasping the tubercles and rotating the arm.

3. Fragments not generally displaced.

4. The hand can be placed easily upon the opposite shoulder; with
the elbow against the front of the chest.

5. Very slight, if any, depression under the acromion process.

(5. Head of the bone generally in its socket, but not felt so distinctly
as before the fracture.

7. Elbow falls easily against the side of the body, or is easily placed

8. Arm not lengthened, nor appreciably shortened, unless the head
be driven so much into the body as to separate the tubercles.

9. In this latter case there are present also the signs of fracture of
the tubercles.

d. Signs of Fracture of the ffumerus through the Tubercles. Extra-
capsular. {Cause, direct blows.)

1. Generally, there is neither marked mobility nor immobility, ex-
cept what immobility may be due to a contusion of the muscles.

2. Crepitus, discovered, but not so easily as in intra-capsular frac-
tures, by rotating the arm while the tubercles are grasped firmly.

3. If displacement exists, the fragments are not always easily kept
in place when once reduced.

4. The hand can be placed upon the opposite shoulder, with the
elbow against the front of the chest.

5. No depression under the acromion process.

6. Head of the bone in its socket, and moving with the shaft, when,
as is usually the case, it is impacted.

7. Elbow hangs against the side of the body.

8. Arm shortened when impacted, but not very appreciably.

The signs which characterize this accident are more obscure than in
either of the other shoulder accidents. They are mostly negative, and
will not generally be determined positively except in^the autopsy.

e. Signs of a Longitudinal Fracture of the ffead and Neck, or splitting
oj^^ of the Greater Tubercle. {Cause, direct blow upon the front of the

1. Mobility of the limb natural.

2. Crepitus; elicited especially by grasping the tubercles and rotat-
ing the arm, or by carrying it up and back and then rotating.

3. When reduced, the fragments will not remain in place.

4. The hand can be placed upon the opposite shoulder, while the
elbow rests against the front of the chest.

5. Some depression under the acromion process.

6. A smooth bony projection directly underneath the coracoid pro-

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cess, or close upon its inner or outer side, moving with the shaft. The
head of the bone cannot be felt in the socket, yet the space under the
acromion is not entirely unoccupied.

7. Generally, but not always, the elbow hangs against the side.
Sometimes it inclines a little backwards. It can always be easily
brought to the side.

8. Arm generally neither lengthened nor shortened.

9. A remarkable increase in the antero-posterior diameter of the
upper end of the bone.

10. A deep vertical sulcus between the tubercles, corresponding with
the upper part of the bicipital groove.

f. Signs of a Fracture through the Surgical Neck. (Oause, generally
direct blows, but in old people frequently caused by a fall upon the

1. Preternatural mobility often, but not constantly, present.

2. Crepitus, produced easily when there is no impaction, or when
the displacement is not complete, but with difficulty when impaction
exists or the displacement is complete.

3. When once the fragments have been displaced, it is exceedingly
difficult ever afterward to maintain them in place.

4. The hand can be easily placed upon the opposite shoulder, while
the elbow rests against the front of the chest.

5. A slight depression below the acromion, not immediately under-
neath its extremity, but an inch or more below.

6. Head of the bone in the socket, and moving with the shaft when
impacted, but not moving with the shaft when not impacted. The
upper end of the lower fragment being often felt distinctly pressing
upwards toward the coracoid process; its broken extremity being
easily distinguished by its irregularity from the head of the bone.

7. Elbow hanging against the side when the fragments are not dis-
placed, but away from the side when displacement exists.

8. Length of arm unchanged unless the fragments are impacted or
overlapped; or both fragments are much tilted inwards. If the frag-
ments are completely displaced, the arm is shortened.

g. Signs of a Separation at the Epiphysis. {Cause, direct blows.)

1. Preternatural immobility.

2. Feeble crepitus ; less rough than the crepitus produced when
broken bones are rubbed against each other.

3. Fragments- replaced are not easily maintained in place.

4. Same as in preceding variety of fracture.

5. The depression is not immediately under the acromion, yet higher
than in most fractures of the surgical neck, perhaps one inch below
the acromion process.

6. Head of the bone in its socket, and not moving with the shaft.
Upper end of lower fragment projecting in front, when displacement
exists, and feeling less sharp and angular than in case of a broken
bone; indeed, being slightly convex and rather smooth, it may easily
be mistaken for the head of the bone.

7. Same as preceding variety.

8. Length of arm not changed unless the fragments are overlapped,

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or both fragments are tilted upon each other. When the fragments
are overlf^ped, the arm is shortened.

9. This accident is almost peculiar to infancy and childhood. It
can seldom occur after the twentieth year.

There are other accidents about the shoulder-joint, such as a patho-
logical partial luxation of the humerus, dislocation of the tendon of
the biceps, &c., which might possibly be confounded with fractures^
but the consideration of which I shall reserve for another time.

JitatTnent. — I have already spoken of the treatment of fractures of
the neck of the scapula, and my remarks will now be confined to frac-
tures of the upper end of the humerus.

Fractures of the Anatomical Neck; Intra-capaular. — As has already
been stated, these are generally compound fractures, and, from the
extent of the injury, often demand resection or amputation of the entire
arm. If an efibrt is made to save the arm, splints will not be applied,
and the treatment will have little or no reference to the existence of a
fracture ; it will be directed only to the reduction or prevention of the
inflammation, &c.

Simple fracture of the anatomical neck, without any external wound
communicating with the joint, and accompanied, as it often is, with
impaction, frequently unites, or the upper fragment becomes encased
in the lower.

It is not proper in such cases to employ great violence for the pur-
pose of detecting crepitus, lest the fragments should become displaced ;
and if the arm should be found to be a little shortened, it must not be
extended, with a view to overcoming the shortening, since upon the
impaction probably depend, in a great measure, the chances of union.
The elbow and forearm may be suspended in a sling, while the arm
is gently supported against the side, merely to insure quietude. No
splints are necessary or useful.

Treatment of Fractures through the Tubercles {Fxtra-capsular); Non-
impacted and Impacted. — In these cases, also, the fragments being
seldom displaced, very little if any mechanical treatment is demanded.
A sling is all that is usually required. If, however, on account of dis-
placement of the fragment, a splint is thought necessary, it must be
applied in the manner hereafter to be directed in cases or fractures of
the surgical neck.

If impaction, with shortening, exists, the same remarks are appli-
cable here as in intra-capsular impacted fractures, namely, that we
ought not to rotate the limb much, nor violently, in order to discover
crepitus, nor make extension with the view of overcoming the short-
ening, since the fragments unite more promptly and certainly when
the impaction remains, and its continuance in no way damages the
usefulness of the limb.

T^reaimeni of Longitudinal Fracture of the Head and Neck, or of a
Separation of the Cheater Tubercle, — In the only instance which I have
recognized as a fracture of the greater tubercle, and already referred
to, the displacement was moderate, and could not be overcome either
by change of position or by pressure with extension. The patient
was therefore merely laid upon his back in bed. No dressings of any

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kind were employed, and the fragments seemed to unite promptly,
and with no increase in the displacement.

If the displacement is originally more considerable, attempts ongbt
still to be made to reduce the fragments, by extension and abduction

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 27 of 100)