Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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simple fractures, and occurred near the middle of the humerus; the
third was compound, and occurred near the middle also ; the fourth
was compound, and occurred near the condyles.



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SHAPT BELOW THE SUBGICAL NECK. 241

" This analysis supplies us, therefore; with four cases of non-union,
from a table of twenty-eight cases of fractures through the shaft.

" Of eighty -seven fractures of the femur, twenty occurred through
the neck, one through the trochanter major, and one through the con-
dyles. The remaining sixty-five occurred through the shaft, and
generally near the middle, and not in one case was the union delayed
beyond six months.

" To make the comparison more complete, I must add that of the
twenty-eight fractures of the shaft of the humerus, six were compound ;
and of the sixty-five fractures of the shaft of the femur, six were
either compound, comminuted, or both compound and comminuted.
The six compound fractures of the shaft of the humerus furnished two
cases of non-union. The six cases of either compound or comminuted,
or compound and comminuted fractures of the femur, furnished no
case of non-union.

" I beg to suggest to the Society what seems to me to be the true
explanation of these facts.

"It is the universal practice, so far as I know, in dressing fractures
of the humerus, to place the forearm at a right angle with the arm.
Within a few days, and generally, I think, within a few hours, after
tbe arm and forearm are placed in this position, a rigidity of the mus-
cles and other structures has ensued, and to such a degree that if the
splints and sling are completely removed, the elbow will remain fiexed
and firm ; nor will it be easy to straighten it. A temporary false an-
ohylosis has occurred, and instead of motion at the elbow-joint, when
the forearm is attempted to be straightened upon the arm, there is
only motion at the seat of fracture. It will thus happen that every
upward and downward movement of the forearm will inflict motion
apon the fracture ; and inasmuch as the elbow has become the pivot,
the motion at the upper end of the lower fragment will be the greater
in proportion to the distance of the fracture from the elbow-joint.

"No doubt it is intended that the dressings shall prevent all motion
of the forearm upon the arm ; but I fear that they cannot always be
made to do this. I believe it is never done when the dressing is
made without angular splints, nor is it by any means certain that it
will be accomplished when such splints are used. The weight of the
forearm is such, when placed at a right angle with the arm, and en-
cumbered with splints and bandages, that even when supported by a
flling, it settles heavily forwards, and compels the arm-dressings to
loosen themselves from the arm in front of the point of fracture, and
to indent themselves in the skin and flesh behind. By these means
the upper end of the lower fragment is tilted forwards. If the fore-
arm should continue to drag upon the sling, nothing but a permanent
forward displacement would probably result. The bones might unite,
yet with a deformity.

" But the weight of the forearm under these circumstances is not
uniform, nor do I see how it can be made so. It is to the sling that
we must trust mainly to accomplish this important indication. But
you have all noticed that the tension or relaxation of the sling depends
upon the attitude of the body, whether standing or sitting ; upon the



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242 FRACTURES OF THE HUMERUS.

erection or inclination of the head; upon the motions of the shoulders;
and in no inconsiderable degree upon the actions of respiration. Nor
does the patient himself cease to add to these conditions by lifting the
forearm with his opposite hand whenever provoked to it bj a sense
of fatigue.

" This difficulty of maintaining quiet apposition of the fragments
while the arm is in this position, at whatever point it may be broken,
becomes more and more serious as we depart from the elbow-joint,
and would be at its maximum at the upper end of the humerus, were
it not that here a mass of muscles, investing and adhering to the bone,
in some measure obviate the difficulty. Its true maximum is, there-
fore, near the middle, where there is less muscular investment, and
where, on the one hand, ttie fracture is sufficiently remote from the
pivot or fulcrum to have the motion of the upper end of the lower
fragment multiplied through a long arm, while on the other hand, it
is sufficiently near the armpit and shoulder to prevent the upper
portion of the splint and arm-dressings from obtaining a secure grasp
upon the lower end of the upper fragment.

" It must not be overlooked that the motion of which we speak
belongs exclusively to the lower fragment, and that it is always in
the same plane forwards and backwards, but especially that it is not
a motion upon the fracture as upon a pivot^ but a motion of one frag-
ment to and from its fellow. This circumstance I regard as important
to a right appreciation of the difficulty. Motion alone, I am fully
convinced, does not so often prevent union as surgeons have generally
believed. It is exceedingly rare to see a 'case of non-union of the
clavicle. Of forty -seven cases of fracture of the clavicle which have
come under my observation, and in by far the greater proportion of
which considerable overlapping and consequent deformity ensued,
only one has resulted in non-union, &nd in this instance no treatment
whatever was practised, but from the time of the accident the patient
continued to labor in the fields, and hold the plough as if nothing had
occurred. I have, therefore, seen no case of non-union of the clavicle
where a surgeon has treated the accident. Indeed, what is most per-
tinent and remarkable, its union is more speedy, usually, than that of
any other bone in the body of the same size. Yet to prevent motion
of the fragments in a case of fractured clavicle with complete separa-
tion and displacement, except where the fracture is near one of the
extremities of the bone, I have always found wholly impracticable.
Wherever bandages or apparatus has been applied, I have still seen
always that the fragments would move freely upon each other at each
act of inspiration and expiration, and at almost every motion of the
head, body, or upper extremities. It is probable, gentlemen, that you
have made the same observation.

" From this and many similar facts I have been led to suspect, for
a long time, that motion has had less to do with non-union than was
generally believed.

" I find, however, no difficulty in reconciling this suspicion with
my doctrine in reference to the case in question; and it is precisely



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SHAFT BELOW THE SURGICAL NECK. 243

because, as I have already explained, the motion, in case of a fractured
humerus, dressed in the usual manner, is peculiar.

" In a fracture of the clavicle through its middle third (its usual
situation), the motion is upon the point of the fracture as upon a pivot ;
although, therefore, the motion is almost incessant, it does not essen-
tially, if at all, disturb the adhesive process. The same is true in
nearly all other fractures. The fragments move only upon themselves,
and not to and from each other. I know of no complete exception
but in the case now under consideration.

"Aside f/om any speculation, the facts are easily verified by a per-
sonal examination of the patients during the first or second week of
treatment, or at any time before union has occurred, both in fractures
of the humerus and clavicle. The latter is always suflBlciently exposed
to permit you to see what occurs; and as soon as the swelling has a
little subsided in the former case, you will have no difficulty in feeling
the motion outside of the dressings, or, perhaps, in introducing the
finger under the dressings sufficiently far to reach the point of fracture.
I believe you will not fail to recognize the difference in the motion
between the two cases. Such, gentlemen, is the explanation which I
wish to oflFer for the relative frequency of this very serious accident —
non-union of the humerus.

"I know of no other circumstance or condition in which this bone
is peculiar, and which, therefore, might be invoked as an explanation.
Overlapping of the bones, the cause assigned by some writers, is not
sufficient, since it is not peculiar. The same occurs much oftener,
and to a much greater extent, in fractures of the femur, and equally
as often in fractures of the clavicle, yet in neither case are these results
so frequent. Nor can it be due to the action of the deltoid muscle, or
of any other particular muscles about the arm, whether the fracture
be below or above their insertions, since similar muscles, with similar
attachments, on the femur and on the clavicle, tending always power-
fully to the separation of the fragments, occasion deformity, but they
seldom prevent union.

"If I am correct in my views, we shall be able sometimes to con-
summate union of a fractured humerus where it is delayed, by straight-
ening the forearm upon the arm, and con^ning them to this position.
A straight splint, extending from the top of the shoulder to the hand,
constructed from some firm material, and made fast with rollers, will
secure the requisite immobility to the fracture. The weight of the
forearm and hand will only tend to keep the fragments in place, and
if the splint and bandages are sufficiently tight, the motion occasioned
by swinging the hand and forearm will be conveyed almost entirely
to the shoulder-joint. Very little motion, indeed, can in this posture
be communicated to the fragments, and what little is thus communi-
cated is a motion, as experience has elsewhere shown, not disturbing
or pernicious, but a motion only upon the ends of the fragments, as
upon a pivot.

" I do not fail to notice that this position has serious objections, and
that it is liable to inconveniences which must always, probably, pre-
vent its being adopted as the usual plan of treatment for fractured



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244 FRACTURES OF THE HUMERUS.

arms. It is more inconvenient to get up and lie down, or even to sit
down, in this position of the arm, and the hand is liable to swell.
But I shall not be surprised to learn that experience will prove these
objections to have less weight than we are now disposed to give them.
Eemember, the practice is yet untried — if I except the case which I
am about to relate, and in which case, I am free to say, these objec-
tions scarcely existed. The swelling of the hand was trivial, and ooly
continued through the first fortnight, and the patient never spoke of
the inconvenience of getting up or sitting down, or even of lying down.

"The following is the case to which I have just referred^ 'Michael
Mahar, laborer, set. 35, broke his left humerus just below its middle,
Dec. 14, 1853. The arm was dressed by a surgeon in Canada West,
and who is well known to me as exceedingly "clever." After a few
days from the time of the accident, "the starch bandage was put on
as tight as it could be borne, and brought down on the forearm, so
as to confine the motions of the elbow-joint." Six weeks after the
injury, Jan. 29, 1854, Mahar applied to me at the hospital. No union
had occurred. The motion between the fragments was very free, so
that they passed each other with an audible click. There was little
or no swelling or soreness. In short, everything indicated that unioa
was not likely to occur without operative interference. The elbow
was completely anchylosed. I explained to my students what seemed
to me to be the cause of the delayed union, and declared to them that
I did not intend to attempt to establish adhesive action until I had
straightened the arm. They had just witnessed the failure of a pre-
cisely similar case, in which I had made the attempt to bring about
union without previously straightening the arm.

"'On the 6th of Feb. 1854, we had succeeded in making the arm
nearly straight. I now punctured the upper end of the lower frag-
ment with a small steel instrument, and, as well as I was able, thrust
it between the fragments. Assisted by Dr. Boardman, I then applied
a gutta-percha splint from the top of the shoulder to the fingers,
moulding it carefully to the whole of the back and sides of the limb,
and securing it firmly with a paste roller. March 4th (not quite four
weeks after the application of the splint) we opened the dressings for
the second time, and carefully renewed them. A slight motion was yet
perceptible between the fragments. March 18th, we opened the dress-
ings for the third time, and found the union complete. This was
within less than forty days. The patient was now dismissed. On the
29th of April following, the bone was refraotured. Mahar had been
assisting to load the " tender" to a locomotive. As the train was just
getting in motion, he was hanging to the tender by his sound arm,
while another laborer seized upon his broken arm to keep himself
upon the car, and with a violent and sudden pull wrenched him from
the tender and reproduced the fracture. The next morning I applied
the dressings as before, and did not remove them during three weeks;
at the end of which time the union was again complete. The splint
was, however, reapplied, and has been continued to this time — a period
of about six weeks.' "'

1 Buffalo Med. Joum., vol. x. pp. 14-147.



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BASE OF THE CONDYLES. 245

Since the date of the above paper, I have three times had oppor-
tunities to test the value of this mode of treatment in cases of delayed
union of the humerus, and in each case with the same favorable result.

§ 6. Basb of the Condyles. Syn. Supracondyloid Fracture of the Hu-
merus. — Malgaigne.

Causes, — Of sixteen fractures at this point, ten occurred in children
under ten years of age, the youngest being two years old.

In ten cases the fracture had been produced by a fall, and it is
presumed that the blow was received upon the elbow; in the remain-
ing six cases the cause is not stated. I believe, therefore, that this
fracture is generally the result of an indirect blow, inflicted upon the
extremity of the elbow ; in a few examples it has been produced by
a "blow received directly upon the point of fracture, as by the kick of
a horse, &c., but I have never, save in a single instance, been able to
trace it to a fall upon the hand. Dr.Shearer, U.S. A., has reported
a case also, which seems to have occurred in the same manner.'

Fig. 70.



Fractures at the base of the condjles. (From Gray.)

Direction of the Fracture^ Displacement, and Symptoms. — I think
this fracture is generally oblique, and its line of direction upwards
and backwards; in nine of the eleven cases where this point was
determined, such has been its apparent direction, and the lower frag-
ment has been found drawn up behind the upper. Once I have found
the lower fragment in front, and once on the outside of the upper.

Three of the sixteen were compound comminuted fractures, this
being a larger proportion of serious complications than is usually
found in connection with fractures of long bones.

I have never met with what I supposed to be a separation of the
lower epiphysis, but surgical writers have occasionally spoken of this
accident, and Dr. Watson, of New York, believes that he has seen one
example in an infant not quite two years old. The limb had been
violently wrenched by the mother, in attempting to lift her. She was
not seen by Dr. Watson until the fourth day, at which time the swelU

> M. M. Shearer, Act. Asst. Surgeon U. S. A. Boston Joum. of Chemistry,
Feb. 1, 1870.



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246



FRACTURES. OF THE HUMERUS.



Fig.



ing was such that the diagnosis could not be easily made out; but on
the ninth day "it was apparent that the shaft of the humerus had been
separated from its cartilaginous expansion at the condyles, near the
elbow." By the use of angular pasteboard splints, the reduction was
maintained, and the fragnients became united after about four or six
weeks.*

Dr. J. C. Eeeve, of Dayton, Ohio, has recently sent me a specimen
of this fracture which occurred in his practice in the year 1864:. A
girl, 8Bt. 10, fell a few feet, striking, probably, upon her
elbow. The fracture was compound, and union not hav-
ing occurred at the end of three weeks, the condition
of the arm rendered amputation necessary. In this case
a small fragment of the shaft came away with the epi-
physis. Drs. Little, Voss, and Buck, of this city, have
each reported a similar case.'

The diagnosis of this fracture is attended* with pecu-
liar difficulties, and it has occasionally been mistaken
for a dislocation of the radius and ulna backwards.
Dupuytren says: ''There is nothing so common as to
see a fracture of the lower end of the humerus, imme-
diately above the elbow-joint, mistaken for a dislocation
backward;" and he mentions three cases which have
come under his own observation. I have found an op-
posite error, however, by far the most frequent, namely,
a dislocation of both bones backwards has been sup-
posed to be a fracture.
/^■k The sources of this embarrassment are found in the

^^^K^ proximity of the fracture to the joint, in the rapidity
with which swelling occurs, and in the striking simi-
larity of the symptoms which characterize the two acci-
dents.
It will be necessary, therefore, to establish with care
the differential diagnosis. The following are the signs of fracture: —

1. Preternatural mobility, which, owing to the rapidity of the swell-
ing and the contraction of the muscles whose tendons are stretched
over the projecting ends of the bones, is often soon lost, being suc-
ceeded, sometimes after a few hours, by a rigidity equal to that which
is usually present in dislocations, or even greater. It is especially
difficult to flex the arm, owing to the pressure by the upper fragment
into the bend of the elbow.

2. Crepitus. This can usually be detected at any period if the arm
is sufficiently extended, so as to bring the broken surfaces again into
apposition.

8. When the extension is sufficient, reduction is easily effected, and
the natural length of the arm is restored; but the limb immediately
shortens when the extension is discontinued — especially if at the
same moment the elbow is bent. This is a very important means of
diagnosis.

> Watson, New York Joum. Med., Nov. 1858, p. 480, second series, vol. xi.
s Little, Voss, and Buck, New York Journ. Med., Not. 1865, p. 183.



"tim-m^



Separation of
lower epiphysis.



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BASE OF THE CONDYLES. 247

4. A careful measurement, made from the point of the internal con-
dyle to the acromion process, declares a positive shortening of the
humerus.

5. By flexing and extending the forearm upon the arm, while the
fingers are placed upon the lower portion of the humerus, the project-
ing fragments can be felt Generally, the upper fragment being in
front of the lower, and pressing down into the bend of the elbow, its
end cannot be so easily recognized; but the upper end of the lower
fragment can easily be made out when the forearm is considerably
flexed. The lower end of the upper fragment feels more rough, and
18 less wide, than in dislocations.

6. The whole of the lower fragment is carried backwards, and with
it the radius and ulna, producing a striking prominence of the elbow
and olecranon process. Efforts to straighten the forearm upon the
arm, when no extension is used, increase rather than diminish this
projection.

7. The forearm is slightly flexed upon the arm, the angle made at
the elbow being about 25 or 80 deg.

8. The hand and forearm are pronated.

9. The relations of the olecranon process with the two condyles
remain unchanged.

In a case of epiphyseal separation, the lower end of the upper frag-
ment has greater breadth than in the case of a fracture at the base of
the condyle, and the line of separation is nearer the end of the bone.

Signs of a dislocation of the radius and ulna backwards.

1. Preternatural immobility. That is to say, extension and flexion
are limited, but there is almost always present a preternatural lateral
mobility.

2. Absence of crepitus. It is in this joint especially that surgeons
have been deceived by the chafing of the dislocated bones upon the
inflamed joint surfaces, and have supposed that they discovered crepi-
tus when no fracture existed. The rapidity with which inflammation
develops itself after dislocations of the elbow-joint, and the consequent
abundant effusion of lymph, afford the probable explanation of this
frequent error.

3. When reduced, the bones are not generally disposed to become
again displaced, even though the elbow should be flexed.

4. The humerus is not shortened, but the olecranon process ap-
proaches the acromion process.

5. There are no sharp projecting points of bone. The lower end
of the humerus may not always be felt in the bend of the elbow; but
when it is felt, it is found to be relatively smooth, broad, and round.

6. A remarkable prominence of the elbow and olecranon process,
which prominence is sensibly diminished when an effort is made. to
straighten the forearm on the arm.

7. Forearm flexed upon the arm to about the same degree as in
fracture.

8. Hand and forearm pronated, precisely as in fracture.

9. Belations of the olecranon process to the condyles changed very
greatly.



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248 PBACTUBES OF THE HUMERUS.

Tbe most constant diagnostic signs are, then, in the case of a frac-
ture, crepitus, shortening of the humerus, projection of the sharp
ends of the fragments, and an increase of the projection of the elbow
-when an attempt is made to straighten the arm; and in the- case of a
dislocation, the absence of crepitus, humerus not shortened, while the
olecranon approaches the acromion process; the smooth, round head
of the humerus lost, or indistinctly felt in the bend of the elbow, and
the projection of the point of the elbow diminished when an attempt
is made to straighten the forearm on the arm.

It is proper, also, to repeat here what we have already said in rela-
tion to the causes of this fracture. A fracture at this point is pro-
duced almost always by a fall upon the elbow, but a dislocation of the
radius and ulna backwards can never be. On the other hand, a dislo-
cation is produced, in most cases, by a fall upon the palm of the hand,
while I have never known but one fracture above the condyles to be
thus produced.

Results. — Nine times have I found the arm shortened from half an
inch to one inch, or a little more.

Muscular anchylosis is almost always present when the apparatus
is first removed, and it is seldom completely dissipated until after
several months; but I have found more or less anchylosis at seven
and nine months ; and twice after the lapse of three years the motions
of the joint have been very limited. A few years since, I examined
the arm of a gentleman who was then twenty-seven years old, and
who informed jne that when he was four years old he broke the
humerus just above the condyles. There still remained a sensible
deformity at the point of fracture — he could not completely supine
the forearm. The whole arm was weak, and the ulnar nerve re-
markably sensitive. The ulnar side of the forearm, and also the ring
and little fingers, were numb, and have been in this condition ever
since the accident. I know the surgeon very well who had charge of
this case, and I have no doubt that the treatment was carefully and
skilfully applied.

In June of 1850, 1 operated upon a lad, nine years old, by sawing
off the projecting end of the upper fragment, whose arm had been
broken nine months before. This fragment was lying in front of the
lower, and the skin covering its sharp point was very thin and tender.
There was no anchylosis at the elbow-joint, but the hand was flexed
forcibly upon the wrist, the first phalanges of all the fingers ex-
tended, and the second and third flexed. Supination and pronation
of the forearm were lost. The forearm and hand were almost com-
pletely paralyzed, but very painful at times. The ulnar nerve could
be felt lying across the end of the bone.

In the hope that some favorable change might result to the hand
by relieving the pressure upon the nerve, yet with not much expecta-
tion of success, I exposed the bone and removed the projecting frag-
ment. The nerve had to be lifted and laid aside. About one year



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 29 of 100)