Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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from this time I found the arm in the same condition as before the

Non-union is a result not so frequent in fractures at this point as

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higher up ; but Stephen Smith, of the Bellevue Hospital, New York,
reports a case of non-union in a young man of twenty-three years. He
was admitted to the hospital on the seventh day after the accident.
The fracture was simple and transverse, yet at the end of four months
he was dismissed " with perfectly free motion at the point of fracture."^
The failure to unite was attributed to a syphilitic taint.

A case was tried a few years since in the Supreme Court at Brook-
lyn, N. Y., in which, after a simple fracture at this point, the arm
being dressed with splints and bandages, the little finger sloughed off
in a condition of dry gangrene, and the adjacent parts of the hand
were attacked with humid mortification. Drs. Parker and Prince
believed that this serious accident was the result of bandages applied
too tightly and suffered to remain too long, while Drs. Valentine Mott,
Rogers, Wood, Ayres, Dixon, and others, believed the gangrene might
have been due to other causes over which the surgeon had no control.'
A few years ago, a similar case occurred in the town of Spencer,
Tioga Co., N. Y. ; a boy, six years old, having broken his humerus
just above the condyles. The fracture was oblique. The surgeon
who was called to treat the case was an old and highly respectable
practitioner. I am not informed of the plan of treatment any farther
than that a roller was applied. On the eighth day, a second surgeon
was employed, who, finding the hand cold and insensible, removed all
of the dressings; after which the thumb and forefinger sloughed, with
other portions of the skin and flesh of the hand and arm. The sur-
geon who was first in attendance was prosecuted, and the case was
tried in the Supreme Court of that county, but the jury found no
cause of action. Dr. Hawley, of Ithaca, and the late Dr. Webster, of
Geneva Medical College, testified that, in their opinion, the death of
the fingers was owing to the pressure of the fragment upon the bra-
chial artery, and not to the tightness of the bandages.

Dr. Gross has also informed us of still another case of the same
character, which occurred in Warren Co., Ky. A boy, ten years old,
had broken his arm above the condyles, and his parents having em-
ployed a surgeon residing at some distance, the dressings were applied,

and directions given to send for

^g- 72. the surgeon whenever it became

necessary. The parents saw the

arm swell excessively, and knew

that the boy was suffering very

much, but did not notify the

surgeon until the tenth day,

when the hand was found to be

in a condition of mortification,

and at length amputation became


I Long afterward, in the year

Phy8ick»B elbow spimu. l^^l, whcu the boy became of

1 Smith, New York Journal of Medicine, May, 1857, p. 386, third series, vol. ii.
« New York Medical (Gazette, vol. xii. pp. 46, 80, 111.

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age, he prosecuted his surgeon, but with no result to either party
beyond the payment of their respective costs.

While I would not deny that in all of these cases the sloughing might
have been solely due to the tightness of the bandages, against which
cruel and mischievous practice we cannot too loudly declaim, a know-
ledge of the anatomy of these parts, and the opinions of the very dis-

Fig. 78.

Kirkbride's elbow tpUnt.

tinguished gentlemen who testified in defence of these surgeons, must
compel us to admit the possibility of such accidents where the treat-
ment has been skilful and faultless.

Fig. 74. Fig. 75.

Welch's splint. The hinges m%j be transferred to
'* splints of different sites.

Treatment. — The splints generally employed in this country, in frac-
tures about the elbow-joint, are simple angular side splints, without
joints, such as those recommended by Physick:* angular pasteboard

» Elements of Surgery, by John Syng Dorsey, Philadelphia edition, vol. i.
p. 145.

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splints, felt, leather, gutta percba, &c., or angular splints with a
hinge, such as Kirkbride's,' Thomas Hewson's Day's, or Rose's, or
the more perfect and elegant angular splint of Welch.

Kirkbride's splint, which has been used in the Pennsylvania Hos-
pital in several instances, is composed of two pieces of board, connected
together by a circular joint, and having eyes on the inner edge, two
inches apart, and holes through the splint at graduated distances
between them. There is also a swivel eye, passing through the upper
part of the splint, and riveted below. A wire is fastened to the swivel,
and bent at right angles at its other extremity, of a size to fit the eyes
and holes in the splint. This splint, properly supported by pads, is
to be placed either upon the outside or inside of the arm, and secured
by rollers. When the angle is to be changed, the wire is unhooked
and removed to another eye, or to some of the intermediate holes upon
the side of the splint. Dr. Kirkbride reports two cases of fracture of
the lower part of the humerus treated by this plan, one of which
resulted in anchylosis, but the other was much more successful.

H. Bond, of Philadelphia, has contrived a very ingenious splint for
the elbow-joint, and which is designed also to afford a complete sup-
port to the forearm.

For myself, I generally prefer gutta percha, moulded and applied
accurately to the limb. It should be extended beyond the elbow to

Fig. 76.

Bond*8 elbow splint.

the wrist, so as to support the whole length of the arm, elbow, and
forearm. Some experience in the use of wooden angular splints has
convinced me that they cannot be very well fitted to the many in-
equalities of the limb; and neither pasteboard nor binder's board has
suflScient firmness, especially in that portion which covers the joint.
Angular splints, furnished with a movable joint, possess the advantage
of enabling us to change the angle of the limb at pleasure, and of keep-
ing up some degree of motion in the articulation without disturbing
the fracture or removing the dressings ; but the crossbars of Day's and

' American Journal of the Medical Sciences, vol. xvi. p. 315.

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Eose's splints render them complicated, and are in the way of a nice ap-
plication of the rollers ; while they are all equally liable to the objec-
tion stated against angular wooden splints without joints, viz., that they
seldom can be made to fit accurately the many irregularities of the
arm, elbow, and forearm. In applying the author's splint, care mast
be taken that the humeral portion is not too short, or the result will
be an unnecessary degree of overlapping ©f the fragments. This may

generally be avoided if the sur-
Fig. 77. geon will first shape his material

~ to the sound arm, while the whole

length is underlaid with three or
four thicknesses of woollen cloth.
Welch's splints, made of a mate-
rial possessing a slight amount of
flexibility, approach more nearly
the accomplishment of these indi-
cations than any other manufac-
tured splint with which I am
acquainted, but the number o[
cases in practice to which they
are applicable will be found to
be limited, while gutta percha
has no limit in its application.

Whatever material is employed,
the splint should be first lined
with one thickness of woollen
cloth, or some proper substitute.
A pretty large pledget of fine
cotton batting ought also to be
The author's eihow ipiiBi. laid in frout of the elbow-joint, to

prevent the roller from exco-
riating the delicate and inflamed skin ; and great care should be taken
to protect the bony eminences about the joint, or, rather, to relieve
them from pressure, by increasing the thickness of the pads above
and below these eminences.

At a very early day, so early, indeed, as the seventh or eighth day,
the splint should be removed, and, while the fragments are steadied,
gentle, passive motion should be inflicted upon the joint. This prac-
tice should be repeated as often as every second or third day, in order
to prevent, as far as possible, anchylosis. If much swelling follows
the injury, it is my custom to open the dressings, without removing
the splints, on the second or third day after the accident, or at any
time when the symptoms admonish of its necessity. Occasionally
it is well to change the angle of the splint before reapplying it. If
the angular splint with a movable joint is used, slight changes may be
made while the splint is on the arm ; but if the angle is much changed
without removing the rollers, they become unequally tightened over
the arm, and may do mischief.
When anchylosis has actually taken place, we may more or less

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overcome the contraction of the muscles and of the ligaments by pas-
sive motion, or by directing the patient to swing a dumb bell or some
other heavy weight, as first recommended by Hildanus.

§ 7. Fracture at the Base op thi;^ Condyles, complicated with Frac-

This fracture, which is blit a variety or complication of the preced-
ing, is even more difficult of diagnosis ; and its signs, results, and
proper treatment differ sufficiently to demand
a separate consideration. • ^*

I have recognized the accident six times.
Confined to no period of life, it seems to be the
result of a severe blow inflicted directly upon
the lower and back part of the humerus, or
npon the olecranon process. Dr. Parker, of
New York, was inclined to regard an obscure
accident about the elbow-joint, which he saw
in a lad sixteen years old, as a longitudinal
fracture of the humerus, with separation of one
condyle, but which had been occasioned by a
fall upon the hand.^ For myself, I should re-
gard this latter circumstance as presumptive ^e^wee^thtUtd^T''''"*
evidence that it was not a fracture, of this cha-
racter, yet I do not mean to deny the possibility of its occurrence in
this way.

Its characteristic symptoms are, increased breadth of the lower end
of the humerus, occasioned by a separation of the condyles ; displace-
ment upwards and backwards of the radius and ulna ; crepitus and
mobility at the base of the condyles, with crepitus also between the
condyles, developed by pressing them together ; or when the radius
and ulna are drawn up, by restoring these bones first to place by
extension, and then pressing upon the opposite condyles ; shortening
of the humerus.

Its consequences are, generally, great inflammation about the joint,
permanent deformity and bony anchylosis. An opposite result must
be regarded as fortunate, and as an exception to the rule.

Of the treatment we can only say that it must be chiefly directed
to the prevention and reduction of inflammation, at least during the
first few days. Nor is this inconsistent with an early reduction of the
fragments, and moderate efforts, by splints and bandages, such as we
have directed in case of a simple fracture at the base of the condyles,
to keep the fragments in place. No surgeon would be justified in
refusing altogether to make suitable atteippts to accomplish these im-
portant indications ; but he must always regard them as secondary
when compared with the importance of controlling the inflammation.

When splints are employed, the same rules will be applicable, both
as to their form and mode of application, as in cases of simple fracture
above the condyles.

» Parker, New York Journal of Medicine, Nov. 1856, p. 891, 3d series, vol. i.

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The following examples will more completely illustrate the charac-
ter, history, and proper treatment of these cases than any remarks or
rules which we can at present make.

A woman, set. 44, fell upon the side-walk in January, 1850, striking
npon her right elbow. I saw her a few minutes after the accident,
but the parts about the joint were already considerably swollen, and
it was not without difficulty that the diagnosis was made out. The
forearm was slightly flexed upon the arm, and pronated. On seizing
the elbow firmly, a distinct motion was perceived above the condyles,
and a crepitus. I could also feel, indistinctly, the point of the upper
fragment. While moderate extension was made upon the arm, the
condyles were pressed together, when it was apparent that they had
been separated. On removing the extension, they again separated,
and the olecranon drew up. She was in a condition of extreme ex-
haustion, and the bones were easily placed in position.

An angular splint was secured to the limb, and every care used to
support the fragments completely, but gently.

From this date until the conclusion of the treatment the dressings
were removed often, and the elbow moved as much as it was possible
to move it.

Seven months after the accident, the elbow was almost completely
anchylosed at a right angle. The fingers and wrist also were quite
rigid. Six years later, the anchylosis had nearly disappeared ; she
could now flex and extend the arm almost as much as the other ; the
wrist-joint was free, and the fingers could be flexed, but not sufficiently
to touch the palm of the hand. The line of fracture through the base
could be traced easily, but the humerus was not shortened. There
was, moreover, much tenderness over the point of fracture through the
base, and at other points. Occasionally, a slight grating was noticed
in the radio-humeral articulation. She experienced frequent pains in
the arm, and especially along the back and radial border of the ring
finger. During the first year or two after the accident, the arm per-
ished very much, but although the hand remained weak, the muscles
were now well developed.

A gentleman was struck with the tongue of a carriage with which
a couple of horses were running. The blow was received directly
upon the back of the left elbow. Dr. Sprague and myself removed
some small fragments of bone, and while opening the wound for this
purpose, we could see distinctly the line of fracture extending into the
joint as well as across the bone. The condyles were not separated.

The subsequent treatment consisted only in the use of such means
as would best support the limb, and most successfully combat inflam-
mation. The arm and forearm were laid upon a broad and well-
cushioned angular splint, covered with oil-cloth, to which they were
fastened by a few light turns of a roller.

Twelve years after, I found the humerus shortened one inch and a
half. During the first year, he says, there was no motion in the elbow-
joint, but he can now flex and extend the forearm through about 45° ;
when flexed to a right angle, it seems to strike a solid body like bone.
Rotation of the forearm is completely lost, the hand being in a posi-

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tion midway between supination and pronation. He suflfers no pain,
and his arm is quite strong and useful. No means have been em-
ployed to restore the functions of the limb but passive motion at first,
and subsequently constant, active use of the hand and arm.

The late Dr. Thomas Spencer, of Geneva, used to relate a case in
which a surgeon was called to what he supposed to be a fracture of the
lower end of the humerus, and which he treated accordingly, with
splints, &c. On the second or third day, another surgeon was called,
who removed the splints and bandages, and pronounced it a disloca-
tion of the radius and ulna backward ; but he was unable to reduce it.
After some time, the first surgeon was prosecuted for having treated
as a fracture what proved to be a dislocation. Dr. Spencer, who had
examined the arm carefully, gave his testimony last, and at a time
when, from the evidence, it seemed almost certain that the surgeon
must be mulcted in heavy damages ; but he declared his belief that
hoth surgeons were right, since, on measuring the breadth of the
humerus through its two condyles, he found that the humerus of the
injured arm was three-quarters of an inch wider than the opposite.
His conclusion, therefore, was that the condyles had been split asunder
and were now separated ; that the first surgeon properly reduced this
fracture, but that when, on the second or third day, the second sur-
geon removed the splints and the dressings, a contraction of the mus-
cles had taken place and the dislocation occurred, the bones of the
forearm being drawn up between the fragments. Dr. Spencer believed
this was an example of the variety of fractures now under considera-
tion, but it is not quite certain that there was anything more than an
oblique fracture extending into the joint, followed by a dislocation.
In either case, the first surgeon was entitled to an acquittal, and so the
jury promptly declared by their verdict.

In a case of compound comminuted fracture of the character now
under consideration, Dr. Stone, of the Bellevua Hospital, New York,
removed the condyles and sawed off the sharp end of the humerus.
The woman was twenty-six years old and intemperate. The opera-
tion was made as a substitute for amputation. No serious complications
followed. On the ninety -sixth day the wounds were completely healed,
and she could bend the forearm to a right angle with the arm, the
action of the muscles having drawn up the radius and ulna against
the lower end of the shaft of the humerus, so that the motions were
natural and free.^ The practice, as the result sufficiently shows, was
eminently judicious; and its practicability ought always to be well
considered before resorting to the serious mutilation of amputatton.
The great principle upon which the success of resection is here based
is the shortening of the bone, whereby the' reduction may be accom-

Slished without painful tension to the muscles ; a principle which will
emand of us hereafter a more careful consideration and a wider

» Stone, New York Joum. of Med., May, 1S51, p. 302, vol. vi. 2d series.

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Fractures of the Condyles.

Chaussier described that portion of the lower end of the humerns
which articulates with the ulna as the trochlea, and that portion which
articulates with the radius as the condyle ; naming the two lateral pro-
jections, respectively, epitrochlea and epicondyle. Some of the French
writers have adopted this nomenclature, but I prefer, as being more
familiar to mv own countrymen, the terms external and internal con-
dyle, to which it will be convenient to add the terms external epicon-
dyle and internal epicondyle, as indicating the extreme lateral projec-
tions, which are formed from separate points of ossification, and which
do not become united to the condyles by bone until about the sixteenth
or eighteenth year of life.

When, therefore, we speak of a fracture of the epicondyle, we refer
only to a separation of the epiphysis, such as it is in early life; or to
its true fracture, when, at a later period, it has become united by bone.

§ 8. Fractures of the Internal Epicondyle. (Epitrochlea, Chaussier.)

This is the fracture which Granger first described in the Edinburgh
Medical and Surgical Journal,^ and which he ascribed solely to muscu-
lar action. " A distinguishing circumstance attending this fracture is
that of its being occasioned by sudden and violent
Fig. 79. muscular exertion ; and it will be recollected that

from the inner condyle those powerful muscles
which (jonstitute the bulk of the fleshy substance
of the ulnar aspect of the forearm have their
principal origin. The way in which the muscles
of the inner condyle are involuntarily thrown
into such sudden and excessive action I take to
be this : the endeavor to prevent a fall by stretch-
ing out the arm, and thus receiving the per-
cussion from the weight of the body on the

It is a fact, perhaps of some significance in
this connection, that most of these fractures
occur in children, before the union of the epi-
Fracture of internal epicon- physis is Completed, whcu muscular Contraction ,
dyie. might more often prove adequate to its separa-

tion, and when the epicondyle is less prominent,
anH, therefore, less exposed to direct blows than in adult life; thus, of
five fractures which I have distinctly recognized as fractures of the
epicondyle, all, except one, occurred between the ages of two and
fifteen years. But then it is equally true that a large majoritv of all
the fractures of the internal condyle, including those which enter
the articulation, as well as those which do not, belong to childhood

> "On a Particular Fracture of the Inner Condyle of the Humerus,'' by Benja-
min Granger, Surgeon, Burton-upon-Trent. Op. cit., vol. xiv. pp. 196-201, April,

« Ibid., p. 1S6.

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and youth. I have seen but two exceptions in fifteen cases. Since,
then, direct blows generally produce those fractures which penetrate
the joint, no good reason can be shown why they should not produce
fractures of the epicondyle. One of the exceptions to which I have
referred as not having occurred in early life, is sufficiently rare to en-
title it to especial notice.

On the 16th of May, 1856, a laborer, thirty-four years of age, fell
from an awning upon the side-walk, dislocating the radius and ulna
backwards; the dislocation was immediately reduced by a woman who
came to his assistance, but when he called on me soon after, I found
a small fragment of the inner condyle, probably the epicondyle alone,
broken oflf and quite movable under the finger. It was slightly dis-
placed in the direction of the hand.

I could not learn positively whether in falling he struck the elbow
or the hand, but there was presumptive evidence that he struck the
hand ; if so, then probably the fracture was the result of muscular
action, which is the more extraordinary as having taken place in a
man of his age.

It is pretty certain, however, that the theory of causation adopted
by Granger is too exclusive. A lad was brought to me in October,
1848, aged eleven, who had just fallen upon his elbow, the blow having
been received, as he affirmed, and as the ecchymosis showed pretty
conclusively, directly upon the inner condyle. The fragment was
quite loose, and crepitus was distinct. He could fiex and extend the
arm, and rotate the forearm, without pain or inconvenience. I am
quite sure the fracture did not extend into the joint ; the result seemed
also to confirm this opinion, for in three months from the time of the
accident the motions of the elbow-joint were almost completely re-

Indeed, Mr. Granger has failed to establish, by any particular proofs,
that in more than one or two of his cases the fracture was the result
of muscular action ; but, on the contrary, I am disposed to infer, from
the violent inflammation which generally ensued in his cases, from
the frequency of ecchymosis, and especially from the injury done to
the ulnar nerve in at least three instances, that most of them were
produced by direct blows inflicted from below in the fall upon the
ground. Fractures produced by muscular action are seldom accom-
panied with much inflammation or effusion of blood, and it is much
more probable that the ulnar nerve should have been maimed by the
direct blow which caused the fracture, than by the displacement of the
epiphysis, which is, as we shall presently show, almost always carried
downwards, and oftener slightly forwards than backwards. It is only
when the fragment is forced directly backwards that the ulnar nerve
could be made to suffer ; a direction which, it does not seem to me, it
could ever take from muscular action alone.

Direction of Displacement, Symptoms, (kc, — I have seen this fragment
displaced in the direction of the hand, or downwards, very manifestly,
twice, and in two other examples a careful measurement showed a
slight displacement in the same direction. The greatest displacement
occurred in a boy fifteen years old, who was brought to me from St.

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Catharine, Canada West. He had fallen upon his arm in wrestling,
and his surgeon found a dislocation of the bones of the elbow-joint,
which he immediately reduced. The fracture was not at that time
detected, the arm being greatly swollen. No splints were applied. It

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 30 of 100)