Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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was three months after the accident when I saw him, at which time I
found the internal epicondyle broken off and removed downwards
toward the hand one inch and a quarter; and at this point it had
become immovably fixed. Partial anchylosis existed at the elbow-
joint, but pronation and supination were perfect.

In one instance I believed the fragment to be carried about three
lines upwards and two backwards toward the olecranon; in each of
the other examples the fragment has not seemed to suffer any sensible
displacement.

Granger found, also, in the five examples which came under his
notice, the epicondyle carried toward the hand, with more or less
variation in its lateral position, so that while in some instances it
touched the olecranon, in others it was removed an inch or more in
the opposite direction.

It is probable that, except where controlled by the force and direc-
tion of the blow, or by some complications in the accident, the frag-
ment, if displaced at all, always moves downwards towards the hand,
or downwards and a little forwards, in the direction of the action of
the principal muscles which arise from this epiphysis ; and when the
fracture or separation is the result of muscular action alone, this form
of displacement seems to me to be inevitable. In addition to the
mobility, crepitus, and generally slight displacement of the fragment,
which are the principal signs of this fracture, it may be noticed that
there is usually some embarrassment in the motions of the elbowgoint,
which may be due in part to the swelling, and in part to the detach-
ment of the point of bone from and around which most of the pro-
nators and flexors of the forearm have their rise. In one instance,
already quoted, that of the lad aged eleven years, who broke the
epicondyle from a direct blow, the motions of pronation, with flexion,
were not at all impaired, neither immediately nor at any subsequent
period, but the fragment was never sensibly, or only very slightly,
displaced.

Granger has recorded another class of symptoms, to which I have
already alluded, his explanation of which, however, I am not prepared
to admit. One of these cases he describes as follows : A boy, eight
years old, fell with violence, and broke off completely the whole of
the inner epicondyle of the right humerus. The lad said he had
fallen on his hand. The fragment was displaced toward the hand.
Severe inflammation followed, but he recovered the free and entire
use of the elbow-joint in less than three months after the accident.
No splints or bandages were ever employed.

From the moment of the accident, the little finger, the inner side of
the ring finger, and the skin on the ulnar side of the hand, lost all
sensation. The abductor minimi digiti and two contiguous muscles
of the little finger were also paralyzed. This condition lasted eight or
ten yearsy after which sensation and motion were gradually restored



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FRACTURES OF THE INTERNAL EPICONDYLE. 259

to these parts. As a consequence of this paralyzed condition of the
ulnar nerve, also, successive crops of vesications, about the size of a
split horse-bean, commenced to form on the little finger and ulnar
edge of the hand some weeks after the accident, leaving troublesome
excoriations. This eruption did not entirely cease for two or three
months.

In two other cases, Mr. Granger remarks that he has found " the
same paralysis of the small muscles of the little finger, the same loss
of feeling in the integuments, and the same succession of crops of
vesicles on the affected parts of the hand, as is described to have
occurred in the preceding case."

Without intending to intimate a doubt of the accuracy of Mr. Gran-
ger's statement, that such phenomena have followed in three cases out
of the five which he has seen, I must express my belief that it was
only a remarkable concurrence of circumstances, since the same phe-
nomena have never been seen by myself, nor do I know that they
have been observed by any other surgeon.

Results. — As in all other accidents about the elbow-joint, a tem-
porary rigidity is almost inevitable. The mere confinement of the
arm in a fiexed position is suiBcient to determine this result without
the interposition of a fracture ; but when inflammation occurs, more or
less contraction of the tendons, muscles, &c., about the joint must en-
sue. To this circumstance, therefore, added to the confinement, rather
than to the fracture, will be due the anchylosis. If the fragment is
not displaced, the fracture cannot certainly be responsible for the loss
of motion, since it does not in any way involve the joint ; and if dis-
placement exists, its ultimate effect in diminishing the power of the
muscles which arise from the epiphysis must be only trivial and
scarcely appreciable. We might, therefore, reasonably conclude that
where the accident has been properly treated, permanent anchylosis
would be the exception, and not the rule. This view of the matter
seems also to be sustained by the recorded results. In'Granger's cases,
the full range of flexion and extension of the forearm has been finally
restored, or with so trifling an exception as not to be observable with-
out close attention, in every instance; except in the one already
mentioned, which was originally complicated with dislocation; and
even in this case the ultimate maiming was inconsiderable. Malgaigne,
who says '* it ought to be understood that in this accident articular
rigidity is almost inevitable," seems nevertheless to admit the justness
of Granger's observations as to the final result, if the proper means
are employed to prevent it. I have myself found only once any con-
siderable impairment of the motions of the joint ailer the lapse of a
lew years.

Treatment. — This accident does not constitute an exception to the
rule which experience has established, that epiphyseal projections
when once displaced can seldom be restored completely to position or
maintained in position, until a bony union is consummated. Granger
remarks : " I have purposely avoided saying one word about replacing
the detached condyle (epicondyle), and for these reasons : during the
state of tumefaction of the limb, no means could be adopted for con-



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260 FRACTURES OF THE HUMERUS.

fining the retracted condyle in its place, beyond that of the relaxation
of the muscles; and both before the tumefaction has commenced, and
after it has subsided, all endeavors to replace the condyle, or even to
change the position of it, have failed." He even proceeds so far as to
declare that while attention ought to be given to the reduction of the
inflammation by appropriate means, we ought, nevertheless, to instruct
the patient to flex and extend the arm daily from the moment the ac-
cident occurs until the cure is completed, and without any regard to
the consolidation of the fragment ; '' the exercise of the joint in this
manner must constitute the principal occupation of the patient for
several weeks ; and should it be remitted during the formation and
consolidation of the callus, much of the benefit which may have been
derived from this practice will be lost, and will with difficulty be re-
gained."

With only slight qualifications I would adopt the advice of Mr.
Granger. The limb ought, at first, to be placed in a position of semi-
flexion, so that if anchylosis should unfortunately ensue, it should be
in the condition which would render it most serviceable, and also
because in this position the muscles which tend to displace the frag-
ment would be most completely relaxed. While thus placed, an
attempt ought to be made, by seizing the epiphysis, to restore it to
position ; and if the efibrt succeeds, as it certainly is not very likely to
do, a compress and roller ought to be so applied as to maintain it in
position ; provided, always, that it shall not be found necessary to
apply the roller so tight as to endanger the limb, or increase the in-
flammation. An angular splint would be an almost indispensable
part of the apparel, at least with children, where this indication is in
view. In no case, however, ought more than seven or fourteen days
to elapse before all bandaging and splinting should be abandoned,
and careful but frequent flexion and extension be substituted.

In three cases seen by me, a displacement of the fragment, either
forwards or backwards, has occurred whenever the arm was flexed,
and it has been necessary, therefore, to treat the case with the arm in
a straight position. These are plainly only exceptions to the rule.

Fig. 80. § 9. Fractures op the External Epioondyle.

{Epicondylef Ghaussier.)

I have only mentioned this supposed fracture,
of which some writers have spoken as a fact, in
order that I may declare my conviction .that its
existence has never been made out. If we admit
the possibility, that, while in a state of epiphysis,
it might, like the corresponding internal epi-
physis, be separated by muscular action, we
must yet deny its probability, since it is so ex-
ceedingly small; and we must, for the same
reason, be permitted to doubt whether the fact
of its separation could be recognized in the
, . living subject. Moreover, if a true fracture

Fnetnre of external epl- <..*li.' -x xil !*./• . i

condyle. occurs at this poiut as the result oi external



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FRACTURES OF THE INTERNAL CONDYLE. 261

violence, it is 8ufl5ciently plain, from an examination of the anatomical
structure, that it must more or less extend into the joint and involve
the condyle itself.

§ 10. Fractures op the Internal Condyle. {Trochlea, Chanssier.)

B. Cooper, South , Sir Astley Cooper, and others, speak of fracture
of the internal condyle as very common, and more so than fracture
of the external condyle ; while Malgaigne, who
admits its existence, has never met with a single Fig. 81.

living example, and regards its occurrence as
exceedingly rare. In a record of fifteen frac-
tures, I have found no difficulty in recognizing
five as fractures of the inner condyle : five, I
have already said, were fractures of the epicon-
dyle, and the remainder were undetermined,
-while my records furnish eighteen examples of
undoubted fractures of the external condyle. It
is probable that Sir Astley did not intend to
make any distinction between fractures of the
condyle and epicondyle, and this might explain
somewhat his opinion of the relative frequency
of these accidents ; but even rejecting this im-
portant distinction, it has happened to me to see p^eture of internal eon-
more examples of fracture of the outer condyle ayie.
than of the inner.

Causes, — It has already been stated that fractures of the internal
condyle, as well as fractures of the epicondyle, belong almost exclu-
sively to infancy and childhood, only two instances having come under
my notice after the eighteenth year of life,

I have seen no instance which could be traced to any other cause
than a direct blow, such as a fall upon the elbow, the force of the
concussion being received directly upon the condyle.

Line of Fracture, Displacement, Symptoms. — The direction of the
line of fracture is tolerably uniform, namely, commencing about one-
quarter or half an inch above the epicondyle, it extends obliquely
outwards through the olecranon and coronoid fossae, and enters the
joint through the centre of the trochlea.

Displacement of the lower fragment can take place only in a direc-
tion upwards, backwards, forwards, and inwards (to the ulnar side).
The fragment cannot be carried downwards, in the direction of the
hand, nor outwards, in the direction of the radius, unless the radius
also is broken or dislocated.

The most common form of displacement is upwards and backwards,
and perhaps at the same time a little inwards ; the ulna remaining
attached to the lower fragment, and following its movements. I have
seen one instance in which the fragment was carried directly down-
wards toward the hand, but this accident was originally complicated
with a dislocation of the radius backwards. The dislocation was
immediately reduced. Five years after, when the young man was



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262 FRACTURES OP THE HUMERUS.

twenty-three years old, I found the condyle displaced downwards and
forwards about half an inch, so that when the forearm was extended
it became strikingly deflected to the radial side.

The symptoms which characterize this fracture are crepitus, alnaoat
always easily detected; mobility of the fragment, discovered espe-
cially by seizing upon the epicondyle, or by flexing and extending
the arm ; displacement of the smaller fragment and a projection of the
olecranon process, this latter being very marked when the forearm is
extended upon the arm, but almost completely disappearing when the
elbow is bent; projection of the lower end of the humerus in front
when the arm is extended ; the humerus shortened when measured
along its ulnar side, from the internal epicondyle; the breadth of the
humerus through its condyles generally increased slightly, sometimes
half an inch or more ; if the lesser fragment is carried upwards, it will
also be found that when the limb is extended, the forearm will be
deflected to the ulnar side.

Sir Astley Cooper remarks that it is frequently mistaken for a dis-
location ; and Thomas M. Markoe, of New York, has shown that it is,
in fact, frequently complicated with a dislocation of the head of the
radius backwards ; indeed, he expresses a belief that this dislocation
of the radius seldom or never occurs without a fracture of the internal
condyle.* I shall refer to his views again when considering disloca-
tions of the head of the radius.

Results. — It is probable that in a majority of cases no permanent
displacement exists ; although the irregularity of the bony deposits
around the base of the condyle, which generally may be easily felt,
would lead to a contrary opinion. The fact that the lower fragment
usually follows the motions of the olecranon, renders its replacement
and retention comparatively easy, unless some complication exists.
It is not from displacement, therefore, so much as from permanent
muscular, and especially bony anchylosis, that serious maiming so
often results. Under any treatment bony anchylosis will very often
ensue, and under improper treatment it is almost inevitable.

l^reoUmenU — The arm must be immediately flexed to nearly or quite
a right angle, when, without much manipulation, the fragments will
be made to resume their place. A gutta-percha, or felt, right-angled
splint, such as I have already directed for fractures occurring just
above the condyles, well and carefully cushioned, may now be applied,
and secured by rollers. Suitable pads must also aid the splint and
roller, in keeping the fragments in place. Markoe prefers keeping
the forearm in a position about ten degrees short of a right angle, be-
lieving that in this position the ulna itself will act as a splint, and, by
its support on the uninjured portion of the trochlea, hold in its place
the broken condyle. Very properly, also, he prefers to lay the angular
splint, made of tin, and fitted to the arm and forearm, upon the l3ack
of the limb, instead of upon the front or sides. If it is upon the inside,
it covers the broken condyle, and we are unable to know so well its

' Markoe, New York Journal of Medicine, May, 1855, p. 382, second series,
vol. xiy.



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FRACTURES OF THE EXTERNAL CONDYLE. 263

position; if upon either side, it is apt to press injuriously upon the
epicondyles ; and if it is in front, the fragments cannot be so well ad-
justed or supported. Upon this point, however, surgeons are not very
well agreed, and no doubt more will depend upon the care with which
the splint is applied than upon the surface against which it is laid.

Considerable swelling is almost certain to follow, and no surgeon
ought to hazard the chances of vesications, ulcerations, &c., by neglect-
ing to open or completely remove the dressings every day. Within
seven days, and perhaps earlier, passive motion must be commenced,
and perseveringly employed from day to day until the cure is accom-
plished; indeed, in a majority of cases it is better not to resume the
use of splints after this period: for, although at this time no bony
union has taken place, yet the effusions have somewhat steadied the
fragments, and the danger of displacement is lessened, while the pre-
vention of anchylosis demands very early and continued motion.

When the fracture is compound, or otherwise complicated, these
simple rules will seldom be found applicable; indeed, fractures attended
with no such complications will occasionally be found difficult to re-
duce, or to maintain in position after reduction.

§ 11. Fractures of the External Condtle.

Causes, — ^All the fractures(18)of the external condyle, of which I have
a record, occurred in children under fourteen years of age, except one;
in which instance a woman, eighty-eight years of age, fell upon her
elbow while intoxicated, breaking off the outer condyle. Two months
after the accident I found the fragment displaced half an inch upwards,
and firmly united.

In a large majority of these cases the patients themselves have
affirmed, and the surface of the skin has furnished conclusive evidence,
that the fracture was produced by a direct blow, generally by a fall
upon the elbow.

Line of Fracture, Displacement, and Symptoms. — The direction of the
fracture is generally such that, commencing always above and without
the capsule, it descends obliquely and enters the joint either just within
or through the " small head" or articulating surface upon which the
radius is received ; or else it penetrates more deeply in its progress,
and passing through the olecranon fossa, it enters the joint through
the middle of the trochlea.

In the first of these classes of examples, which I think also is the
most common, the condyle alone is*broken off, and it is liable only to
become displaced backwards, forwards, or outwards; generally, I have
found it displaced a little outwards sufficiently to increase manifestly
the breadth of the condyles; or it has been carried backward^; once
slightly forwards; it is also, in some cases, carried upwards in a small
degree, although the action of the supinators and extensors would seem
to render a downward displacement more common. These displace-
ments are usually not considerable, and in a few cases there is none at
all. Whatever may be the direction or degree in which the fragment
is moved, however, the head of the radius is found almost always to



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264 FRACTURES OF THE HUMERUS.

accompany it; but in the case which I am about to relate, the head
of the radius became completely separated from the condyle.

Frederick Keaflfer, set. 11, fell from a load of hay, and he is confident
that he struck the ground with the back of his elbow. Six hours
after the accident, he was brought to me by the
Fig. 82. physician who was first called to him. The arm

was much swollen, and the external condyle could
not be distinctly felt^ but when pressure was made
directly upon it, crepitus and motion became mani-
fest. The head of the radius was at the same time
dislocated backwards, and separated entirely from
the condyle; its smooth button-like head being
very prominent. It is diflScuIt to conceive how
a blow from behind should leave the head of the
radius dislocated backwards, or how the radius
could have separated from the broken condyle:
but as the examination was repeated several
. times, and while the patient was under the influ-
ence of ether, I have no doubt of the fact. Several
eolTyTe!" "*' ^^^ •^^^''^ other surgcous who were present concurred with
me in opinion fully.
While prosecuting ihe examination, I reduced the dislocation of the
radius, but it would not remain in place a moment when pressure or
support was removed. The lad recovered with a very useful arm, the
motions of flexion and extension, with pronation and supination, after
the lapse of a year, being nearly as complete as before the accident;
the radius remaining unreduced.

Sometimes it will be noticed that while the portion of the condyle
which is attached to the radius falls backwards, its upper and broken
extremity pitches forwards; and this attitude it is especially prone to
assume when the forearm is extended.

It is even possible, when the fracture traverses the trochlea, for the
ulna also to become displaced backwards along with the radius and
the lesser fragment.

Crepitus, which is usually very distinct, is most easily obtained by
rotating the radius, or by seizing upon the condyle with the thumb
and fingers, and moving it backwards and forwards.

Results, — Ordinarily, this fragment unites promptly, and by the
interposition of a bony callus ; but in four cases, I have noticed that
either no union has occurred, or the union has been accomplished
only through the medium of fibrous structures, and the fragment con-
tinued afterward to move with the radius.

As a consequence, probably, of the displacement of the lesser frag-
ment upwards, the forearm, when straightened, is occasionally found
deflectAi to the radial side. The surgeon must not, however, confound
the deflection which is natural, and which is greiater in some persons
than in others, with the unnatural radial inclination which is occa-
sioned sometimes by this accident. I have met with this phenomenon
three times in children under three years of age, in one of which I
could not discover that the condyle was carried towards the shoulder,



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FRACTURES OF THE EXTERNAL CONDYLE. 265

but only outwards; in each of the other cases the fragment had united
by ligament. The following is one of the examples referred to : —

A girl, »t. 8, fell and broke the.external condyle of the left humerus ;
the fracture extending freely into the joint ; crepitus distinct ; forearm
slightly flexed ; prone. Lesser fragment displaced outwards and a little
backwards, carrying with it the radius. On the second day I was dis-
missed on account of the unfavorable prognosis which I gave, or rather
because I refused to guarantee a perfect limb, and an empiric was
employed.

July 2, 1857, several months after the accident, the father brought
her to me for examination. There was no anchylosis, but the lesser
fragment had never united, unless by ligament, moving freely with
the head of the radius. When the forearm was straightened upou
the arm it fell strongly to the radial side, but resumed its natural
relation again when the elbow was flexed.

Two other examples are reported at length in the second part of
my Beport on Deformities after Fractures as Cases 57 and 59 of frac-
tures of the humerus.

In one other example, however, mentioned also in my report as
Case 56, the deflection was to the opposite side. I examined the lad
one year after the accident, he being then five years old, and I found
the external condyle very prominent and firmly united, but not appa-
rently displaced in any direction except outwards. The radios and
ulna had evidently suffered a diastasis at their upper ends, but all of
the motions of the joint were free and perfect.

Dorsey^ speaks of this lateral inclination as being always to the
ulnar side, but does not indicate to what particular fracture of the
elbow it belongs. He has also described a splint, contrived by Dr.
Physick, intended to remedy the deformity in question.

Chelius also speaks of the same deformity as occurring after frac-
tures of the internal, but does not mention it in connection with frac-
tures of the external condyle, that is, an inclination of the forearm to
the ulnar side.

In more than half of the cases of fracture of this condyle some
degree of anchylosis has resulted, lasting at least several months. I
have seen it remaining after a lapse of from one to twenty years, but
generally it gradually diminishes, and, in a majority of cases, com-
pletely disappears after a few years.

Treatment. — I do not know that I need add much to what has
already been said in relation to the treatment of fractures of the
opposite condyle, and at the base of the condyles, since the measures
applicable to the one are, in general, applicable to the other.

Generally, the forearm ought to be flexed upon the arm, especially
with a view to overcome the usual tendency in the upper end of the
lower fragment to pitch forwards, and which form of displacement is



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 31 of 100)