Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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greatly increased by straightening the arm. A remarkable exception
to this rule, and one of two which I have seen, must be mentioned.

James Cronyn, aged six, was brought to me in March, 1857, having,

» Elements of Surgery, by Philip Syng Dorsey, PUila. ed., 1813, vol. i. p. 146.
lb



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266 FBACTURES OF THE HUMERUS.

a few minutes before, fallen from a height of four or five feet to the
ground. His father said the elbow had been broken at the same point
two years before, and from that time, had remained stiff and crooked.
I found the external condyle broken off, and, with the head of the
radius, carried backwards. This was the position which it occupied
constantly, though it wad easily restored and maintained in position
when the arm was straight, but not by any possible means when the
elbow was flexed. I dressed the arm, therefore, in an extended posi-
tion, with a long felt splint, and the fragments remained well in place
until a cure was accomplished.

In certain exam.ples, I have no doubt also that advantage might be
derived from the use of Physick's splint, intended to obviate the out-
ward or inward inclination of the forearm.

It is especially deserving of notice that, in the four cases in which
I have observed bony union to fail, and the fragments to continue
movable, the motions of the elbow-joint have, in a very short time,
been completely restored. If it does not prove that Granger was
correct in his views, as applied to fractures of the internal epicondyle,
namely, that it was of little or no consequence whether the fragment
united or not, and that the elbow -joint ought to be submitted to free
motion from the beginning to the end of the treatment — if it does not
absolutely prove, I say, the correctness of his views, it at least must
abate bur apprehensions of the supposed evil results of non-union in
the case of the fracture now under consideration.

I shall take the liberty of quoting also, with a qualified approval,
the opinion of Dr. John C. Warren, of Boston, as stated by Dr. Norris
in his Beport on Surgery, made to the American Medical Association
in 1848.

" In the treatment of fractures of the condyles of the os humeri, a
course is usually recommended which he believes to be hurtful, inas-
much as it favors the worst consequences of the injury, namely, loss
of motion in the joint; By this mode of treatment, the fractured piece
becomes sufficiently fixed to create partial anchylosis ; and there is so
much pain afterwards in the proposed passive movements as to cause
the omission of these measures until permanent stiffness takes place.
The proper course in the management of these accidents, he conceives
to be — 1st. To apply no splints, but in the earlier days to make use
of the proper means to prevent inflammation. 2d. To accustom the
patient to early and daily movements of flexion and extension. 8d.
When the action of the joint becomes limited, to overcome the resist-
ance by force, and repeat it daily until the tendency of the joint to
stifl'en ceases.

** The accomplishment of this process, he adds, is so very painful
that few patients have courage to submit to it, and few surgeons firm-
ness to prosecute it. The consequence has been that in a great num-
ber of cases the use of the articulation to a greater or less extent has
been lost. The introduction of etherization, by preventing the pain,
gives us, in the opinion of Dr. Warren, the means of overcoming the
resistance. By its aid he has restored the motion of a considerable
number of anchylosed elbows, and has successfully applied the same



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FRACTURES OF THE NECK OF THE RADIUS. 267

measures to other joints, particularly to the shoulder and knee. This
has now become his settled practice, with the results of which he is
entirely satisfied. The inflammation consequent upon the forced
movements of an anchylosed joint is not to be lost sight of. By a
reasonable abstraction of blood, and other anti-inflammatory treatment,
he has never found it alarming."*

My respect for the distinguished surgeon whose opinion is here
given does not permit me to question the correctness of his practice;
but I cannot avoid a belief that his language does not convey a precise
idea of his views. If he intends to say that he would move the joint
freely when it is suffering from acute inflammation, and when motion
occasions great pain, I must protest against the practice as likely to
do vastly more harm than good in any case ; but if he would move the
joint from the first, when the inflammation and swelling are trivial,
and when it occasions only an endurable amount of pain, then his
views are just and his practice worthy of imitation.



CHAPTER XXI.

FRACTURES OP THE RADIUS.

Of one hundred and one fractures of the radius which have been
recorded by me, not including gunshot fractures, or fractures demand-
ing immediate amputation, three belonged to the upper third, six to
the middle third, and ninety-two to the lower third. Three were
compound, and ninety-eight simple. Forty-eight are reported as
occurring in males, and thirty-five in females ; forty-two as having
occurred in the left arm, and thirty-four in the right.

Fracture of the neck of the radius, as a simple accident uncompli-
cated with any other fracture or dislocation, is exceedingly rare ; yet,
owing to the depth of the superincumbent mass of muscles, and the
difficulty of determining, where so many bones and processes approach
each other, precisely from what point the crepitus, if any is found,
proceeds, surgeons have often been deceived, and they have believed
that they were the fortunate possessors of this rare pathological trea-
sure, when the autopsy has too soon disclosed their error. Both B.
Cooper and Robert Smith have alluded to this difficulty, and the case
reported by Dr. Markoe to the New York Pathological Society, and
published in the American Medical Monthly, will serve to illustrate
the same point ; in which case the signs of a fracture of the radius at
its neck were such as to deceive that experienced surgeon, yet the
autopsy disclosed the fact that it was a dislocation of the head of the
radius forwards, with a fracture of the ulna. Indeed, its existence
as a form of fracture was doubted by Sir Astley Cooper, and by

1 Transactions of the American Medical Association, vol. i. p. 174.



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268 FRACTURES OF THE RADIUS.

Others has been actually denied. I have seen no specimen obtained
from the cadaver, except the doubtful one contained in Dr. Watts'
cabinet, and of which I have furnished an account, accompanied with
a drawing, in my report to the American Medical Association,^ and
the specimen owned by the late Dr. Mutter, of Philadelphia, of which
he has kindly furnished me the following description : " History un-
known. The line of fracture seems to have passed through the neck
of the left radius, just at the upper extremity of the bicipital protu-
berance. Union with deformity has resulted.
Fig. 83. Owing to the fracture having taken place

within the insertion of the biceps, that muscle
appears to have drawn forward and upward
the lower end of the short upper fragment.
In consequence of this movement, the articu-
lating facet of the head of the radius is tilted
backwards, so as no longer to be in contact
with the humerus. As a secondary conse-
quence, the anterior edge of the head of the
radius rests permanently against the articu-
lating surface of the humerus. At this new
point of contact a new surface of articulation
is seen to have been formed, while the origi-
nal articulating facet is directed backwards,
and lies at right angles to the one of more
recent formation. At the inner edge of the
new articulation of the head of the radius
with the humerus, contact with the ulna has
developed another surface of articulation.
The upper and lower fragments are united
at an angle, and the radius does not appear
to have lost in length."

Yelpeau has once demonstrated the exist-
ence of this fracture in a dissection, but the
Traciare of ueck of radiut (Mot- fracturc was accompauicd with a fracture
u«:;?rrir;.rMl:r, also of the coronoid process; and B^rard
facets, e. Projeeung (h^menu. Obtained posscssiou of a Similar spccimeu.

I do not remember to have seen a notice of
any others. Malgaigne affirms, with his usual frankness, that although
he has occasionally believed that he had met with it, the autopsy,
whenever it has been obtained, has shown that it was rather a sub-
luxation than a fracture. On the other hand, Mr. South calls it a " not
unfrequent accident," but in confirmation of this declaration he cites
no examples."

While, therefore, the presence of what appear to be the rational
diagnostic signs has compelled me to record one case as an uncompli-
cat^ fracture of the necK of the radius, and two others as fractures at
this point accompanied either with a fracture of the humerus or a dis-
location of the ulna, 1 am prepared to admit that some doubt remains

1 Transactions, vol. ix. pp. 157 and 229.



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PRACTUBES OP THE NECK OP THE RADIUS. 269

in my own mind as to whether in either case the fact was clearly ascer-
tained ; nor do I think, speaking only of the simple fracture, that it will
ever be safe to declare positively that we have before us this accident,
lest, as has happened many times before, in the final appeal to that
court whose judgment waits until after death, our decisions should be
reversed.

Nothing, perhaps, could more fully illustrate the diflSculty of diag-
nosis in the case of injuries received in the neighborhood of the head
of the radius than the testimony given in the case of Noyes vs. Allen,
tried in the Supreme Court at Cambridge, January, 1856, before Judge
Bigelow. Mr. Noyes injured his elbow, January 7, 1854, and Dr.
Allen, who was called immediately, believed that the ligaments of the
joint had been torn, but that no bones were broken or displaced. On
the following morning he was dismissed, and Mr. Noyes went home.
Tl;iree weeks later it was seen by Dr. Dow, who also thought there
was no fracture. About eight weeks after the accident a physician
examined the arm, and declared the neck of the radius broken, and
the fragments displaced ; and when the case was finally brought to
trial he testified still that such was certainly the fact ; and five other
physicians, not one of whom, however, we are told, was a member of
the State Medical Society, testified positively that the radius was
broken at its neck, producing a bony protuberance; that such an
injury only could account for the symptoms manifested at the time of
the accident, and that no other fractures or injuries of the joint could
explain so well the present appearances of the arm. While, on the
part of the defence, six of the most intelligent medical gentlemen of
the State, Drs. Kimbal and Huntington, of Lowell, and Drs. Town-
send, Lewis, Clark, and G-ay, of Boston, testified that the head and
neck of the radius were not displaced, nor was there any evidence
that this bone had ever been broken. There is every reason to believe
that these latter gentlemen were correct; yet it is to be presumed
that the gentlemen who first testified were not without some grounds
for their opinions so confidently expressed.

The case was given to the jury after a trial of five days, who
promptly returned a verdict for the defendant.^

When this fracture occurs, the upper end of the lower fragment will
probably be carried forwards by the action of that portion of the
biceps which has its insertion into the tubercle ; and the displacement
in this direction must necessarily be increased in proportion as the
arm is straightened. In the cabinet specimen belonging to Dr. Mutter,
the line of fracture, commencing in the neck, has terminated in the
tubercle; consequently the biceps, having still some attachment to
the upper fragment as well as the lower, has drawn them both for-
wards.

The same anterior displacement I have noticed in all of the sup-
posed living examples, but whether both fragments or only one had
suffered displacement I am unable to say.

A girl, 8Bt. 11, living in Ontario Co., N. Y., fell from a tree, and

> Amer. Med. Gazette, vol. vii. p. 299.



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/



270 PBACTURES OP THE RADIUS.

injured her right arm. Her surgeon, who regarded it as a fracture of
the neck of the radius, reduced the fragments, and placed the forearm
at a right angle with the arm. On the twenty-eighth day all dress-
ings were removed, and the patient was dismissed; the fragments
seemed to be in place. The parents, finding the elbow stiff, now made
violent and successful efforts to straighten the arm.

Fifteen months after the accident, the child was brought to me.
There was at this time a bony projection in front, opposite the neck
of the radius, which I believed to be the point of fracture. The hand
was forcibly pronated, and she had only a limited amount of motion
at the elbow-joint. The anchylosis was probably due to inflamma-
tion directly resulting from the severe contusion; but it is quite
probable that the forward displacement of the fragments was alone
due to the too early and too violent attempts to straighten the arm ;
at least, this was the explanation which I ven-
^" tured to give to the parents at the time.

The second case occurred in a lad eight years
old, living in Wyoming Co., N. Y. His parents
brought him to me ten weeks after the injury
was received, and I then found the forearm bent
to a right angle with the arm, and anchylosed
at the elbow-joint. The hand was also forcibly
pronated, and could not be supinated. In front,
and opposite the neck of the radius, there was
a distinct bony projection, which I believed to
be the point of union of the bony fragments.
The external condyle seemed also to have been
broken.

The third example, treated originally by Dr.
Nott, of Buffalo, was seen by me six months
after the accident. The upper end of the lower
fragment seemed to be displaced forwards.
There was very little motion at the elbow-joint,
and both pronation and supination were com-
pletely lost.

I have seen, in Dr. Miitter's cabinet, two spe-
cimens of fracture of the outer half of the head
of the radius. In one case, the small fragment
is slightly displaced downwards in the direction
of the axis of the bone ; and, in the other, the
fragment is thrown outwards, or to the radial
side. Both are firmly united in their new po-
sitions.

Dr. Hodges presented to the "Boston Society
for Medical Improvement" a specimen very
much resembling those of Dr. Miitter's, in which
case the patient survived his injuries only six
hours ; and in the examination after death he
(M^a'tt^X" oiiettfon^'s^*^^ ^^^ ^^"°^ ^ ^*^® ^'^^ ^" obliquc fracture of



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FRACTUBBS OP THE HEAD OP THE RADIUS. 271

mencing above the coronoid process, and extending obliquely down-
wards and backwards. He remarks, moreover, that he has three
times found .a longitudinal fracture of the head of the radius asso-
ciated with a fracture of the coronoid process of the ulna.* I have
already observed thatVelpeau had once noticed the same coincidence.
In the treatment of fractures of the neck of the radius, we must not
neglect to flex the forearm upon the arm, so as to relax, as completely
as possible, the biceps, whose advantageous insertion into the tubercle
of the radius would be certain to produce displacement, unless this
position was adopted. A single dorsal splint^ properly padded, should
support the forearm, while the surgeon, having placed a compress
over the upper end of the lower fragment, proceeds to secure the
whole with a roller.

Especial care must also be taken to prevent the forearm from being
extended before the bony union is fairly consummated, lest the biceps,
now firmly contracted, should draw the lower fragment forwards, as
it must inevitably do while the bony union is imperfect; an accident
which, there is some reason to believe, occurred in one of the examples
which I have already cited.

If the patient be a child, or if there is any reason to suppose that
these rules will not be faithfully complied with, it would be well to
secure the arm in this position with a right-angled splint.

When the fracture occurs in any portion of the radius below the
insertion of the biceps, and above the insertion of the pronator radii
teres, Mr. Lonsdale suggests the propriety of placing the forearm in a
condition of supination, at least so far as is practicable, for the purpose
of securing a proper apposition of the fragments. His argument in
favor of this practice is ingenious, and deserves consideration.

When the bone is broken anywhere in this portion, the action of
the pronators upon the upper fragment ceases ; while that of the biceps,
which is a powerful supinator, continues ; consequently the upper frag-
ment becomes at once, and completely, rotated outwards or supinated.
Now, if the hand, to which the lower end of the radius alone remains
attached, should be forcibly proaated, the radius will also be rotated
inwards upon its own axis ; and although it might be possible in this
condition to bring the broken ends into contact, and a bony union,
without deformity, might be consummated, yet the power of supi-
nation must be forever lost; since the union has been effected while
the head and upper fragment are already in a state of complete supi-
nation ; and if such is the fact, it is evident that the whole bone, to-
gether with the hand, will be incapable of any further supination.

It is not, indeed, the practice with any surgeons, so far as I know,
to treat this fracture with the hand placed in a position of extreme
pronation ; but the case has been supposed for the purpose of render-
ing the argument mc "e intelligible. The usual practice is to place
the forearm and hand in a position midway between supination and
pronation, and then to lay it across the body at a right angle with the
arm ; but it is plain that the same objection, differing only in degree,

> Hodges, Boston Med. and Surg. Journ., Dec. 6, 1866.



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272



FRACTURES OF THE RADIUS.



will apply to this position as to that of pronation. The axes of the
two fragments are not made to correspond, since, while the lower frag-
ment is only half rotated outwards, the upper fragment is completely,
and the result of the union must be the loss of one-half the power of
supination in the hand.

It is only, then, by complete supination of the hand during treat-
ment that this difficulty can be avoided, and I have no doubt that we
ought to adopt this plan whenever it is practicable to do so, or when-
ever we are not hinaered by serious obstacles ; and the only obstacle
which occurs to me as likely to interpose itself, is the practical one
which most surgeons must have experienced in treating all injuries of
the forearm, whether fractures, or only severe contusions of the mas-
cles, &c., namely, the constant and almost uncontrollable tendency
of the hand to assume the prone or semi-prone position. This is due,
no doubt, to the great preponderance of power in the pronators ; and
such is the resistance which they afford to supination that it is often
quite impossible to lay the hand upon its back while the forearm is
across the body, and if accomplished, the position generally becomes
in a few hours so painful as to be intolerable. By extending the
arm, however, and laying it upon a pillow, the hand will be found
again to rest easily upon its back, because in this way we avail our-
selves of the outward rotation of the humerus at the shoulder-joint.

Dr. X. C. Scott, formerly Eesident Surgeon to the Brooklyn City
Hospital, in his inaugural thesis, submitted in March, 1869, has dis-
cussed very fully the advantages of this position in many fractures of
the forearm, and he has devised a very ingenious mode of securing
the limb after supination is effected, adding also a moderate amount
of extension by adhesive plasters and elastic bands.

Fig. 85.




8cott*8 apparatas for f^aetarefl of the forearm.



Dr. Scott informs me that he has treated twenty-five cases very
successfully, at the Brooklyn City Hospital and elsewhere, by this
method.

It has already been stated that of the whole number of fractures of



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FRACTURES OF THE HEAD OF THE RADIUS. 273

this bone recorded by me, amounting in all to one hundred and one,
only six belonged to the middle third. An observation which is in
striking contrast with the remark of Chelius, that it is broken most
frequently in its middle.

If the fragments are com- ^g- 86.

pletely separated at this
point, the lower end of the
upper half is drawn forward
by the action of the biceps
aided by the pronator radii
teres, in case the fracture is
below its insertion ; while
the lower fragment is tilted

toward the ulna by the con- Fnctare or the shaft of the radlas. (From Gray.)

joined action of the supi-
nator radii longus, and pronator quadratus. But as to the direction
of the displacement much will depend upon the direction of the force
by which the fracture has been occasioned.

A laboring man, 8Bt. 85, broke the radius near the lower end of the
middle third. On the same day I replaced the fragments as well as
I could in the midst of the swelling which had already occurred, and
applied two broad and well-padded splints, one to the palmar and one
to the dorsal surface of the forearm.

On the twenty-eighth day I first discovered that the fragments were
projecting in front, and I at once proposed to thrust them back by
force, but the patient declined allowing me to do so. I then applied
a compress near the summit of the projection, but not exactly upon
it, lest it should cause ulceration, and secured over this a firm splint.
At first this seemed to produce a change in the fragments, but after
a couple of weeks I found there was no improvement, and it was dis-
continued. About six months after the fracture occurred, this man
had the same arm terribly lacerated in a railroad accident, and I was
obliged to amputate near the shoulder-joint; and I thus obtained the
broken radius. The bone was firmly united, but with an angle, sa-
lient forwards, of about ten degrees. There was no inclination toward
the ulna.

My impression is that these fragments were never completely re-
placed, a point which I could not well determine at first on account
of the rapid efi^usion. 1£ they had been, I think they could have been
retained in place with the appliances used. Almost every day the
limb was examined, and as often as every fourth or fifth day the
dressings were removed and carefully reapplied. And only once did
they become so loose as not to afford the requisite support, and this
at a period too late to have occasioned the deformity.

We ought not to be deceived, therefore, and promise too confi-
dently a perfect limb, even when but the radius is broken, since we
may not always be certain that the ends are well replaced, or perhaps
they may become displaced subsequently, and in either case we are
not likely to discover the deformity until the swelling has subsided,
and it is too late to apply the remedy.



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274 FRACTURES OP THE RADIUS.

In the treatment of fractures of the middle third, the same rules,
with only slight modifications, will be applicable, as in fractares of
both bones. Two straight, long, and broad splints must be applied
after being carefully padded-; and especial attention should be paid
to the tendency of the fragments to become displaced forwards and
toward the ulna through the action of both the biceps and the prona-
tor radii teres ; a tendency which may in some measure be provided
against by flexion of the arm, but which must be overcome chiefly by
steady and well-adjusted pressure, near, but not upon, the ends of the
fragments.

Fractures of the lower third, occurring above the line of Colles'
fracture, are almost as rare as fractures of the middle or upper thirds.
I have recorded five; one of which it will be proper to relate as a
representative example.

George Vogel, 8Bt. 80, was admitted to the Buffalo Hospital of the
Sisters of Charity, Nov. 2, 1852, with a fracture of the right radius
about three and a half inches above its lower end. ' The hand was
prone, and inclined to the radial side ; while the broken ends of the
radius fell against the ulna, from which it was found difficult to sepa-
rate them. The lower end of the ulna was prominent, and projecting



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 32 of 100)