Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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upon the ulnar margin of the hand.

I was unable completely to separate the fragments of the radius
from the ulna, by either pressure with my fingers between the bones,
or by seizing upon them with my thumb and fingers. Having,
however, adjusted them as well as possible, I flexed the arm, and
applied a broad and well-padded splint to the palmar surface of the
forearm, securing it in place • with a paste bandage. These dressings
were finally removed at the end of four weeks, when I found scarcely
any displacement or deformity remaining.

Most of these fractures, when properly treated, result in perfect
limbs. In a certain proportion, however, it will be found impossible
effectually to resist the action of the pronator radii teres and of the
quadratus, and the fragments will unite at an angle resting against
the ulna, and sometimes, by the interposition of intermediate callus,
they will become firmly united to the ulna. Occasionally, also, espe-
cially where the fracture has been produced by a fall upon the hand,
and the radio-ulnar ligaments of the wrist have been torn or stretched,
the lower end of the ulna will be found to project permanently, and
the hand to fall more or less to the radial siae.

Of the ninety-two fractures belonging to the lower third of the
radius, eighty-seven were near the lower end, or within from half an
inch to one inch and a half from the articular surface, all being in-
cluded in those fractures called "Colles' fractures," most of which
were no doubt true fractures, and probably a small proportion sepa-
rations of the epiphyses.

In every instance, except one, which has come under my notice,
where the cause of a Colles' fracture has been ascertained, it has been
occasioned by a fall upon the palm of the hand. The exceptional
case was in the person of Mrs. D. B., who fell in getting out of a street
car in the city of New York, May 20th, 1865, striking upon the back

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of her hand while the hand was shut. The displacement was in the
same direction as in cases caused by a fall upon the palm. Robert
Smith has seen a similar accident cause a displacement of the frag-
ment forwards.

CoUes described this fracture as occurring always about one inch
and a half above the carpal end of the bone ; but Robert Smith, who
has carefully examined all of the cabinet specimens he could find,
about twenty-three in number, has never seen the line of fracture
removed farther than one inch from the lower end of the bone, and
in several specimens it was within one-quarter of an inch of this
extremity. Dupuytren has also described the fracture as occurring
from three to twelve lines above the joint. I think I have found the
fracture generally as low as these latter surgeons have placed it, but
occasionally as high as it was placed by CoUes.

Fig. 87.

Praetnre of the radius near its lower end.

Case. A woman, set. 40, fell upon the side- walk, striking upon the
palm of her left hand. She was brought immediately to my oflBice,
and I found the radius was broken about one inch and a half above
the wrist. The lower fragment was tilted back considerably. Hand

Placing my thumb against the back of the lower fragment, it was
easily restored to position, and with only a slight crepitus. When
my thumb was removed it manifested no tendency to displacement.
The arm was dressed with a curved palmar splint, secured in place
with a roller applied moderately tight. On the seventh day a straight
splint was substituted for the curved. The arm was examined almost
every day, and the dressings occasionally renewed until the twenty-
sixth day, when the splint was finally removed. The wrist was at
this time only slightly anchylosed, and there seemed to be no deformity
or imperfection remaining. Passive motion, which had been practised
at each removal of the dressings, was directed to be continued.

Case. A boy, set. 11, was brought to me, having just fallen from a
pair of stilts. His right radius was broken transversely, three-quarters
of an inch above the wrist, and the lower fragment was much tilted
back ; the lower end of the ulna was prominent, and the hand fell to
the radial side.

Pushing from behind, the lower fragment was made to resume its
place, and the deformity immediately disappeared. It was noticed,
however, that it required unusual force to accomplish this, but it was
nOt found necessary to use extension. There was also, accompanying
the reduction, a slight crepitus.

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The treatment was the same as in the first case, except that the
curved splint was employed throughout. Little or no deformity ex-
isted when the dressings were removed.

Case. George Lofinch, set. 42, fell upon an icy side-walk, striking
upon the palm of his left hand. Fracture three-quarters of an inch
above the lower end. Fragment displaced backwards. A friend had
partially replaced the fragment by pushing upon it, before he came to
me. Within half an hour after the accident he was at my office, and
I restored the lower end of the bone very easily to place by pushing
from behind with my thumb. No extension was necessary. It would
not, however, remain in place unless the forearm was pronated so that
the weight of the hand could aid in the retention.

I applied my own palmar splint. The recovery was rapid and

Case. Margaret Reed, set. 48, fell, September 23, 1855, striking on
the palm of the left hand, and breaking the radius about one inch from
its lower end. One week after, she came under my care at the hos-
pital. The arm had been previously dressed carefully by one of my
colleagues, with curved dorsal, and palmar splints ; but, on examina-
tion, we found the fragments a good deal displaced. It was found
necessary now to use both extension, and pressure from behind to re-
store the lower fragment to position. This we finally succeeded in
doing, and immediately splints were again snugly applied. Two days
after, on opening the aressings, the lower fragment was a second time
found displaced backwards. It was again reduced, but only by using
great force. Fifteen days later, we were pleased to find the bone firm
and without deformity.

Margaret left the hospital on the 4th of November, with her hand
and wrist still swollen, and with a good deal of stifihess at the elbow
and wrist joints.

Case.. Charles Stratton, a healthy and temperate laborer, aet. 36.
fell forwards from a wagon, Nov. 22, 1854, striking upon the palm of
his hand, and breaking the radius a little more than one inch above
the joint. I found the lower fragment displaced backwards, and it was
easily reduced by pressure in the opposite direction. The forepart of
the wrist being quite tender to pressure, the splint was applied to the
dorsal surface of the forearm. The splint was curved (pistol-shaped),
and the surface which was applied to the arm was padded with care ;
it was secured in place by a few light turns of a roller, and laid across
the body in a sling.

The arm was seen by me on each of the succeeding seven days, and
on the third, fifth, and seventh days the splint was removed com-
pletely ; but on this last day an erysipelatous inflammation had com-
menced in the neighborhood of the wrist. The splint and roller were
therefore not reapplied, but the limb was laid upon a broad board,
cushioned and covered with oiled silk, and cool water irrigations were
directed. The inflammation soon subsided, but the splint was never
resumed, as the fragments were found to stay in place perfectly with-
out its aid. At the end of five weeks, union seemed to be consum-
mated ; and one year later the bone was found to be perfectly straight,

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yet the wrist-joint and the finger-joints remained stiff, so much so that
he was unable to perform any labor. The stiflFness was, however,
gradually disappearing ; while all swelling and tenderness had long

The observations of M. Voillemier also have shown that, instead of
being oblique, as has generally been supposed, the fracture is almost
uniformly transverse from the palmar to the dorsal surfaces of the
bone, and only occaBionally slightly oblique in its other diameter, or
from the radial to the ulnar side. I have seen, however, in the mu-
seum of the College of Physicians of Philadelphia, a specimen of this
fracture in which the line of fracture is transverse, from side to side,
but very oblique from before backwards, and from below upwards..
There is also a line of incomplete fracture extending into the joint.
It is united by bone, with the usual displacement backwards.

The observations of both R. Smith and Voillemier have shown,
moreover, that the displacement of the lower fragment is seldom suffi-
cient to enable it to escape completely from the upper ; and that where,
in extremely rare instances, and in consequence of extraordinary vio-
lence, such complete separation does occur, a disruption of those liga-
ments which attach the lower fragment to the ulna occurs also, and
the deformity becomes at once very great, so that it no longer presents
the peculiar features of Golles' fracture, but resembles a dislocation.
. In the so-called CoUes' fracture, the lower and outer border of the
radius, or its styloid apophysis, is swung around or tilted, as it were,
upon the ulna ; the lower and inner border of the same fragment being
retained in place by the radio-ulnar ligaments, which do not usually
suffer a complete disruption, but only a stretching or partial laceration.
The upper or broken margin of the lower fragment, and also the
ulnar margin, undergo very little displacement; while the lower or
articular surface, and the radial margin, are carried backwards, up-
wards, and outwards.

Surgeons have spoken of a falling in of the upper end of the lower
fragment toward the ulna, as an almost inevitable result of the action
of the pronator quadratus, and against which tendency they have
sought carefully to provide ; but there is much reason to believe that
any considerable degree of displacement in this direction is a rare
event, and that, when it does exist, it is in consequence mostly of the
direction of the force which has produced the fracture, rather than of
the action of this muscle, only a few of the fibres of which are usually
attached to the lower fragment, and, in some instances, when the
fracture is within a half or quarter of an inch of the articulation, not
any. Besides, there is actually in these latter cases no interosseous
space into which the fragment may fall, and its displacement toward
the ulna becomes, therefore, impossible.

Still, however, if one were disposed to speculate upon the condition
of these parts after the fracture, it might perhaps be easy to persuade
ourselves that the action of the pronator quadratus upon the upper
fragment, whose broken extremity was not completely, or at all, dis-
engaged from the lower, would carry both fragments together toward
the ulna. But whatever might be the result of our speculations, still

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the fact, as proved by specimens, is not generally so ; and this is not
the first time that facts and theories have disagreed.

The truth is, that it is unusual to find any of the museum speci-
mens of this fracture thus united. But they maybe found constantly
tilted back in the manner I have described, occasionally tilted for-
wards, and, still more rarely, slightly displaced upon their broken
surfaces antero-posteriorly.

The general absence of this internal displacement may find its ex-
planation in the direction of the force which generally produces this
fracture, in the occurrence of the fracture sometimes at a point so low
as to render its displacement in this direction impossible, and in the
breadth of the bone, ^t the seat of the fracture, which does not permit
it to fall laterally without actually increasing its length ; a circum-
stance which its secure ligamentous attachment to the ulna at its op-
posite extremities, and its complete apposition to the wrist and elbow-
joint, do not allow.

The mistake of those surgeons who have attempted to describe this
fracture has originated in the appearance presented in nearly all re-
cent fractures occurring at this point. The hand falls to the radial
side, and seems to carry the lower end of the lower fragment with ity
while the lower end of the ulna becomes unnaturally prominent in
front and to the ulnar side ; a condition of things which has naturally
enough been ascribed to the displacement of the upper 'end of the
lower fragment in the direction of the interosseous space.

But this same radial inclination of the hand, and prominence of the
ulna, are present frequently when the radius is broken at its lower
end, and no displacement in any direction has taken place ; and I have
even observed it in simple sprains of the wrist, and in the hands of
old or feeble persons where all the ligaments have become relaxed.

It is seen, however, in a more marked degree when the bone is
actually both broken and displaced backwards in its usual direction.
In short, the deformity in question is due, in a large majority of in-
stances, to the relaxation, stretching, or more or less disruption of the
radio-ulnar ligaments, which permits the hand to fall to the radial
side by a simple rotatory movement over its articular surface. For
this reason, also, because these ligaments once lengthened or broken
can never, or only after a lapse of many years, be completely restored,
this deformity may be expected, in a certain number of cases, to con-
tinue, however exact and perfect may be the bony union.

It must be added, however, that so long as the tilting of the frag-
ment remains, the articular surface is actually presenting somewhat to
the radial side. While in the normal condition it presents downwards,
forwards, and inwards, it now presents, when the displacement is con-
siderable, downwards, backwards, and outwards.

Diday maintained that there existed usually in this fracture an over-
lapping or shortening of the bone in its entire diameter, and Yoillemier
thought that the specimens which he had examined proved that an
impaction was almost universal.

Both of these opinions have been combated by Robert Smith; the
shortening observed by Diday being found only on that side of the

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bone to which the hand inclines, and being, according to B. Smith,
the result of the motion of the lower fragment already described ; and
the appearance of impaction being due to the ensheathing callus which
is deposited usually, if the displacement is allowed to continue, in the
retiring angle opposite the seat of fracture.

These are questions, however, requiring for their decision a very
careful study of specimens, and in relation to which farther observa-
tions may be necessary. Indeed, some recent observations made by
Mr. Callender, of Saint Bartholomew's Hospital, London, go far to
sustain the opinion of Diday, that some impaction generally exists,
but rather upon the posterior margin than upon
either the radial or ulnar side.^ Fig. 88.

Meanwhile there is no doubt that occasional ex-
amples may be found illustrating one or more of all
these varieties of displacement, and that to the im-
paction is sometimes added a comminution of the
lower fragment, the lines of the fracture extending
freely into the joint. One of the most curious exam-
ples of which has been reported by Dr. Bigelow,
of Boston. The patient had fallen, and being other-
wise seriously injured, ultimately died in the Massa-
chusetts Hospital. At first he had only complained
of lameness at the wrist, as if it had been severely
sprained; but at the end of several days the joint
became swollen, and from the persistence of the
swelling Dr. Bigelow was led to diagnosticate a
stellate crack in the articulating extremity of the
radius, he- havin/z met with a similar case two „« , ,

, rt , o . .11 Bigelow'i ease of com-

years before, when a patient with the same symp- minuted fracture of the
toms had died of other injuries, and exhibited a lower end of the radiu«.
crack in the same place, but less extensive than
in this case. There was found, in this last example, a star-shaped
fissure on the articulating surface, without displacement. These fis-
sures penetrated the shaft for an inch or more. Dr. Bigelow thought
that the bones of the wrist acted as a wedge to spread the correspond-
ing hollow of the articulating extremity ; and that this specimen would
explain the persistence of some cases of sprained wrist.'

Bobert Smith has described a fracture occurring at the same point,
and probably possessing nearly the same characters as OoUes' fracture ;
in which the lower fragment is thrown forwards instead of backwards,
and which has generally been the result of a fall upon the back of
the hand. There is no such specimen, however^ in any of the patho-
logical collections in Dublin, nor has Mr. Smith ever seen a specimen
obtained from the cadaver, although he reports a case which fell under
his observation in practice.

I have myself seen one such case,' but I regret to say that my

» Callender, St. Barth. Hosp. Rep., p. 281, 1865.
< Boston Med. and Surg. Jonm., vol. Iviii. p. 99.
' Trans. Am. Med. Assoc, vol. ix. p. 145.

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examinatioD of the condition of the arm was not such as to enable
me to add anything to the information already possessed upon this
subject ; indeed, until we have an opportunity of studying it in the
cadaver, we cannot speak very definitely of its anatomical characters^

N^laton observes that all the varieties of this fracture which he has
seen are often accompanied with fracture of the styloid apophysis of
the ulna, and with a tearing of the triangular ligament. I am not
aware that any other writer has made the same observation in relation
to the frequent occurrence of a fracture of the styloid apophysis of the
ulna, and I think the accident is not so common as the remark of
N^Iaton would lead us to suppose.

Dr. Butler, House Surgeon to the Brooklyn Hospital, reports a case
of fracture of the right radius at the junction of the middle and lower
thirds, accompanied with a fracture also of the styloid apophysis in
the same bone. The accident occurred in a lad fourteen years old,
who had fallen from a height of thirty feet upon the pavement. The
lower fracture commenced at the base of the styloid process of the
radius, and extended down obliquely into the wrist-joint, breaking ofif
about one-fifth of the articular surface. The process was drawn up
on the posterior surface of the radius, about one inch and a half, by
the supinator radii longus muscle. It was movable, but, in consequence
of the contusion and swelling, could not be returned to its place. The
hand occupied the same position that it does in Golles' fi*acture.

On the eighth day an attempt was made to force down the process
with a compress secured by adhesive plaster straps ; but it could not
be done. The hand and arm were confined also to a pistol-shaped
splint ; ulcerations ensued from the pressure of the compress, and the
process was laid bare, but it finally became united in its abnormal
position ; the motions of the wrist, however, were not impaired, and
the power of pronation and supination soon returned.*

I believe I have seen two examples of a fracture commencing on
the radial side of the bone and terminating in the joint, the separated
fragment including considerable more than the apophysis ; but neither
of these cases has been verified by an autopsy. They are treated at
length in the preceding edition of this book.

Recently Dr. E. Moore, of Rochester, N. Y., has demonstrated by
examinations upon the cadaver and by experiment, that in a certain
proportion of cases the internal lateral ligament, and the triangular
fibro-cartilage having given way under the force which has occasioned
the fracture, the styloid process is thrust under the annular ligament
and imprisoned; in fact, the ulna becomes dislocated, and is retained by
the annular ligament in its new position. Nor can the reduction of the
fracture be accomplished until the ulna is released from its imprison-
ment. Reduction is to be accomplished by extension and partial cir-
cumduction'; the hand being grasped firmly aud extended first to the
radial side, then backwards to the ulnar side, and finally forwards, or
in the position of fiexion. During the entire manoeuvre the wrist is
held firmly by the opposite hand of the surgeon. The test of reduc-

« New York Joum. of Med., 1857.

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tion is to be found in the presence of the head of the ulna on the
radial side of the ulnar extensor.

In order to retain the ulna in place when reduction is effected, Dr.
Moore places a thick, firm compress over its lower end, on the palmar
and ulnar margins of the forearm ; and secures this in place with
a broad band of adhesive plaster drawn firmly around the wrist. The
forearm is then placed in a narrow sling passing under the wrist and
compress. This completes the dressing.^

In the first volume of the Philadelphia Medical Examiner (1838)
will be found a description by J. Bhea Barton, of Philadelphia, of a
form of fracture occurring through the lower end of the radius, which
is probably much less common than Colles' fracture, and which had
hitherto escaped the notice of surgeons. Its peculiarity consists in
the line of fracture extending very obliquely from the articulation,
upwards and backwards, separating and displacing the whole or only
a portion, as the case may be, of the posterior margin of the articu-
lating surface. I have not recognized this fracture in any instance
which has come under my own observation, nor have I been able to
find a cabinet specimen in any pathological collection. Dr. Barton
was not able to prove the correctness of his diagnosis by an autopsy,
and the only well-authenticated example which I can find upon record
is that to which Malgaigne has alluded, as having been seen by M.
Lenoir; and of which an account was published in the Archives CHrU-
rales de Midedne in 1889. M. Lenoir believed it to be a simple
luxation of the hand backwards, but the patient having died, he was
able to correct his diagnosis by an autopsy. A considerable fragment
had been broken from the posterior lip of the articular surface, the
line of fracture being from below upwards, and from before back-
wards. This fragment had become displaced upwards and backwards,
carrying with it the carpal bones, and producing thus the appearance
of a simple dislocation.* I believe that the accident so carefully de-
scribed by Barton was either a Colles' fracture, or a fracture simply
of the radial margin, of which I have given two supposed examples,
with the usual signs of which his account so exactly coincides, and
that it was not a fracture of the posterior lip of the articulating .
surface, as he believed.

Ninety -two examples of fracture of the lower third of the radius
have furnished no cases of non-union, nor indeed do I remember ever
to have seen the union delayed ; yet only twenty-six are positively
known to have left no perceptible deformity or stiffness about the
joint: it is probable, however, that the number of perfect results
might be somewhat extended. In one example, the case of a man
whose arm was broken in Germany, when he was only ten years old,
the fragments of the radius were driven into each other, or overlapped
one inch; and the ulna had been displaced downwards toward the
fingers the same distance. This was examined twelve years after the
accident, and he had then a very useful arm. Twice I have found

> Moore, New York Med. Rec, April 1, 1870.
< Malgaigne, Traits des Frac, etc., torn. ii. p. 700.

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the wrist and finger-joints quite stiff after a lapse of one year; in one
case I have found the same condition after two years ; in one case
after three years, and in two cases after five years.

If we confine our remarks to Golles' fracture, the deformity which
has been observed most often consists in a projection of the lower
end of the ulna inwards and generally a little forwards. In a large
majority of cases this is accompanied with a perceptible falling of the
hand to the radial side, while in a few it is not. After this, in point
of frequency, I have met with the backward inclination of the lower

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 33 of 100)