Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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on the ulnar side.

Having restored the fragment to place, in case of Colles' fracture,
by pressing forcibly upon the back of the lower fragment, the force
being applied near the styloid apophysis of the radius, the arm is to
be flexed upon* the body, and placed in a position of semi-pronation,
when the splints are to be applied, and secured with a sufficient num-
ber of turns of the roller, taking especial care not to include the
thumb, the forcible confinement of which is always painful and never
useful.



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FRACTURES OF THE RADIUS.



291



I cannot too severely reprobate Fig. 96.

the practice of violent extension
of the wrist in the efibrts at re-
daction when no overlapping of
the fragments exists and the ulna
is not dislocated, and that, whether
this extension be applied in a
straight line, or with the hand
adducted. It has been shown
that in a great majority of cases
no indication in this direction is
to be accomplished, and to pull
violently under these circum-
stances upon the wrist is not only
useless but hurtful. It is adding
to the fracture, and to the other
injuries already received, the
graver pathological lesion of a
stretching, a sprain of all the lig-
aments connected with the joint.
I am persuaded that to this vio-
lence, added to the unequal and
too firm pressure of the splints,
are, in a great measure, to be at-
tributed the subsequent inflamma-
tion and anchylosis in very many
cases.

The first application of the bandages ought to be only moderately
tight, and as the inflammation and swelling develop in these struc-
tures with rapidity the bandages should be attentively watched, and
loosened as soon as they become painful. It must be constantly borne
in mind that, to prevent and control inflammation, in this fracture, is
the most difficult and by far the most important object to be accom-
plished, while to retain the fragments in place, when once reduced, is
comparatively easy.

During the first seven or ten days, therefore, these cases demand
the most assiduous attention ; and we had much better dispense with
the splints entirely than to retain them at the risk of increasing the
inflammatory action. Indeed, I have no doubt that very many cases
would come to a successful termination without splints, if only the
hand and arm were kept perfectly still in a suitable position until
bony union was effected.

I must also enter my protest against many or all of those carved
splints which are manufactured, hawked about the country, and sold
by mechanics, who are not surgeons; with a fossa for each styloid
process, a ridge to press between the bones, and various other curious
provisions for supposed necessities, but which never find in any arm
their exact counterparts, and only deceive the inexperienced surgeon
into neglect of the proper means for making a suitable adaptation.



The author's dressing complete. The ennred
palmar splint is not in Tiew, only the dorsal. The
faint white lines represent the roller. The Hling
is omitted for the purpose of bringing the other
dressings into yiev.



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292 FRACTURES OF THE RADIUS.

They are the fruitful sources of excoriations, ulcerations, inflamma-
tions, and deformities.

In reference to the treatment of these fractures, the following cases
and the accompanying remarks, by that great surgeon, Dupuy tren, are
too pertinent not to merit a place in every treatise of this character.

" The two succeeding cases are not only interesting as fractures of
the radius, but they are farther deserving of attentive consideration,
on account of the serious complications which accompanied them, and
which were the consequence of forgetting an important precept. More
than once, indeed, it has occurred that the surgeons have been so in-
tent on preserving fractures in their proper position that the extreme
constriction employed has actually caused destruction of the soft parts.
A piece of advice which I have very frequently given, and which I
cannot too often repeat, is to avoid tightening too much the apparatus
for fractures during the first few days of its teing worn ; for the swell-
ing which supervenes is always accompanied by considerable pain,
and may be followed by gangrene. It cannot, dierefbre, be too ur-
gently impressed on young practitioners, to pay attention to the com-
plaints which patients make ; and to visit them twice daily, and relax
the bandages and straps as need may be, in order to obviate the
frightful consequences which may spring from not heeding this neces*
sary precaution; by carefully attending to this point I have been
saved the painful alternative of ever having to sacrifice a limb for
complications which its neglect may entail.

" Antoine Bilard, set. 44, fractured his right radius whilst going
down into a cellar, in Feb. 1828, and went at once to the Hospital of
La Charity. When the fracture was reduced (it was near the base of
the bone) an apparatus was applied, but fastened too tightly ; and,
notwithstanding the great swelling and the acute pain which the
patient endured, it was not removed until the fourth day, when the
hand was cold and oedematous, and the forearm red, painful, and
covered with vesications. Leeches, poultices, and fomentations were
applied, and followed by some alleviation of the local symptoms,
though there was much constitutional disturbance. At the close of a
fortnight from the accident, the palmar surface of the forearm pre-
sented a point where fluctuation was supposed to exist; but when a
bistoury was plunged into it no matter followed. Portions of the
flexor muscles subsequently sloughed, and the skin subsequently
mortified. The only resource was amputation, which was performed
above the elbow six weeks after his admission ; and he afterwards
recovered without the occurrence of any further untoward symptoms.

" B., set. 36, was at work boring an artesian well in 1832, when he
was struck by part of the machinery on the right forearm ; he was
instantly knocked down and thrown violently on the right thigh. A
surgeon who was sent for detected a fracture of the radius, and ap-
plied the usual apparatus, consisting of pads and splints, confined by
a roller extending from the extremities of the fingers to the elbow,
which compressed the arm so tightly as to give rise to very great
Bufiering. The fingers, hand, and forearm were numbed almost to
insensibility, and yet the surgeon in attendance did not think proper



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FBACTURES OP THB BADIU8. 298

to loosen the apparatus. Sach was the condition of the patient until
lie came to the Hdtel Dieu, four days ailer the accident; the fingers
were then black, cold, and insensible, and when I removed the splints
I found the hand likewise black, especially on its palmar surface.
The lower part of the forearm was a shade less livid, but equally cold
and insensible ; and several vesicles filled with pink-colored serum
were apparent on both its surfaces where the splints had pressed ; the
npper part of the forearm was inflamed, swollen, and very painfuL
He was bled and leeches were applied to the inflamed part of the arm ;
camphorated spirit was applied to the fingers.

" On the following day heat was restored as low as the wrist, but
the hand remained for the most part livid and cold, and the radial
artery did not pulsate. Seventy leeches were applied to the forearm,
and the local application was continued." On the second day after
admission thirty more leeches were applied. On the fourth day the
hand looked a little better, so as to " encourage some hope of its being
saved ; but this was again blighted on the sixth day, by the entire los9
of heat and sensibility in the part and increased pain and swelling in
the forearm, to which the gangrene subsequently extended. On the
twelflh day amputation was performed at the elbow-joint; but the
patient did not survive the operation more than ten days, the imme-
diate cause of death being acute pleurisy. There was a considerable
quantity of purulent serosity poured out on the right side of the chest ;
and abscesses were found in the lungs and liver. On examining the
arm, there was found to be a simple fracture of the radius about its
centre.

" The kbove case presents a painful illustration of the neglect to
which I have alluded. In nearly every instance the swelling of the
limb requires that careful attention should be paid to the bandage or
straps, by which the apparatus is confined. Similar accidents are
likely to result from the employment of an immovable apparatus, of
which an example occurred in the practice of M. Thierry, one of my
pupils. He was summoned to visit a young girl, on whom such an
apparatus had been applied for suppo^ fracture of the radius.
After suftering excruciating torment^ the forearm mortified, and am-
putation was the only resource ; on examining the limb no trace of
fracture could be discovered. Had a simple apparatus been here em-
ployed, and properly watched, this patient's limb would not have been
sacrificed."^

Bobert Smith mentions, also, the case of a boy, 89t. 18, who had a
fracture of the lower extremity of the radius, through the line of the
junction of the epiphysis with the diaphysis, caused by being thrown
from a horse. A surgeon applied, within an hour, a narrow roller
tightly around the wrist On the following day the limb was in-
tensely painful, cold and discolored ; still the roller was not removed,
nor even slackened. On the fourth day he was admitted into the
Richmond Hospital, when the gangrene had reached the forearm.
Spontaneous separation of the soft parts finally occurred, and the

■ Dapuytren, Injuries and Diseases of Bones, Syd. ed., London, 1847, pp. 145-7.



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294: FRACTURES OF THE RADIUS.

bones were sawn through twenty-four days after the fracture was
produced, from which time " everything proceeded favorably."*

Nov. 21, 1851, a boy, ten years old, living in the town of Andover,
Mass., had his left hand drawn into the picker of a woollen mill, pro-
ducing several severe wounds of the hand and a fracture of the radius
near its middle. One of the wounds was situated directly over the
point of fracture, but whether it communicated with the bone or not
was not ascertained. A surgeon was called, who closed the wounds,
covered the forearm with a bandage from the hand to above the elbow,
and applied compresses and splints. This lad made no complaint^ his
appetite remaining good and his sleep continuing undisturbed, until
the third day, when he began to speak of a pain in his shoulder ; on
the same day also it was noticed that his hand was rather insensible to
the prick of a pin. Early on the morning of the fourth day his sar-
geon being summoned, found him suffering more pain and quite rest-
less ; and on removing the dressings, the arm was discovered to be
insensible and actually mortified from the shoulder downwards.

Opiates and cordials were immediately given to sustain the patient,
and fomentations ordered.

On the sixth day a line of demarcation commenced across the shoul-
der, and on the twenty -first day the father himself removed the arm
from the body by merely separating the dead tissues with a feather.
Subsequently a surgeon found the head of the humerus remaining in
the socket, and removed it, the epiphysis having become separated
from the diaphysis. The boy now rapidly got well.

In the year 1858 this case became the subject of a legal investiga-
tion, in the course of which Dr. Pilsbury, of Lowell, Mass., declared
that in his opinion this unfortunate result had been caused by too
tight bandagipg, and by neglecting to examine the arm during four
days.

On the other hand, Drs. Hayward, Bigelow, Townsend, and Ains-
worth, of Boston, with Kimball, of Lowell, Drs. Loring and Pierce,
of Salem, believed that the death of the limb was due to some injury
done to the artery near the shoulder-joint; and in no other way could
they explain the total absence of pain during the first two days ; nor
could they regard this condition as consistent with the supposition
that the bandage occasioned the death of the limb.'

I cannot but think, however, that these gentlemen were mistaken,
and that the gangrene was alone due to the bandages. In a similar
case which came under my own observation, and in which both the
radius and ulna were broken, the roller extended no higher than just
above the elbow, and the patient complained of no pain until the
bandages were unloosed, yet the arm separated at the shoulder-joint.
I shall refer again to this example in the chapter on fractures of the
radius and ulna ; and I shall take occasion then also to speak more
fully of the causes of these terrible accidents.

Norris mentions another case of compound fracture of the lower

> R. Smith, Treatise on Fractures, &c., Dfablin, 185i, p. 170.
s Boat. Med. and Surg. Joum., vol. xlviii. p. 281.



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PBACTTTRES OP THE RADIUS. 295

end of the radias which came under his notice at the Pennsylvania
Hospital in August, 1837, the arm having been dressed by a surgeon
within half an hour after the accident, with bandages and splints.
When these bandages were removed at the hospital, on the fifth day,
" the soft parts around the fracture were found to have sloughed, an
abscess extended up to the elbow-joint, and sloughs existed over the
condyle. Several constitutional symptoms arose, making amputation
of the arm necessary."'

A lady, set. 50, was also seen by Thierry, who, having broken the
radius near its lower end, lost her fingers by the sloughing consequent
upon a tight bandage.*

A woman was admitted into one of Dr. Wood's wards in the Belle-
vue Hospital about the first of February, 1868, who had fallen upon
her hand a few days before and broken the radius just above the
wrist. Her arm was dressed with splints and bandages at one of the
dispensaries in this city. Gangrene ensued, and when I saw her on
the 8th of February, the death had extended to the middle of the fore-
arm ; the dead tissues being dry and black. Dr. Wood amputated the
arm, but she died.

The remarks which have now been made in relation to the treatment
of Colles' fracture, are applicable, with only such slight modifications
as would naturally be suggested, to fractures of the lower end of the
radius commencing upon the radial side of the bone and extending
obliquely downwards into the joint; and it is to this form of fracture
especially, that the pistol-shaped splint must be found applicable. If
the fracture actually extends into the joint, it must not be forgotten
that, in order to the prevention of anchylosis, the wrist should be
early subjected to passive motion.

The following example of a compound comminuted fracture of the
radius may serve to illustrate the value of a somewhat novel mode
of treatment under certain circumstances: —

William Croak, of Buffalo, aet. 80. January 2f9, 1856, a large piece
of iron casting fell upon his arm, crushing and lacerating the wrist,
and comminuting the lower part of the radius; he was immediately
taken to the Hospital of the Sisters of Charity. I found the whole of
the soft parts torn away in front of the joint, and the fragments of the
radius projected into the fiesh in every direction. The hope of saving
the hand seemed to be scarcely sufficient to warrant the attempt ; at
least by the ordinary mode of procedure. I, however, stated to the
gentlemen present, among whom were Dr. Kochester, my colleague,
and the house surgeon. Dr. Lemon, that I believed it could be saved
if, having removed the fragments of the radius, we practised resection
of the lower end of the ulna, and allowed the muscles to become com-
pletely relaxed. Accordingly, after placing my patient under the
influence of chloroform, I enlarged the wounds so as to enable me to
remove six or seven fragments of the radius, leaving others which
were broken off but not much displaced. I then removed with the

> Norris, note to Liston^s Surgery, p. 54.

> Amer. Journ. Med. Bci., vol. xxy. p. 461, from L^Exp^rience for 1838.



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296



FBACTURES OF THE RADIUS.



Fig. 97.



saw one inch and a half of the lower end of the ulna. The hand was
immediately drawn up bj the contraction of the remaining muscles,
but their tension was completely relieved.

The wounds were closed and dressed lightly, and the Whole limb
was placed on a broad and well-padded splint covered with oiled cloth.
The hand, which was very pale and exsanguine, was
covered with warm cotton batting.

The subsequent treatment was changed from time to
time to suit the indications ; but his recovery was rapid
and complete, nor was there at any time excessive inflam-
mation in any part of the limb.

I have seen this man frequently since he left the hospi-
tal, and while he has recovered only a little motion in the
wrist-joint, his hand and lingers are nearly as useful as
before the accident. He is able to perform all ordinary
kinds of labor with almost as much ease as most other
men ; and what is always gratifying to the humane sur-
geon, he does not fail to appreciate fully the service which
has been conferred upon him by the preservation of his
somewhat mutilated hand.

I have recently adopted the same treatment with equal
success in a case of gunshot wound of the lower end of
the radius.

Epiphyseal Separations. — This bone is formed from
three centres, namely, one for the shaft and one for either
extremity. The shaft is ossified at birth. About the end
of the second year ossification commences in the lower
epiphysis, and it becomes united to the shaft at about the
twentieth year. The same process commences in the
upper epiphysis at about the fifth year, and is completed
by consolidation with the shaft at the age of puberty.
I have met with no recorded examples of separation of the upper
epiphysis, and the examples of separation of the lower epiphysis have
seldom been clearly made out. I have already mentioned one as
having been reported by Bobert Smith. He speaks also of other
cases occurring in oonju action with a separation of the lower end of
the ulna, and which is very liable to be mistaken for a dislocation.^

The treatment of this accident will not require any special con*'
sideration, since it will not differ essentially from the treatment re-
quired in a fracture occurring at the same point.

1 Robert Smith, op. dt, p. 164.



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SHAFT OF THE ULNA. 297



CHAPTER XXII.

FRACTURES OP THE ULNA.

§ 1. Shaft of the Ulna.

Causes. — The shaft of the ulna, when it alone is the seat of fracture,
is generally broken by a direct blow. I have never seen an excep-
tion to this rule; but Voisin has related in the Gazette Mtdicale for
1833 a single exception, in which it was said to have been broken by
a fall upon the palm of the hand. Malgaigne thinks it is most often
broken when one seeks to ward off a blow with the arm ; but it has
happened most often to me to see it broken by a fall upon the side of
the arm.

Point of Fracture, Direction of Displacement, <tc. — In an analysis
of thirty-three cases, I find the shaft has been broken eleven times in
its upper third, twelve times in its middle third, and ten
times in its lower third. All portions seem, therefore. Fig. 98.
to be about equally liable to fracture. I think, also, the
fractures have generally been oblique.

Contrary to what has been observed by other writers,
I have noticed that no law prevailed as to the direction
in which the fragments have become displaced ; the
broken ends being found directed forwards, backwards,
inwards, or outwards, according to the direction of the
blow which has occasioned the fracture ; and this is in
accordance with the general rule in other fractures
occasioned by direct blows. No doubt, however, other
things being equal, the tendency of the lower fragment
would be toward the interosseous space, in consequence
of the action of the pronator quadratus in this direction,
while the upper fragment, owing to its broad and firm
articulation at the elbow-joint, can only be displaced
forwards or backwards, at least to any great extent.

Complications, — In no case of the shaft of a long bone
have I found serious complications more frequent than
in fractures of the shaft of the ulna. Four have been
compound ; eleven complicated with a forward, or for-
ward and outward dislocation of the head of the radius ; Fracture of the
one with a partial dislocation of the lower end of the shaft of the uina.
radius backwards, and one with a dislocation of both
radius and ulna backwards at the elbow-joint. It will be seen, there-
fore, that sixteen, or nearly one-half of the whole number, have been
seriously complicated.

Symptoms. — Occasionally this fracture is found to exist without
sensible displacement. In such cases the diagnosis is sometimes diffi-
20



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298 FRACTURES OF THE ULNA.

cult, and can only be determined by the crepitus and mobility. IP
however, the ulna is firmly seized above and below the point which
has suflFered contusion, and pressed in opposite directions, these signs
will generally be sufficiently manifest, and will render the diagnosis
certain.

But in cases where there is considerable displacement, the inner
surface of the bone is so superficial as to enable us to detect its devia-
tions with the eye alone, or, when swelling has already occurred, by
the fingers carried firmly and slowly along this margin.

If the head of the radius is dislocated also, the displacement of the
broken ends of the ulna must always be considerable, and the con-
sequent deformity palpable. I have known one instance, however,
in which a surgeon living in the neighboring Province of Upper
Canada recognized and reduced a dislocation of the radius and ulna
backwards, but did not detect a fracture of the ulna two inches above
its lower end. Six months after, in the month of March, 1856, the
patient called upon me with a marked deformity near the wrist, oc-
casioned by the backward projection of the broken ulna, and with a
complete loss of the power of supination. It will not surprise us that
this fracture was overlooked when we learn that the man had fallea
fifty -five feet.

Prognosis. — In simple fractures the prognosis is generally favorable,
since no overlapping can occur, and the lateral displacements are not
usually sufficient to produce a marked deformity, or to interfere
materially with the functions of the arm ; yet it is not unfrequent to
find the fragments inclining slightly forwards or backwards, inwards
or outwards. If the fragments fall toward the radius, I have noticed
in three or four instances a slight projection of the lower end or sty-
loid process of the ulna to the ulnar side; but not interfering in any
degree with the motions of the wrist-joint.

I have seen the radius left unreduced seven times after a fracture of
the ulna, and in each example the forearm was shortened. A boy, a&t.
17, was struck by a locomotive, and severely injured in various parts
of his body, June 5, 1855. I saw him with two very intelligent coun-
try practitioners, a few hours after the accident. The whole left arm
was then greatly swollen. Crepitus was distinct, and we easily recog-
nized the fracture of the ulna about three inches below its upper end,
with which an open wound was in direct communication. We sus-
pected, also, a dislocation of the head of the radius forwards, but as we
could not make ourselves certain, and finding that the arm was in
such a condition as to preclude any further manipulation without
greatly diminishing the chance of saving the limb, we made no attempt
at reduction, but laid the arm upon a pillow and directed cool water
lotions.

At no subsequent period, in the opinion of the medical gentleman
who was left in charge, did a favorable opportunity occur to reduce
the radius; and at the end of two months I found the ulna united,
with the fragments bent forwards and outwards toward the radius,
while the head of the radius lay in front of the humerus. The forearm



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SHAFT OF THE ULNA. 299

was shortened three-quarters of an inch. He could flex his arm freely
to a right angle and a little beyond ; and he could straighten it per-
fectly. Hand slightly pronated, with partial loss of supination. Whole
arm nearly as strong and as useful as before the accident.

The second case occurred in the person of a man aet. 26, residing



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 35 of 100)