Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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losis after a simple fracture, when the case has been properly treat^,
whether by the nexed or straight position ; while, if the limb is flexed,
a maiming, as a result of the great length of the intermediate liga-
ment, is almost inevitable.

Yet if, in any case, from the great severity and complications of the
injury, especially in certain examples of compound and comminuted
fracture, it were to be reasonably anticipated that permanent bony
anchylosis must result, or even where the probabilities were strongly
that way, the surgeon might be justified in selecting for the limb, at
once, the position of semi-flexion ; or he might leave the arm without
a splint, and at liberty to draw up spontaneously and gradually to this
position, as it is always very prone to do.

In favor of moderate, but not complete extension, it is claimed that
it is less fatiguing than the latter position, while it accomplishes a
more exact apposition of the fragments, if they happen to be brought
actually into contact.

I am unable, however, to understand how the apposition can be
rendered less exact by complete extension, unless by this is meant a
degree of extension beyond that which is natural, and which, I am
well aware, is permitted to the elbow-joint when this posterior brace
is broken off. It would certainly derange the fragments to place the
arm in this extreme condition of extension — that is, in a condition of
extension approaching dorsal flexion, which is beyond what is natural.
Indeed, perhaps we may admit that, in order to perfect apposition,
the extension ought to be less by one or two degrees than what is

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natural, sufficient to compensate for the trifling amount of effusion
which may be presumed to have occurred in the olecranon fossa, and
w^hich would prevent the process from sinking again fairly into its

As to its being less fatiguing, it is well known to those accustomed
to treat fractures of the thigh by permanent extension that the muscles
rapidly acquire a tolerance, which soon dissipates all feeling of fatigue,
and that, after a few hours, or days at most, the patients express them-
selves as being more comfortable in this position than in the flexed.

Finally, the advocates of complete, natural extension claim that in
this position alone is the triceps most perfectly relaxed, and conse-
quently the most important indication, namely, the descent of the ole-
cranon, most fully accomplished. In this opinion we also concur; and
regarding all other considerations, in the early days of the treatment,
as secondary to this one, lye unhesitatingly declare our preference for
what has been called the ** position of complete extension," as opposed
to flexion, semi-flexion, or extreme extension.

It only remains for us to determine by what means the limb can be
best maintained in the extended position, and the olecranon process
most easily and effectually secured in place.

For this purpose a variety of ingenious plans have been devised :

Fig. 103.

Sir Aatlej Cooper's method.

such as the compress and " figure-of-8" bandage of Duverney, without
splints; or a similar bandage employed by Desaalt, with the addition
of a long splint in front ; the circular and transverse bandages of Sir
Astley Cooper, with lateral tapes to draw them together, to which
also a splint was added ; and many other modes not varying essentially
from those already described, but nearly all of which are liable to one
serious objection, namely, that if they are applied with sufficient firm-
ness to hold upon the fragment, and Boyer says they " ought to be
drawn very tight," they ligate the limb so completely as to interrupt
its circulation, and expose the limb greatly to the hazards of swelling,
ulceration, and even gangrene. How else is it possible to make the
bandage effective upon a small fragment of bone, scarcely larger than
the tendon which envelops its upper end, and with no salient points
against which the compress or the roller can make advantageous
pressure? If, then, these accidents — swelling, ulceration, and gan-
grene — are not of frequent occurrence, it is only because the bandage
has not been generally applied " very tight," and while it has done
no harm, it has as plainly done no good.

The dangers to which I allude may be easily avoided, without re-
lazing the security afforded by the compress and bandage, by a

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method which is very simple, and the value of which I have already
sufficiently d.etermined by my own practice.

The surgeon will prepare, extemporaneously always, for no single
pattern will fit two arms, a splint, from a long and sound wooden
shingle, or from any piece of thin, light board. This must be long
enough to reach from near the wrist-joint to within three or four
inches of the shoulder, and of a width equal to the widest part of the
limb. Its width must be uniform throughout, except that, at a point
corresponding to a point three inches, or thereabouts, below the top
of the olecranon process, there shall be a notch on each side, or a
slight narrowing of the splint. One surface of the splint is now to be

Fig. 104.

The anthor'a method.

thickly padded with hair or cotton-batting, so as to fit all of the in-
equalities of the arm, forearm, and elbow, and the whole covered
neatly with a piece of cotton cloth, stitched together upon the back
of the splint. Thus prepared, it is to be laid upon the palmar surface
of the limb, and a roller is to be applied, commencing at the hand
and covering the splint, by successive circular turns, until the notch
is reached, from which point the roller is to pass upwards and back-
wards behind the olecranon process and down again to the same
point on the opposite side of the splint ; after making a second oblique
turn above the olecranon, to render it more secure, the roller may
begin gradually t6 descend, each turn being less oblique, and passing
through the same notch, until the whole of the back of the elbow-
joint is covered. This completes the adjustment of the fragments,
and it only remains to carry the roller again upwards, by circular
turns, until the whole arm is covered as high as the top of the splint.

The advantage of this mode of dressing must be apparent. It
leaves, on each side of the splint, a space upon which neither the
splint nor bandage can make pressure, and the circulation of the limb
is, therefore, unembarrassed, while it is equally eflFective in retaining
the olecranon in place, and much less liable to become disarranged.

Before the bandage is applied about the elbow-joint, the olecranon
must be drawn down, as well as it can be, by pressure with the
fingers, and a compress of folded linen, wetted to prevent its sliding,
must be placed partly above and partly upon the process; at the same
time, also, care must be taken that the skin is not folded in between
the fragments.

This dressing ought, no doubt, to be applied immediately, since, if
we wait, as Boyer seems to advise, until the swelling has subsided, it

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will be found much more diflScult to straighten the arm completely
than it would have been at first, and the olecranon process will be more
drawn up and fixed in its abnormal position. Something will be
gained by these means, adopted early, even if the bandage cannot be
applied tightly, and moderate bandaging will not in any way interfere
with the proper and successful treatment of the inflammation. We
must alwaj's keep in mind, however, the fact that the fracture being
usually the result of a direct blow, considerable inflammation and
swelling around the joint are about to follow rapidly ; and on each suc-
cessive day, or oftener if necessary, the bandages must be examined
carefully, and promptly loosened whenever it seems to be necessary.
For this purpose it is better not to unroll the bandages, but to cut
them with a pair of scissors, along the face of the splint, cutting only
a small portion at a time, and as they draw back, stitch them together
again lightly ; and thus proceed until the whole has been rendered
sufficiently loose.

As soon as the inflammation has subsided, and as early sometimes
as the fifth or seventh day, the dressings ought to be removed com-
pletely; and while the fingers of the surgeon, resting upon the compress,
sustain the process, the elbow ought to be gently and slightly flexed
and extended two or three times. From this time forward, until the
union is consummated, this practice should be continued daily, only
increasing the flexion each time, as the inflammation and pain may
permit. If it is thought best, at length, to change the angle of the
arm, and to flex it more and more, it may be done easily by substi-
tuting a very thick sheet of gutta percha for the board.

Diefienbach has several times, in old fractures of both the olecranon
and patella, where the fragments were dragged far apart, divided the
tendons, so as to be able to bring the two portions together, and, by
friction of them one upon the other, has endeavored to excite such
action as might end in the formation of a shorter and a firmer bond of
union. In some instances, it is said, considerable benefit was obtained,
after all other means had failed; in others, the result was negative.
One example of an old ununited fracture of the olecranon is mentioned,
in which he divided the tendon of the triceps, secured the upper frag-
ment in place, and every fourteen days rubbed it well against the
lower one; in three months " the union was firm."^

The practice, not without its hazards, needs further observations to
determine its value.

Recently a gentleman called upon me with his son, aged seven years,
who had an unreduced dislocation of the radius and ulna backwards
of nine weeks' standing. While reducing this dislocation, it being
necessary to flex the arm forcibly, the epiphysis constituting the
olecranon process gave way, and became separated from one-half to
three-quarters of an inch. This is the only example of separation of
this epiphysis which has come to my knowledge. I have, however,
twice since broken the olecranon in attempts to reduce old dislocations

I Dieffenbach, American Journal of Medical Science, vol. zxix. p. 478 ; from
Casper's Wochenschrlft, Oct. 2, 1841.

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of the radius and ulna backwards, and I have not regretted the occur-
rence, since it enabled me to reduce the dislocations without catting
the triceps.



Cauaea. — In a large majority of the examples of this fracture seen
by me, which have been of such a character as to warrant an attempt
to save the limb, the accident has been occasioned by a fall upon the
palm of the hand while the arm was extended in front of the body.
Yet this cause is not so constant as in fractures of the radius alone,
since a considerable number have been occasioned by direct blows ;
and if we were to add to this estimate all of those bad compound frac-
tures which have demanded immediate amputation, the proportion of
fractures occasioned by direct and indirect blows might be found to
be pretty nearly balanced.

Point of Fracture, Character, Direction of Displacement^ Jee. — In a
record of sixty fractures of both bones, not including gunshot frac-
tures, or those demanding immediate amputation, I have found six
brolcen in the upper third, twenty-four in the middle third, and thirty
in the lower thira.

Fig. 105.

Fraetaro in the niddl* third.

In one case the radius was broken three-quarters of an inch above
its lower end, and the ulna about one inch below the coronoid process.
Four of the fractures belonging to the lower third were probably
epiphyseal separations.

Forty-six were simple, eight compound, one was comminuted, three
both compound and comminuted, one complicated with a fracture of
the humerus, and one with a partial luxation of the lower end of tbe
radius. With three exceptions, all of these more serious accidents
were arranged among fractures of the lower third, and generally the
bones had been broken near the wrist.

Partial fractures have been frequently observed, but having treated
of these accidents fully in the general chapter on Incomplete Frac-
tures, I shall not think it necessary to make any further allusion to
them in this place.

Prognosis. — Generally these bones unite in from twenty to thirty
days ; but I have seen the union occasionally delayed considerably

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beyond this time, and this delay has occurred especially F»g- 106.
in the case of the radius. Thus, in three cases of com-
pound and comminuted fracture, the ulna uuited within
four or five weeks, while the radius did not unite until
the ninth or tenth week. Twice in simple fractures the
ulna has united in the usual time, but the radius not
until the sixteenth week. Once the ulna has united
promptly and the radius remained ununited at the end
of two years, at which time I practised resection of the
broken ends of the radius, and nniou was speedily es-

On the other hand, I have once seen the union de-
layed four months in the case of the ulna, when the
radiuis had united in the usual time; and in one ex-
ample of compound fracture both bones refused to
unite until after the fifth mouth.

Thirty-three of the whole number have united with-
out any appreciable deformity, and fifteen are known
to have left some marked defect, while two have re-
sulted finally in the loss of the arm. Of the remainder
I cannot speak positively.
I have seen the frairments deviate slightly in almost , Fracture jn the

T . 1 ° fl. .1 i®*'.ii lower third.

every direction, but most often it has been noticed that
the deviation was to the radial or ulnar sides. Thus, in three examples,
two of which had been, compound fractures, the bones have united
in such a position as that from the point of fracture downwards the
forearm has been deflected to the ulnar side, and a
marked projection has been left at the seat of fracture Fig. 107.

on the radial side; while in two examples, both of
which were simple fractures, exactly the opposite con-
dition has obtained, the lower part of the forearm
being deflected to the radial side.

In a majority of cases the hand has been left with
8ome tendency to pronation; in many instances this
tendency was very slight and scarcely appreciable,
but in others it has been quite marked, so that the
patients have been wholly unable to supine the fore-
arm except by a motion of the humerus in its socket.

From what has been said it must be seen that the
prognosis in these accidents takes the widest range :
for while a larger proportion than in the case of almost
any other of the long bones, unite without any appre-
ciable deformity, a considerable number delay to
unite or do not unite at all, and some, even where the
fracture is most simple, result in the complete loss of
the limb. I am not now speaking of those more severe
accidents in which the limb is at once condemned to
amputation, and which, in the case of the arm, are
numerous; but, as I have already mentioned, our unioa with eiight
observations here apply only to cases which came latwaidiapiacement.
under treatment with a view especially to the fracture.

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I shall State the facts more fullj, and then perhaps we shall think
it proper to inquire why, when, as a rule, the treatment is found to be
so simple and successful, occasionally, and pretty often indeed, it re-
sults so disastrously.

A boy, aged about ten years, fell from a tree, April 22, 1856, frac-
turing the right forearm near the lower end of the middle third. It
was evident that he had fallen upon the palm of his hand, as the lower
fragments were inclined backwards, and one of the bones had been
thrust through the skin on the front of the arm.

It was at first dressed carefully by Dr. Wilcox, but the father of the
lad on the following day placed him under the care of an empiric.

Six days after the fracture occurred, I was called to see him, with
several other gentlemen. He was then suffering under a severe attack
of tetanus which had commenced the night before. His arm was much
swollen and very painful. He died the same evening.

I was unable to learn very particularly what had been the treat-
ment since the patient was seen by Dr. Wilcox, except that the band-
ages had been most of the time very tight, and that the empiric had
applied stimulating liniments, the boy constantly complaining greatly
of the pain. I found the arm done up in a most slovenly manner with
several narrow splints, underlaid with loose and knotty fragments of

We removed all of these immediately, and laid the arm upon a
cushion supported by a board, to both of which the arm was lightly
secured by a few turns of a bandage ; cool water lotions were dili-
gently applied, and chloroform administered by inhalation ; but the
fatal event was delayed only a few hours.

I shall not stop to inquire the cause of a result so unfortunate, where
the treatment has been so palpably unskilful.

I have already mentioned one case of gangrene of the hand, after
a fracture of the lower part of the humerus; Norris, in a note to the
American edition of LiaiorCs Surgery^ mentions a case which came
under his observation in the Pennsylvania Hospital, the fracture hav-
ing taken place just above the condyles, and still another has been
related to me lately. I have brought together also no less than six
cases of sloughing of the arm, after fracture of the radius, and one of
sloughing from tight bandaging, where the radius was supposed to be
broken, although the dissection proved that it was not.

Bobert Smith says that similar cases have been recorded in the
Gazette Medicale. To these I shall now add five examples of sloughing
after fracture of both radius and ulna; making a total of fifteen cases
in the upper extremities, in addition to those reported in the Gazette
Medicale, an exact account of which I have not seen.

John McGrath, eat. 9, fell, July 2, 1847, from a ladder, about thirty
feet to the ground, breaking the right radius and ulna in their middle
thirds. A surgeon was in attendance about four or five hours after
the accident occurred. He then reduced the fractures and applied two
broad splints, one on the palmar and one on the dorsal surface of the
forearm. Whether a roller was first applied to the arm or not, I am

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unable to say. The splints were secured in place by a roller and the
arm laid in a sling.

The third day was our national holiday, and the patient was not
visited. 'Nor was he seen on the fourth day, not being found at home.
On the fifth day the surgeon removed the bandages and found the arm
gangrenous; and within an hour afterwards I was requested to see it

I found him lying in a miserable apartment, with his right arm
resting upon a pillow. The arm, forearm, and hand were gangrenous
through their whole extent; and the skin of the right side, on the
front of the chest, had assumed a dusky color, the extreme margin of
which was indicated by an abrupt orescentic line. The thumb and
fingers were black. His countenance was bright and cheerful, and
bis mind intelligent; pulse 75, and soft; tongue clean. He had slept
undisturbed the night before, and he had all along felt perfectly well,
except that he had a slight diarrhoea. I was assured by the surgeon,
and by all of the family, that the bandages had not been applied
tightly ; but we were told that on the third day of the accident, having
been locked into the house by his mother, who was a peddler, he
climbed out of the window, and that during all of that and most of
the following day he was running about the streets firing crackers,
during most of which time his arm was removed from his sling and
hanging by his side. On the morning of the fourth day his mother
noticed that his fingers were black, but she thought they were stained
with powder.

We ordered him to take one-quarter of a grain of opium every
four hours, and applied a yeast poultice to the arm. On the seventh
day the gangrene was still extending, and the pulse was 124; yet he
continued to feel well and to eat as usual. On the tenth day the line
of demarcation had commenced opposite the shoulder-joint; and the
orescentic discoloration on the breast, which had at first spread rapidly
until it covered nearly the whole upper half of the chest, was quite
faint, in some parts almost lost.

In a few days more he was removed to the county almshouse, the
separation continuing rapidly to take place until the arm fell off at
the shoulder-joint; after whioh he made a good recovery.

A child, two years and three months old, had fallen from a chair
upon the floor, a distance of about two feet. A German physician
being called, found, as he believes, a fracture of both bones of the left
arm. The fracture was near the middle. He immediately applied a
roller from the fingers to the elbow, and over this three narrow splints
made of the wood of a cigar-box. One of these was laid upon the
palmar, one upon the dorsal, and one upon the radial side of the fore-
arm, and the whole were bound together by another roller. From
this time until the tenth day the child continued to play about on the
floor. Ten days after the accident occurred the doctor noticed that
the ulnar side of the little finger was blue. The bandages were im-
mediately removed, and were never again applied tightly.

Three or four days after, I was requested to see the arm with the
attending physician. The gangrene had continued to extend, involving

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now the whole of the little finger and most of the thamb. There were
also gangrenous spots over the hand and forearm, extending to within
one inch from the elbow -joint; these spots were more numerous in
front and on the back of the forearm, and seemed to correspond to
the pressure of the splints. The hand was much swollen, and also
the arm above the line of the gangrene. The sloughs had already
commenced to be thrown ofi; and the gangrene was only extending in
a few points. The child appeared well and rather playful, except when
the arm was being dressed.

I ordered a yeast poultice, and a nourishing diet.

I have since learned that the arm and a large portion of the hand
were finally saved.

About the year 1865, as near as I can remember, a lad aged about
nine years was brought to the Long Island College Hospital Dis-
pensary, with a fracture of the radius and ulna. It was dressed by
the visiting surgeon with splints and bandages. He did not return
to the Dispensary as directed to do, and on the third or fourth day
portions of the arm and hand were found in a gangrenous condition.

Alice Thompson, »t. 50, was admitted into my service at Bellevue^
March 16, 1870, with a compound fracture in the lower third of the
forearm, caused by a fall upon the hand two or three days before
admission. The hand and forearm were gangrenous. She said it was
dressed at the Dispensary, immediately after the receipt of the injury,
with splints and bandages. This woman died about the seventh day
after admission, from a sudden hemorrhage induced by the sloughing.

In March, 1867, 1 was consulted by the parents of D. C, of Catta-
raugus Co., N. Y., on account of a serious distortion of the hand and
forearm, caused by sloughing, splints and bandages having been
applied by her surgeon for a supposed fracture ; but when examined
by me about ten weeks after the accident, there was no evidence that
the bones had ever been broken. She complained to her surgeon that
the bandages were too tight, but he thought otherwise, and they were
not removed until the third day, when the gangrene had already
occurred. The child was five years old at the time of the accident.

South also says that he has seen one or two instances of mortifica-
tion produced by splints applied too tightly, and previous to the acces-
sion of the swelling after fracture, and which have not been loosened
as the swelling increased.'

How shall we explain the frequency of these accidents after fracture,
especially of the forearm ?

Malgaigne, speaking of fractures of both bones of the forearm, re-

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 38 of 100)