Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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not enough to say that such rough manipulation is generally unneces-
sary, it is positively mischievous, provoking the muscles to more
violent contractions, increasing the displacement which. already exists,
and sometimes producing a complete separation of the impacted, den-
ticulated, transverse, or partial fractures, which can never afterwards
be wholly remedied ; augmenting the pain and inflammation, and not
unfrequently, I have no doubt, determining the occurrence of suppu-
ration, gangrene, and death.

In proceeding to establish the diagnosis in any case, the surgeon

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should sit down quietly and patiently by the sufferer, so as to inspire
in him from the first a confidence that he is not to be hurt, at least
unnecessarily. He ought then to inquire of him minutely as to all
the circumstances immediately relating to the accident, in order that
he may determine as nearly as possible its cause, which alone, to the
experienced surgeon, often aflfords presumptive, if not conclusive, evi-
dence as to the nature and precise point of the- injury. From this, he
should proceed to examine the disabled limb ; removing the clothes
with the utmost care by cutting them away rather than by pulling ;
and when completely exposed, he should notice with his eye its posi-
tion, its contour, the points of abrasion, discoloration, or of swelling ;
and not until he has exhausted all these sources of information, ought
the surgeon to resort to the harsher means of touch and manipulation.
Nor will his sensations guide him to the point of fracture by any other
method so accurately as when, the patient being composed and his
muscles at rest, he moves his fingers lightly along the surface of the
limb, pressing here and there a little more firmly, according as a trifling
indentation or elevation may lead him to suspect this or that to be the
point of fracture.

The limb, in case of a supposed fracture of a long bone, may now
be measured with a tape-line, and compared with the opposite limb,
having first marked with a soft pencil or with ink the several points
from which the measurements are to be made.

Finally, if any doubt remains, the limb must be firmly but steadily
held while the necessary manipulations are performed, for the purpose
of ascertaining the existence of mobility and of crepitus. Mobility is
most easily determined by giving to the limb a lateral motion, but, in
general, crepitus is most efiectually developed by gentle rotation. If
the place of fracture is already pretty well declared by the previous
examinations, the surgeon should place one finger over the suspected
point, during this manipulation, by which means the crepitus will be
more certainly recognized.

I do not often find it necessary to resort to anaesthetics for the pur-
pose of insuring quietude and annihilating pain in making these
examinations, since it is seldom that the patient need to be much dis-
turbed; but if the examination is not satisfactory, and the diagnosis
is important, I do not hesitate to render the patient completely insen-
sible, after which the questions in doubt may be more thoroughly
investigated and perhaps definitely settled.

The surgeon ought not to forget, however, that while the patient is
under the influence of an anaesthetic, violent manipulations are no less
liable to rupture bloodvessels, and to lacerate other tissues, than if
employed when the patient is conscious. Surgeons have not seemed
always to understand this, and the result has been that in too many
instances they have inflicted serious and irreparable injury ; in one
instance which came under my notice, the injury thus inflicted caused
tetanus and death.

It is scarcely necessary to say that the earlier the examination is
entered upon, the more readily will the diagnosis be made out ; and
i^ unfortunately, some time has already elapsed before the patient is

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seen by the surgeon, and much swelling has taken place, the exami-
nation is still not to be omitted, and whatever doubts remain we must
endeavor to remove by repeated examinations made, from day to day,
until the subsidence of the tumefaction has brought the surfaces of the
bone again within the reach of our observation.



It is not my intention to enter very fully into a consideration of the
process of repair in fractures, preferring to leave this subject where it
more properly belongs, to the general treatises on surgical pathology.

I only propose to state very briefly a few practical, and I trust I
may now say, pretty well established facts, such as the manner or
position in which this reparative material, whenever it is employed,
is applied to the broken bones, the length of time which is usually .
required for the completion of the process of repair, and the causes
which may impede or prevent bony union.

If I think it necessary to say anything more upon this subject, it
will be simply to announce my belief that the reparative material,
consisting originally of a plastic lymph, is poured put from the vessels
of the Haversian canalsf, the medullary tissue, the periosteum, the
broken ends of the bone, and more or less from all of the lacerated
tissues which are immediately adjacent to the seat of fracture ; that
after a period, longer or shorter, this lymph becomes organized, and
begins to receive from the same sources particles of oony matter,
through which the consolidation is finally effected ; that the transition
from the original plastic material to bone is in adults almost con-
stantly through the interposition of connective tissue, rarely, unless in
the case of children, through a cartilaginous tissue, and sometimes
through both consentaneously or consecutively ; that, perhaps, in a
few fortunate examples bones unite directly or immediately, without
the intervention of a reparative material ; and finally, that granula-
tion tissue sometimes becomes transformed into bone, in certain cases
of compound fractures, or of fractures in which the process of inflam-
mation exceeds certain limits.

Dupuytren, enlarging upon the doctrines taught by Galen, Duhamel,
Camper, and Haller, declared that "nature never accomplishes the
immediate union of a fracture save by the formation of two successive
deposits of callus;" one of which is aerived from the periosteum and
from the adjacent tissues, and from the medulla; while the other, de-
rived, perhaps, from the broken extremities of the bone itself, is found
at a later period directly interposed between these surfaces. The
material or callus derived from the tissues outside of the bone, and
which Galen compared to a ferule, but which Mr. Paget calls " eu-

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Breathing," together with the material derived from the medulla, com-
pai;^ often to a plug, and -by Mr. Paget named " interior" callus, are
by l)upuytren spoken of as the "provisional/' or temporary callus,
by which the fragments are supported, and maintained in contact
until the permanent callus is formed. This temporary splint is com-
pleted, or has arrived at the condition of bone in a spongy form, at
periods varying from twenty to sixty days ; but it does not assume
the character of compact bone until a period varying from fifty days
to six months has elapsed ; after which it is gradually removed by
absorption. The second process, by which the ends of the bone are
definitively or permanently united, commences when the provisional
callus has arrived at the stage of spongy bones, and is not completed
usually within less than eight, ten, or twelve months, " when," says
Dupuytren, "it acquires a solidity greater than the original bone."

While it is certain that this eminent surgeon and most accurate
observer has described faithfully the various phenomena which usually
accompany the repair of bones in those animals which were the
subjects of his experiments, and that his conclusions have a certain
degree of application to the human species, it is equally certain that
he erred in assuming that in man simple fractures always unite by
this double process ; yet, such is the power of authority, these doctrines
were accepted from the first without hesitation or debate, and for
nearly half a century they have occupied the minds of surgeons, to
the almost complete exclusion of every other theory. Mr. Stanley
was among the first to question the solidity of the doctrines of Dupuy-
tren, but it remained for Mr. Paget to fully expose their many falla-
cies ; nor has Malgaigne, although not strictly a disciple of Paget,
failed to detect certain of these errors.

I should also do injustice to myself were I not to mention that at
the very moment when Mr. Paget was making his observations upon
the specimens in " the large collection of fractures in the museum of
the University College," I was myself employed in similar researches
both among cabinet specimens and in the hospitals of this country and
of Europe ; and that the conclusions to which I had arrived were
nearly identical with, although the inferences were far from being so
complete in their detail as those to which this distinguished patholo-
gist was himself brought.' I do not, however, wish to make Mr. Paget
responsible for any of the opinions upon this subject which I shall
hereafter express, except so far as they may be found to agree with
his own published views.'

I think it may now be fairly stated that the repair of bones by the
double process described by Dupuytren is, in man, only an exception
to a very general rule ; and that fractures may unite by either one of
the following modes : —

First. Immediately, or in the same manner that the soft tissues
sometimes unite, by the direct reunion of the broken surfaces, and
without the interposition of any reparative material. This happens

» Paper on " Provisional Callus," by Frank H. Hamilton. Buffalo Medical Jour-
nal, Feb. 1853.
« Lectures on Surgical Pathology, by James Paget, Pliil. ed., 1854, Chapter XI.

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probably sometimes in the spongy bones, and in the extremities or
spongy portions of the long bones, especially when one portion of bone
is driven into another and becomes impacted ; as in certain fractures
of the neck of the humerus or of the femur.

Second. By interposition of a reparative material between the broken
ends; as when the fragments remain in exact apposition, but imme-
diate union fails. This is especially apt to occur in superficial bones,
such as the tibia ; or upon those siaes of the bone which are most
superficial. It is not an unusual circumstance to find the shaft of the
tibia during the process of union presenting no exterior callus upon
its anterior and inner surface, whilst the posterior and outer section of
its circumference is covered with an abundant deposit. In other cases,
however, of fractures of the shaft as well as of the epiphyses, the
intermediate callus secures a prompt union, but no ensheathing callus
is ever formed.

Third. Bones broken and not separated, unite occasionally by the
process described by Dupuytren, namely, by the formation, first, of an
ensheathing callus, whilst at the same moment the cylindrical cavity
becomes closed by a spongy plug or a compact septum of bone ; and
second, by definitive callus deposited between the broken ends. It is
probable that this happens generally in children, and it is a common
mode of union in the ribs, which bones, during the whole progress of
the union, are necessarily kept in motion. My cabinet furnishes many
illustrations of ensheathing callus in ribs ; and also a few in fractures
of the tibia and fibula.

Fourth. Under similar circumstances, where no displacement exists,
the fracture may unite by ensheathing and interior callus alone, no in-
termediate callus ever being formed between the broken ends; in which
case it may bo properly said that the bone itself has never united, and
the ensheathing callus, instead of being provisional, is permanent or
definitive. This was essentially the doctrine of Galen, Haller, and
Duhamel before Pupuytren added his " fifth period," or the formation
of definitive callus ; and by these older surgeons it was held to be of
universal application, except perhaps in the case of children. To this
doctrine also Malgaigne has returned — at least to the question " Is
there always a definitive callus, or complete union of the fragments ?"
he has made this laconic reply : " Galen admitted its occurrence, but
only in young subjects ; it has been obtained in animals, where there
had been no displacement. I would willingly believe that such is
sometimes the case in human adults ; but I must confess I have seen
only the instance above cited, which might just as well be used to
prove the compact ossification of the provisional callus." He accepts,
therefore, the doctrine of Galen as having not merely an occasional
application, but as explaining the process of union in the large ma-
jority of cases ; and in support of this extreme view he finds that the
exterior callus, which Dupuytren called provisional or temporary, is
actually permanent, unless removed by the absorption consequent
upon pressure.

To all of which we can only say that an examination of five or six
specimens in our own cabinet, after having carefully divided them

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with a saw, has furnished only one illustration of union by ensheathing
and interior callus alone. In each of the other specimens the union
was completed by definitive or intermediate callus. We cannot,
therefore, avoid the conclusion that Malgaigne has been deceived as
to the relative frequency of these different modes of union, and that
union without intermediate callus is exceptional.

Fifth. When bones are broken and overlap, they may unite by the
interposition of a callus between the opposing surfaces, that is, by an
intermediate callus, but which will differ from that described as the
second method, inasmuch as the new material will be deposited upon
the sides of the fragments and not upon their extremities. The limb
being kept perfectly at rest, and all other circumstances proving
favorable, this union may take place without any excess or irregularity
in the deposit. The surfaces will unite firmly where they are in actual
contact, and smooth and well-formed buttresses will fill up all the
spaces between the bones where they are not in actual contact, suffi-
cient generally to give the requisite strength to this new bond of

Fig. 8. Fig. 4.

Fnetnre of the thigh of a torkey ; united with the frag-
aent« widelj eeparated. From a specimen in the author's

union. This mode of union will be
completed sometimes when the two
ends of the bones are separated later-
ally an inch or more from each other.
I have in my collection the bone of a
turkey's thigh (Fig. 3) thus united by
a transverse bony shaft, although sepa-
rated more than one inch ; and what is
less common, I possess also a specimen
of the adult human thigh (Fig. 4), in
which an oblique shaft of solid callus
bas, afler many months, and while no
splints were employed, bound together
firmly the two opposite extremities of
the broken bone.

Sixth. The fragments being overlap-
ped more or less, and suffering unusual
disturbance, or the adjacent tissues
haying been much torn, or much blood
being effused, so that considerable in- ^uu«n«KHnn-.aii„. Pm™ - .no.i.n«„

n , . 11 /vi ▼ith an obliqne callus. From a specimen

nammation is caused, the amount of cal- in the amhor's cabinet,
lus will exceed what is necessary for

Fractare of the shaft of the femnr ; nnlied

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the complete nnion of the bones ; and this redundancy may be de-
posited around and upon the broken ends of the bones, or anywhere
in their immediate vicinity, in layers, or in masses of irregular shape
and size. Even the bones which are not broken, but which are near,
as in the case of the fibula after a fracture of the tibia, may become
inflamed, or their coverings may inflame, and they may also con-
tribute to the general mass of bony callus.

Compound fractures, or rather, we ought to say, fractures accom-
panied with granulations and suppuration, obey no uniform law of
repair so far as the manner and position of the deposit are concerned ;
but they come together finally with more or less irregular distributions
of ossified matter, according to the varying circumstances of imperfect
coaptation, mobility, &c., in which they may chance to be • placed.
Occasionally the amount of callus is less than occurs in simple frac-
tures, and at other times the excess is very great.

That was, no doubt^ a beautiful thought, which ascribed the forma-
tion of provisional callus to an intelligent efficient cause, which in
this manner sought to support the fragments until a reunion of their
divided ends was accomplished. But the beauty of a conception
supplies no evidence of its truth ; and we have grave doubts whether
Nature ever allows any interference with her laws even in an exigency,
unless by the substitution of a miracle. Provisional callus is, in our
opinion, just as much the necessary result of natural laws, as is defini-
tive. It is formed because in that condition of the parts and of the
general life its formation was inevitable. Whether useful for the

furposes of repair or not, it will, under certain circumstances, exist;
n the repair of certain fractures, provisional callus, it is conceded,
seldom occurs. Thus it is with the cranium, the acromion, coracoid
and olecranon processes, the patella, and with all those portions of
bones which are immediately invested with a synovial capsule. Will
it be affirmed that in the examples just named this callus is not formed
because it is not required 7 To us it seems that nowhere could it
prove more useful, since, with the single exception of the cranium, it
IS in these very cases that the obstacles to a reunion are the most
serious. In fractures of the patella, olecranon, &c., the action of the
muscles tends constantly and powerfully to displace the fragments, and
gladly would the surgeon avail himself of the assistance of a tem-
porary callus, but it is rarely present, at least in any useful degree. So
also in fractures of the neck of the femur within thd capsule, and in
other similar cases, we cannot say that temporary callus would not be
advantageous in facilitating the retention of the fragments, yet the
"intelligent efficient agent" neglects to furnish it.

The only satisfactory reason which, as we think, can be assigned for
the absence of callus in these cases, is found in the doctrines we now
advocate ; that is to say, it is usually absent because that amount of
excitement and irritation is usually absent which alone determines its
formation. In the case of the olecranon, patella, &c., the fragments
being separated from each other by muscular action, so that no painful
pinchings or chafings occur, and their rough surfaces or sharp points
Deing rather drawn away from, than protruded into the flesh, no

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sufficient provocation exists for the production of inflammation and
effasion. Hence the failure of provisional callus; but wherever the
fracture occurs, and however moderate the action, definite callus does
not fiEkil ; still the broken surfaces of the patella and olecranon are
softened, and smoothed, and covered over with a new matter, which,
if contact could have been secured and preserved, would certainly
have served to consolidate and repair the breach. The natural re-
parative process proceeds, but only the accidental process is omitted.
This latter, however, is seen again even here, when from other and
unusual causes a sur-excitement is established.

Temporary callus is not formed upon bones invested with synovial
membranes^ because here, too, as in the neck of the femur, there are
not so many structures lacerated and irritated, and the supply of this
effusion must be the less not only in proportion to the less intensity
of the inflammation, but also to the less amount of structures impli-

Possibly other and more satisfactory reasons may be assigned why
provisional callus is not formed usually when the neck of the femur
is broken within the capsule ; but we certainly can never admit the
common, and, as here ap{)lied, the too palpably absurd explanation,
that it is not wanted. It is wanted, and in no case so much as in the
one now supposed.

Provisional callus has, therefore, no final purpose, but it is the
nnavoidable result of certain abnormal conditions. It still occurs
everywhere when against and in the vicinity of the bone there is the
requisite lesion and action, and it will occur as certainly when there
is no fracture at all, but only a caries, a necrosis^ or a simple bony or
periosteal inflammation; and whilst it is doubtless true that in frac-
tures it sometimes renders valuable aid to the surgeon, it is equally
true that it often proves a source of hindrance.

From these remarks I choose to except fractures occurring in chil-
dren, in relation to which the observations are not yet sufficiently
numerous to determine absolutely the laws of repair. If, however, I
were to venture an opinion based upon a few examinations, I should
say that in children we mav accept with but little qualification the
doctrine of Dupuytren as already explained.

Dupuytren, in determining the limits of his " third" period, or of
that in which a provisional callus is formed of sufficient strength to
support the fragments, has given what has been usually quoted as the
natural period within which bones may be said to be united, that is,
"from the twentieth or twenty-fifth day, to the thirtieth, fortieth, or
sixtieth." But this depends so much upon the age of the patient, his
general condition of health, the condition and position of the broken
ends, as well as .upon the bone itself, and the point at which it is
broken, with many other circumstances, that it would be unsafe to
establish any absolute laws in reference to this point.

In very early infancy, union is accomplished in half the time re-
quired in adult life, and it is generally thought to be still more re-
tarded in advanced age, but Malgaigne has not found this latter
observation confirmed by his own experience. Various constitutional

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causes, as we shall hereafter explaia more fully, retard bony union.
Motion, also, sometimes delays consolidation: fragments which are
overlapped do not unite as speedily as those which are placed end to
end, and other complications interfere in a similar manner, such as
lesions of nerves, of bloodvessels, comminution of the bone, the inter-
position between the ends of the fragments of a blood-clot, a portion
of muscular, tendinous, or other tissue, &c. In general the bones of
the lower extremities, independently of their size, unite more slowly
than the bones of the upper extremities.

Epiphyses, when separated, unite by the same process as fractures
of the bone. It is affirmed, however, that, when certain epiphyses
unite with much displacement, the shafts from which they have been
separated cease to grow, and the limbs become atrophied.

For a more complete consideration of the causes which retard the
union of bones, I beg to refer the reader to the chapter on " Delayed
Union, and Non-Union of Bones."



All that has been said in relation to the propriety of handling a
broken limb gently when the surgeon is examining the position and
character of the fracture, is equally applicable to the lifting and trans-
porting of the patient to his bed, to the removal of the clothing, and
to the general management of the limb before it is dressed. Bude or
awkward manipulations, by which needless pain is inflicted, are not
simply acts of wanton cruelty, but they are sources, and I think I
may say frequent sources, of inflammation, suppuration, and gangrene.
Here, as in all the subsequent handlings, everything should be done
slowly, thoughtfully, and systematically. Yet it is difficult to state
the precise manner in which the surgeon ought to proceed. Much
will depend upon the circumstances of the case, something upon one's
natural tact, and upon the amount of experience, but more, I think,

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 4 of 100)