Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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drawn by the action of the extensor carpi radialis longior muscle.
By pressure alone it could be replaced, but it was much more easily
reduced when the hand was forcibly carried backwards on the fore-
arm. I therefore secured the hand in this position with appropriate
splints, and it was maintained in this posture during most of the sub-
sequent treatment. Union finally took place, but not without some
backward displacement. Four ngionths after the accident occurred, on
the 31st of December, 1858, 1 examined the hand, and found the skin
healed over completely, the end of the fragment having become
rounded and smooth, so as not to give him any degree of annoyance.
His wrist was as flexible and as strong as before. No doubt the pro-
jection of the fragment might have been prevented entirely by cutting
at the point of its attachment the tendon of the extensor muscle, but
this would have sensibly weakened the wrist-joint, and I preferred the
alternative of a projection of the fragment.

Treatment. — With moderate extension made upon the finger cor-
responding to the broken bone, while the fragments are forced home
by firm pressure, the bone may generally be brought at once into line.




and we may now proceed to adapt a gutta-percha, felt, or thick paste-
board splint, to either the whole surface of the back or palm of the
hand and fingers, while they are held in a position of easy flexion.
It is not very material to which of these surfaces the splint is applied;
or rather, I may say, it ought to be applied to the one or the other
according as circumstances seem to indicate. It should be well pad-
ded, and especially at certain points, in order to the more effectual
support of the fragments. It is then to be secured in place with
several turns of a roller. When either of the metacarpal bones, ex-
cept those of the great or ring finger, is broken, the splint must be
wide enough to secure the sides of the hand against the pressure of
the roller.

Thus dressed, the hand may be laid in a sling beside the chest, or
while sitting it may rest upon a table.

The apparel must be examined daily, and readjusted as often as it
shall become disarranged, or as a doubt shall arise as to the condition
of the parts.

When the fracture is followed by much inflammation, or occurs
near, and especially if it actually involves a joint, the same precau-
tions must be adopted to prevent anchylosis as in the case of similar
fractures in other bones.



Development of ike Phalanges of the Hand, — The phalanges of the
hand are formed from two centres of ossification, namely, one for each
shaft and one for each proximal end. Ossification commences in the
shafts at about the sixth week ; in the epiphyses of the first phalanges
between the third and fourth years, and in the epiphyses of the two
last phalanges somewhat later. Complete bony union takes place
between the epiphyses and the shafts at from the eighteenth to the
twentieth year.

Clauses. — I do not remember to have seen a fracture of one of the
phalanges produced by a counter-stroke; I am aware, however, that
they are occasionally produced in this way, as by falling upon the
ends of the fingers, and especially by the stroke of a ball in the game
of base.

The fact, however, that they are generally the consequence of a
direct blow, and that the finger bones are small and only protected by
a thin covering of skin and tendons, renders them peculiarly liable to
comminution and to other serious complications. Thus, in a record
of thirty fractures, only eighteen were sufficiently simple to warrant
an attempt to save them ; and only five are recorded as simple frac-
tures without complications.

Point of Fracture and Direction of Displacement. — In the following

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case there was probably an epiphyseal disjunction. A lad four years
old was admitted to the Hospital of the Sisters of Charity, Dec. 24,
1849, with a simple fracture of the first phalanx of the ring finger of
the left hand ; the fracture being at the proximal end of the bone, and
at the junction of the epiphysis with the shaft.

The finger was so much swollen at first, that no dressings were
applied until the fifth day, at which time a gutta-percha splint was
moulded to it carefully. It resulted in a perfect cure.

I have never seen the fragments much overlapping, except in one
instance. Frequently there has been no perceptible displacement
whatever; but generally there will be found a slight displacement
in the direction of the diameter of the bone.

The case to which I refer as presenting an extraordinary overlapping,
was that of an Irish laboring woman, aged about thirty-five years,
who, having fallen down a flight of steps, broke the first phalanx of
the thumb below its middle. Dr. Congar was first called on the day
following the accident, but was unable to reduce the fracture, and on the
same day invited me to see the patient with him. The distal fragment
was displaced backwards, overlapping the proximal fragment a little
more than one-quarter of an inch. We made repeated efforts, by
pulling upon the thumb with a sliding noose, and with all the
strength of our four hands, but to no purpose. The fragments could
not be reduced for one moment ; and we left the patient as we had
found her, only somewhat the worse for our violent and repeated
extensions and manipulations. The finger was already considerably
swollen when we began our efforts, and we cannot therefore say what
might have been accomplished at an earlier moment, but I confess
that our defeat was unexpected, and does not seem to me to be satis-
factorily explained.

Besulia. — At least ten have left no appreciable lameness or deform-
ity, and possibly several more. It is therefore probably true that
these consequences may be avoided with proper care in one half of
the examples in which we attempt to save the finger ; and perhap>s it
will occasion surprise that a perfect result may not be claimed in a
larger proportion ; but when we consider how frequently the accident
is compound, and that even when it is not, the blow having generally
been received directly upon the point of fracture, how promptly
swelling ensues, it will be easily understood that it will be often found
diflScult to determine whether the bone is exactly in line or not> or to
maintain it in this position after absolute coaptation has been once

I have seen the finger in two or three cases deviate laterally, or
become permanently deflected to one side or the other ; and once I
have found it united, but rotated on its own axis. This latter case is
not without instruction.

A girl, 8Bt. 6, had her little finger caught by a door violently shut,
breaking one of the phalanges, and nearly severing the finger. I
closed the wound, and dressed the finger with a moulded pasteboard
splint. My dressings were repeated often, and applied carefully ; nor
did I detect the rotation which the lower fragment had made upon its

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own axis until the union was consummated. I then found the ex-
tremity of the finger turned so that its palmar surface presented
diagonally toward the ring finger.

If the surgeon believes that this ought to have been prevented, and
that the result evinces a lack of skill or of care, its record may still
serve one of the purposes for which it was designed, and secure to the
patient sometimes hereafter more faithful and assiduous attention.

Treatment. — Boyer, and afker him Bransby Cooper, have taught that
when the extreme phalanx is broken, from the small size of the bone,
and from its having attached to it the nail and its matrix, it is better
in all cases to amputate at once, as the process of reparation is in such
case extremely slow and uncertain.

Whether in any of the cases treated by myself, or which have been
seen by me, the fracture involved the last phalanx, I am not now able
to say, but my impression is that such cases have come under my
notice which have been successfully treated, and I cannot but regard
the rule established by these gentlemen as much too stringent. Ex-
amples must, no doubt, sometimes occur, in which the fracture is so
simple in its character as to render prompt reunion pretty certain;
and even though the restoration should prove tedious, this ought
scarcely to be regarded as a sufficient justification for so serious a
mutilation as these surgeons propose, since the loss of even an extreme
phalanx is not only a deformity, but must prove in many occupations
a troublesome maiming.

Prof. J. Lizars, of the Toronto school of medicine, C. W., has re-
ported to me a case exactly in point. " A man in the employ of the
Toronto Rolling Mills Company fractured the distal extremity of the
ring finger of the right hand. The fracture was transverse, and the
nail was severely bruised, the accident being caused by a direct blow.
Crepitus distinct. A dorsal splint and bandage were applied, and in
a short time the fragments were united firmly by bone. The nail
subsequently fell off) and a new one was formed."

The rule ought still to be held inviolate, which surgeons have so
oflen repeated in reference to injuries inflicted upon the h^nd and
fingers, namely, that we should save always as much as possible.

It is remarkable, too, how much nature, assisted by art, can do
toward the accomplishment of this purpose. If the bone of a finger
is not only severed completely, but also all of its soft coverings, save
only a narrow band of integument, are torn asunder, a chance remains
for its restoration. And it is especially interesting to observe what
recuperative powers are possessed by the articular surfaces of these
smaller joints, so that although they may be broken into, or sawn
through, or comminuted, and although small fragments be entirely
removed, a complete restoration of their functions is sometimes per-
mitted. I have seen and reported some such examples. It is true,
however, that such fortunate results are rare, and they are rather to
be hoped for than anticipated.

Since, in the case of these delicate bones, the slightest deviation
from the natural form or position determines in the end an ugly de-
formity, it becomes exceedingly necessary, especially with females,

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lat we should open the dressings and examine the fingers carefully
'om day to day, so that, as the swelling subsides, we may discover
od correct any displacement which may happen to exist.

As a splint, I have found nothing so convenient as gutta percha or
5lt, moulded accurately to either the dorsal or palmar aspect of the
nger; and the form of which I have found it generally necessary to
bange slightly every third or fourth day, until consolidation is nearly
r quite completed.

If the fracture is near or extends into a joint, the finger ought to
e a little flexed so as to place it in the most useful position in the
vent that anchylosis should occur; and as early as the end of the
scond week the joint surfaces should be slightly moved upon each
ther, in order to the prevention of fibrous or bony adhesions. Nor is
lere much danger of preventing the union of the bone by moving
le joints at this early day. Union occurs between these fragments
ery speedily, and I have never met with a case of non-union of the
halanges, nor do I remember to have seen a case reported.

It is the lateral inclination of the distal end of the finger which,
ccording to my experience, it will be found most difficult to obviate,
nd which may, perhaps, in some cases be most successfully combated
y laying the two adjoining sound fingers, against the broken finger,
nd then applying a moulded splint to the palmar surface of the whole,
n other cases it will be more convenient to apply the splint only to
be broken finger.

Botation of the lower fragment on its own axis is especially to be
uarded against, as the deformity which it occasions is more unseemly,
nd the impairment of utility more decided, than that occasioned by
lateral deviation.

It may be well also to remind the surgeon of the convenience of
xtending the splint beyond the end of the last phalanx, and moulding
; to this extremity, in order that the finger may be protected against
ijuries, and that when, from time to time, the splint is removed, it
lay be reapplied with accuracy.

In all cases the splint should be lined with two or three folds of
otton cloth, or with a single piece of soft fiannel, or patent lint, and
scured in place with narrow and neatly cut cotton rollers. Bandages
f this width should never be torn, but carefully cut with scissors.



Development of the Os Innominatum. — This bone is formed from
ight centres, three of which are called primary, and five secondary,
'he three primary centres belong respectively to the ilium, ischium,
Qd pubes, and by their extension form eventually the greater portion

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PUBES. 83£

of the innominatum. They have a common point of union in the
acetabulum ; and the ischium unites with the pubes, also, by the junc-
tion of their rami. These conjunctions occur usually between the
fifteenth and twentieth years of life. The secondary centres do not
begin to ossify until the age of puberty, and may therefore properly
be considered as epiphyses. One forms the crest of the ilium ; one

Fig. 108.

I>«yelopmeiit of the os innomiiuitam. (From Graj.)

its anterior inferior spinous process; one forms the symphysis pubis;
one the tuberosity of the ischium ; while the fifth constitutes the centre
of the bottom of the acetabulum. The epiphyses become joined to
the primary bones, or the bodies of the innominata, at about the
twenty-fifth year.

§ 1. PUBBS.

Lente, in his reports from the New York Hospital, mentions the
case of a young man, aet. 18, who was crushed between a couple ol
cars, in consequence of which he died two days after. The autopsy
disclosed a separation at the symphysis pubis, unaccompanied with
any other fracture. The right side was displaced backwards about
half an inch, so that the fingers could be passed between the bones.
There was- also a wound in the top of the bladder large enough to
admit the thumb.^ Similar accidents have been several times met with

* Lente, New York Joum. Med., 2d ser., vol. iv. p. 286.

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by surgeons. Hall reports a case in the Provincial Medical and Surgi-
cal Joumalf May 1, 1844, in which the pubes, thus separated, was
actually thrust into the bladder; but in this example the ilium was
broken also, I need scarcely add that this patient died ;^ but Sir
Astley Cooper has furnished us with an example of a simple fracture
or traumatic separation at the symphysis, from which the patient after
a long time almost completely recovered. The following is Sir Astley's
account of the case : —

" Case 79. Richard White, eet. 22, was admitted into Guy's Hospital
on the 80th of July, 1832, having sustained a severe injury in conse-
quence of a large quantity of gravel having fallen upon his back while
in the act of stooping. It knocked him down ; and on rising, which
he did with considerable difficulty, he attempted to walk ; this pro-
duced violent pain in the region of the bladder, extending upwards
in the course of the ureters to the kidneys. Upon inquiry, he stated
that the urine he had voided since the accident was bloody and passed
with difficulty.

"On examination, a fissure was found at the symphysis pubis, pro-
ducing a separation of about two fingers' breadth. On pressure being
made upon any part of the ilium, he complained of increased pain in
the region of the pubes, and of numbness down the lefl thigh.

"A catheter was immediately passed, and the urine which was drawn
off was clear and healthy. Leeches were applied over the pubes, and
a broad belt was firmly buckled around the pelvis sufficiently tight
to bring the separated pubes nearly in contact, and the patient ordered
to be kept perfectly quiet in the recumbent posture, on low diet. The
leech-bites ulcerated, and some slight degree of fever resulted, which,
however, readily yielded to the usual treatment.

"He remained in the hospital for three months without any check
to the progress of his cure ; the length of time it required being
accounted for by the difficulty of reparation in the amphiarthrodial
articulation ; and when he left there was some slight separation of the
pubes remaining ; nor were the two lower extremities, or the anterior
and superior spinous processes of the ilia, perfectly symmetrical,
although he could walk very well."^

Malgaigne has collected four cases of simple separation at the sym-
physis pubis occasioned by external violence, and in three of the foiir
cases it was occasioned by pressing out the thighs with great force ;
the separation being directly due, therefore, to muscular action.

Two of these patients succumbed to the accidents. The same author
has brought together, also, seventeen cases of separations of this sym-
physis occurring in childbirth, of which only seven survived.

It is much more common, however, to find the pubes broken through
its horizontal or ascending ramus ; and Clark, of the Massachusetts
General Hospital, has described a case of simultaneous fracture of the
pubes and ischium in three places. The man, 8Bt. 29, had been caught
between two heavy timbers, and on the following day. May 7, 1852,
he was brought to the hospital.

1 Hall, Amer. Joum. Med. Sci., vol. xxxiv. p. 34S.

' 8ir Astley Cooper, Frac. and Disloc, Amer. ed., p. 144.

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No crepitus could be detected, but he was unable to lie upon the
right side, and the right limb was nearly paralyzed. It was evident
that the bladder or urethra had been ruptured, and on the third day
Dr. Clark opened the bladder through the perineum, evacuating a
large amount of blood and urine, and aflfording to the patient very
sensible relief. On the first of June, however, he died, having sur-
vived the accident twenty-five days.

The autopsy disclosed several fractures, all of which belonged to
the right os innominatum. First, a fracture of the pubes near the
symphysis ; second, a fracture near the junction of the pubes and ilium ;
third, a fracture through the ramus
of the ischium anterior to the tube- -Fig. 109.


Sir Astley mentipns a case (Case
83) of fracture of the " ramus of the
pubes," unaccompanied with injury
to the bladder or urethra, which re-
sulted in a complete recovery ; and
in another case (Case 84) the patient
recovered in eight weeks, and was
able to walk nearly as well as before ;
but he soon after died of disease of
the chest. The os pubis was found,
at the autopsy, to have been broken
in three places; there was also a
fracture extending in two directions
through the acetabulum, with an
extensive comminuted fracture of

the ilium accompanied with great Clark'seaseof fractareofthepelyls.


Marat has even found it necessary, after a fracture, to remove nearly
the whole of the body of the pubes by incision, in a girl of 18 years,
and who not only recovered completely, but having subsequently
married, she gave birth to two children in easy and natural labors.'

Cappelletti relates that a man, 8Bt. 54, jumped from a carriage, the
horses having run away, and alighted with his feet to the ground, but
with one limb in the greatest possible degree of abduction. A surgeon,
who saw him immediately, found an enormous swelling at the superior
part of the thigh, accompanied with very acute pain. When seen by
Cappelletti, at Trieste, six months after, there still remained a slight
swelling near the ramus of the ischium and pubes, under which a
careful examination detected a fragment of bone two and a half inches
long and of the "size of the finger." The patient was able to walk,
but not without pain and limping. Cappelletti soon began to suspect
that' this fragment of bone consisted of a part of the ramus of the
ischium and pubes detached by muscular contraction. On examining
it anteriorly he found this part of the pelvis defective, and the loose

> Clark, Boston Med. and Surg. Journ., vol. Uii. p. 185.
s Marat, from Malgaigne, op. cit., p. 646.

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portion of the bone had all of the anatomical characters of the defective
part. He felt distinctly the circular projection indicating the point
where the ascending branch of the ischium unites with the descending
branch of the pubes.^

Whitaker, of Lewistown, N. Y., saw the body of the left os pubis
broken in a female while in the seventh month of pregnancy. She
had fallen down a pair of stairs, striking astride the edge of an open,
upright barrel. The fracture was oblique, and with but little dis-
placement, yet she complained of excruciating pain in the left pubic
region on the least motion. The accident was followed by no positive
attempt at miscarriage.'

The danger in these accidents consists not so much in the fracture,
as in the injury done to the bladder and other pelvic viscera. If the
bladder is opened into the peritoneal cavity, death is almost inevi-
table; and even when the bladder or urethra has suffered laceration
lower down or at any point above the deep perineal fascia, extensive
urinary infiltrations, followed by abscesses and gangrene, generally
expose these patients to the most imminent hazards.

The practice pursued at Guy's Hospital in the case of separation at
• the symphysis pubis, commends itself both by its simplicity and by
its success. Antiphlogistic remedies steadily pursued, rest in the re-
cumbent posture, the use of the catheter when necessary, and in certain
cases the girding the pelvis with a firm belt or band, are measures
which seem to meet all of the important indications.

If the fracture is accompanied with displacement it will be proper
to attempt to restore the fragments, but except in the case of separa-
tion at the symphysis very little aid can be expected from a band or
any similar means in retaining them in place. It will be sufficient,
generally, in such examples to place the patient quietly upon his back,
with his thighs flexed upon his body, and to treat the accident in all
other respects as a case of inflammation.

If the urine has become extravasated underneath the pelvic fascia,
no time ought to be lost in opening freely through the perineum, and
in extending the incisions, if necessary, into the urethra and bladder.

§ 2. Ischium.

When speaking of fractures of the pubes we have already noticed
some examples of fractures of the ischium also ; indeed, it is seldom
that one of the bones of the innominatum is broken without a coincident
fracture of one or both of the others. The records of surgery furnish
several other examples, produced generally by a fall upon the tubero-
sities ; but, perhaps, the most remarkable instance is that mentioned
by Marat as having occurred in a female during labor.

The following summary of a case of fracture of the ischium, reported
by Sir Astley Cooper, will serve to illustrate one of the most fortunate

* Cappelletti, Rankinj^'s Abstract, No. viii. p. 83 ; from Giomale per servire al
Progress! della Patologie della Terapeutica, 1847.
« Whitaker, Amer. Joum. Med. ScL, July, 1857, p. 283.

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terminations of these accidents when accompanied with a rupture of
the urethra : —

A young man who was driving a cart, was thrown down and a
wheel passed over him. On the following morning he was found to
have a fracture of the left leg and a contusion of the inner side of the
left thigh. There was also great swelling and ecchymosis of the
scrotum, with a slight appearance of injury over the pubes and left
hypochondrium. No fracture of the pelvis was at that time discovered.
The patient was suffering great pain, and was cold and exhausted.
Bloody urine escaped from the bladder. On the eighth day an abscess
had pointed on the left side of the perineum, which, being opened,
discharged a great quantity of pus having the odor of urine ; extensive
sloughing occurred, and the patient sank very low. On introducing
the finger into the wound, the ascending ramus of the ischium could
be distinctly felt, and the fracture traced in an oblique course, the

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 40 of 100)