Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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made in the following manner, or in a manner very nearly such as
I shall now describe.

A plaster of Paris bandage having been applied to the foot and leg
some hours before, or sufficiently long to permit it to harden, a noose
was placed about the ankle for the purpose of attaching the pulleys.
The patient was now placed with his nates overhanging one corner
of the bed or table, and with the perineum resting against an upright
stanchion wound with woollen cloth. The pelvis was then lifted by
a broad band tied over a cross-bar resting upon the stanchion. Ex-
tension was made in a horizontal line by the pulleys fastened to a



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414 FRACTURES OF. THE FEMUR.

Staple at one end of the rope, and by the noose around the ankle at
the other. In this position, with or without anaesthetics, the woollen
cloth having been first neatly stitched around the thigh, and the p)eri-
neum well protected by extra padding, the plaster of Paris dressings

Fig. 167.



Extension continued until the plaster is hard.







were applied, extending downwards below the knee, and upwards as
high as the alse of the pelvis. Extension was not relaxed until the
dressings hardened, and then it was removed altogether.

It may be remarked that if the employment of anaosthetics and of
the pulleys during the setting and dressing of the fractures shall be
found useful or advantageous, the same methods may be applied with
equal advantage to other permanent dressings, and to my own as well
as to any. I propose to make the trial in cases which may hereafter
come under my care.

Finally, having considered somewhat at length the leading plans
of treatment which have from time to time been suggested and em-
ployed by our best surgeons both at home and abroad, I desire to
describe in greater detail those methods and forms of apparatus which
my own experience has taught me to prefer.

As to posture, my opinions are in accord with the opinions of a
vast majority of the most experienced surgeons of the present day.
The straight position will, on the average, give the best results.
Careful measurements made by myself in several hundreds of cases, a
portion of which have been published in my statistical tables,' have
demonstrated that the average shortening of the limb is greater after
any method of treatment in which the flexed position is employed,
than after treatment with extension in the straight position. These
observations have also shown that the flexed position, contrary to the
reiterated statements of its advocates, is more apt to entail angular
deformity.

There are a few who, rejecting the flexed position in fractures of



Fracture Tables, by F. H. Hamilton, 1858.



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FRACTURES OF THE ^HAFT OF THE FEMUR. 415

the middle of the shaft, still declare for this position a preference
when the fracture occurs just below the trochanters, and in the case
of fractures at the base of the condyles.

According to Malgaigne, who has devoted especial study to this
subject, there is no satisfactory evidence in favor of the flexed posi-
tion when the fracture occurs below the trochanters. It is not
directly forwards, but forwards and out-
wards, that the lower end of the upper ^^S- 1^8.
fragment is carried by the action of the
psoas magnus and iliacus intern us; so that
in order to meet the supposed indication
it would be necessary to carry the lower
part of the limb outwards also, a posi-
tion which would certainly be found
inconvenient, if not actually impracti-
cable, in the majority of cases. Nor
can the tendency of the upper frag-
ment to advance in the forward direc-
tion, and consequently to separate from
the lower, be met eflFectually by posture
alone, unless the thigh is completely
flexed upon the body. Indeed, it is ap-
parent that the position of moderate
flexion will rather favor the action of
those muscles which are supposed to be
chiefly responsible for the displacement.
When the thigh is extended upon the
body, the psoas magnus and iliacus
internus are acting in the direction of,

J n 1 A x? • r j.\. r Fracture of femur J art below trochan-

and parallel to, the axis of the femur, tgrminor.

and consequently to a disadvantage ; but

when the limb is lifted, their action is more nearly at a right angle

with the shaft, and their ability to displace the fragment is greatly

increased.

Moreover, it ought to be understood that broken bones are seldom or
never displaced or separated, in the same manner they would be if they
were not surrounded with many other structures which have suffered
little or no disruption: they pass each other, but do not separate
widely, being held together by shreds of periosteum, muscles, tendons,
ligaments, &c. The same happens when this bone is broken just below
the trochanters; the upper fragment lies always, or almost always, in
immediate contact with the lower, and whatever force is brought to
bear upon the lower fragment more or less directly influences the
upper; we can then by extension, applied to the leg, draw down not
only the lower fragment, but we can drag into line the upper fragment.
No doubt in this attempt we shall meet with some resistance from the
muscles above named; but experience has always shown that even
moderate extension, applied steadily and without interruption, seldom
or never fails to overcome the resistance of the most powerful muscles.
We constantly avail ourselves of this principle in overcoming the ab-



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416 FRACTURES OF THE FEMUR.

normal contraction of muscles in connection with diseased joints, in
the reduction of old dislocations, and in many other ways.

Whatever the advocates of flexion in fractures of the femur may
say to the contrary, they are never able in this position to employ
extension and counter-extension. A careful examination of all the
double-inclined planes which have been brought under my notioe,
including Nathan B. Smith's and Dr. Hodgen's suspending apparatus,
will convince any experienced observer that such is the/act. What-
ever other excellences they may possess, this does not belong to them.
But extension is, of all the indications of treatment, that which is of
the greatest importance in nearly all fractures of the thigh, and no
less important in the upper third than in the lower. In fact, the higher
we ascend in the limb, the greater is the tendency to shorten, as my
measurements have shown, in consequence of the action of those
powerful muscles which, arising above, have their insertions into the
lower fragment.

In the case of all those double-inclined planes where the body rests
upon a bed, there can be no counter-extension except the weight of
the pelvis and its contents. It will not do to fasten the pelvis to the
bed by bands, as every one who- made the experiment would soon
learn ; nor will the groin tolerate the pressure of counter-extending
splints, or bands. These things have been tried in a thousand ways,
and abandoned. The weight of the pelvis alone, not of the entire body,
is the only counter-extending force which can be made available, and
this is wholly insufficient. In Nathan B. Smith's anterior suspension
splint, not even the weight of the pelvis is employed as a means of
counter-extension, the pelvis being secured to the splint by rollers,
equally with the thigh and leg.

After all, I prefer to leave this question to the verdict of experienee,
and happily this seems to be conclusive, if we may accept the almost
unanimous testimony of those surgeons who have enjoyed the largest
hospital practice. In my own experience the ordinary double-
inclined planes have constantly given the worst results, both in regard
to length, and lateral displacement; they are the most difficult to
manage, and are the most fatiguing to the patients. Nathan B. Smith's
suspending apparatus permits the limb to shorten more than the pre-
sent methods of extension; and it afibrds inadequate support along the
centre of the shaft, in consequence of which the limb is apt to unite
with a backward curvature or angle. In some gunshot fractures
treated by this apparatus this posterior curve or angle has been
excessive.

Even the old methods of extension were preferable to flexion; but
they had always two serious drawbacks. First, in the excoriations
and ulcerations incident to the application of extending bands or
gaiters, or whatever else was employed for this purpose. Again and
again I have seen ulceration of the instep, of the integuments above
the heel, and of other parts of the foot and ankle, from extending
bands; and second, from similar excoriations, ulcerations and deep
sloughs about the groin and perineum caused, by the counter-extend-
ing band. It is true, these accidents did not occur often, and some-



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FRACTUBES OF THE SHAFT OF THE FEMUR. 417

'tiines they were due wholly to negligence; but in order to avoid
them we were compelled to limit very much the amount of extension,
and to exercise unceasing vigilance. Only recently, at Bellevue, an
attempt was made to employ counter-extension in the perineum of an
adult, by plaster of Paris applied in the usual manner for a broken
femur, and as a consequence a perineal slough was soon formed two or
three inches in depth by several inches in length. Lente, the Burges,
myself, and others sought to overcome some of the difficulties of the
perineal band by various contrivances ; and perhaps in some measure
we have been successful, but still the danger of ulceration existed
wherever much force was employed, or the integuments were unusu-
ally delicate. Gilbert's plan of substituting adhesive plasters for the
usual counter-extending band, and Buck's plan of employing elastic
tubing, possess no real advantages. The truth is, there is no point
about the groin, perineum, or pelvis upon which, by one surgeon or
another, the pressure has not been made, and more or less distributed,
and there is no method perhaps which has not been employed, yet,
after a fair trial, the results are the same. The pressure must be
moderate, or serious accidents will occasionally happen.^

Hodge's attempt to make the counter-extension from the sides of
the trunk by strips of adhesive plaster, as already described, is wholly
inefficient in a large majority of cases.

Our first great step of progress in the treatment of fractures of the
thigh consists, then, in having secured counter-extension by the
weight of the body alone, and this is accomplished by simply ele-
vating the foot of the bed from four to six inches. I have not used
a perineal band, except in case of children, for eight or ten years ;
and in the case of children the weight of the body is still my chief
reliance. None of my colleagues at Bellevue use the perineal band
to-day.

The second step of progress was the introduction of the method
of extension by adhesive plasters, weights, and pulleys, without
which we would be unable to employ effectively the weight of the
body as a means of counter-extension, and by the use of which all
danger of excoriation, ulceration, and sloughing about the foot is
completely avoided. The suggestion of adhesive plaster extension
has been claimed for both Dr. Gross and Dr. Wallace, of Philadelphia,
and for Dr. Swift, of Easton, Pennsylvania ; but, however this may be,
to Dr. Josiah Crosby, of New Hampshire, is certainly due the credit
of having brought it conspicuously before the profession.*

As to the bed upon which the patient is to repose, it seems proper
to say that, whenever the circumstances of the patient will warrant
the expense, a bed constructed with especial view to fractures of the
thigh ought to be regarded as an essential part of the apparatus;
always contributing to the comfort of the patient, if it is not absolutely
necessary to the attainment of the most complete success. Indeed,
where some form of fracture-bed cannot be procured, or extempora-

* For cases of sloughing, &c., from perineal band, see N. Y. Joum. of Med.,
vol. xiv., 2d ser., p. 261, March, 1856 ; also same journal, Jan. 1840, p. 239.
' New Hampshire Joum. Med., 1851 ; Trans. Amer. Med. Assoc, vol. iii. p. 882.



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418 FRACTURES OF THE FEMUR.

neously constructed, and the patient is compelled to lie upon a com-
mon cot J)edstead, or a common post bedstead, or upon the floor, I
cannot think the surgeon ought to be held in any degree responsible
for the result.

The fracture-beds in use among American surgeons are exceedingly
various, among which I will mention, as being especially ingenious,
the beds invented by Jenks, Daniels, the Surges, Addinell Hewson,
of Philadelphia,* J. Rhea Barton, B. H. Coates, of the same city,* and
J. Crosby, of Manchester, N. H.'

Of these several contrivances, Jenks' bed (Fig. 168) has been for the
longest period in use among American surgeons, and its excellence
most thoroughly tested. It is composed of "two upright posts about
six feet high, supported each by a pedestal ; of two horizontal bars at
the top, somewhat longer than a common bedstead ; of a windlass of

Fig. 169.



Jenks' fractare-bed. (From Gibson.)

the same length, placed six inches below the upper bar ; of a cog-wheel
and handle; of linen belts, from six to twelve inches wide; of straps
secured at one end to the windlass, and at the other having hooks
attached to corresponding eyes in the linen belts; of a head-piece
made of netting ; of a piece of sheet-iron twelve inches long, and hol-
lowed out to fit and surround the thigh ; of a bed-pan, box and cushion
to support it, and of some other minor parts.

" The patient lying on this mattress, and his limb surrounded by the
apparatus of Desault, Hagedorn, or any other that may be preferred,
the surgeon, or any common attendant, will only find it requisite to

' Hewson, Amer. Journ. Med. Sci., July, 1858, p. 101.

« Eclectic Repertory, 5th and 9tli vols.

» Crosby, Treatise on Milit. Surg., by Frank H. Hamilton, 1865, p. 413.



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FRACTURES OF THE SHAFT OF THE FEMUR.



419



pass the linen belts beneath his body [attaching them to the hooks on
tte ends of the straps, and adjusting the whole at the proper distance
s^nd length, so as to balance the body exactly], and raise it from the
imattress by turning the handle of the windlass. While the patient is
t*lius suspended, the bed can be made up, and the faaces and urine evacu-
ated. To lower the patient again, and replace him on the mattress,
the windlass must be reversed. The linen belts may then be removed,
and the body brought in contact with the sheets."^

But in tny own experience no bed has proved so complete and uni-
irersally applicable as the fracture-bed invented more recently by
Daniels, of Owego, New York, and which may be used either as a
double-inclined plane or as a single horizontal plane suitable for the
support of the patient when his limb is dressed with the straight
splint.



Fig. 170.




B. Daniels' fractare-bed.

Fig. 171.



Gibson's Surgery, vol. i. p. 820.



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420 FRACTURES OF THE FEMUR.

Fig. 172.



^



B. Dakibu' Fbaoturk-Bbd.
"A (Fig. 170) repreieDts a platform of eaitable length and width, supported bj foar legs, a. To the
upper Borface of the platform is attached a crois-piece, ft, at a thort distance from the centre, aad
directly through the centre of the platform is made a circular hole, c (in dotted lines), said hole
having a semicircular cut or recess in the cross-piece b. To the straight edge of the cross-piece b
there is attached, by hinges, d, a board, J9, termed the body plane, the width of which may corre-
spond with that of the platform A^ and when depressed its outer edge may be eren with the edge of
the platform. The sides of the body plane may be elevated, or raised so as to be slightly concave on its
outer surface. To the opposite side or edge of the cross-piece ft, and at each side of the semieircnlar cot
or recess formed by the aperture c, there are attached by hinges, e, cast-iron plates, (7, C, which are
provided with grooves or ways at their sides, in or between which plates D D work. The plaiee
C C, D D (one on each side) are thigh plates, and their edges are provided with projections,/, in which
a shaft, fft works, one on each plate C. On each shaft g there is placed a pinion, which gears into
a rack attached to the under surface of the plates D D. At one end of the shafts ff are attached ratchets,
ff\ in which pawls, J, catch, said pawls being attached to the sides of the platee C C. To the oat«r
edges of the plates D D are attached by hinges, Hr, boards, E E ; these boards are leg planes, and are
sLightly raised at their inner ends, where they are connected to the plates 2>, in order to form depres-
sions to correspond to the shape of the legs. To the under surface of each leg plane there is attached a
metal guide, Z, in which a rack, m, works ; the outer ends of the racks have bars, n, projecting from
them at right angles. To each leg plane is attached a shaft, o, having a pinion, j», and ratchet, 9,
thereon, and pawls, r, which catch into the ratchets 9, the pawls being attached to the outer sides of
the leg planes. The pinions gear into the racks m. The body plane, and also the thigh and leg planes,
are covered by a suitable mattress, £, with a hole made through it to correspond with the bole in the
platform A, and the mattress is slit or cut to cover properly the thigh and leg planes without interferiog
with their movements. To the under side of the platform is attached by hinges a flap, F, having a
stuffed pad or cushion, t, upon it, which, when the flap is secured upwards against the platform, fits in
the hole in the platform and mattress. This flap is secured against the platform by a button, u."

Sometimes I have had constructed a simple frame, covered with a
stout canvas sacking, having a hole at a point corresponding with the
position of the nates, and this I have laid directly upon a common four-
post bedstead. A mattress and one or two quilts must be placed upon
the boards of the bedstead underneath the sacking, and a sheet or two
above the sacking, upon which last the patient is to be laid. In ar-
ranging the linen underneath the patient, the most convenient plan is,
instead of using only one sheet, which will require that a hole shall
be made in it corresponding to the hole in the sacking, to employ two
sheets, and, doubling them separately, to bring the folded margin of
each from above and from below to the centre of the opening. When
the patient has occasion to use the bed-pan, it is only necessary that



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TRACTURES OF THE SHAFT OF THE FEMUR. 421

ti-wo or four persons should lift this frame, and place under each corner
a. block about one foot in height, or it may be raised by a pulley and
ropes suspended from the ceiling.

The "invalid-bed," to which I have already alluded as a "fracture"
l^ed, invented by Dr. Josiah Crosby, of Manchester, N. H., and which
^w^as introduced into many of the U. S. general hospitals by order of
the Surgeon-General, has been found to be of great service, not only
in the management of invalids, in the general sense of that term, but

Fig. 173.



GsoaBT's Invalid-Bed, closbd.
Fig. 174.



Crosbt'b Iktalid-Brd, opbit.

The bed is morable, and can be rnn out from under the patient and changed. It In then run back,

the hooks B being made fast to the catches A. Bj taming a crank at (7, the rail 2> is rerolTed, which

winds up a strap passing orer the pnlley G, and the bed is raised to its position, thas taking off the

weight of the patient from the bands by which he was temporarily suspended.

also in the treatment of gunshot fractures of the thigh. Indeed, I
have had occasion to use this bedstead in Bellevue Hospital, and I
can say that its value in many cases can scarcely be overestimated.
We may also floor over a common bedstead, having previously, in



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422 FRACTURES OF THE FEMUR.

case it is an adult whom we have to treat, removed the foot-board, so
that we may extend the floor two or three feet beyond the usual length
of the bedstead. In the centre of this floor we may make an opening,
so arranged as to be closed by a board slid underneath, or by a door
fastened with a couple of leathern hinges, and closed by a spring
catch.

A very comfortable bed, especially for children, can sometimes be
made from a cot. But it will be necessary always to nail a piece of
board firmly across the top and bottom of the bedstead when the sack-
ing is at its utmost tension, in order to prevent the side rails from
falling together. The top board must be nailed on vertically, like
an ordinary head-board, so as to prevent the pillows from falling off,
but the bottom piece should be at least one foot wide, and laid hori-
zontally to support and steady the apparatus as it extends beyond the
foot. ' I

Having had occasion to assist the late Dr. Treat in the management ;
of a fracture of the thigh in the case of a little girl not quite three \
years old, I was struck with the simplicity and completeness of an
arrangement which he had made to prevent the bed and the dressings
from becoming soiled with the urine. It was only to leave directly
underneath the nates a complete opening through to the floor for the
escape of the urine, and to protect the margins of the sacking and
sheets, which came nearly together at the opening, with pieces of oiled
cloth folded upon themselves. It was found that not only the bed
was in this way kept dry, but the dressings also ; it being now ob-
served that the dressings had become wet heretofore by soaking up
the moisture from the bed, rather than by the direct fall of the urine
upon them.

Having prepared the bed for the i-eception of the patient, and ele-
vated its lower end about four inches by placing blocks underneath
the foot-posts, the following adaitional preparations
Fig. 175. should be made before we proceed to reduce the frac-
ture and dress the limb : —

There should be provided a piece of board of the
requisite length and breadth, furnished with a slot
to receive the pulley, and called the "standard," a
small iron rod, a pulley, a yard of rope, and a vessel
or bag to receive the weights. The slot should have
sufficient length, and the standard should be perfo-
rated in the direction of its breadth at short distances,
to enable the surgeon to elevate or depress the pulley,
as may be required. In case a metallic pulley cannot be
obtained, a spool will answer as a tolerable substitute.
The adhesive plaster which I have generally used
both in private and hospital practice is that which is
usually found in drug stores, spread upon linen ; but
some of my colleagues prefer the plaster spread upon
jeans or canton-flannel, as being stronger. I cannot,
however, appreciate their advantage, since the ordinary
standard. plastcr ncvcr gives way.



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FRACTURES OF THE SHAFT OF THE FEMUR.



423



A thin block or piece of board, called the " foot-piece," is to be pro-
"vided, perforated in the centre to receive the cord, and of sufficient
length to prevent the adhesive strips or "extension bands" from
I>ressing upon the malleoli. An average size for the foot-piece in the
oase of an adult is about three inches and three-quarters in length, by
t; wo and a half in breadth.

The adhesive plaster may be cut in the shape shown in the illus-
t^ration : five and a half inches wide in the centre, and two and a half
inches wide at the narrowest point,
and gradually widening again to- Fig. 176.

vrard each extremity to four inches ;

the narrower portions beiug slit

down two-thirds of their length.

T'or an adult we generally require

a strip of about four feet and eight

inches in length, namely, sixteen

inches for the central and widest

portion, and twenty inches for each

extremity. The shoulders of the Foot-pieoe.

central portion are cut as repre-
sented, in order that when folded upon the foot-piece and upon itself

it may reinforce the lateral bands at their weakest points.




Fig. 177.




Bxtenslon-baud aod foot-pieoe.




Fig. 178.




Same, folded and ready for aie.

The lateral or side splints may be made of stout leather, cut and
moulded to the limb, or of thin pieces of board covered with cotton
cloth, and stuffed on the sides next to the skin with cotton batting to
fit all the inequalities of the limb. The cotton cloth must be stitched
over the splints like a sac, but left open at the ends until the padding



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 49 of 100)