Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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I should be reluctant to recommend them.

For the same reason the apparatus invented by the late Dr. Turner,
of Brooklyn, N. Y.,* is objectionable. Moreover, all forms of appa-
ratus which, like this of Dr. Turner's, are secured to the limb by
straps with intervals, are objectionable, since these straps do not, like
bandages, give uniform support to the surface of the limb.

Mr. Hutchinson, of London, has of late omitted to elevate the foot
in the treatment of this fracture, and he thinks that the fragments are
maintained in apposition with quite as much ease.' I cannot agree

> Turner, N. Y. Med. Rec, July, 1867.

« Hutchinson, London Hospital Reports, vol. ii.

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witli him that nothing is ever gained by the eleva- -p. ^^g

tion of the foot. On the contrary, in the treatment
Of ct certain proportion of cases this position will be
found essential to the best success.

X have recently seen in use at the Long Island
CJollege Hospital a very ingenious apparatus devised
"by Dr. J. H. Hobart Burge, one of the surgeons of
tbat hospital. The fragments being approximated
by well-adjusted sole-leather pads, which are ope
rated upon by weights, cords, and pulleys.*

Lausdale, U. S. N., has contrived an apparatus
similar' to that invented by Burge, but more simple.'
Gibson, of St. Louis, has introduced, in a modi-
fied form, the circular pad or ring, first devised by
Albucasis.' Dr. Eve, of Nashville, and Dr. Black-
man, of Cincinnati, have employed this method, and
speak of it in terms of high commendation.^ I can-
not think, however, that it will be found applicable
to any large number of cases, and especially to such
cases as are attended with much contusion and swell- Maigaigne'a hookt.
ing of the soft parts.

In case the fracture is oblique or longitudinal, it will only be neces-
sary to lay the limb in a straight position, so as to prevent that lateral

Fig. 197.

Barge's apparatnt for fractured patella.

displacement of the fragments which has been shown to occur when
the limb is flexed. It will not be necessary to employ a splint, unless
the patient is unmanageable and demands restraint, nor to elevate the
foot. After the swelling has subsided, a slight amount of lateral

' Burge, N. Y. Med. Rec., April 15, 1868, p. 80.

« Lausdale, Wales's Surgery, p. 476.

' Gibson, Amer. Journ. Med. 8ci., Jan. 1867, p. 281.

« Western Journ. Med., May, 1868. NashviUe Journ. Med., February, 1867.

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pressure, accomplished by a few turns of a roller, with or without
compresses, as the circumstances may seem to demand, will complete
the mechanical part of the treatment.

Fig. 198.

LaoNlAle'a appatatiif.

I have not mentioned the rapid and sometimes intense inflammation
to which the knee-joint is liable after a fracture of the patella ; and
which is often greatly aggravated by the injudicious application of
bandages. In no instance ought the bandages to be applied very
tightly at the first dressing; and during the first five or six days the
patient ought to be seen once or twice daily, and the most prompt
attention given to any complaints of pain or soreness about the knee.

If the swelling and inflammation increase rapidly, it would be far
better to remove the bandages altogether for a few days, than to take
the risks consequent upon their continuance.

The anchylosis which often follows the recovery of the patient^ and
which is sometimes almost complete, is to be overcome by long-coD-
tinued passive motion ; but great care must be taken not to rupture
the ligament, as we have already seen happen in some cases.

Dr. Alfred C. Post, of the ISew York Hospital, has excised the
knee-joint in a case of anchylosis of long standing ; the limb being
so much flexed in consequence of a comminuted fracture of the patella,
as to be not merely useless, but an intolerable encumbrance. The
patient was a laboring man of about forty years of age. This opera-
tion was made in preference to amputation, at the request of the man



Development of the Tibia. — The tibia is formed, usually, from three
centres of ossification — one for the shaft, and one for either extremity.
Ossification commences in the shaft at about the fifth week of foetal
life. In the upper epiphysis it appears at birth, and unites with the

> Poet, New York Med. Gazette, vol. i. p. 809, Nov. 1850.

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sliaft at about the twenty-fifth year. Generally it forms the tubercle,
"but occasionally the tubercle has a distinct point of ossification.
The lower epiphysis commences to ossify during the
second year, and unites with the shaft at about the ^S- 1^^-
tvrentieth year. The malleolus internus is occasionally
formed from an independent centre.

JBJiiology of Fractures of the Tibia, — Fractures of the
tihia alone are, in a large majority of cases, produced
"by direct blows, such as the kick of a horse, or a blow
from a stick of wood ; in one instance I have seen it
"broken by a kick from a Dutchman's boot. It is occa-
sionally broken by a fall upon the foot, the force of
tbe impulse being expended before the fibula gives
'way, but almost always the fibula breaks at the same
Tnoment, or immediately after the fracture has taken
place in the tibia.

Dr. Proudfoot, of New York, has reported an exam-
ple of fracture of the tibia in utero, produced in the
sixth month of pregnancy, by violent pressure upon
the abdomen.'

Pathology, Division, <tc. — ^In an analysis of twenty-
seven fractures of the tibia, not including ^actures of
the malleoli, six were found to have occurred in the
upper third, eleven in the middle third, and eight in
the lower third. Six of the twenty-seven are known to
have been transverse, or only slightly oblique. It is ^^^^1^^,^°^^^^^
probable, also, that several of the remainder were trans- q^^j^^ **
verse. In this respect, therefore, fractures of the tibia
alone will be found to differ materially from fractures of the tibia and
fibula; but it is only in accordance with the general observation that
indirect blows produce almost constantly oblique fractures, and direct
blows somewhat more frequently transverse.

Many examples of fractures of the tibia extending into the knee-
joint are recorded by surgeons, most of which were compound, or
otherwise seriously complicated, so as to render amputation necessary,
and the consideration of which scarcely belongs properly to a treatise
upon fractures.

The malleolus internus is broken frequently at the same time that
the ankle-joint is dislocated, and this accident will be considered in
that connection.

Separation of Epiphyses. — We have already mentioned that Madame
Lachapelle has reported a case of separation of the upper epiphysis of
the tibia, and of the lower epiphysis of the femur, occasioned by
pulling at the foot during birth.

Dr. Voss, of New York, has seen a separation of the lower epiphy-
sis in a boy 14 years old, who in falling had caught his foot between
two blocks of wood. The upper fragment protruded through the

' Proudfoot, Bost. Med. and Surg. Journ., vol. xxxv. p. 268, 1846; from New
York Journ. Med.

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skin. Reduction was effected, but subsequently a portion of tbe
epiphysis became necrosed and was removed. He finally recovered
with a useful joint.*

Dr .R. W. Smith has reported a similar case in a boy 16 years
of age, and which, having occurred six months before, remained unre-
duced. The lower end of the shaft was displaced forwards. Richard
Quain records one other example, in a lad 17 years old, which was
easily reduced and maintained in position."

Prognosis, — No shortening can occur in this fracture unless one or
both ends of the fibula are displaced, a complication which I have
noticed in two instances, but in neither case did the shortening exceed
one-quarter of an inch; unless, indeed, the fracture occurs above the
fibula, or the fibula bends and remains bent, or the comminution aad
direction of the fracture is such at either end as to allow the femar
or the astragalus to become impacted. I have never recognized either
of these conditions.

Occasionally the upper fragment has been slightly displaced for-
wards. With these exceptions, and one other of delayed union which
I shall presently mention, this bone, in my experience, has been found
to unite promptly and without any appreciable deformity. Other
surgeons have noticed occasionally that the upper end of the lower
fragment has become displaced toward the fibula. Dr. Donne, of
Louisville, has reported an example of delayed union in a simple
transverse fracture of the upper end of the tibia. The man was in-
temperate. Ten weeks after the accident no union had occurred, and
Dr. Donne introduced a seton, and in about six weeks the fragments
were firm.*

If the fracture extends into either the knee or ankle-joint, the danger
of anchylosis is imminent, yet experience has shown that it may some-
times be avoided.

When the malleolus is broken off, it generally becomes slightly
displaced downwards, and in this position a complete bony or liga-
mentous union takes place.

Treatment. — The tendency to displacement, in a fracture of the tibia,
is usually so slight, if it exists at all, that simple dressings, light
splints of leather, felt, or binder's board, with rest in the horizontal
posture upon a pillow, fulfil nearly all the indications which are
present. The following cases will illustrate the usual course of these

Mrs. W. fell, Oct. 19, 1848, striking on her right knee, breaking
the tibia transversely just below the tuberosity.

The fall was the result of a misstep on level ground, and was at-
tended with only slight bruising of the soft parts. She says that on
attempting to rise she discovered what had happened, the bone pro-
jecting very distinctly, and she pushed and pulled it into place with
her own hands.

» Voss, N. Y. Joura. Med., Nov. 1865, p. 188.

« New York Journ. Med., June, 1868, from British Med. Joum., Aug. 81, 1867.
3 Donne, Amer. Journ. Med. Sci., vol. xzviii. p. 524; from Western Joum.
Med. and Surg., Aug. 1841*.

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I dressed the limb by laying it upon a pillow, outside of which
"were placed two broad deal splints, tying the whole snugly together
'witli several strips of bandage. At a later period the leg and thigh
'Were Ij^id over a double-inclined plane.

At the end of six weeks all dressings were removed, and the frag-
ments were found to have united firmly, and so perfectly as that the
point of fracture could not be traced.

X^eter Hamil, sdt. 29, was admitted into the hospital Aug. 81, 1849,
\ritli an injury to his left leg, which had occurred two days before.
JL yoang surgeon had examined the limb, and thought the-femur was
"broken just above the joint. He had applied a roller from the toes
to the thigh; and to the thigh were applied lateral splints. These
dressings were on the limb at the time of his admission, and were
not removed until the next day. I could not then discover any
fracture or displacement, and the dressings were discontinued, the
limb being merely laid upon pillows.

Oct. 4, when examining the limb, I detected a slipping sensation,
like that produced in a false joint, through the upper end of the tibia,
and I now easily understood what had been mistaken for a fracture of
the femur. It was a transverse fracture through the upper end of the
tibia, and without displacement.

No splints were afterwards applied, and on the 25th of November,
thiree months after admission, he was dismissed, the motion between
tbe fragments having ceased, but the knee still remaining quite stiff.
The presence of inflammation, with other complications, may, how-
ever, occasionally render the treatment more difficult and tbe results
less satisfactory.

John Mahan, sat. 39, admitted to the hospital Feb. 16, 1858, with
a compound fracture of the right tibia, near the middle of the leg.
The bone was broken by the kick of a Dutchman. I found the limb
much swollen and very painful, and I laid it carefully over a double-
inclined plane, and directed cold water irrigations; I also directed
morphine in full doses. The inflammation for several days threatened
the complete loss of his limb. On the tenth day the distal end of the
upper fragment was projecting in front of the lower, and I depressed
the angle of the splint and made moderate pressure upon the upper
fragment. On the twentieth day the fragments were bent backwards,
and I placeda compress behind. On the thirty-seventh day we took
the limb from the inclined plane, and trusted alone to side splints.
On the forty-fifth day we removed all dressings. The fragments had
not united. The limb was then laid upon a pillow, and six days later
a firm gutta-percha splint was. applied for the purpose of steadying
the bone, but the splint was removed daily in order that the leg
might be bathed and rubbed. He was allowed to sit up. On the
fifty -ninth day motion could still be perceived between the fragments,
and he was directed to use crutches. On the ninety-third day the
union was found to be firm, the upper fragment remaining slightly
displaced forwards.
In case the fracture extends into the knee-joint, it is best to lay the

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limb upon pillows or in a nicely-cashioned box, and nearly straigbt.
No extension or counter-extension is necessary here any more than
in other fractures of the tibia alone, nor are lateral splints or rollers
necessary or proper at first, as a general rule ; but especial at^ntion
should constantly be given to the prevention of inflammation, and of
subsequent anchylosis. The omission to employ splints in a case of
this kind was charged against a surgeon in Vermont as evidence of
malpractice. I am happy to say, however, that, in this particular caae^
he was sustained by the testimony of the medical men and by the
verdict of the jury ; but the attempt which the reporter has made to
defend this as a universal practice in fractures of the leg, or of the
tibia alone, is unfortunate, and evinces a lack of practical experience.^

Whatever position is adopted, and whatever means of support or
retention are employed, if bandages and splints are applied tightly or
injudiciously, great suffering and irreparable mischief to the knee-joint
may be the consequence.

A man, sdt. 28, entered the Pennsylvania Hospital, July 18, 18S9,
with an oblique fracture through the head of the tibia. A physician
had applied a bandage and splint to the leg, and sent him twenty miles
to the city, and, on examination afber his arrival, the whole limb as
high as the groin was much swollen, red, and excessively painfal.
The knee-joint was distended and very tender. All dressings were
immediately removed, and the limb laid in a long fracture-box sligfatij
elevated at the foot ; cool lotions were applied, and the patient was
freely bled, both from the arm and by the application of leeches. The
limb was kept in this position about six weeks, and at the end of two
or three weeks more be was dismissed, cured. Dr. Norris, who was
the hospital surgeon in attendance, -has, in his report of the case, very
properly taken this occasion to warn surgeons of the danger bf exces-
sive bandaging and splinting in this kind of fracture, as well as in all
other fractures of the lower extremities.'

Fractures of the malleolus, unaccompanied with any other accident^
demand only that the limb should be laid upon its outer or fibular
side, with the foot so supported as that it shall incline inwards towards
the tibia. In this simple disposition of the limb we have done all that
can be done by any mechanical contrivance toward approaching the
lower fragment to the shaft from which it has been broken.

1 Boston Med. Joura., vol. liy. p. 1, March, 1856.

« Norris, Amer. Journ. of Med. ScL, vol. xxiii. p. 291.

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Fig. 200.

Development of the Fibula. — The fibula is formed from three centres
or oasificatioQ — one for the shaft, and one for each extremity. Bone
begins to be deposited in the shaft at about the sixth
week of foetal life, in the lower extremity during the
second year, and the upper extremity during the fourth
year. The lower epiphysis unites with the shaft about
the twentieth year, and the upper about the twenty-fifth

I have not found any recorded examples of separation
of these epiphyses.

Causes of Fracture, — ^In a record of thirty-two cases I
have been able to ascertain the cause satisfactorily in
eif2;hteen, of which number three were the results of falls
directly upon the bottom of the foot, but which were
probably accompanied with a twist of the foot, four of a
slip of the foot in walking on level ground, or on ground
only slightly irregular, and twelve of direct blows.

Pathology. — In all of the fractures which have been
produced by falls upon the bottom of the foot, and in all
except one produced by a slip of the foot, the accident
was accompanied with a dislocation of the ankle ; the
foot being turned outwards. In the one exceptional
case mentioned, the dislocation may also have occurred,
but the fact is not known.

Both Malgaigne and Dupuytren have noticed a dis-
location in the opposite direction, or a turning of the
foot inwards, more often than a turning outwards. I
cannot think their observations were carefully made.

Moreover, in at least seven of the twelve fractures pro-
duced by direct blows the tibia has been thrown more or less inwards,
and consequently the foot has turned out.

In twenty-four examples the fracture of the fibula has taken place
within from two to five inches of the lower end of the bone. Twice
the external malleolus was broken ofi^ and seven times the internal

Four of the fractures occurring in consequence of direct blows were
compound, and one was also comminuted.

Prognosis. — In a majority of cases, where the fibula has been broken
from two to five inches above the lower end, the fragments have united
inclined toward or resting against the tibia ; occasionally I have seen

DeFelopment of
thePibaU. (From

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them displaced backwards or forwards. Once the fibula refused to
unite altogether.

The malleoli have generally united nearly or quite in place, bat in
two instances the external malleolus has been found displaced very-
much downwards.

Of the compound fractures, two required amputation, one was treated
by resection of the lower end of the tibia, and one
Fig. 201. died without any operation. Douglas has reported

a case of compound dislocation with fracture of the
fibula, which being reduced, he was able to save the
limb, but not without much difficulty, and the ankle
remained stiflF.^ Other surgeons have met with simi-
lar success, but I shall refer to this subject again
under the head of compound dislocations.

Of those which recovered, twenty-eight in number,
ten have been found to have more or less unnatural
prominence of the internal malleolus, and in two of
these the malleolus, or lower end of the tibia, projects
very much. In nearly all of these examples the foot
appears somewhat inclined outwards.

Generally the ankle-joint has remained stiff for
sometime after the bandages have been removed;
and probablv in all cases in which the accident was
Fracture of iibnia accompanicd with a dislocation of the tibia. But
neaMowwend. " tbis stiffucss has usually disappeared after a few
weeks or months. Twice I have noticed considerable
stiffness after about six months; three times after one year; in one
case after two years ; and in one case after twenty years the ankle
would occasionally swell, and become quite stiff. In one case it re-
mained almost immovable after twenty years; and in a still more
remarkable instance, I examined the limb thirty years after the acci-
dent, when the man was sixty-three years old, and although there
existed no swelling or deformity, yet this leg was not as muscular
as the other, and he declared that up to this time the ankle remained
quite tender to the touch, and that occasionally it became painful.
. When I come to speak of dislocation of the ankle, I shall adopt
the usual nomenclature, and shall name all those dislocations in which
the tibia projects inwards from the foot, " inward dislocations of the
tibia;" yet I have some doubts as to the propriety of this appellation.
This accident seems to me to have been in general rather a lateral
rotation of the foot, or of the astragalus, upon the lower articulating
surfaces of the tibia and fibula. Of all the ginglymoid joints, the
ankle approaches most nearly in form to a ball and socket joint, in
consequence especially of the marked prolongations of the malleolus
internus and externus. In other ginglymoid articulations lateral dis-
placements are not unfrequent, but lateral rotation can scarcely by
any accident occur. Here, however, the reverse holds true ; lateral

> Boston Med. and Surg. Joum., vol. xxxiv. p. 836, from Southern Joum. of Med.

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displacement is difficult, while lateral rotation is comparatively easy
of accomplishment.

The majority of cases which occur, involving a disturbance of the
relative position of the ankle-joint surfaces, are, I am satisfied, of this
latter character, viz., lateral rotations within the capsule, rather than
true dislocations; and although the restoration of the joint surfaces
to position is, in general, easily accomplished, yet, in consequence of
either a fracture of the fibula or malleolus internus, or of a rupture
of the internal lateral ligaments, it will generally happen that some
deformity will remain. The fragments of the fibula will fall inwards
towards the tibia, and the foot, unsupported by either its fibula or its
internal ligaments, will incline perceptibly outwards. Nor can this be
wholly prevented, in most cases, by any mechanical contrivance. In-
deed, it would be easy to demonstrate, as I have often done to my
pupils, that even Dupuytren's splint, usually employed in this acci-
dent, must fail of success in a great majority of cases, since the sub-
sequent deformity is due less to the fracture of the fibula and its
consequent displacement than to the loss of the internal ligaments,
which loss nature can seldom fully repair. As further evidence of
the correctness of this view, I will state that in three of the examples
in which I have found the fractured fibula united and resting against
the tibia, the motions of the ankle-joint have been completely re-

If, however, it were true that a fracture and displacement of the
fibula is the sole or essential cause of the subsequent deformity, it
would still be found often impracticable to avoid the maiming, since
it would still remain impossible to lift the broken ends from the tibia,
against which, or in the direction toward which, they are so prone to
fall. Inversion of the foot does not accomplish it, nor have I ever
been able to make anything but the most trivial impression upon the
upper end of the lower fragment by^ pressure upon the lower extremity
of the fibula.

I think too much confidence has been placed in the efficiency of
"Dupuytren's splint." I believe, indeed, that this splint is a very
appropriate means of support and retention after this accident ; but
I doubt whether it is able to accomplish all that its illustrious inventor

Treatment. — Dupuytren's mode of dressing is essentially as fol-
lows: —

A pad, or long junk, made of a piece of cotton cloth, stuffisd with
cotton batting, is constructed of sufficient length to extend from the
condyles of the femur to a point just above the malleolus internus.
This pad must be about five or six inches in width, and thicker by
two or three inches at its lower than its upper end. This is to be laid
upon the inside of the leg, with its base or thickest portion resting
against the tibia just above the internal malleolus. Over this pad is
to be placed a long firm splint, extending also from above the knee
to three inches beyond the bottom of the foot. With a few turns of
a roller the upper end of the splint will now be made fast to the

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Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 52 of 100)