Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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452



FBACTURES OP THE FIBULA.



Fig. 203.



knee, and with a second roller the lower end must be secured to the
foot. The application of this last bandage requires, howeyer, some
care in its adjustment. Its purpose is simply to rotate
the foot inwards, while at the'same time the tibia is pressed
outwards; and to this end it must be applied in the form
of a figure-of-8 over both splint and foot, embracing al-
ternately the heel and the instep. In order to be eflfectaal,
it must be drawn pretty firmly, and no portion of the
bandage must pass higher than the malleolus extemus.
In some surgical books I have seen this apparatus repre-
sented with a roller embracing the whole length of the
leg ; and in others it is represented as encircling the limb
two or three inches above the malleolus; but it is evident
that these modes of dressing must defeat the great object
which Dupuytren had in view, namely, the throwing out
of the upper end of the lower fragment.

When the limb is thus dressed, the knee may be flexed
and the leg laid upon its outside, supported by a pillow,
or upon its inside, as in the accompanying engraving.

If it is only a fracture of the external malleolus, or if
the fracture has occurred in the middle or upper third of
the bone, this treatment is no longer appropriate, and it
will generally be found sufficient to place the limb at rest for a few
days upon a suitable cushion or upon a pillow.

Of late years I have not employed Dupuytren's splint quite so
much as formerly, and especially because I have met with several
examples of backward displacement of the foot following fractures of
the fibula, which Dupuytren's splint is not competent to prevent or to

Fig. 208.




DnpoTtren'a
aplint ineor-
reotlj applied.



Dapoytren'a splint as oxiglnallj applied bj himself.

remedy. This subject will be considered more fully in connection
with forward luxations of the tibia at its lower end ; but it is neces-
sary to say here that this accident can be most certainly avoided by
employing the plaster-of-Paris or starch dressing; taking care in
applying the dressing to secure a thorough inversion of the toes and
foot, the same as in case the limb were dressed with Dupuytren's
splint. Care must be taken, also, not to press upon the limb much
with the bandages above the malleolus externus. The same results
may be attained, also, by a well-adjusted leather splint, or by two
splints, which shall inclose the heel as well as the sides and front of
the limb.

It is scarcely necessary to say that, since after this accident anchy-
losis is so frequent, early and unremitting attention should be given



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FRACTURES OF THE TIBIA AND FIBULA. 458

to the establisbmept of passive motion in the joint Indeed, I cannot
l>ut think that a desire to accomplish the indications recognized and
ixrged by Dupuytren has led to the neglect of the indication which
ought to have been regarded as of equal, if not of the greatest, im-
portance, namely, the prevention of contractions and adhesions around
and between the joint surfaces.

As a general rule, the dressings ought to be wholly laid aside by
the end of the third or fourth week ; and although it may be well for
& somewhat longer time to keep the foot turned in, by having it pro-
perly supported as it lies upon the pillow, yet after this date I regard
the use of splints and bandages as only pernicious.



CHAPTER XXXII.

FRACTURES OF THE TIBIA AND FIBULA.

Causes. — Probably four-fifths of these fractures are the results of
direct blows or of crushing accidents, such as the kick of a horse, the
passage of a loaded vehicle across the limb, the fall of heavy stones or
timbers, &c.

In an analysis of one hundred and eleven cases, I find the bones
broken in the upper third from a direct cause four times, and from an
indirect cause once. In the middle third forty have been referred to
a direct cause, and two to an indirect; and in the lower third thirty-
nine to a direct cause, and eighteen to an indirect. An observation
which does not sustain the remark of Malgaigne, based upon his
analysis of sixty-seven cases, that fractures of the upper third are
produced by direct causes alone, those of the middle third much more
frequently by indirect causes, and that those of the lower third are
especially due to indirect causes. Direct causes produce a large
majority of the fractures of the lower third, but the proportion is
smaller than in the middle third.

Of the indirect causes, falls upon the feet from a considerable height
— as from a scaflEblding, or from the top of a building — are by far the
most common. Four times I have found the bones broken by muscu-
lar action alone, as in the following example: —

Mrs. W., of Bufialo, aged about twenty-five years, and weighing at
this time nearly two hundred pounds, was descending her door-steps
with an infant in her arms, when, the step being covered with ice, she
slipped and fell, breaking her right leg just above the ankle. Mrs. W.
says she felt and heard the bones snap before she touched the steps.
Of this she is certain.

- We found the tibia broken obliquely, the fragments being quite
movable, but not much, if at all, displaced. The limb was dressed
with a carefully moulded and well-padded gutta-percha splint, and
then laid in a pillow upon the bed. Mrs. W. experienced unusual



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454 FRACTUBES OF THE TIBIA AND FIBULA.

pain from the fracture for several days, for the relief of which we were
compelled at times to permit her to inhale chloroform. She was of a
nervous temperament, and had frequently resorted to chloroform
before to relieve neuralgic pains. The limb became very mach
swollen, and remained so for a week or two. No extension was ever
employed.

Within the usual time the bones united in perfect apposition, and
in about four months she was able to walk without any bait.

Pathologyy Symploms, <tc. — We have seen that fractures of both
bones through some, part of the lower third are most frequent. Thus,
of one hundred and fifty -five fractures, eleven belonged to the upper
third, forty-five to the middle, and ninety-three to the lower. In six
cases the two bones were broken in different divisions. It is probable
that in this analysis some errors have occurred, and that in a larger
proportion than here stated the two bones have given way at opposite
extremities, since it is often difficult, and sometimes quite impossible,
to determine precisely where the fibula is broken ; but the analysis is
sufficiently correct to illustrate the much greater frequency of fractures
of the lower third, and also the fact that the two bones generally
break nearly on the same level ; usually the point of fracture in the
tibia is between two and three inches above the joint

In an examination of twenty museum specimens, I have found both
bones broken at the same point, or within two or three inches of the
same point, sixteen times, and at extreme points four times ; and in
these last examples the tibia has always been broken in the lower
third, while the fibula has been broken in the upper third.

In seventeen of the fractures mentioned as belonging to the lower
third only the malleolus of the tibia was broken, while the fibula was
broken two or three inches above its lower end. Some of these were,
perhaps, examples of dislocation of the ankle.

I have seldom seen a transverse fracture of the tibia, except in its
lower or upper extremity, in the expanded portions of the bone ; and
even in those examples which we are accustomed to call transverse,
because they are sufficiently so to prevent any sliding or overlapping
of the fragments, there has existed, generally, a marked inclination of
the line of fracture in one direction or another.

The examples of fracture produced by muscular action have, with-
out an exception, occurred in adults. Three of them were in the lower
third of the leg, and one in the middle third. I think they were, all
of them nearly transverse, since they never became much, if at all,
displaced.

Most of the fractures of the tibia produced by falls upon the feet
are very oblique, and the direction of the fracture is generally down-
wards, forwards, and inwards; but I have found almost every con-
ceivable variation from this general rule.

The fracture in the fibula is even more constantly oblique than the
fracture in the tibia; but this is a point of very little practical conse- •
quence, and one which we can seldom determine positively, unless one
of the fractured ends protrudes through the fiesh.

Compound and comminuted fractures are more frequent here than



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I
FRACTURES OF THE TIBIA AND FIBULA. 455 |

in any other of the bones of the body. My tables, which have rejected
all fractures demanding immediate amputation, most of which are
compound, do not for this reason give a just idea of their proportion
to simple fractures; yet even in these tables, of one hundred and
seventy-two fractures, sixty-two were compound, and also, generally,
more or less comminuted. Of eighty cases reported by W. W. Mor-
land, of Boston, from the Massachusetts General Hospital, and in
which the character of the accident is recorded, thirty-nine were com-
pound.^

The svmptoms indicating a fracture of both bones of the leg are the
same which are usually present in other fractures, namely, mobility,
crepitus, shortening of the limb, distortion, swelling, &c. Generally

Fig. 204.



Compound and eommlnated fraotnre of the leg.

the lower end of the upper fragment projects in front, and can be seen
or felt; but in some instances the swelling follows so rapidly that it is
impossible to feel distinctly the point of fracture, and its existence can
only be determined by the crepitus, mobility, and shortening of the
limb, or, perhaps, by the marked deformity or deviation from the
natural axis.

The shortening, where it exists at all, varies at the first from a line
or two to a half or three-quarters of an inch. Generally, it is about
balf an inch.

Prognosis, — The average period of perfect union in twenty-nine
cases, including those in which union was delayed by extraordinary
causes beyond the usual time, was forty days. The general average
under ordinary circumstances may be stated at about thirty days.

Union has been delayed in seven cases, five of which were simple
fractures, and two were compound. The longest period was seventeen
weeks.

F. C. T., of Erie Co., N. Y., set. 85, had an oblique, simple fracture
of both bones, in the upper third, caused by jumping from a buggy, in
June, 1862.

The limb was dressed with lateral splints, compresses, and bandages,
and laid upon a pillow.

* Transac. of Mass. Med. Soc. for 1840 ; Fractures, by A. L. Piereon.



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466 FBACTURES OF THE TIBIA AND FIBULA.

Eight weeks after the fracture had occurred, the gentlemen in
attendance wished me to see the limb with them. I found Mr. T. still
in bed, and the fragments not at all united.

Mr. T. had enjoyed average health heretofore, but he was never
very robust. When I was called to see him he looked pale ; his skin
was cold and moist, pulse 120, and appetite poor. The broken leg
and foot were greatly swollen. The swelling was oedematous. Con-
siderable excoriations existed on the back of the leg. The fragments
were quite movable, and were overlapped three-quarters of an inch.

We agreed that the patient oaght, as soon as possible, to be got out
of bed, so as to enable him to recover his strength, which had mdlv
declined. To this end, a gutta-percha splint was made to fit accurately
the whole length of the leg ; and, having attached a large number of
tapes, it was to be secured upon the limb. Several times each day it
was to be removed, and the limb bathed with brandy and water.
Gradually, also, the limb was to be brought down to the floor, and the
patient be made to sit up, and, as soon as possible, he was to walk
with crutches, or to ride.

Nov. 4, 1852, Mr. T. visited me at my house. The directions bad
been followed implicitly. About two weeks after my visit he rode
out, and in about nine weeks, or seventeen weeks from, the time of
the fracture, the bones were found united. His health and strength
were quite restored, and the limb was no longer oedematoua It was
found to be straight, or with only a slight projection of the upper
fragment in front of the lower, and shortened three-quarters of an
inch.

A gentleman, set. 88, from Bergen, N. Y., was struck by a billet of
wood on the 8d of August, 1856, breaking his left leg nearly trans-
versely, three and a half inches above the joint. The fracture was
simple. A surgeon was called immediately, who applied bandages and
side splints, and then laid the limb over a double-inclined plane. At
the end of six weeks the dressings were removed, but the bones had
not united. Four years after the accident, this gentleman consulted
me. I found him in good health, but no union had yet taken place.
This is the only example, except where amputation or death inter-
posed, in which the union has been so lon^ delayed as to entitle it to
be considered as a case of non-union. My own observation would,
therefore, incline me to think that, while non-union is a rare event in
fractures of the leg, delayed union is more frequent than in most
other fractures.

It has once occurred to me to see a complete non-union of the fibula
after a period of several years, while the tibia had united well. This
circumstance occasioned no inconvenience to the patient, and was not
known to him until I had made the discovery.

A little more than one-half of those cases in which an accurate
note of the result has been made, have been found to be more or less
shortened by overlapping, namely, sixty-one cases out of one hundred
and ten. The greatest amount of shortening in any one case has been
•one inch and a half ; and the average shortening of the sixty-one cases
has been half an inch and a fraction over. This analysis includes both



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FRACTURES OF THE TIBIA AND FIBULA, 457

simple and compound fractures; but a pretty large proportion of the
simple fractures have also been found shortened, as in the following
extreme illustration : —

John Granger, of England, adt. 43, was tripped by a stone while
walking, breaking his right leg through its lower third. Fracture
simple and oblique. It was treated by a surgeon, of Hungerford,
England, who employed only side splints.

Two years after, I found the leg shortened one inch, the upper
fragment riding upon the front and inner side of the lower.

Generally, when a shortening has occurred, I have found the upper
fragment in front of the lower, and oftener a little upon the inner than
upon the outer side.

The deviation from the natural axis of the limb has been noticed
by me in a good many instances. Seven times the lower part of the
limb has fallen backwards, and five times it has, in a degree much
less marked, inclined inwards. Once I have seen it inclined outwards,
and twice forwards.

Ulcers upon the back of the heel, seen by me seven times, as a result
of undue pressure upon this part, have, however, been presented but
three times in cases of simple fractures.

It is not verv unusual to find, also, over the exact point of frac-
ture, and after the lapse of several months, or even years, an ulcer, or
sinus, which is due sometimes to the presence of a small fragment of
bone which has remained in the wound from the time of the accident,
or to a thin scale which has subsequently exfoliated. In other cases
it is due to the prominence of the salient angle when the lower part
of the limb inclines considerably backwards, and in still other cases,
no doubt, to the general dyscrasy of the system, and to the same
causes which produce chronic ulcers in the lower extremities where
only the skin has been originally injured. I haveTeported elsewhere
examples of this complication existing after five months, two and
three years,' and in the remarkable case which I shall now briefly
relate an ulcer existed at the end of twenty-three years.

Thurstone Carpenter, when four years old, received an injury, break-
ing both bones of one of his legs near its middle. The fracture was
compound. It was dressed and treated by an excellent surgeon, then
residing in Buffalo, but long since dead.

Twenty-three years after the accident, Mr. Carpenter called upon
me on account of a paralysis of his lower extremities, which had
recently occurred. He stated that from the time of the fracture until
within about one /ear an open ulcer had existed over the seat of
fracture, and that soon after it had closed over completely be began
to lose the use of his limbs. During the time it was open, small scales
of bone have frequently been thrown off. The limb is half an inch
shorter than the other, but straight.

A gentleman residing in Quincy, Chautauque Co., N. Y.. had his
tibia and fibula broken near the ankle-joint in the year 1844, by the
passage of a carriage-wheel across his limb. The skin was a good

» Trans. Amer. Med. Assoc. Report on Deformities after Fracture.
'60



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458 FRACTURES OF THE TIBIA AND FIBULA.

deal lacerated. The wounds, however, healed kindly, and the broken
bones united in the usual time without any apparent deformity; bat
the limb continued swollen and painful, until finally suppuration took
place. After twelve years of great sufiering, I amputated the leg near
its middle, from which time he made a speedv recovery. I found the
lower end of the tibia inflamed, softened, and expanded, and contain-
ing in its interior about three ounces of pus, but no sequestrum.

Anchylosis of the knee or ankle-joint may follow as a result of the
accident or of improper treatment; and at one or both of these joints
I have found more or. less anchylosis at the end of nine months, one
year, six years, twenty-five, thirty, and forty years. Generally, how-
ever, it disappears in a few weeks, and seldom remains to any con-
siderable extent in the knee-joint after the dressings have been
removed two or three weeks; but an Irishman called upon me in
1868, whose leg had been broken about three inches below the knee-
joint six years before. It was a simple fracture. A surgeon in
Ireland had treated the case. I found the limb shortened one inch
and a half, the fragments being overlapped and displaced backwards
at the point of fracture. The knee was also partly anchylosed. I
could not learn what the treatment had been.

In other cases, where no permanent anchylosis has followed, the
ankle-joint has been occasionally painful, and subject to swellings,
after the lapse of many years.

After all that has been said as to the occasionally serious nature of
the consequenqes of these accidents, as shown in the shortening of the
limbs, in their deviations from their natural axes, in the stiff ankles,
ulcers, and abscesses, it must be still admitted that in another point of
view these results are not extraordinary, and may hereafter continue
to be fairly anticipated in a certain proportion of cases, even under
the best management ; since it must be understood that more fractures
of the leg are attended with serious complications than of any other
limb ; and that while many produce death rapidly from the severity
of the shock, and very many are condemned at once to amputation, a
large number of those which are saved have been in that condition
which has rendered the application of bandages or splints impossible
for many days. Indeed, not a few of these crooked limbs may still
be presented as real triumphs of the art of surgery, inasmuch as by
consummate skill alone have they been saved.

IVeatment. — It is wholly impossible in a class of fractures which
present so great a variety in regard to form, seat^ and complications,
to establish any universal system of practice; nevertheless it is
possible to declare certain general principles in reference to a few
well-recognized classes or varieties: and I shall deem it especially
important to record my disapproval of certain plans of treatment
which have from time to time been suggested and adopted.

In the revision of the present edition I have sought constantly to
keep pace with the progress of that department of surgery of which
it treats, and especially with my own experience ; but nowhere have I
found my own practice so far in advance of my precepts as in the
treatment of fractures of the leg. In my earlier editions I found it



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FEACTURES OP THE TIBIA AND FIBULA. 459

necessary to combat strongly the then too prevalent custom of treating
simple fractures of the leg, as well as compound fractures, in boxes;
and also the almost equally prevalent custom in some directions of
attempting to treat all fractures of the leg by extension. The treat-
ment of these fractures by the method recommended by Pott^ the
distinguished surgeon of St. Bartholomew's Hospital; left no oppor-
tunity for the practice of either of these popular errors, and it was
early adopted by me as far preferable to any then in general use. I
liave no reason to regret my preference then so fully expressed. The
plan will still be found applicable to a large proportion of these
accidents, and will on the whole give probably as many favorable
results and occasion as few accidents as any other ; but farther ex-
perience has shown that one or two other methods, which will pre-
sently be described, are in most cases equally valuable and in some
cases manifestly preferable.

The method recommended by Pott is as follows: —
A splint is constructed, made of a thin piece of board, long enough
to extend from a little above the knee to a point two inches beyond
the sole of the foot, about seven inches in width, and reaching for-
wards at the lower end, so as to support the foot. This splint is to
be covered heavily with cotton batting, in order that it may fit all the
inequalities of the outer side of the leg and foot, taking, however,
especial care that there should be a depression at a point correspond-
ing to the external malleolus, so deep as that even when the limb is
bound down to the splint the malleolus shall not touch. The splint
with its padding must then be covered with cotton cloth neatly sewed
on.

The remaining splint may be made of leather, binder's board, felt,
or gutta-percha; but in either case it need not extend higher than

Fig. 205.




Long tpUnt for trMtment of a fhtelnro of the leg In PoU'i poeiUon. ,

the bend of the knee or lower than the upper margin of the malleolus
internus, unless the fracture should be near one of these extremities;
and in case it does extend lower, the same precautions must be taken
to protect the malleolus internus from pressure. Whichever also of
the materials is employed, the splint never ought to be applied directly
to the skin, but a thin pad made of a few layers of cotton sheeting
covered with cotton cloth must be laid underneath.

It is seldom that I have found it necessary or useful to apply any
bandages directly to th6 skin, whatever form of apparatus has been



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460 FRACTURES OF THE TIBIA AND FIBULA.

employed, but in certain cases of compound fractures, where dressings
have been applied which needed support and protection, a bandage
has been of service. The roller, unless the patient is a child, whose
limb can be easily lifted and managed, is always objectionable; bnt
the many-tailed bandage, made of narrow strips of cloth, laid opon
each other, as we have already described in our general remarks
upon bandages, kc., is occasionally useful.

Having made these preparations, we proceed to flex the leg to a
right angle with the thigh, and by the hands make extension and
counter-extension as much as the patient will bear, or as much as
may be necessary to restore the fragments to place, in case this
restoration is found to be practicable. If the fracture is compound,
and the point of bone protrudes through the skin, it is often difficult
to replace it. That is, we are unable to overcome the action of the
muscles sufficiently to make the limb of its natural length, and for
this reason, mainly, we are unable to get the point of bone beneath
the skin. If we cannot then "set" the bone, or bring the ends into
apposition, and this will be the fact pretty often, we still have no apologj
generally for leaving the bone outside of the skin. First, an attempt
must be made to accomplish this reduction by palling aside the skin



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 53 of 100)