Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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for a considerable time, but had no effect in changing the position of
the bone.

"Six hours afterwards, Drs. Huston and Harris saw the patient in
consultation, when efforts were again made at reduction, which not
proving more effectual than in the first trial, the excision of the bone
was determined on.

"The patient being properly placed, an incision was made through
the integuments, parallel with the course of the tendons, commencing
a short distance above the projection on the foot, and extending down
£ar enough to expose fairly the astragalus and its torn ligaments.
The bone was then seized with forceps, and easily removed after the
division of a few ligamentous fibres that continued to connect it to
the adjoining parts.

"Very little hemorrhage occurred, two small vessels only requiring
the ligature.

"After removal, it was discovered that about one-half of the surface
which pUys in the lower end of the tibia had been fractured, and
remained firmly attached to the extremity of that bone, and as it was
judged that the efforts to remove this would be likely to produce more
injury to the joint than would arise from allowing it to remain, no
attempt was made to extract it.

"The joint being carefully sponged out, the sides of the incision
were brought accurately together by means of sutures and adhesive
straps, after which simple dressings and a roller were applied, and
the foot, restored to its natural situation, placed in a fracture-box."

Sabsequently that portion of the astragalus which was permitted to
remain, having become carious and loosened, was removed also.

The case continued to do badly ; all the bones of the tarsus, and
even the lower ends of the tibia and fibula, becoming eventually cari-
ous; and on the 27th of March, 1853, more than a year and a half
after the receipt of the injury, the leg was amputated ; but no healthy
action ensued, and the patient soon died.^

The result of this case can scarcely be regarded as having settled
anything in reference to the value of the procedure which I have
recommended. For reasons which seemed satisfactory to the sur-
geons who made the operation, only one-half of the broken bone was
removed ; whether the result would have been different if the whole
had been at once taken away, we cannot now determine. I have
related it, however, as the only example of a simple fracture with
displacement which I have been able to find upon record ; and in this
case, several surgeons of merited distinction concurred in the opinion
that the protruding fragment ought to be removed.

A fracture of the posterior portion of the calcaneum, especially when
it has been produced by muscular action, constitutes an exception to
fractures of the tarsal bones generally, and demands usually that
apparatus of some kind should be employed in its treatment.

In order to replace the posterior fragment when displaced, or to

I Norris, Amer. Joum. Med. Sci., vol. xx. p. 879.



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480



FRACTURES OF THE TARSAL BONES.



Fig. 222.



K




maintain it in apposition until a bony union is accomplished, it will
be necessary to shorten the gastrocnemii by flexing the leg upon the
thigh and extending the foot upon the leg. But to retain the limb
in this position it. will be expedient always to employ apparatas. A
very simple contrivance, however, will generally answer all the indi-
cations. A bandage, padded strap, or a stuffed collar may be fastened
about the thigh just above the knee, and made fast to the heel of a
slipper by a tape (Fig. 222). The apparatus is the same which has
been recommended for a rupture of the tendo Achillis.

In addition to this, the limb ought to be covered from the foot
upwards as far as the knee with a snug roller, xinderneath which, on

each side of and above the detached frag-
ment, ought to be placed suitable com-
presses, the object of the roller being to
diminish muscular contraction, and the
compresses being intended to retain the
detached piece in contact with the main
body of the bone. Some surgeons have
not found it necessary to flex the leg upon
the thigh, and they have contented them-
selves with extending the foot upon the
leg, and conflning it in this position by
a splint of wood or gutta percha laid
along the front of the leg, ankle, and foot
In slill other cases, the fragment has
shown so little disposition to become
displaced as to render no precautions of
any' kind necessary, except to impose
upon the patient complete quiet, with the
limb resting upon its outside and flexed,
as in Pott's fracture of the fibula.

As soon as the inflammation has suffi-
ciently subsided, passive motion must
be given to the ankle, in order to pre-
vent, as far as possible, the anchylosis
which is an almost constant result of
these accidents. Indeed, the patient is
fortunate who recovers a tolerable use
of his foot after the lapse of many months, nor can he be assured
that the inflammation will leave these bones and their dense fibrous
envelopes for a long period, and that it may not result in caries of
more or less of the tarsal bones, demanding finally amputation of the
whole foot.

We have not intended to speak in this place of those severer acci-
dents, accompanied with comminution and extensive laceration, which
forbid the hope of saving the foot, and for which immediate amputa-
tion is the only proper resource, but which constitute, in fact, the great
majority of all the fractures of the tarsal bones.



Apparatus for fraetnre of the tube-
rosity of the ealeaneum.



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FBAOTURES OF THE •METATARSAL BONES. 481



CHAPTER XXXIV.

FRACTURES OF THE METATARSAL BONES.

These bones can scarcely be broken except by direct blows, and
be great majority of their fractures are the results of severe crushing
accidents, such as render amputation sooner or later necessary. Of
tbose which do not demand amputation, by far the largest proportion
are compound fractures ; of which class the following example will
serve as an illustration : —

A man in the employ of one of the railroads which connect with
this city was run over by a loaded car on the 14th of June, 1856,
crushing his right arm so as to render its immediate amputation
necessary. I found also a compound comminuted fracture of the
fourth metatarsal bone of the right foot. Considerable hemorrhage
occurred from the wound, but this ceased spontaneously. Cool water
dressings were diligently applied, without splidts or bandages, and
although some inflammation and suppuration ensued, the parts finally
healed over and the fragments united^ with only a slight backward
displacement at the seat of fracture.

When only one bone is broken, the displacement is usually very
trivial ; but when several are broken, it may be considerable. Mal-
gaigne relates an example of this latter accident in which, the three
middle bones being broken by the wheel of a carriage, and the integu-
ments being badly torn and bruised, it was found impossible to retain
the fragments in place. The patient recovered, and was able to place
the foot well to the ground, but the proximal fragments continued to
project upwards upon the top of the foot to such a degree as to require
a special shoe.

In a majority of cases the direction of the displacement is backwards
or upwards, especially when the middle metatarsal bones are the sub-
jects of the fracture.

I have in my cabinet a second metatarsal bone broken obliquely
near its middle, with only a very slight displacement of the lower
fragment backwards ; and also the cast of a bone which has united
with an enormous backward projection.

In one instance I have seen the metatarsal bone of the little toe
cut in two with an axe, and the fragments united in about thirty days,
but with the lower fragment slightly displaced outwards.

Delamotte relates a case also in which the first four metatarsal
bones were cut ofiF, and complete union was accomplished on the
fortieth day ; at the end of two months the patient walked without
lameness.

If the fragments are not displaced^ nothing is required except that



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482 FRACTURES OF THS PHALANGES OF THE TOES.

the foot shall be kept at rest» and the inflammation controlled by
suitable means.

In case, however, a displacement exists, it ought to be remedied, if
possible, since, if only very slight, it may become the source of a
serious annoyance. If the fragments project upwards, they interfere
with the wearing of a boot, and if they sink toward the sole, the skin
beneath is liable to remain constantly tender, and the patient may
thus be seriously maimed for life.

In case the displacement is not due to the action of the muscles,
but only to the nature and direction of the force producing the frac-
ture, or to entanglement of the broken ends, and it is likely to cause
any of the inconveniences which I have mentioned if permitted to
remain, it will be advisable at once to employ considerable force in
the way of pressure, or to elevate the fragments through an opening
previously made upon the dorsum of the foot, calling to our aid even 1
the saw or the bone-cutters, if necessary. After which the fragments 1
may be retained in place by carefully applied pasteboard splints and ]
compresses. |



CHAPTER XXXV.

FRACTURES OP THE PHALANGES OP THE TOES.

If fractures of the other bones of the foot are generally of such a
character as to require immediate amputation, these fractures demand
this extreme resort still more often. Our experience, therefore, in the
treatment of fractures of the phalanges of the toes is extremely limited.

Lonsdale observes that it is not uncommon to find great irritation
arise after fracture of the great toe ; an inflammation extending along
the absorbents on the inside of the leg to the groin, causing abscesses
to form in different parts of the limb, and producing sometimes great
constitutional disturoance. An illustrative case has come under my
own observation at the Buffalo Hospital of the Sisters of Charity.
The patient^ Morgan McMann, SBt. 18, was admitted Dec. 28, 1853,
having several days before received an injury upon the great toe
which contused the flesh severely and broke the first phalanx. He
was then suffering from severe pain in the foot and leg, and the
absorbents were inflamed quite to the groin. Poultices being applied
to the foot and cool lotions to the limb, the inflammation soon sub-
sided, but not until a portion of the toe had sloughed away. Even-
tually also it became necessary to remove some portion of the phalanx,
which had died ; after which the wounds healed kindly.

When any of the smaller toes are broken, it will be found easier to
support the fragments by a broad and long splint which shall cover
the whole sole of the foot and all the toes at the same time, than to
attempt to apply a splint to the broken toe alone. If, however, we



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GUNSHOT FRACTURES. 488

prefer this latter mode, a thin piece of gutta peroha will be foand
altogether the most couvenient material for the purpose.

If the great toe is broken, its great breadth may prevent any dis-
placement, and a well- moulded gutta-percha splint will generally
secure a perfect and rapid union.



CHAPTER XXXVI.

GUNSHOT FRACTURES.

Gunshot fractures have already been considered, more or less in
detail, in the several portions of this work, wherever it seemed to be
necessary to call especial attention to them. This chapter will be
devoted, therefore, to a brief resume of my own observations and con-
clusions in this department ; to which will be added a few general
statistical statements, drawn chieQy from the published records of the
late war.

Causes. — Gunshot fractures are caused by a great variety of missiles,
such as musket and rifle balls, solid shot and shell, grape, canister,
sbrapnel, chain and bar shot, fragments of iron, stone, splinters of
wood, &c. &c. The only qualities which these missiles possess in
common is, that they are all projected by the elastic power of gun-
powder, and generally strike the body with great force ; and that they
cause fractures by direct violence — seldom if ever by counter-stroke.

Bound, smooth balls frequently impinge upon bones without caus-
ing a fracture, for the reason that they are easily deflected ; and this
happens especially when they are not moving with great velocity.

Conical rifle-balls seldom fail to fracture the bones which lie in their
direct course ; never, perhaps, when, at the moment of contact, the ball
is moving with its average velocity. The peculiar destructiveness of
this missile is due to its weight, momentum, and form.

Canister, grape, shrapnel, solid shot, shells, chain and bar shot are
still more destructive ; generally tearing the limbs from the body in
such a manner as to render readjustment and restoration impossible.

Pathohgy. — These fractures may be simple, compound, comminuted,
or complicated ; and in addition to these common varieties of fractures
there is occasionally presented an example of simple " perforation," or
mere penetration of the bone without fissure or other fracture ; and
still more frequently are seen examples of perforation with fissures.

Probably ninety-nine per cent, of all gunshot fractures are both
compound and comminuted; the comminution being, in general, ex-
oessive.

As in gunshot wounds of the sofl parts it has been generally
observed that the point of entrance is more round, more smooth, and
somewhat smaller than the point of exit^ and that the tissues are a
little depressed at the entrance, while they are slightly protruded at



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484 • GUNSHOT FRACTURES.

the exit, so also in gunshot fractures it will often be found that the
side of the bone on which the ball has entered, or upon which it first
impinged, is less comminuted than the opposite side ; and, if it is a
"perforation," that the opening is smaller upon the one sidethaa upon
the other ; that the edges are slightly depressed upon the one side,
and elevated or protruded upon the other ; and, finally, that numeroas
small, as well as some large, fragments of bone have been carried into
that portion of the track of the wound which lies between the bone
and the point of exit of the missile.

"When a ball fractures the shaft of a long bone, although the blow
may have been received three, four, or even six inches from an arti-
culation, the comminution or a single longitudinal fissure may some-
times be found extending into the joint. These fissures or splittings
of the shaft often extend also a long distance up or down, without
terminating in the joint.

Perforations without fissure occur most often in the broad bones
of the pelvis, in the scapula, or in the spongy extremities of the long
bones. In the latter, however, it is exceedingly rare to find perfora-
tion without fissure.

Perforations with fissure are pretty common in the head of the
humerus and in the head of the tibia ; they occur also, but less often,
in the lower ends of the femur and tibia, in the trochanteric portion
of the femur, and in the head of the femur. We wish to be under-
stood to say that fissures occur less often at the points last mentioned,
simply because perforations are there less common. It must be
known that if perforations do occur at these points, a splitting or
fissure communicating with the joints is almost inevitable. A mis-
understanding here would lead to a very fatal error in many cases.

Prognosis. — In general it may be stated that gunshot fractures of
the upper extremities do not demand amputation, and that similar
injuries in the lower extremities do demand amputation.

This statement is very broad, and cannot be understood except by
a consideration of these accidents somewhat in detail. Thus : —

Gunshot fractures of the clavicle, scapula, of the shaft of the hu-
merus, of the shafts of the radius and ulna, and of the carpal, meta-
carpal, and phalangeal bones, notwithstanding these bones have suf-
fered extensive comminution, do not usually demand amputation ; they
will in most cases eventually unite, and give to the patients tolerably
useful limbs. If, however, at the same time that the shaft of the
humerus, or of the radius and ulna, is thus broken, the large nervous
trunks are torn asunder, so that the extremity is cold and insensible,
the limb cannot probably be saved, nor, if it could be, would it be of
any value. Destruction of the main artery supplying the limb dimi-
nishes the chance of its being saved, but does not, in the case of the
upper extremities, necessarily demand amputation.

Penetration of the shoulder-joint by a musket or rifle ball, pro-
ducing a fracture of the head of the humerus or of the glenoid cavity
of the scapula, demands amputation when either the axillary artery
or axillary nerves are injured; but resection can generally be prac-
tised with a reasonable chance of success when the arteries and nerves



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GUNSHOT FRACTURES. 485

wkfe untouched. Beseotion is also made successfully at the shoulder-
Joint in some cases where larger missiles haj^e traversed the joint,
such as canister, fragments of shell, &c.

Penetration of the elbow-joint by a large shot, or by a Minnie rifle
"ball, the missile fairly entering or traversing the joint, demands am-
putation when the main arterial and nervous supplies are cut off, and
resection, generally, when both remain uninjured. Resection may be
attempted at the* elbow -joint, also, in some cases where, the nervous
supply remaining good, only one of the principal arterial trunks is
cat off.

Frequently a ball strikes the outer or inner condyle of the humerus,
making but a small opening into the joint, and producing only slight
comminution, and in such cases we often save the limb with more or
less anchylosis, and without resection.

The remarks which we have made in reference to gunshot fractures
of the elbow-joint apply, almost without qualification, to the same
accidents at the wrist-joint.

For gunshot wounds with fracture of the carpal, metacarpal, and
phalangeal bones we seldom practise either resection or amputation,
unless the soft parts are almost completely torn away.

The prognosis which, as we have now seen, is so favorable in the
tipper extremities, will be found very different in the lower extremi-
ties ; indeed, it is almost reversed. Thus : —

Gunshot fractures of the shaft of the thigh, of the shafts of the tibia
and fibula, and of the tarsal bones, generally demand amputation; or,
to be more precise, gunshot fractures of the head and neck of the
femur almost always terminate fatally under amputation or excision,
and equally under treatment as fractures, that is, where an attempt is
made to save the limb without interference with the knife. The same
accidents in the upper third of the shaft of the femur are generally
fatal; but if the main artery and the principal nerves are uninjured,
the life is, in general, less hazarded by an attempt to save the limb
than by amputation. In the middle third, under the same circum-
stances, the chances may be considered equal, as between amputation
and the attempt to save the limb by apparatus ; in the lower third
the chances are in favor of amputation.

The above statements in relation to fractures of the femur are based
mainly upon my own experience, and have been carefully considered.

I have seen no resections of the knee-joint, and but few of the shaft
of the femur, after gunshot fractures, which have not terminated fatally ;
and I am convinced that they should never be attempted in fractures
of the thigh, unless it be that case which presents so little hope in any
direction, viz., gunshot fracture of the head or neck of the femur.

Gunshot fractures of the shafts of both tibia and fibula demand
amputation where the comminution is extensive, or the pulsation of
the posterior tibial artery is Ibst, or the foot is cold ana insensible.
We do not mean to say that some limbs thus situated have not been
saved, but only that the attempt to save such limbs greatly endangers
the life of the patient, while amputation at or below the knee is rela-
tively safe.



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486 GUNSHOT FRACTURES.

Amputation is the only safe expedient in deep pehetrating woands
of the tarsal bones prodaced by missiles of the size of musket-balls
or larger. The only exceptions, which can safely be made, are in
cases where balls have opened partially and superficially these articu-
lations.

Resections at the ankle-joint are much more hazardous than ampa-
tations, and scarcely to be preferred, in army practice, to attempts to
save the foot without surgical interference.

Treatment. — While considering the prognosis in these accidents, I
have necessarily spoken of the treatment in certain cases ; especially
with a view to the propriety of amputation or resection. It remains
only to speak briefly of the treatment of those cases in which we may
attempt to save the limb without resection, properly so called ; for we
must not forget that pretty often we find it necessary to remove small,
loose fragments of bone bv the finger, or by the aid of the knife, or to
resect sharp points with the saw or the bone-cutters, when we do not
practise " resection," in the sense in which this term is usually em-
ployed by surgical writers.

I shall take the liberty, in this connection, of reproducing what I
have written elsewhere m relation to gunshot fractures, since it com-
prises nearly all that seems necessary to be added upon this subject.^

" If an attempt is made to save a limb badly lacerated and broken,
certain conditions in the treatment are necessary to success.

''AH projecting pieces of bone which cannot be easily replaced and
are not firmly attached to the soft parts, must be at once cut or sawn
away.

"All foreign substances, such as fragments of balls or other missiles^
pieces of cloth, wadding, dirt, &c., must be removed.

"Auy portions of integument, fascia, or muscles, which are entangled
in the wound, and prevent a thorough exploration, or may obstruct
the free escape of blood or of matter, must be freely divided.

''Counter-openings must be made at once, or at an early period
after the formation of matter, to insure its easy escape.

" The limb must be placed in an easy position, and not confined by
tight bandages or forcibly extended by apparatus.

" The inflammation must be controlled by constitutional and local
means, and especially by the use of water lotions whenever their em-
ployment is practicable."

If joints are implicated seriously, and an attempt is still made to
save the limb, the joint surfaces must be laid freely open, so as to
prevent all possibility of the confinement of blood, serum, or pas; and
the joint must be placed perfectly at rest» without adhesive strips,
bandages, or anv apparatus which shall compress the limb or em-
barrass its circulation.

I do not know that it is necessary to speak more particularly of the
treatment of gunshot fractures, unless it be to say that I still give the
preference, in fractures of the femur, to the straight position. In

I Treatise on Military Surgery, by Frank Hastings Hamilton. 1 vol. Svo. Pab-
lished by BaiUiere Brothers. Kew York, 1861: also enlarged ed. of same work in
1865.



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GUNSHOT FRACTURES.



487



zv^ost cases I have preferred my own apparatus, already described
'^jv'hen speaking of fractures of the thigh in general, with moderate ex-
'^ension ; and by moderate extension is to be understood such as may
\>« effected with from five to ten pounds.

A movable canvas, such as is shown in the accompanying wood-
out^ with a hole in the centre, and reinforced by an additional piece




Author** morable canTM.



of canvas where the weight of the hips rests, will enable the surgeon
to move his patient and clean the bed when necessary. The standard
which supports the pulley can be received in a slot in the frame.

Pig. 224.



MoTabl« canraa, with «zt«naioii, on "horses."



An apparatus similar to this was used, during our late war, in the
Lincoln General Hospital at Washington.

I have also used, with the movable canvas, and upon an ordinary bed,
Hodgen's apparatus, or " cradle" as he terms it, and have found it ex-
ceedingly useful, and much preferable to any form of double-inclined



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488 GUNSHOT FBACTURES.

plane, whether suspended or not. The cradle is simply a skeleton
box, of the length of the thigh and leg, made of light strips af wood.



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 56 of 100)