Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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Across the two upper bars are laid, transversely, cloth bands^ upon
which the limb is laid at full length.*

As supplementary to this chapter, it seems proper to add a brief
resume of the statistics of the war of the rebellion just closed, drawn
from the reports of the Surgeon-General, made in 1865 and in 1867.*

Of 4167 gunshot wounds of the face, 1579 were accompanied with
fractures of the facial .bones. Of these latter, 107 died, and 891 re-
covered. The remainder are undetermined. Secondary hemorrhage
is said to have been the most frequent cause of death.

Of 187 examples of gunshot injuries of the spine (not including
those in which the chest or abdomen was penetrated), 180 died. Six
of those reported as having recovered were examples of fracture of
the transverse or spinous processes. The seventh is that of a soldier
wounded at Chicamauga, September 20th, 1863, by a musket-ball,
which fractured the spinous process of the fourth lumbar vertebra, and
penetrated the vertebral canal. The ball and fragments of bone were
extracted, and one year after he was reported as " likely to recover."

Of 859 gunshot wounds of the pelvis (not including those in which
the abdominal cavity was penetrated), 77 died, and 97 recovered. In
the remainder the result is not ascertained. In 256 cases the ilium
alone was injured; in 19, the ischium alone; 'in 12, the pubes; in 32,
the sacrum ; and in 40 cases the lesions extended to two or more por-
tions of the innominata. Pyaemia was a frequent cause of death.

Of 1689 gunshot fractures of the humerus, 436 died, and 1263 re-
covered. Nine hundred and ninety-six of these 1689 cases were
treated by amputation or resection, with a mortality of 21 per cent.
In 693 cases the conservative treatment was adopted, with a mortality
of 30 per cent.

Of 68 cases in which attempts were made to save the limb after
gunshot injury of the hipjoint, without resection, all died. (I have
seen two cases of successful treatment of these accidents by the con-
servative plan, and others have been reported.)

Fifty-three amputations at the hip-joint, made by surgeons in the
federal and confederate armies, including also reamputations, gave
seven successful results. The fate of two is uncertain.

Sixty-three excisions at the same joint, made by federal and con-
federate surgeons, furnished five successful cases.

Three hundred and thirty cases of gunshot fracture of the upper
third of the shaft of the femur, in which neither amputation nor resec-
tion was practised, gave a mortality of 71.81. Thirty-two cases io
which amputation was made gave a mortality of 75 per cent. Twenty-
two in which resection was made, gave a mortality of 81.18. (We
have rejected three cases given in the report as cured. Two of these
were resections of the head, and one was merely a " rounding off of
sharp edges.")

" Hodgen, Treatise on Military Surg., by the author, p. 408.
« Circular No. 6, Surgeon-GenerarB Office ; also Circular No. 7.



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GUNSHOT PBAOTURES. 489

Two hundred and thirty-two cases of gunshot fractures of the mid-
dle third, treated without amputation or resection, gave a mortality of
55.46. Ninety-three treated by amputation gave a mortality of 54.83.
Fifteen treated by resection gave a mortality of 86.66.

One hundred and seventy-three gunshot fractures of the lower third,
treated without amputation or resection, gave a mortality of 67.79.
Two hundred and forty-three amputated — mortality 46.09. Two re-
sected — both died.

Of 808 gunshot wounds of the knee-joint, with or without fracture,
treated without amputation or resection, 258 died — mortality 83.76.
Of the 50 which recovered there were, however, only six or eight in
which the testimony is unequivocal that the joint was opened. Of 452
amputated, 331 died — mortality 73.23. Of 10 resected, 9 died — mor-
tality 90 per cent.

Of 696 gunshot fractures of the leg, 169, or 24 per cent., were fatal.
No analyses have been made of fractures of the smaller bones.
It is much to be regretted that in these comparative analyses of
the treatment of gunshot fractures, except in the case of the hip-joint,
by the three methods, it is not stated whether the amputations or
resections were primary or secondary. In all secondary amputations
and resections, which, for aught that appears, may have constituted a
majority of the whole number, the conservative treatment had been
tried and had failed; and the deaths which followed ought in justice to
be charged to conservatism, and not to the operation. As the reports
now stand, they are of little or of no importance in determining the
relative value of conservative and operative treatment.

From the reports of the Confederate army, as published in the Con-
federate States Medical Journal^ we learn that of 221 cases of gunshot
fractures of the thigh treated without amputation or resection, 105
died, and 116 recovered. The shortest period of recovery was 41 days ;
the longest, 255 days ; the average, 104 days. The shortest period of
fatal termination was one day; the longest, 185 days; average, 52
days. Greatest shortening, five inches ; least, half an inch ; average,
one inch and nine-tenths.^

Of 507 amputations for gunshot fractures of the thigh, 250 recov-
ered.*

» Richmond Med. Joum., Feb. 1S66, from Confederate States Med. Journal.
« Ibid., January, 1866, p. 52.



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PABT II.



D I SLOCATIO



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DISLOCATIONS.



CHAPTER I.

GENERAL CONSIDERATIONS.
§ 1. GeNEBAL DiVISIOIf AND NOMENOLATUBE.

A DISLOCATION is the displacement of one bone from another at its
place of nataral articulation.

Dislocations may be divided into accidental or traumatic, sponta-
neous or pathologic, and congenital.

Our remarks upon the etiology, pathology, symptomatology, prog-
nosis, and treatment of these injuries must be considered as applicable
only to accidental or traumatic dislocations, unless the fact is in any
case otherwise stated.

Accidental dislocations are those in which the bones have suffered
displacement in consequence of the application of a sudden force; and
surgeons have divided these accidents into (Complete and Partial,
Simple, Compound and Complicated, Becent and Ancient, Primitive
and Consecutive.

A complete dislocation is one in which no portions of the articular
surfaces remain in contact.

A partial dislocation is one in which the articular surfaces are not
completely removed from each other.

A simple dislocation is that form of the accident in which the bone
has only slid from its articulation, and is accompanied with the least
or only an average amount of injury to the soft parts or to the bones
adjacent to the joint.

A compound dislocation implies that the articulating surface of the
bone has been thrust through the flesh and skin; or that in some other
way a wound has been made which communicates with the joint.

Complicated dislocation, is a term employed by some writers to
designate a condition wholly differing from a cdmpound dislocation,
or, in some cases, a condition of extra complication. Thus, a simple
dislocation may be complicated with a fracture, or with the laceration
of an important bloodvessel, &c.; and a compound dislocation may be
complicated in the same way, and with the addition, perhaps, of exten-
sive laceration and destruction of integument, muscles, nerves, &c.



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494 GENERAL CONSIDERATIONS.

A recent luxatioD, has taken place within a period of a few days, or,
at most, of a few weeks; and an ancient luxation has existed daring
a longer period. The exact point of time at which a dislocation shall
be called recent or ancient is not fully determined by surgeons, and
the application of these terms is therefore always somewhat arbitrary.

A primitive luxation, is a luxation in which the bone remains nearly
or precisely in the position into which it was at first thrown; while a
secondary or consecutive luxation is one in which the bone has sub-
sequently, in consequence of the action of the muscles, or from un-
successful efforts at reduction, or from some other cause, changed its
position sufficiently to entitle the accident to a new designation. Thus
a primitive dislocation upon the ischiatic notch may become a second-
ary dislocation upon the dorsum ilii, or the reverse.



§ 2. Genbkal PREDisPOSiNa Causes.

Age. — According to Malgaigne, whose conclusions are based upon
an analysis of six hundred and forty-three cases, dislocations are very
rare in infancy, only one having occurred under five years ; but the
frequency increases gradually up to the fifteenth year, from this period
more rapidly up to the sixty-fifth year, and from this time onwazd
again dislocations become more rare. He has mentioned none after
the ninetieth year ; and the period of greatest frequency is between
the thirtieth and sixty-fifth year. To this middle period belong four
hundred and seven of the whple number.

The inference from this analysis may be thus briefly stated: age, as
a predisposing cause, is most active in middle life, less active in ad-
vanced life, and least active of all in early life.

It is proper, however, to observe that while such statistics may be
relied upon as indicating the relative frequency of these accidents at
different periods of life, they cannot be regarded as determining abso-
lutely the value of age alone as a predisposing cause, since the direct
or exciting causes may be more active at one period than another, and
in some measure these latter causes may be, and doubtless are, respon-
sible for such results.

Constitution, and Condition of the Muscles and Ligaments. — It may be
stated as a general fact that persons of feeble constitutions, and whose
muscular systems are much weakened, suffer dislocation from slighter
causes than those who are in health, and whose muscular systems are
firm and vigorous ; and that a relaxation of the ligaments which sur-
round a joint, however this may have been occasioned, predisposes to
dislocation. Thus, a paralyzed and atrophied limb is predisposed to
luxation ; a joint in which the capsule has become stretched by effu-
sions, or by violent extension, or weakened by laceration from a
previous dislocation, or by ulceration, or if in any other way the
articulation is deprived of these natural protections, we need scarcely
say that it is thereby rendered more liable to luxation.

Ball and socket joints, other things being equal, are more liable to
displacement than ginglymoid; but then much more depends upon



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GBNEBAL SYMPTOMS. 495

t;he relative exposure of the joint than upon its anatomical structure,
so that the elbow is much more frequently dislocated than the hip ;
the shoulder-joint, -however, being, from its position and extent of
motion, peculiarly exposed, and being also a ball and socket joint, is,
of all others, most liable to dislocation.

§ 3. Direct or Exciting Causes.

These may be classed under two general heads, namely, external
violence and muscular action.

External violence operates either directly or indirectly. When a
person falls upon the knee and dislocates the head of the femur, the
force is said to have acted indirectly, and this is by far the most
frequent mode of dislocation; but when the blow is received upon the
upper end of the humerus, and its head is sent into the axilla, it is
said to have been dislocated by direct violence.

Muscular action produces a dislocation slowly, as in some cases of
chronic rheumatism, and then it is trailed a spontaneous or pathologic
dislocation; or suddenly, as in the violent spasmodic contractions
which accompany convulsions ; or sometimes by the mere voluntary
effort of the muscles; and both of these latter are true accidental
luxations.

It is very probable that external force can seldom be regarded as
the sole cause of a dislocation, but that, in a large majority of cases,
muscular action consenting with the shock, performs an important
rdle in the history of the accident. The limb being driven obliquely
across its socket by the external violence, is seized by the stretched
and excited muscles with such vigor as to contribute not a little to
the unfortunate result. Thus it will be found that the same force
which is adequate to the production of a dislocation in the living and
healthy subject is wholly insufficient to accomplish the same in the
dead; and a man who is fully intoxicated seldom suffers a dislocation.

§ 4. General Symptoms.

As fractures are characterized by preternatural mobility and crepi-
tus, to which may be generally added the circumstance that when
reduced the fragments will not remain in place without external
support, so, on the other hand, dislocations are characterized by pre-
ternatural rigidity, an absence of crepitus, and by the fact that when
reduced the bone does not generally require support to maintain it
in position.

These three are the usual, and they may be termed the common,
signs of distinction between fractures and dislocations, but no one of
them can be alone depended upon as positively diagnostic. Generally,
when a bone has been dislocated, we shall find the limb in a certain
position, which is uniform for all dislocations of the same character,
and almost immovably fixed; but when the ligaments and muscles
about the joint have been extensively torn, or the whole body is still
suffering under the shock, or in any other circumstances where the



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496 GENERAL CONSIDERATIONS.

power of the muscles is weakened, this rigidity may give place to
extreme mobility.

True crepitus does not exist without fracture, but is not always
present in fractures, and there is often a sensation produced in tbe
rubbing and chafing of dislocated bones which very much resembles
certain kinds of crepitus, and by the inexperienc^ has been often
mistaken for it. I allude to the subdued rasping sound or sensation
which is found generally on the second or third day, and sometimes
earlier, and which is the result of fibrinous effusions,, or, perhaps^ in
some instances, of the mere rubbing of firmly compressed ligamentous
and cartilaginous surfaces upon each other. The crepitus of a recent
fracture can be scarcely confounded with this obscure sensation, unless
it is in some cases of incomplete fracture, or of a fracture situated
remote from the surface, as in the case of the hip; but a fractare
which is a few days old, whose surface has become softened hy in-
flammation and more or less covered with lymph, and, when the
rigidity is great, may sometimes deceive the most experienced snr-
geon, so exactly will it be found to imitate the sensations prodaoed
by the chafing of an inflamed joint, or of closely approximated fibrous
surfaces.

I have said that a true crepitus does not exist without a fracture ;
but then a very minute fracture, such as the detachment of a scale of
bone by the tearing away of a tendon or of a ligament, may produce
crepitus; or even the separation of a pie6e of cartilage may sufficiently
expose the bone to determine the presence of this phenomenon. These
are, however, no longer examples of simple dislocation.

Nor are the two inverse propositions, in relation to the retention of
the bones in place, invariable in their application. A broken bone,
well reduced, does not always manifest a tendency to displacement^
nor does a dislocated limb, when restored to its socket, in all cases
maintain its position without support.

The other general signs of dislocation are pain, swelling, and dis-
coloration. The pain is generally more intense in dislocations than
in fractures, the expanded end of the bone resting often upon one or
more large nerves, which usually, with the arteries, approach very
near the joints, this pressure being also greatly increased by the
extreme tension of the muscles. Not unfrequently numbness and
temporary paralysis of the whole limb are the consequences. In
other cases the pain is due solely to the pressure upon the muscles or
to the tension of the muscles, or, perhaps, to the tension of the untom
ligaments and capsule.

Generally the limb is shortened, but in a few cases it is found
slightly lengthened, while the natural axis of the bone with its socket
is always changed. If examined early, and before the supervention
of swelling, the joint end of the displaced bone may be felt in its
unnatural position, and a corresponding depression may be discovered
in the situation of the articulation, especially if the bones are super-
ficial.



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PATHOLOGY. 497



§ 5. Pathology.



The dissection of recent dislocations produced by external violence
shows the capsular ligaments more or less torn, and also a rupture of
some of the lateral and other short ligaments, with a complete rupture
in most cases of some of the tendon^ which immediately surround the
joints or of those which are attached to the capsule: the muscles,
nerves, arteries, &c., through which the bone in its passage has passed,
OT upon which it is found resting, being also contused, stretched, or
torn assunder.

This description, however, does not apply to dislocations produced
by muscular action alone, in a majority of which cases the capsule is
only stretched, and not torn, and no lesions of other structures are
necessarily present.

If the dislocation remains unreduced, the margins of the old socket,
in the case of enarthrodial articulations, become gradually depressed,
while the concavity of the socket is filling in with a fibrous or bony
tissue, until at length the whole of this portion of the joint apparatus
is nearly or entirely obliterated. This process is generally very slow,
and may not be consummated until after the lapse of many years.

At the same time, but with much greater rapidity, the head of the
bone in its new position, and the soft or hard parts upon which it rests,
are undergoing certain changes to adapt them to their new relations,
and calculated in some measure to restore the limb to its normal func-
tions. If the head of the bone rests upon muscle, the cellular and
fibrous tissues which enter into the composition of the muscle become
condensed and thickened, forming a shallow or elongated cup, whose
margins are attached to the neck or shaft of the bone, and whose walls
are lubricated with synovia. If it rests upon bone, by a process of
interstitial absorption a true socket is formed, sometimes deep and
sometimes shallow, whose edges, receiving additional ossific deposi-
tions, become lifted so as to form a rim. At the same time the head
of the bone is undergoing corresponding changes, to adapt itself to the
newly-formed socket ; it is flattened or otherwise changed in form, and
in the progress of this change its natural secreting and cartilaginous
surfaces are gradually removed, a porcelaneous deposit taking its place.
The same kind of hard, polished, ivory-like deposit is found also in
those portions of the new socket which have been especially exposed
to pressure and friction. Instead of the eburnation, an imperfect
fibro-serous surface or synovial capsule may be formed.

I have in my cabinet an example of ancient luxation of the hip-joint
in which the head of the femur, having rested upon the dorsum ilii, has
formed a nearly flat but smooth surface — a kind of elevated plateau :
in other cases I have seen the margins of the new socket so elevated
as to rest against the neck of the femur, and completely lock it in.

Consenting with these changes, and in consequence partly of the
disuse of 'the limb, the muscle, and even the bones sometimes, sufier
a gradual atrophy. In some measure these alterations may be due
also to the pressure of the dislocated bone upon arterial and nervous
trunks, by which their functions become partially or completely anni-



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498 GENERAL CONSIDERATIONS.

hilated, and their structure even may be wholly obliterated. In conse-
quence also of the inflammation which immediately results, we ought
not to omit to notice that the trunk of a large artery sometimes
becomes firmly adherent to the capsule or periosteum of a displaced
bone, and its reduction is attended with imminent danger of laceration
and of a fatal hemorrhage. Numerous instances of this grave accident^
especially in attempts to reduce old dislocations of the shoulder-Joint,
are upon record.

§ 6. General Prognosis.

We shall study the prognosis of these accidents to better advantage
when we come to speak of the individual bones and their various
forms of dislocation ; but it is proper to state in this place, generally,
that very few joints, having been once completely displaced from their
sockets by external violence, are ever so completely restored as not to
leave some traces of the accident for many years, if not for the whole
of the subsequent life of the patient, either in the partial limitation of
their motions, or in the diminished size and power of the muscles of
the limbs, or in the presence of an occasional arthritic pain : the degree
and permanence of these sequences depending upon the joint which is
the subject of the displacement, the extent of the original injury, the
length of time it has remained unreduced, the means employed in its
reduction, the health and condition of the patient, with so many other
contingent circumstances as to preclude the idea of a complete specifi-
cation.

If the bone is not reduced, a permanent maiming is inevitable; but
it is surprising how much time and the intelligent processes of nature
can eventually accomplish toward a restoration of the natural fonc-
tions, especially when aided by a good constitution and judicious
treatment. If the symmetry of form and grace of motion are never
replaced, the value of the limb, for all the practical purposes of life,
is not unfrequently completely re-established.

§ 7. General Treatment.

The first indication of treatment is to reduce the bone. Whatever
delays may be proper or justifiable in certain cases of fracture, such
delays are never to be argued in cases of dislocation. The sooner the
reduction is accomplished the better. For this purpose we resort at
once to such manipulations or mechanical contrivances as the nature of
the case demands; and if these fail, or if at the first they are deemed
insufficient, we invoke the aid of constitutional means, or such as are
oalculated to diminish the power and antagonism of the muscles.

Many dislocations may be reduced promptly by manipulation alone;
which mode is always to be preferred when it will prove sufficient^
for the reasons that it is generally the least painful to the patient^ and
the least apt to inflict additional injury upon the muscles and liga-
ments.

A person wholly unacquainted with anatomy or surgery may occa-



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GENERAL TREATMENT. 499

sionally succeed in reducing a dislocated limb ; indeed it frequently
happens that the patient himself, by mere accident in getting up or
in lying down, accomplishes the reduction ; and even in a very large
rrwyority of cases force and perseverance will finally succeed by whom-
soever they may be employed; but the observing student of surgery
will soon discover the difference between accident and brute force on
the one hand, and intelligent manipulation on the other. The char-
latan bone-setter does not often allow himself to fail, unless the cou-
rage of his patient gives out, or he ignorantly supposes the reduction
to be effected when it is not ; but his success, achieved through great
and unnecessary suffering, is often obtained, also, at the expense of
the limb. While the surgeon, whose knowledge of anatomy enables
him to understand in what direction the muscles are offering resist-
ance, and through what ligaments the head of the bone must be
guided, lifts the limb gently in his hands, and the bone seeks its
socket promptly and without disturbance, as if it needed only the
opportunity that it might demonstrate its willingness to return.

We must understand not only what muscles and ligaments antag-
onize the reduction, if we would be most successful, but also what
muscles, by being provoked to contraction, will themselves aid in the
reduction. In short, to become expert bone-setters in the department
of dislocations, one must possess a complete knowledge of the phy-
siognomy or the external aspect of joints, acquired only by repeated
and careful examinations, he must be familiar with the anatomy and



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 57 of 100)