Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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dislocated phalanx, and slide it into its place, which can generally be
accomplished with ease.

" More than twenty-five years ago, the chairman of this committee,
from attention to the mechanism of the metacarpo-phalangeal joint of
the thumb, convinced himself that the principal impediment to tbe re-
duction of the first phalanx from backward displacement is the short
flexor of the thumb, between the two portions of which (lying close
together where they are fastened to the sesamoid bones) the head of
the metacarpal bone has been thrust, the contracted part or neck of
this bone lying firmly grasped by them. Fifteen years ago, a case
occurred of this dislocation which he could not reduce in the ordinary
way. A subcutaneous division of one of the heads of this muscle was
made with an iris knife, and the reduction was accomplished with the
greatest ease.

"Last year another case occurred, in which we failed of reduction
by Dr. Crosby's method, which we believe to be the be^t, and the
subcutaneous division of both heads of the muscle was made, and the
reduction instantly eflfected. The punctures were covered with collo-
dion, and the thumb supported by a splint. As the patient was in-
temperate, entire abstinence from liquor and the adoption of a light
diet were enjoined. Neither pain nor inflammation followed, and a
month afterwards the joint had free motion. After the intemperate
and irregular habits were resumed, the joint in a few weeks was found
anchylosed. In these cases, the knife, in the subcutaneous operation,
was carried down to the metacarpal bone, so far behind its head as to
preclude the possibility of mistaking the lateral ligaments for the
muscles. The ligaments are very short, and inserted close to the
articular surfaces, and are probably, one or both, ruptured in this dis-

Dr. J. P. Batchelder, of New York, in a paper read before the New
York Medical Association in 1856, says: "The surgeon should take
the metacarpal portion of the dislocated thumb between the thumb
and finger of one hand, and flex or force it as far as may be into the
palm of the hand, for the purpose of relaxing the muscles connected
with the proximal end of the phalanx, particularly the flexor brevis
poUicis. He should then apply the end of the thumb of his hand
against the displaced extremity of the dislocated phalanx, for the pur-
pose of forcing it downwards, and at the sahie time grasp the displaced
thumb with his other hand, and move it forcibly backwards and for-
wards, as in strongly forced flexion and extension, the pressure against

» Muasey, Trans. Amer. Med. Assoc, vol. iii., 1S50, p. S57.

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the upper extremity of the first phalanx being kept up. In this way
the dislocated bone may be made to descend, so as to be almost or
quite on a line with the articulating surface of the metacarpal bone,
w^hen the thumb may be forcibly flexed, and, if it be not reduced, as
forcibly extended, and brought backwards to a right angle with the
metacarpal bone, when, if the downward pressure, with the thumb
placed ns before, directed for that purpose, has been continued (which
thumb, by maintaining its position, acts as a fulcrum, as well as by its
pressure), the bone will slip into its place, and the reduction be effected
in less time than has been spent in describing the process."^

Six successive cases of treatment by this method are mentioned in
the American Journal of Medical Sciences for April, 1858 ; one by
Kickard, one by Morgan, two by Cutter, and two by Crosby. I have
also once succeeded by the same method.

By those who have regarded extension as an important element in
the 'reduction, various instruments have been devised Tor the purpose
of obtaining a secure hold upon the dislocated member. Sir Astley
Cooper, as we have already seen, recommended the sailor's clove
hitch:' Lawrie advises that the thumb shall be thrust into the open
handle of a large door key;* Charrifere and Luer, of Paris, have each
invented forceps, so constructed with fenestra and straps, as that when
the blades are closed the member is held very firmly in its grasp.
Richard J. Levis, of Philadelphia, recommends " a thin strip of hard
wood, about ten inches in length, and one inch, or rather more, in width.

Fig. 287.

Lerls*! imtrnment for redaetion of dislocations of fingers or tbo thmnK

One end of the piece is perforated with six or eight holes. The oppo-
site end is partly cut away, forming a projecting pin, and leaving a
shoulder on each side of it. Towards this eud of the strip, a sort of
handle shape is given to it, so as to insure a secure grasp to the ope-
rator. Two pieces of strong tape or other material, about one yard in
length, are prepared. One of these is passed through the holes at the
end of the strip, leaving a loop on one side. The other tape is passed
through another pairof holes, according asit may bea thumborafinger
to which it is to be applied, or varied to suit the length of the finger,
leaving a similar loop. If a dislocated thumb is to be acted on, the
second tape should be passed through the holes nearest the first. The
ends of each separate tape are then tied together.

* Batchelder, New York Journ. Med., May, 1856, p. 840.

« Op. cit., p. 561 ; also Bost. Med. and Surg. Journ., Oct. 1, 1857.

» Lawrie, Am. Journ. Med. Sci., vol. xxii. p. 229.

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"To apply this apparatus, the finger is passed through the loops.
The loop nearest the first joint is then tightened by drawing on the

Fig. 268.

Levis'i InstraMent applied to the first finger.

tape, which is then brought along the strip to the opposite end, across
one of the shoulders, and secured by winding it firmly aroand the
projecting pin. The other tape is tightened in a like manner, cross-
ing the other shoulder, and winding around the pin in an opposite
direction, when, for security, the ends of the tapes are finally tied

This apparatus enables the operator to apply both extension and
flexion or leverage in any direction. The proximal end of the pha-
lanx may be lifted, or even rotated so as to allow one side of the bone
to approach the socket before the other.

Malgaigne describes an apparatus invented by Kirchofi^ which is
very similar to, yet not quite so complete as this of Levis.

In the April number of the Buffalo Medical Journal, for 1847, 1
have described an instrument, or rather a toy, in my possession, which
I suggested might be useful for the purpose of making extension
upon dislocated fingers; and which, as will be seen by a reference to
one of the cases already reported in this chapter, I have since applied
successfully. It is made by the Indians, and may always be obtained
during the watering season, at the Indian toy-shops at Niagara Falk
The Indians call it a '' puzzle,*' and know no other use for it than to

Fig. 269.

Indian "puzzle," employed for the reduction of dlslocationt In imall joint*.

fasten it upon the thumb or finger of some victim, and then pull him
about until he begs to be released.

The *' puzzle" is an elongated cone of about sixteen or eighteen
inches in length, made of ash splittings, and braided ; the open end of
the cone being about three-fourths of an inch in diameter, and the
opposite end terminating in a braided cord. When applied to the
finger, it is slipped on lightly, forming a cap to the extremity, and to
half the length of the finger, but on traction being made irom the

> Levis, Amer. Journ. Med. Sci., Jan. 1857, p. 63.

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opposite end, it fastens itself to the limb with a most uncompromising
grasp. If constructed of appropriate size and of suitable materials,
it becomes the more securely fastened in proportion as the extension
is increased; yet, applying itself equally to all the surfaces, it inflicts
the least possible pain and injury upon the limb. When we wish to
remove it, we have only to cease pulling, and it drops off spontane-

Dr. Holmes says that the same instrument is made by the Indians
of Maine, and that several years ago Dr. Davis, of Portland, brought
one to Boston, and showed it to the Society for Medical Improvement,
suggesting that it might be used in the same manner which I have

Finally, in some compound dislocations it would be better not to
attempt the reduction of the dislocation until resection has been prac-
tised. Samuel Cooper relates a case in which the reduction was fol-
lowed by inflammation and death within a week after the accident,
and Norris, of Philadelphia, mentions an instance which came under
his observation, where violent inflammation and tetanus followed the
reduction.* Eoux, Evans, Wardrop, Gooch, Sir Astley Cooper, and
many other surgeons, have practised resection successfully in these
accidents, and have added their testimony in favor of this mode of

§ 2. Dislocations of the First Phalanx of the Thumb Forwards.

TTp to the present moment, I have met with but two examples of
this dislocation, while, as has been already stated, the backward dis-
location has been seen by me nine times.

Horace Kneeland, of Rochester, N. Y., set. 24, dislocated the first
phalanx of the right thumb forwards, by striking a man with his
clenched fist; the ibrce of the blow being received upon the back of
the second joint of the thumb. The dislocation had existed three
days when he called upon me, and in the meanwhile several attempts
had been made to reduce the bone by simple extension. The first
phalanx was in front of the metacarpal bone, and in the same plane ;
but the last phalanx was slightly inclined backwards. The hand was
already swollen and quite painful.

Seizing the dislocated thumb in the palm of my right hand, with
my fingers resting upon the back of the patient's hand, I forced the
two phalanges into flexion by firm and steady pressure continued for
a few seconds, when suddenly the bones resumed their places, and all
deformity disappeared.

Intense inflammation resulted, followed, after a few days, by suppu-
ration under the palmar fascia ; and in the end the thumb was almost
completely anchylosed.'

On the 24th of April, 1855, J. M. Booth, of Buffalo, »t. 19, called
at my office, haviug a dislocation forwards of the first phalanx, occa-

> Trans. Am. Med. Assoc, vol. i. p. 267.

« Norris, Amer. Joarn. Med. Sci., vol. xxxi. p. 16.

8 Trans. N. Y. State Med. Soc, 1855, p. 73.

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fiioned about half an hour before, by being thrown from a borse. The
last two phalanges were neither flexed nor extended, but straight, and
parallel with the metacarpal bone.

By the same manoeuvre adopted in the preceding case, but with
only very moderate force, the dislocation was promptly reduced.

The usual causes of this accident are falls or blows upon the thumh
while it is flexed ; and the symptoms which characterisse it are, in
general, such as we have seen in the two examples which have just
been given. The metacarpal bone projects posteriorly, and the firet
phalanx produces a corresponding projection toward the palm ; the
two phalanges are extended upon each other, and parallel with the
metacarpal bones. N^laton saw a case in which the first phalanx was
flexed about 45^ ; and in several examples it has been observed to
be slightly rotated inwards.

In the few examples of this accident which have been reported, the
reduction was easily accomplished ; or, at least, we may say that the
difficulties in the way of reduction were not so great as thej are
usually found to be in dislocations backwards. Malgaigne has heen
able to collect but four undoubted examples, all of which were re-
duced ; Lenoir was able to effect the reduction by moderate measures,
after the bone had been dislocated thirty-eight days. Ward succeeded
by simple extension.^

Lombard, after the trial of other plans, finally succeeded by revers-
ing the phalanx. Employing, as we have before termed it^ "dorsal
flexion," with extension and lateral motion ; but in all, or nearly all
the other examples, the reduction has been effected by flexing the
thumb forcibly toward the palm ; the reverse of the method which
we have seen preferred, especially by American surgeons, in disloca-
tions backwards. My own experience also authorizes me to recom-
mend this plan.

§ 3. Dislocations of the First Phalanx of the Fingers.

The index and little fingers, owing to their exposed situations, are
most liable to these dislocations. I have met with three examples of
traumatic dislocations of these joints, one of which was a forward and
two were backward luxations, and all had occurred in the index

James Nesbitt, of Buffalo, aBt. 11, dislocated the index finger of the
right hand, backwards, by a fall down a flight of stairs. On the same
day, Feb. 11, 1851, he called upon me, and I found the finger neither
flexed nor extended, but straight and immovable. The projections
occasioned by the ends of the two bones were very marked, and such
as to render an error in the diagnosis impossible. Reduction was
accomplished with great ease, by reversing the finger and employing
moderate extension^ while at the same time the proximal extremity of
the first phalanx was pushed toward the distal end of the metacarpal

» Ward, New York Med. Times, Sept. 8, ISeO.

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bone. In short, the process was the same as that which we have
recom mended in dislocations of the thumb backwards.

Fig. 270.

Backward dislocation of first phalanx. Bednetion hj extension.

In the second case, presented in a woman 35 years of age, at
Charity Hospital, April 16, 1868, the dislocation was caused by her
husband having pulled the finger violently backwards. The meta-
carpal bone was thrust through the skin on the palm of the hand.
Four weeks had now elapsed, and the wound had healed, a few days
before the house surgeon had placed her under the influence of ether
and had attempted reduction, but had failed, and she refused to allow
me to repeat the attempt.

In the example of dislocation forwards, occasioned by a blow from

a hard ball, received upon the end of the finger, the first phalanx was

in a position of extreme extension, and the second moderately flexed.

Redaction was eflfected with great ease by extension in a straight line.

But if the surgeon were to experience diflSculty in the reduction, it

would no doubt be advisable to resort to the method of extreme


In one instance, I have seen nearly all the fingers of the left hand,

and the thumb of the right, dislocated backwards by the contraction

of the cicatrix after a severe burn.



Notwithstanding slight diflferences in the form of the articulations
between the thumb and fingers, and in the size and situation of the
bones which compose the phalanges of the fingers, we are disposed,
contrary to the practice of some other writers upon this subject, to
consider all the dislocations to which these several joints are liable,
under one section. Nor, indeed, after the attention which we have
given to the dislocations at the metacarpo-phalangeal articulations, do
we find much to add in relation to these accidents; since in almost
every point of view in which they may be considered, they have so
much in common.

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The last phalanx of the thumb is, of all the phalanges, raost liable
to dislocation, and this generally takes place backwards. Very
frequently, also, it is accompanied with such a laceration as to render
it compound. The dislocated phalanx is usually reversed in the
backward dislocation, and straight, or nearly so, in the forward dislo-

In most cases reduction may be accomplished easily by forced dorsal
flexion in the case of the backward luxation, and by forced palmar
flexion in the case of the forward dislocation.

In the winter of 1848, a young man was brought into my clinic,
who had met with a forward subluxation of this phalanx about one
month before. He had fallen upon the end of his thumb, and as the
accident was followed by a good deal of inflammation and swelling,
he did not notice the displacement until some time afterwards. The
proximal end of the last phalanx projected two or three lines toward
the palm ; the finger was straight, and this jbint anchylosed. I did
not think the chance of restoring and maintaining the bone in position
sufficient to warrant any interference, and he was dismissed with an
assurance that after a few months it would occasion him no great

On the 2d of March, 1851, Thomas Burton, aged about twenty-two
years, by a fall dislocated the second phalanx of the middle finger of
the right hand, backwards. The force of the concussion was receive*!
upon the extremity of the finger. Nine hours after the accident I
found the bones unreduced ; the finger nearly straight, or with only
slight flexion of the second phalanx upon the first; the third phalanx
forcibly straightened upon the second ; all the joints rigid ; finger very
painful and somewhat swollen.

By moderate extension alone, applied for a few seconds, the reduc-
tion was accomplished.

Fig. 271.

Dieloeatlon of the second phalanx backwards.

James Cooper, set. 23, came to me on Sunday morning, the 14th of
Dec. 1851, to obtain counsel in relation to his finger which had been
dislocated the day before, but which he had himself reduced by simple
extension made in a straight line. His own account of it was, that he
fell upon a- slippery side- walk, striking upon the end of his ring finger
in such a way that it seemed to double under him. On examination,
he found the second bone dislocated inwards, or to the ulnar side, com-
pletely, the end of the first phalanx forming a broad projection upon
the opposite side ; the last two phalanges fell over toward the middle
finger, but they were neither flexed nor extended. Seizing upon the

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end of the finger with his right hand and pulling forcibly, he promptly
reduced the dislocation himself.

The bones were now completely in place, but the joints were swollen,
tender, and quite stiff.

In Sept. 1851, by the politeness of Dr. Briggs, the attending sur-
geon, I was permitted to see, in the hospital, of the New York State
Prison, at Auburn, a forward dislocation of the second phalanx of the

Fig. 372.

Diiloeation of the second phalanx forwarda.

little finger of the left hand, unreduced. This man was at thd date of
my examination forty-one years old, and the dislocation had existed
eighteen years; having been occasioned by a fall. A surgeon in
Greene Co., N. Y., had attempted to reduce it soon after the dislocation
occurred, but had failed. The joint was nearly anchylosed, yet the
finger was quite as useful for all ordinary purposes as before.

Dislocation of the last phalanx is frequently occasioned in the
game of base ball, by the ball being received upon the extremity of
the finger.

A young man who was studying medicine, and a private pupil of
mine, in attempting to catch a very hard ball, received it upon the
extremity of the middle finger of the left hand, dislocating the last
phalanx forwards. Twenty minutes after the accident, I found the
distal extremity of the second phalanx projecting backwards through
the skin, the tendon of the extensor muscle being torn completely off
from its point of attachment to the last phalanx. The last phalanx
was in a position of slight dorsal flexion, or extreme extension.

Seizing upon the extremity of the finger, I attempted to reduce the
dislocation by direct traction, aided by pressure upon the exposed end
of the second phalanx, but I was unable to succeed until I brought
the last phalanx into a position of palmar flexion.

A slight disposition to reluxation was manifested, and a gutta-
percha splint was therefore applied; and, to prevent inflammation,
the young man was directed to keep it moistened with cool water
lotioDs. Only a moderate amount of inflammation followed, and in a
few weeks the cure was complete.

Such accidents, attended with laceration of the integuments, fre-
quently demand amputation, or at least resection of the projecting
bone, but we think Mr. Miller is scarcely right when he says that
compound dislocations of the fingers almost always are of such severity
as to demand amputation. I have myself met with three other cases
which were reduced, and did well.

In one case of simple dislocation of the last phalanx of the thumb

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backwards I have been obliged to resort to section of the lateral liga-
ments before accomplishing the redaction. This was in the person of
a woman admitted to Bellevue Hospital in February, 1864. The acci-
dent had happened seven days before, by falling and striking npon
tlie end of the thumb. The position of the last phalanx was extended,
that is, in a line with the axis of the first phalanx. She said, how-
ever, that it was at first '* bent straight back," but that a man took hold
of it and pulled it out. Having placed her under the influence of
ether, I attempted reduction by forced backward flexion, but failed. I
then cut the lateral ligaments by subcutaneous incision, and the re-
duction was accomplished with great ease.



Ths femur is especially liable to dislocation in four directions,
namely, upwards and backwards upon the dorsum ilii, upwards and
backwards into the ischiatic notch, downwards and forwards into the
foramen thyroideum, and upwards and forwards upon the pubes.

Dislocations are occasionally met with which cannot be arranged
properly under either of these divisions ; indeed, it is scarcely neces-
sary to say that the head of the bone may be thrown in almost every
direction from its socket, upwards, downwards, inwards^ and outwards,
or in either of the diagonals between these lines ; and that while in a
vast majority of cases it will assume one of the positions first named,
it may in a few exceptional examples fall short of, or much exceed, the
limits assigned in this division. Thus, we shall have occasion here-
after to mention examples of dislocation directly upwards, in which
the head of the bone will be found re&ting upon the rossa between the
upper margin of the acetabulum and the anterior inferior spinous pro-
cess of the ilium, or still higher between the anterior superior and the
anterior inferior spinous processes, or a little to the one side or to the
other of these points. Examples will be shown of dislocations directly
downwards, in which the head of the femur will rest upon the notch
between the lower margin of the acetabulum and the tuber ischii, or
still lower, and actually below the tuberosity, or downwards and back-
wards below the spine of the ischium, into the lower or lesser sacro-
sciatic notch. The head may be thrust across the foramen thyroideam,
and be only arrested in the perineum upon the ramus, or even bejond
the ramus of the ischium and pubes ; it may lodge npon the anterior
surface of the body of the pubes, as well as upon its superior edge;
and finally, it may rest against the posterior margin of the aoetabalam
instead of rising upon the dorsum, or it may only mount upon its
margin, in either of the directions named.

In regard to frequency, the four principal dislocations occur in the
order in which we have mentioned them ; thus, of 104 dislocations of

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the hip which I have taken the pains to collate, excluding the anoma-
lous or extraordinary dislocations, and which my intelligent pupil, Mr.
Frank Hodge, has carefully analyzed, 55 were upon the dorsum ilii,
28 into the great ischiatic notch, 13 upon the foramen thyroideura, and
8 upon the pubes. Chelius and Samuel Cooper have, however, re-
versed the order of the last two varieties, arranging dislocations upon
the pubes, in the order of frequency, before dislocations into the fora-
men thyroideum.

Coxo-femoral dislocations may occur at any period of life ; a case
of thyroid dislocation is reported in the Lancet for May 16, 1868,
which occurred in a child six months old. Odc example is men-

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 73 of 100)