Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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tion of drilling or perforating the fragments in a case of ununited
fracture of the tibia, employing for this purpose a large gimlet. He
first bored two holes between the opposing fragments, and then, intro-
ducing the gimlet one and a half inch below the fracture, he pene-
trated the tibia upwards and inwards until he hadH^ra versed, also, the
upper fragment to the extent of an inch. In three weeks the bone
appeared firm, but from this time the patient was not seen.^

Brainard employs for this same purpose a strong metallic perforator,
consisting of a handle, into which points of different sizes may be in-
serted, and which have been hardened so as to penetrate the hardest
bone or even ivory in every direction easily. The points are "some-
what awl-shaped ; but more pointed in the middle rather than like a
drill, which leaves chips." His manner of using this instrument is as
follows : " In case of an oblique fracture, or one with overlapping, the
skin is perforated with the instrument at such a point as to enable it
to be carried through the ends of the fragments, to wound their sur-
faces, and to transfix whatever tissue may be placed between them.
After having transfixed them in one direction, it is withdrawn from
the bone, but not from the skin, its direction changed, and another
perforation made, and this operation is repeated as often as may be
desired." Dr. Brainard, who has already succeeded by this procedure
ifi a number of cases of ununited fracture, thinks it is better to com-

1 Brainard, Trans. Amer. Med. Assoc, vol. vii., 1854: Prize Essay. Report on
Surgery to Illinois State Med. Sotf., May, 1860.
« Miller, New York Joum. Med., July, 1848, p. 184.
> Sandford, Trans. Amer. Med. Assoc., vol. iii. p. 865, 1850.
* New York Med. Gazette, Oct. 12, 1850.



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70



DELAYED AND NON-UNION OF BROKEN BONES.



mence in most cases with not more than two or three perforations, in
order that the effect produced shall not be too severe. It is scarcely



Fig. 18.



^'^^MiiiiiiiiiTiii




Braiiutrd's perforator, redaoed one-half.



necessary to add that, after the punctures have been made, the limb
should be put completely at rest in appropriate splints, or in apparatus
of some kind.




The anthor*s bone-drlU.



Mr. Tieman has made for me a bone-drill which is rotated by the
movement of a handle upon a rod or shaft composed of twisted wire,
and which possesses the advantage of being worked with great facility
and rapidity. Perforators of any size or shape may be fitted to the
shaft at pleasure. In most cases I have found Brainard's drill a
better instrument than my own.

Scraping or rasping the ends of the bones is a practice which dates
from a very early period. Mr. Brodie scraped the ends of the bones,
and then interposed a bit of lint.^ Mayor, in 1828, contrived to intro-
duce an iron, previously heated in boiling water, through a canula,
and thus brought the heat to bear directly upon the ends of the frag-
ments ; and by repeating the application several times, a cure was
effected.'

Eesection of the ends of the bones, first brought into notice by White,
of Manchester, in 1760,' and opposed by Brodie* as dangerous, and
by Malgaigne regarded as generally useless or unnecessary, has still
been practised a great number of times, with more or less success. It
is especially applicable to superficial bones, and in cases where the
bones overlap.



» Brodie, Lond. Med. Qaz., July, 1884.

» Diet, de M6d., vol. xxiii. p. 508.

* Brodie, New Yorlt Joum., vol. yiii. Ist ser., p. 133



' Norris, loc. cit., p. 48.



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DELAYED AND NOK-UNION OF BROKEN BONES. 71

Boux practised resection in one instance, and then managed to en-
gage the point of one of the fragments in the medullary canal of the
other.^ I have succeeded in doing the same.

White, of Manchester, Henry Oline, of London, Hewson, Barton,
and Norris, of Philadelphia, have applied caustics directly to the ends
of the fragments, after having exposed them by a free incision.' Petit
applied the actual cautery.^

Tying the fragments together by means of metallic ligatures after a
recent fracture, is as old as the days of Hippocrates; but in 1805
Horeau adopted the same procedure in a case of ununited fracture.^
Since which date it has been practised successfully bv many surgeons.
My own experience confirms the value of the method, especially when
the fragments overlap.

E. S. Gaillard, of Louisville, Ky., proposes to secure the fragments
in place by means of a metallic pin. The instrument which he em-
ploys is composed of a steel shaft with a handle, a silver sheath, and
a brass nut. For a broken femur, the shaft is six inches long, its
lower extremity being constructed like a gimlet, while two and a half
inches of its upper extremity are cut for a male screw, being intended
to carry the brass nut. The sheath is three inches long.

Through an incision made over the seat of fracture, the sheath,
detached from the shafts is carried down to the bone. The shaft is then
passed through the sheath, and made to penetrate and transfix the two
fragments; as soon as this is accomplished, the nut is turned down
firmly upon the top of the sheath, and apposition of the fragments is
thus secured. The whole instrument is permitted to remain until bony
union is effected.*

Fig. 20.



Gaillard*! instrnment for onnnlted fhtetnres.



-Ml



Finally, having thus brought rapidly before us all of the various
modes of treatment which have been suggested and practised for non-
union of broken bones, we are prepared to affirm the following con-
clusions, or summary of what has been our own practice, and of what
we believe ought to be the general course of procedure in these
cases : —

First. Improve the condition of the general system.

Second* Kemove as far as possible the local impediments, such as a
separation of the fragments, local paralysis, local scurvy resulting
from long exclusion from light and air, congestions, &c.

> Norris, loc. cit., p. 49. « Ibid. » Ibid. « Ibid.

» E. S. GaUlard, New York Joum. Med., Nov. 18C5.



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i2 BENDING OF THE LONG BONES,

Third. Increase the action of the tissues immediately adjacent to
the fracture, upon which tissues, rather than upon the bone, as Mai-
gaigne thinks, the formation of callus depends. A theory which, as
applied to old and ununited fractures, we are not prepared to deny.
This may be accomplished by frictions, and violent flexions of the
limb at the seat of fracture ; possibly in some measure by the applica-
tion of vesicants or of other stimulants to the skin itself.
. Fourth. Emplov again compression and rest for a period of from
two to four or eight weeks.

Fifth. Resort to the method recommended by Brainard.
. Sixth. If in the lower extremity, allow the patient to walk about
with the fragments well supported.

Seventh. If the fracture is not in the femur, and as an extreme
measure, employ the seton, or resection.

Where these measures have failed, after a fair trial, we should
either abandon the case as hopeless, only supporting the limb by such
apparatus as may be found most serviceable, or we should recommend
amputation.



CHAPTER VII.

• INCOMPLETE FRACTURES.
BENDING, PARTIAL FRACTURES, AND FISSURES OP THE LONG BONES.

§ 1. Bending or the Lonq Bones.

Strictly speaking, no bone can be much bent without being also
more or less broken, and that whether it immediately and spontane-
ously resumes its position or not ; for, if the bending and straightening
of the bone be repeated a sufficient number of times, the yielding of
the fibres will become apparent, and at length the separation will be
complete. The first of this series of flexions was quite as much re-
sponsible for this result as the last, and, no doubt, performed its share
in the production of the complete fracture.

There could be no impropriety, therefore, in speaking of a bending
of the bones as a variety of incomplete fractures, as I have done in
the first section of my " Report on Deformities after Fractures," made
to the American Medical Association in 1865.*

They have been called, not inappropriately, interperiosteal fractures,
since in these cases the periosteum is not broken ; M. Blandin thinks
that the outer and semi-cartilaginous laminae of the bone also do not
break, while the deeper laminae suffer an actual disruption.' But it
is quite as probable that in a majority of cases the true pathological

« Op. clt., pp. 421-423.

« Markham'B Obs. on the Surg. Practice of Paris, London Med.-Chir. Rev., voL
xxxiT. p. 478, 1841.



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BENDING OF THE LONG BONES. 73

coBdition is a compressioa of the bony fibres upon one side, with a
corresponding expansion upon the opposite side, with only a slight
interstitial fracture, too trivial to be easily recognized even in the dis>
section. Sometimes, as I have several times observed in my experi-
ments on the bones of chickens, when the bones are small, and the
bending is near the centre of the shaft, the whole of the laminea on
the side of the retiring angle produced by the bending are doubled in,
or indented toward the hollow of the bone, so that the fibres on the
side of the salient angle are not even stretched, and much less broken.
In such cases, the interstitial disruption, if it exists at all, and I think
it does, first takes place in the deeper layers of the retiring angle.

I might, therefore, feel justified in continuing to call these cases
partial fractures, or, perhaps, interstitial fractures, but I believe that
the whole subject will be rendered more intelligible if I call them
simply bending of the bones, as distinguished from those other and
more palpably partial fractures of which I shall speak presently.

1. Bending with an immediaie and spontaneous restoration of the hone
to its original form. — The possibility of this accident, to which, however,
surgical writers have hitherto made no distinct allusion, is rendered
pertain by the following experiments : —

Experiment 1. — July 16, 1857. I bent the tibia of a Shanghai
chicken, four weeks old, at about the middle of the bone. It was bent
to an angle of quite twenty -five degrees, but it was not felt or heard
to break. It immediately and spontaneously resumed the straight
position.

July 18, two days after the bending, I dissected the limb, and found
no trace of the injury, either within or without the bone, unless I
except a very minute blood-clot in the centre of the shaft.

Experiment 2. — I bent the leg of a chicken, four weeks old, at the
same point and to the same degree. It immediately resumed the
straight position.

Dissection after two days. Nothing abnormal except a small blood*
clot in the centre of the bone, and a slight disorganization of the
medulla.

Experiments 3 and 4. — ^Bent both legs of a chicken, four weeks old,
at the same point, and in the same manner. They immediately re-
sumed their positions.

Dissection after two days. No lesions or morbid appearances which
I could detect.

Experiments 5 and 6. — Bent both wings of a chicken four weeks
old. Bent the right wing tq an angle of thirty-five degrees. I did
not feel them break. Both resumed their positions spontaneously.

Dissection after two days. No lesions or other morbid appearances.

Experiment 7. — July i6, 1867, 1 bent the leg of a Shanghai chicken,
five weeks* old, below the knee, and about the middle of the bone.
It was bent to an angle of about twenty -five degrees, but the bone was
not felt or heard to break. It immediately and spontaneously resumed
the straight position.

July 20, four days after the bending, I dissected the leg,. but could
not discover any trace of the injury, except that there was a very
6



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74: BENDING, PARTIAL FRACTURES, AND FISSURES.

minute ossific deposit in the centre of the bone, at the point at whicli
I suppose it to have been bent.

Experiment 8.— July 16, 1857, 1 bent the right leg of a Shanghai
chicken, five weeks old, at the same point as in the first experiment,
and to the same extent. The bone did not seem to break, but it
immediately and spontaneously resumed the straight position.

Dissection of ter four days. Nothing appeared to indicate the seat
of the bending except a small clot of blood in the centre of the shaft.

Experiment 9. — Bent the leg of a chicken, six weeks old, in the
same manner, and to the same degree, as in the other examples. It
resumed itd position spontaneously.

Dissection after ten days. No evidence of injury of any kind; the
bone being sound and straight.

These experiments were made in connection with others to whicli
more especial reference will hereafter be made. They are selected,
and constitute the whole number of those in which I did not feel the
bone break or crack under my fingers. In every instance the bone
sprung back immediately and spontaneously to its natural form. la
no instance could I afterward discover any trace of lesion, or sign
indicating the point at which the bone had been bent before dissection ;
nor did dissection itself disclose anything but the most inconsiderable
marks ; and that in but three examples.

I infer, therefore, not forgetting the caution with which the conclu-
sions from all such experiments ought to be applied to similar acci-
dents upon the human skeleton, that whenever the bones of healthy
infants have been slightly bent and not broken, they will, probably,
in most cases, unless prevented by causes foreign to the bones them-
selves, spontaneously and immediately resume their position; and
that no sign will remain to indicate that a bending has occurred. The
accident will not be recognized; and, as a farther inference, this
bending does not belong to that class of cases of which I shall next
speak.

2. Bending tuiihout immediate and spontaneous restoration of the hone
to its original form. — " Dethleef, believing that he had broken the two
bones of the leg of a dog, found the fibula bent without a fracture.
Similar results were obtained by Duhamel upon a lamb ; by Troja
upon a pigeon ; and I have myself twice succeeded in bending the
fibula while breaking the tibia. The possibility of simple curvature
is then not contestable" (the writer means to say that the possibility
of a simple curvature remaining permanently bent, is not contestable),
" but we must observe that they have never been obtained except
upon young animals, and that they have been unable to maintain
themselves permanently except through the aid of a fracture and dis-
placement of a neighboring bone; and there is a wide difierence
between these and those pretended curvatures which soine believe
they have seen in man, in which the curved bone maintains itself,
and resists perfect reduction until the fracture is complete."^

In this single paragraph Malgaigne seems to have given a fair sum*

I Traits des Frac, etc., par L. F. Malgaigne, torn. 1. p. 48.



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BENDING OP THE LONG BONES.



75



Fig. 21.



mary of the testimony upon this point. With the exception of these
and a few other similar examples, some of which I think I have ob-
served myself, where one of the bones of the forearm has been broken
and the other bent, I know of no well-attested cases of a permanent
bending ; using the term bending in a sense distinguished from a par-
tial fracture.

If, in numerous cases mentioned by surgical writers, there has seemed
to be probable evidence that the permanent bending was ynaccompa-
oied with fracture, there has always been wanting, so
far as I know, the positive evidence of dissection. The
example of partial fracture mentioned by Fergusson,
and represented by a drawing, is described as having
also, "toward the lower extremity, a slight indentation
and curve."* This was the radius of a child ; but how
long the child survived the accident, and what was the
condition of the ulna, we are not informed. The obser-
vations made by Jurine, of Geneva, in Switzerland,' by
Barton' and Norris,* of Philadelphia, all fail to furnish
any such conclusive evidence of the correctness of their
own views. Norris says that " Thierry, of Bordeaux,
Martin, and Chevalier, had all met with and published
cases of this kind prior to the appearance of J urine's
paper (in 1810), the former of whom asserts that Haller,
in experimenting upon the subject, had been able satis-
factorily to produce the same accident in young ani-
mals." For mvself, I cannot say how much confidence
we ought to place in these assertions of Thierry, Martin,
and Chevalier, having never seen the papers referred to ; but since
Dr. Norris has neglected to inform us whether any dissections were
ever made, we shall not be expected to regard their testimony as
conclusive.

With the qualifications now made, Gibson was more nearly right
when he said, " Dupuytren and Dr. John Rhea Barton have each fur-
nished accounts of bent bones. There are no such injuries, however, in
my opinion ; such cases being, in reality, partial fractures from which
deformities result upon the same principle that a piece of tough wood,
like oak or hickory, if broken half through, may be inclined to one
side and shortened, although still held together by interlocking of
fibres. Many specimens in my cabinet, and in the Wistar Museum,
attest the accuracy of this assertion."'

In my own experiments upon the chicken, the bones uniformly re-
sumed their original position as soon Ibis the restraining force was
removed, unless a fracture occurred, and this notwithstanding the
bones were bent quite abruptly and to an angle of twenty-five de-
grees. Certainly, if the bones of children may be bent during life




CaM mentloBed
hj Fergnston.



1 Practical Surgery, by William Fergusson, 4th Am. ed., p. 208.

« Jomm. de Corvisart et Boyer, torn. xx. p. 278, etc.

> Phila. Med. Recorder, 1821.

« Phila. Med. Jonm., vol. xxix. p. 283, 1842.

» Institutes and Practice of Surgery, by Wm. Gibson, Phila. 1841, vol. i. p. 264.



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76 BENDING, PARTIAL FRACTURES, AND FISSURES.

and be made to retain this position without a fracture, then the same
thing might be done upon the bones of children recently dead, and,
by successful experiments, this long-agitated question might be easily
and forever put to rest.

It will be understood that our observations are confined to the long
bones. That the flat bones, and especially the bones of the cranium,
in childhood, may be indented by blows, and remain in this condi-
tion, is undeniable. Scultetus says he had seen " the skull pressed
down in children, without a fracture, so that those who touch or look
upon it can perceive a small pit,"^ and it has been mentioned by many
writers since, and perhaps before his day. I have myself published
two examples of it in the second volume of the Buffalo Medical
Journal,^ and since the date of that publication I have met with
others.

§ 2. Partial Fbaotube of the Lonq Bones.

1. Partial Fracture with immediate and spontaneous restoration of
the bone to its original form. — No writer seems to have given any spe-
cial attention to the form of fracture now under consideration, although
its existence appears to have been occasionally recognized. In the
case reported by Camper, in 1765, of a partial fracture of the tibia,
the bone had regained its natural form, but whether immediately after
the accident occurred, or at a later period, I am not able to learn.*
Jurine, Gulliver, and others, have noticed a gradual straightening of
the bone after a partial fracture, so that its complete restoration has
been accomplished after several weeks or months ; but this, although
partly due to the same cause which produces occasionally an imme-
diate restoration, namely, its elasticity, is in part also due to other
causes, and will be more properly considered under the next division
of partial fractures.

Says Malgaigne : " Finally, at other times the fracture takes place
without opening and without curvature; the only sign which one can
recognize is a yielding of the bone under the pressure of the finger,
at the point of fracture; yet upon the living subject we may see the
same symptom pertain to complete and simple fractures without dis-
placement."*

In the following report of one of M. Blandin's clinics the accident
is described a little more distinctly : " In some cases of fracture of
the clavicle occurring about the middle of the bone in young sub-
jects, displacement of the fragments does not immediately take place,
thus giving rise to a risk of an error in diagnosis, by which the ulti-
mate probability of a cure is diminished. A lad seventeen years of
age was recently admitted into the H6tel Dieu, under the care of M.
Blandin, having, a few days previously, fallen upon one of his com-
rades while playing with him, when he instantly experienced pain



» The Cbirurgeon's Storehouse, by Johannes Scultetus, 1674, p. 126.
• Op. cit., p. 847, 1S46, Cases 1 and 2.

> Essays and Obs. Phys. and Lit. of Soc. of Edinburgh, vol. iii. p. 527.
« Op. cit., torn. i. p. 50.



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PARTIAL FRACTURE OP THE LONG BONES. 77

and a cracking sensation about the middle of the left clavicle, where
there soon formed a tumor, which increasing, induced him to entei^
the hospital. On examination, the swelling was found to occupy the
middle of the clavicle ; it was about as large as half a hen's egg, ovoid
in shapfe, well circumscribed, colorless, and hard, but sensible to pres-
sure. There was not any deformity of the shoulder, nor any abnormal
modification of the axis of the bone, to indicate the existence of a
fracture ; and although the different movements of the arm caused
pain in the shoulder, yet they could be made without much difficulty.

" The symptoms in this case would lead to the belief that it was a
case of simple periostitis, caused by external violence ; but M. Blandin
at once decided that there existed a fracture of the bone, having seen
a similar case previously at the hospital Beaujon, where the tumor
was treated as traumatic periostitis, the patient merely carrying his
arm in a sling, until, by a sudden movement of the limb, displace^
ment of the fragments was produced, and clearly demonstrated the
existence of a fracture. A second case occurring soon afterward, M.
Blandin profited by the experience gained from the preceding, and by
moving the fragments of the broken clavicle on each other, obtained
motion and crepitus. Still these indications were not so clear, that
M. Marjolin could diagnosticate a fracture ; he was of opinion that
the case was one of exostosis, probably syphilitic, and the crepitus,
he believed, depended on an erosion of the osseous surface. In con-
sequence, the patient was left to himself, until a movement of the arm
gave proof of the fracture by the displacement of the broken portions
of the bones.

" Two other cases occurring in young subjects have been admitted
since in the H6tel Dieu, under the care of M. Blandin, one of whom
was purposely left without surgical assistance, while Desault's bandage
was applied to the other. The former soon showed evidence of con-
secutive displacement ; the latter was cured without any deformity
following.

" The surgeon may diagnose a fracture, without displacement of the
middle portion of the clavicle, when a circumscribed tumor forms in
that part of young subjects, consecutive on a fall on the shoulder, and
motion of the fragments, with crepitus, can be detected, there not
being any syphilitic taint in the constitution.'"

The following examples, which have come under my own observa-
tion, will illustrate more completely the usual history and symptbms
of these cases : —

A. B., aged three years, fell from the sofa upon the floor, striking,
it is thought, on her right shoulder. Two days after this, she fell
again, and then for the first time, Mr. B. noticed the deformity. She
was brought to me three days after the second fall. There existed
then a round, smooth projection at the outer end of the middle third
of the clavicle. It felt hard, like bone. The line of the clavicle was
not changed. I advised a handkerchief sling, simply to steady and

' Am. Joam. Med. Sci., vol. xxxi. p. 473, from Journ. de MM. et Chlrurg. Prat.,
July, 1842.



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78 BENDING, PARTIAL FRACTURES, AND FISSURES.

support the arm. Seven months after the accident, she fell sick and
died. The projection continued at the time of death, only slightly



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 8 of 100)