Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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a way that the whole weight of the body was received on the right
foot, and that, at the moment she made an effort to check herself in
falling, she experienced extremely severe pain in this part, and heard
a very distinct snap ; she was unable to raise herself from the ground.
On the following morning Dupuytren reduced the bones with very
little difficulty by extension, combined with pressure against the dis-
located ends. The bones went into place with a loud snap, and in
two or three months she left the hospital, with only a little lameness.^

Mr. Smith, without intending to question the possibility of a sim-
ple luxation of the metatarsal bones, of which, indeed, Malgaigne has
collected a number of well-authenticated examples, is inclined to be-
lieve that, when a luxation of the bones of the metatarsus is the con-
sequence of a fall from a height, the individual alighting upon the
anterior part of the foot, it is, in general, that variety which has now
been described. And this aptness on the part of the cuneiform bone
to maintain its connection with the first metatarsal bone, he would
ascribe mainly to the fact that both the peroneus longus and tibialis
anticus have attachments to each of the bones in question.

» Robert Smith, Treatise on Fractures, &c., Dublin ed.# 1854, p. 324 et seq.
• Dupuytren, op. cit., p. 836.

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Luxations of one or more of the metatarsal bones, at the points
of their articulations with the tarsus, have been known to occur in
almost every direction. They may be occasioned by crushing acci-
dents, by machinery, or more often perhaps they have been caused
by a fall backwards or forwards when the anterior extremity of the
foot was wedged under some solid body and immovably fixed. They
may be produced also, probably, by simply striking upon the ball of
the foot in falling from a height. We have noticed, however, that
Mr. Smith inclines to the opinion that this will, in general, only pro-
duce the species of dislocation which he has particularly described.

The symptoms which characterize the dislocation of the whole
range of metatarsal bones upwards and backwards will, when the dis-
location is complete, resemble very much those which belong to the
dislocation described by Smith. The dorsum of the foot will be
shortened antero-posteriorly, the two arches of the foot will be lost
upon the plantar surface, or even actually reversed, a ridge will
traverse the back of the foot and a corresponding depression will
exist underneath.

In some cases, however, the dislocation is not complete, the articu-
lations being only sprung, and then there can exist no foreshortening
of the foot, and all the other signs will be less striking.

If only a single bone is luxated the diagnosis is generally very
easily made out, unless indeed considerable swelling has already oc-

Mr. South says that, in 1835, a case was admitted to St. Thomases
Hospital, under Mr. Green's care, of dislocation of the last two meta-
tarsal bones, occasioned by the falling of a heavy chest upon the inside
of the foot. Upon the top of the foot was a large swelling below and
in front of the outer ankle, and behind it a cavity in which two fingers
could be easily buried, in consequence of the bases of the metatarsal
bones having been thrown upwards and backwards upon the top of
the cuboid bone. The reduction was accomplished with much diffi-
culty by continued extension, and as the bones resumed their place a
distinct crackling was heard.'

Listen reduced a dislocation upwards of the first metatarsal bone;
Malgaigue mistook a dislocation of the fourth bone for a fracture, and
did not attempt the reduction until the seventh day, when, after five
successive trials, the head entered with a noise into its cavity. In a
dislocation of the second, third, and fourth metatarsal bones, he also

> South, Note to Chelius's Surg., vol. ii. p. 356.

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failed to detect the true nature of the aooident until the tenth day,
^w ben he proceeded to attempt reduction, but failed. Inflammation,
suppuration, and delirium followed, and the patient died on the forty-
first day. Tufnell failed in a similar case, although his patient finally
recovered with a not very useful limb. Malgaigne failed to reduce
the bones also in a recent case of luxation of the first four bones, al-
t^bough he used chloroform, and diligently tried various means. The
same writer has seen one example of ancient dislocation, which was
not recognized by the surgeon. Finally, Monteggia reports a case of
ciislocation of the last two metatarsal bones, which was not at the time
recognized. On the tenth day swelling commenced, and soon after
the patient died in convulsions.*

These references, drawn chiefly from Malgaigne, sufl&ciently illus-
trate the difficulty which surgeons have experienced in the reduction
of these bones, when a portion only is displaced. A difficulty which
is probably due to the fact that it is almost impossible to make ex-
tension upon a single metatarsal bone ; indeed, it is probable that by
pressure only upon the displaced head can we expect to accomplish
much in these accidents, and even this cannot be made to act very
effectively, owing to the small amount of surface presented against
which the force can be properly applied.

If, on the other hand, all the bones are dislocated at once, the
reduction is generally accomplished with ease by simple extension,
combined with properly directed pressure. Bouchard and Meynier
succeeded without difficulty in two cases of backward dislocation ;
Smyly was equally successful on the sixth day, in a case of disloca-
tion dfown wards. Laugier reduced an outward dislocation of all the
bones by pressure and extension easily ; and Kirk succeeded as well,
in an example of the opposite character, all the bones being carried

Mr. Sandwith has given us an account of a case which occurred in
his own person, from the fall of his horse upon his foot. " I was in-
stantly sensible,'' says Mr. Sandwith, " of the nature of the injury,
and as soon as I was upon my feet, the metatarsus was found to be
drawn upwards, and obliquely outwards upon the tarsus, by the action
of the flexor muscles. On the removal of the boot, which was cut
away, these were the appearances : the foot considerably shortened,
the toes turned a little outwards, and a hard swelling, bigger than an
egg, upon the tarsus, with tumefaction of the integuments. The pain,
which was great at first, was kept under by a warm fomentation.

" The reduction was easily effected by my friends Messrs. Williams
and Brereton, and leeches and bread and water poultices prevented
inflammation. For several nights the foot was violently shaken by
spasmodic action of the muscles, but the parts preserved their relative
situation ; and, although it was nearly a year before all lameness
ceased, yet at the end of six weeks I was enabled to lay aside my
crutches. For the ability to use the foot in so short a time, I was
indebted to a contrivance which rendered the foot and ankle inflexible.

» Malgaigne, op. cit., 1077 et seq. * Ibid., op. cit., p. lOSl.

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** Instead of an elastic sole to the shoe part of the apparatus, one of
wood was procured^ around the heel of which was nailed a pieoe of
firm, unbending leather ; this reached as high as the calf of the kg;
three small straps with buckles held the leg in situ, and a broader one
across the instep secured the foot. The comfort I experienced from
this simple apparatijs is my reason for describing it so particalarly ; it
has since been found useful in various injuries of the foot and ankleL^*

In one extraordinary case, however, Dupuytren was not so success-
ful. Paul Eudes, aet. 24, fell, while drunk, into a ditch six feet deep,
and alighted on the soles of his feet. The accident was followed by
great swelling, and he did not suspect the nature of the injury, nor
present himself at the hospital until three weeks after. Dupuytren
then ascertained that he had dislocated the metatarsal bones of both
feet. Several fruitless attempts were made to accomplish the reduc-
tion, but to no purpose, and in about two weeks he left the ho^itaL'



Dislocations of the toes are less common than those of the fingers^
yet a considerable number of cases have been recorded by different
surgeons. They are occasioned by blows received directly upon the
ends of the toes; by the weight of the body brought to bear suddenly
upon their plantar surfaces, as wl^en a horseman springs in his stirrup,
or by a fall, in consequence of which the rider hangs in his stirrup;
by leaping, &c.

They may be partial or complete ; and in the latter case, a slight
overlapping is generally observed. In a great majority of cases the
direction of the displacement is backwards, or with only a slight lateral
deviation. Occasionally several bones are displaced at the same time,
but usually only one suffers displacement It is more common here
to find compound and complicated dislocations than in the case of the

The position of the toes is not always the same in the same form of
dislocations. Thus, in the dislocation backwards, the toe is sometimes
reversed upon the foot to nearly a right angle, and at other times it is
found lying in the same axis as the metatarsal bone, or the phalanx,
from which it is luxated. About one year since, I reduced a backward
dislocation of the first phalanx of the second toe in the person of Lewis
Britton, »t. 60, who had fallen from a fourth-story window, striking
upon his feet, and breaking both thighs. I did not discover the dislo-
cation of the toe until sixteen hours after the accident It was then

J Sandwith, Amer. Joum. Med, Sci., Nov. 1828, p. 216, from Lond. Med. G«.,
vol. i.
« J)upuytren, op. cit., p. 329.

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lying parallel with the axis of the metatarsal bone, upon which it was
slightly overlapped. The reduction was effected easily by pulling upon
tVie last phalanx with my fingers, while at the same moment I pushed
tbe head of the bone toward the socket. No swelling followed, nor
has it troubled him at all since his recovery. •

With regard to the treatment, surgeons have ea^perienced the same
difficulty in certain cases of dislocation of the great toe as we have
seen experienced in similar dislocations of the thumb. Occasionally,
indeed, the reduction has been found to be impossible. The same
doubts have existed also in relation to the causes of this diflSculty, and
in reference to the means by which it was to be overcome. We shall
therefore refer the reader to the chapter on Dislocations of the First
Phalanges of the Thumb and Fingers, for a more full consideration of
tbis matter.

In case the smaller toes are luxated, the reduction is generally
effected with ease, by simple extension, or by extension combined with
pressure ; sometimes, also, the bone will be more easily put in place
hy reversing the phalanx more completely, as we have advised in cer-
tain cases of dislocation of the fingers.

If the skin is penetrated, it will often be found necessary either to
amputate or to practise resection upon the exposed phalanx.

Sir Astley Cooper relates a case of luxation of " all the smaller
toes," from the metatarsus, which had not been reduced, and the sub-
ject of which was, in consequence, so much maimed that he was unable
to labor. It had been occasioned by a fall, from a considerable height,
upon the extremities of the toes. A projection existed at the roots of
all the smaller toes, the extremity of each metatarsal bone being placed
under the first phalanx of its corresponding toe. The swelling which
immediately followed the receipt of the injury, had concealed its
nature, and now, several months having elapsed, reduction could not
be effected, ^he only relief which could be afforded him, therefore,
was in wearing a piece of liollow cork at the bottom of the inner part
of the shoe, to prevent the pressure of the metatarsal bones upon the
nerves and bloodvessels.*



Frequency of Compound as compared with Simple Dishcationa. — Com-
pound dislocations, as compared with simple, are of rare occurrence.
Of ninety-four dislocations reported by Norris as having been re-
ceived into the Pennsylvania Hospital for the ten years ending in
1840, only two were compound ;" and of one hundred and sixty-six

* Sir Ast. Cooper, op. cit., p. 385.

> Norris, Amer. Joum. Med. Bel., April, 1S41, p. 885.

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dislocations in my record of personal observation, only eight were

Relative Frequency in the Different Joints. — In my own recorded cases,
four were dislocations of the tibia inwards at the ankle-joint, one was
a partial (pathological) luxation forwards at the same joint, one was a
luxation of the astragalus, one a luxation of the head of the humerus
into the axilla, and one a forward luxation of the radius and ulna at
the wrist-joint. I have also met with several examples of compound
dislocations of the fingers. Both of the cases reported by Norris were
dislocations of the thumb.

Sir Astley Cooper, speaking upon this point, says that the elbow,
wrist, ankle, and finger joints are most subject to these accidents ; and
that be has seen but two in the shoulder-join t» and one in the knee-
joint. He had never seen a compound dislocation at the hip joints and
he believed that it was "scarcely ever" so dislocated. Mr. Bransby
Cooper, has, however, reported in detail a very interesting case of this
accident communicated to him by Dr. Walker, of Charlestown, Mass^
in which reduction was accomplished by manipulation alone, by Dr.
Ingalls on the second day. The patient aied at the end of about three
weeks.^ So far as I know, this is the only case upon record. Mal-
gaigne says that a compound dislocation at the hip-joint has probably
never occurred.

Among the cases of compound dislocation recorded by Sir Astley
and Bransby Cooper, most of which were communicated to these gen-
tlemen by other surgeons, 45 were dislocations of the ankle, 10 of the
astragalus, 4 of the ulna at the wrist-joint^ 4 of the thumb, 2 of tbe
knee, 1 of the shoulder, 1 of the elbow, 1 of the radius and uhia at
the wrist^ 1 of the scaphoid bone, and 1 of the metatarsal bone of the
great toe. Other writers have occasionally described compound dis-
locations of the clavicle, but I know of no record of a compound dis-
location of the lower jaw.

Prognosis, as determined by the Mode of Treatment adopted by most of
the Ancient and many of the Modem Surgeons. — By most of the early
writers these accidents, whenever they occurred in the larger joints,
were regarded as nearly beyond the reach of art. Says Hippocrates:
"In cases of complete dislocation at the ankle-joint, complicated with
an external wound, whether the displacement be inwards or outwards,
you are not to reduce the parts, but let any other physician reduce
them if be choose. For this you should know for certain, that the
patient will die if the parts are allowed to remain reduced, and that
he will not survive more than a few days, for few of them pass the
seventh day, being cut off by convulsions, and sometimes the leg and
foot are seized with gangrene." Hippocrates adds : " But if not re-
duced, nor any attempt at first made to reduce them, most of such

1 For the most of these cases, see Transactions of the New York State Med. See.
for 18(>5, article entitled ^'Report on Dislocations, with especial reference to their
Results/' by F. H. Hamilton.

« A. Cooper, on Dislocations, &c., by B. Cooper, p. 59.

* Works of Hippocrates, Sydenham cd., London, vol. ii. p. 684.

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The same remarks are applied by Hippocrates to compound dislo-
cations of the head of the tibia, of the lower end of the femur, of the
wrist, elbow, and shoulder joints; death occurring in all cases, as he
believes, more or less speedily whenever the bones are reduced and
retained in place a sufficient length of time, and " were it not that the
physician would be exposed to censure," he would not reduce even
the bones of the fingers, since it must be expected, he thinks, that
their articular extremities will exfoliate even when the reduction is
most successful.

I shall presently show, however, that even Hippocrates advised and
probably practised resection in certain cases of these accidents.

Both Celsus and Galen adopt almost without qualification the line
of practice laid down by Hippocrates, and affirm equally the danger
and almost certain death consequent upon the reduction of compound
dislocations in large joints.^ Celsus recommends resection in some

Faulus jEgineta, however, and after him Albucasis, Haly Abbas,
and Bhazes, do not regard the rules established by Hippocrates, in
relation to the non-reduction of the bones, as so imperative, nor the
results of the opposite practice as so uniformly fatal.

" Hippocrates remarks," says Paulus jEgineta, " in the case of dis-
locations with a wound, the utmost discretion is required. For these,
if reduced, occasion the most imminent danger, and sometimes death,
the surrounding nerves and muscles being inflamed by the extension,
so that strong pains, spasms, and acute fevers are produced, more par-
ticularly in the case of the elbows, knees, and joints above, for the
nearer they are to the vital parts the greater is the danger they induce.
Wherefore, Hippocrates, by all means, forbids us to apply reduction
and strong bandaging to them, and directs us to use only anti-inflam-
matory and soothing applications to them at the commencement, for
that by this treatment life may sometimes be preserved. But what
he recommends for the fingers alone, we would attempt to do for all
the other joints; at first and while the parts remain free from inflam-
mation, we would reduce the dislocated joint by moderate extension,
and if we succeed in our object, we may persist in using the anti-
inflammatory treatment only. But if inflammation, spasm, or any of
the aforementioned symptoms come on, we must dislocate it again if
it can be done without violence. If, however, we are apprehensive of
this danger (for perhaps, if inflammation should come on, it will not
yield), it will be better to defer the reduction of the greater joints at
the commencement; and when the inflammation subsides, which
happens about the seventh or ninth day, then, having foretold the
danger from reduction, and explained how, if not reduced, they will
be mutilated for life, we may try to make the attempt without violence,
using also the lever to facilitate the process."^

In the following quotations from three of the most celebrated
writers of the last two centuries, we find but little if any evidence

' Paulus ^gineta, Syd. ed., vol. ii. p. 510.
8 Ibid., p. 509.

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that the opinions of the fathers upon this subject were not still held
in general respect: "If the joint be dislocated, so that it is either
uncovered, or a little thrust forth without the skin, the accident is
mortal, and of more danger to be reduced than if it be not reduced.
For if it be not reduced, inflammation will come upon it, convulsion,
and sometimes death. 2. There will be a filthiness of the part itself.
8. An incurable ulcer, and if perhaps it be brought to cicatrize at all,
it will easily be dissolved by reason of the softness of it ; but if it
be reduced, it brings extreme danger of convulsion, gangrene, and

'' Si vero in magnis articulis tam valida fuit facta luxatio, ut liga-
mentis ruptis os articuli multum sit protrusum per integumenta, hsec
pars ossis vasis privata moritur, citins autem si reponatur, quam si
non reponitur ; quare sola amputatio restat ad conservationem vitse.'"^

Heister, who makes no allusion to this subject in the first edition
of his great work, published at Amsterdam in 1739, adds the following
remarks in his last edition, translated and published in London in
1768 : "Dislocations attended with a wound, especially of the shoulder
or thigh-bone, are of very bad consequence, and often endanger the
life of the patient; in Celsus's opinion (Book VIII., Chap. XXV.).
whether the bones be replaced or not, there is generally great danger;
and so much the more the nearer the wound is to the joint. Hippo-
crates has declared that no bones can be reduced with security, b^de
those of the hands and feet. ( Vectiar. 19, 6.) See more on this subject
in that passage of Celsus just now quoted, though I by no means re-
commend the following him implicitly."*

Such were the extreme views as to the fatality of these accidents,
and of the feebleness of our resources, entertained by the ancient^ and
even by the more modem writers almost down to our own day ; with
only rare exceptions these limbs were condemned either to great and
inevitable deformity, or to amputation. Nor, if we speak only of
their fatality, have surgeons ceased to regard these accidents as among
the most grave with which they have to deal.

Pathology and Appreciation of the Sources of Danger as compared
especially with Compound Fractures. — The danger, according to Sir
Astley Cooper, consists in the rapid inflammation of the synovial
membranes, which is speedily followed by suppuration and ulceratioD
whereby the ends of the bones become exposed ; and for the repair of
which lesions great general as well as local efforts are required, and
a high degree of constitutional irritation results. In addition to which
circumstances, " the violence inflicted on the neighboring parts, the
injury of the muscles and tendons, and the laceration of bloodvessels,
necessarily lead to more important and dangerous consequences than
those which follow simple dislocations." '

The sources of danger enumerated by Sir Astley Cooper have been

1 ** Chirurgeon's Storehouse.'* By Johannes Scultetus, of Ulme, in SneTia.
London ed., 1674, p. 81.

< Johannes de Gorter. Chinirgia repurgata. Lngdani Batavorem, 174S, t. 86.

» General System of Surgery, by Dr. Laurence Heister. 8th ed. London, 1768.
Vol. i. p. 164.

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regarded as suflBcient to account for their extraordinary fatality by
the majority of those modern surgical writers who have alluded to
the subject; but I must confess that to me they do not appear so. In
compound fractures the mortality is far less ; yet one might naturally
suppose, that when the sharp and irregular fragments are pressing
into the flesh, among nerves and bloodvessels, the irritation and in-
flammation would be equal, if not more than equal, to the irritation
and consequent inflammation produced by exposing a joint surface to
the air; indeed, modern experience has sufficiently shown that these
surfaces are much more tolerant of atmospheric exposure, and of the
action of many other irritants, than surgeons formerly supposed. A
clean incision into a large joint, which exposes the synovial mem-
branes to the air, and which permits the products of inflammation to
escape freely, is attended with much less danger than a small punc-
ture which does not at all permit the air to enter, nor the increased
synovia and the pus to escape. Very grave results sometimes follow
from large wounds into large joints, but under judicious treatment
such results are the exception and not the rule.^ But Sir Astley evi-
dently attributes more of the bad consequences to the exhausting
effects of the efforts at repair, than to the immediate inflammation re-
sulting from the exposure of the joint. It is pretty certain, however,
that a majority of these patients die at a period too early to render
this cause in any considerable degree operative.

As to the bruising of the " muscles and tendons, and laceration of
bloodvessels," it cannot be denied that it must usually be greater than
in "simple dislocations;" and I will not say that it is not in a given
number of instances greater than in the same number of instances of
compound fractures. The tissues have often been thrust rudely through

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 86 of 100)