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A practical treatise on fractures and dislocations online

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by a large and smooth bone, and the tendons have been stretched vio-
lently or torn completely asunder ; while occasionally large arteries,
which are prone to hug the bones about the joints, are lacerated and
left to bleed. That the importance of these complications, however,
may not be overestimated, we must state that Sir Astley Cooper him-
self has remarked how seldom, in compound dislocations of the ankle-
joint, the large arteries are injured ; that a tearing of the ligaments
and of the tendons is almost as likely to occur in simple dislocations
as in compound ; and, indeed, that in neither case are the tendons
usually ruptured, but only thrust aside. Moreover, the skin is ofben
made to give way not so much from the pressure of the round head
within, as from the equal pressure of some sharp angular body from
without. In all these respects, there are many examples of compound
fractures which possess not a whit of advantage ; in which oases, never-
theless, the surgeon feels very little doubt as to the ultimate cure.

In short, the causes which, according to Sir Astley Cooper, deter-
mine the extraordinary fatality of these accidents, do not sufficiently
differ from those which operate in compound fractures to occasion so
great a difference in results, and the fatality of compound dislocations

' Upon this point, see the very able article entitled " Ampntations and Gomponnd
Fractures/' by John 0. Btone, in the New York Journal of Medicine, vol. ill. of
2d series, p. 816, Nov. 1849.

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remains unexplained ; or if surgical writers have here and there in-
timated the true cause, they have failed to give it its proper place
and value.

I think the cause of the greater fatality of compound dislocations
over compound fractures is to be found in the simple fact that dislo-
cations are generally reduced, and by splints or other apparatus sac-
cessfully maintained in place, while compound fractures, as my
statistical report of cases has proven, are not generally reduced com-
pletely, nor can they by any means yet devised, except in a few cases^
be maintained in place if reduced. Broken limbs, whether simple or
compound in their character, will in a great majority of cases shorten
upon themselves in spite of the most assiduous and skilful attempts
to prevent it.^

In adults most bones break obliquely, and cannot be made to sup-
port each other, and even in transverse fractures the broken ends are
generally small compared with the articular ends of the same bones,
and afibrd a very uncertain and inadequate support for themselves;
not to speak of the difficulty of once bringing their ends into exact
apposition where the musctes are powerful, or where they lie imbed-
dea in a large mass of flesh so that they cannot be felt While, on
the other hand, dislocated bones, whether simple or compound, are
capable, when restored to place, of supporting themselves; or with
only slight assistance, their reduction may be maintained; it is also
ordinarily a work of no great difficulty to reduce them.

Herein, then, consists the most important difference between these
two classes of accidents, which are in other respects so similar. In
the one, the very nature of the injury prevents the complete reduc-
tion, and the consequent violent strain of the muscles, tendons, and
other soft tissues; while in the other, the nature of the accident leaves
it in the power of the surgeon to reduce the bones, and modern sur-
gery has in a great measure sanctioned the practice of maintaining
them in place, in defiance of the efforts of the muscles, and sometimes^
no doubt, at the imminent hazard of the life of the patient.

Is it not fair to presume that tissues which have been stretched and
lacerated, require rest in order that they may recover from the effects
of their injuries? And if the soft parts are really more injured in
dislocations than in fractures, does not the indication for rest become,
for this very reason, more imperative ?

Oeneral Inferences. — We have come, then, to regard the shortening
of limbs after fractures, within certain limits and in certain cases, as
a conservative circumstance rather than as a circumstance which the
surgeon should in all cases seek to prevent.

There is abundant evidence that the ancients had some knowledge
of the value of rest to the muscles, tendons, &c., in the prevention of
inflammation after compound dislocations, since they constantly urge
the greater danger of reducing these dislocations, than of leaving
them unreduced ; and they do not hesitate to recommend, that in case

1 ** Heport on Deformities after Fractures/' Trans. Am. Med. Assoc., vols, viii.,
ix. andx.

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violent inflammation supervenes upon the reduction, the bone shall
immediately be again dislocated. Gralen speaks very explicitly on
tbis subject, and says that "the danger in reduction consists partly in
tlie additional violence inflicted on the muscles, and partly ip their
"being then put into a stretched state, whereby spasms or convulsions
are brought on, and gangrene as the result of the intense inflamma-
tion which ensues ;" and Paulus ^gineta remarks : " For these, if re-
duced, occasion the most imminent danger, and sometimes death ; the
surrounding nerves and muscles being inflamed by the extension," &c.
I have already quoted from Sir Astley Cooper the causes or rea-
sons which he has assigned for the fatality of compound dislocations;
and the same reasons have generally been assigned by those who have
vrritten since his day ; but he has elsewhere, when speaking of ex-
section, given place to the very idea for which we claim so much pro-
minence, the danger arising from a stretching of the muscles. Mr.
Ijiston, also, and Mr. Miller, when speaking especially of dislocations
of the tibia at the ankle-joint, refer to the same source of danger.

Treatment. — Let us see now the alternatives which surgery presents
for the treatment of these intractable accidents.

1. Reduction of the bone.

2. Non-reduction.
8. Amputation.

4. Tenotomy.

5. Resection and reduction.

The questions for us to consider are, first, by which of these several
methods is the life of the patient rendered most secure ? and second,
where, of two or more methods, all are equally safe, by which will he
suffer the least maiming or mutilation ?

By Reduction, — We have seen already how the old surgeons re-
garded the practice of reducing com})ound dislocations of the large'r
joints. It is not difficult, however, to find in the records of surgery
numerous examples of successful terminations under this practice.

Dr. White, of Hudson, N. Y., has reported a case of this kind in
which the dislocation was at the ankle-joint.* Pott says he has seen
this practice occasionally succeed,' and Mr. Scott communicated to
the Lancet^ in March, 1887, a case of compound dislocation of the
humerus successfully treated by reduction. Sir Astley Cooper also
records several cases of compound dislocations at the lower end of the
tibia and fibula, successfully treated by reduction.

A careful examination, however, of those cases reported by Sir
Astley as having been reduced without resection, and which resulted
in cures, does not, in my opinion, leave much substantial evidence in
favor of the practice ; or perhaps we ought rather to say that it leaves
only a qualified evidence of its propriety in certain cases. He has
mentioned about sixteen of these examples, comprising dislocations of
the lower end of the tibia, or of the tibia and fibula, outwards, also
inwards and forwards, all of which, save one quoted from Mr. Liston, •

» White, Araer. Journ. Med. Scl., Nov. 1828, p. 109.
" Pott, Cbirurg. Works, vol. ii. p. 243.

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have been reported to him by other surgeons, and not one of which
had he ever seen himself. Many of the cases are reported very loosely,
evidently in reply to circular letters, and from memory, without re-
corded, notes, and by unknown, and in some sense irresponsible sur-
geons. It is not always said whether the wounds in the soft parts
were made by the protrusion of the bones, or by some external
violence ; yet this is certainly a very material point in determining
whether reduction is to be foUowea by inflammation or not The
results, sometimes only attained after exposure to great hazards, are,
after all, often sufficiently unfavorable.

It will be noticed, also, that in Cases 152 and 153, the astragalus
was comminuted and removed, either at first or at a later day; and
in Cases 154, 155, 156, and 160, the tibia, and also probably the
fibula, were broken, and it does not appear but that in consequence of
this complication the limb became shortened, and the muscles were
thus put at rest, very much as if the bones had been retracted; and
in one of the cases enumerated under 161, the lower end of the tibia
spontaneously exfoliated. That a comminution or that any fracture
of the astragalus, or of the tibia and fibula, should be regarded in these
cases as rendering the accident less grave, can only be comprehended
by a full appreciation of the value of relaxation of the muscles.

The few cases which remain after this exclusion do indeed illustrate
how nature and skill may triumph over great difficulties, but nothing

It is possible, also, that some of these examples of recovery after
reduction may admit of an explanation entirely consistent with oar
own views of the true source of the danger in these accidents, if indeed
they do not tend actually to confirm our doctrines. I have myself
seen one example of complete recovery after the reduction of a com-
pound dislocation at the ankle-joint, although resection was not prac-
tised ; but in this case, all the tissues, or nearly all which suffered any
injury, were completely torn asunder, and therefore wholly removed
from the danger of which we have spoken. The example to which
we allude is the following : On the 80th of Oct. 1858, John Bourquard,
88t. 30, was caught in the tow-line of a canal-boat, causing a compound
dislocation of the right ankle-joint. I found the foot, immediately
after the accident, thrown completely back against the lower part of
the leg, the integuments in front of the joint, as well as all of the ten-
dons and ligaments on this side, being completely torn asunder, while
the tendo- A chillis, and the tendons behind both of the malleoli, with
the corresponding integuments, were uninjured. This immunity of
the tissues behind the malleoli was due to the direction in which the
foot was drawn, namely, directly backwards. Everything which had
suffered a strain being thoroughly severed, I did not hesitate to attempt
to save the limb without resection. The reduction was accomplished
very easily. The leg and foot were placed in a box filled with bran,
and cool water dressings were applied to the portion which was ex-
posed. On the 22d of November the limb was removed from the
bran to a pillow, the union being sufficient not to demand so much

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lateral support. About the first of March he left the hospital, the
wound having closed, but the ankle remaining swollen and stiff.

I have also seen two cases in which the foot has been nearly
severed from the leg through the ankle-joint, by means of a " reaper."
In eacYi case the patient was standing with his back to the machine,
and one of the blades cut horizontally from side to side, severing
everything except about three inches of integuments in front, and
the extensor tendons of the toes. In the first instance, having seen
the patient, a gentleman nearly sixty years of age, within three or
four hours of the time of the receipt of the injury, 1 found him ex-
ceedingly exhausted by the hemorrhage. Both malleoli were cut off
smoothly, the knife, having severed the limb so exactly through the
joints as to have touched the cartilage at but one or two points. Having
secured the bloodvessels, I replaced the foot, and after a few days of
attendance I left him in the charge of an excellent young surgeon, Dr.
Rohertson, of Lancaster, N. Y., to whose diligence and skill the patient
is no doubt mainly indebted for his recovery. After the lapse of
nearly one year he was able, by the assistance of a shoe furnished with
lateral supports, to walk very well. In the second case, which was
only brought to my notice some months after the accident occurred,
in consequence of a troublesome fistula near the ankle-joint, the re-
covery had been complete except that a small fragment of one of the
malleoli was necrosed and required removal.

Dr. Eli Hurd, of Niagara Co., N. Y., was equally fortunate in a case
of compound dislocation of the shoulder-joint. This was in the person
of G. T., 8Bt. 80, who was caught in the gearing of a threshing-machine
on the 18th of Feb. 1852, which, having drawn him in with great force,
dislocated the head of the left humerus downwards through the integu-
ments into the axilla. Beduction was accomplished according to the
method recommended by Nathan Smith, by pulling from each wrist
at right angles with the body, while the operator himself seized the
naked bead of the humerus with his left hand, his right resting upon
the top of the shoulder, and pushed it into place. The time occupied
in the reduction was about thirty seconds. The forearm was then
suspended in a sling, and the venous hemorrhage, occasioned by a
rupture of the subclavian vein, was arrested by compression. The
tegamentary wound, between three and four inches in length, was
subsequently closed by sutures, and cool water dressings were applied.
On the fourth day the wound had united by first intention, and the
man was walking about his room. In less than a month he was dis-
missed cured, and in the following harvest he was able to cut his own
hay and grain, and to use his arm as before the accident^

Miller and Hoffman reduced successfully a compound dislocation

of the knee,^ and Galli has communicated a similar case to Malgaigne.'

Whether either of the last three mentioned examples admit of the

same explanation as the preceding three, I am unable to say, but

whether they do or do not^ they are too exceptional in their character

> Hurd, Buffalo Med. Joum., vol. ix. p. 119.

s Miller and Hoffman, London Med. Repos., vol. xxiv. p. 846.

< Galli, Malgaigne, op. cit., 1. 11. p. 958.

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to prejudice the argument materially which we shall hereafter make
in favor of resection.

Non- Reduction. — On the other hand, it will be very diflScult to find
an equal number of cases of compound dislocations, unreduced, which
have terminated favorably. The fact is, no doubt, that at the present
day very few surgeons would feel themselves justified in leaving a
bone out of place unless they proceeded to amputate. In the Tram-
actions of the New York State Medical Society for 1855, 1 have re-
ported (Case 16 of Tibia and Fibula, p. 87) a compound dislocation
at the ankle-joint, which, being unreduced, terminated fatally on the
twenty-eighth day. This is the only example of a compound dislo-
cation of a long bone, left unreduced, which has fallen under my
observation ; excepting, of course, those cases in which amputation
was immediately practised.

The united testimony, however, of the old surgeons, who generally
neither amputated nor adopted the method of resection, but who re-
commendea and practised non-reduction, is, that it is much more safe
to leave these bones unreduced, than to jreduce them without resec-
tion ; and I see no reason to doubt the correctness of their opinions
in this matter. But whether it would be more safe to leave such
limbs unreduced, or having practised resection to restore them, is
another question, in which the advantage and comparative safety of
the latter practice are too obvious to require explanation or defence.

Amputation, — Says Pott : '* When this accident (dislocation of the
ankle) is accompanied, as it sometimes is, with a wound of the integu-
ments of the inner ankle, and that made by the protrusion of the boue,
it not unfrequently ends in a fatal gangrene, unless prevented by
timely amputation, though I have several times seen it do very well
without." And Sir Astley Cooper, speaking of compound disloca-
tions of the ankle-joint, remarks: "Thirty years ago it was the prac-
tice to amputate limbs for this accident^ and the operation was then
thought absolutely necessary for the preservation of life, by some of
our best surgeons." Nor is it difficult to see by what reasoning sur-
geons of " thirty years ago" had fallen back upon this desperate remedy.
Both reduction and non-reduction having proven eminently hazardous,
in the absence of perhaps both knowledge and experience in resec-
tion, they finally adopted the alternative of amputation, as that which
after all must give to the patient the best chance for life; and were
no other alternatives to be presented; this would be our choice in a
large proportion of cases.

It must not be understood, however, that amputation is an expedient
wholly free from danger ; or, indeed, that the chances of the patient
are in the average very greatly increased by this practice. Of thirteen
amputations made for compound dislocations at the ankle-joint, in the
Eoyal Infirmary at Edinburgh, only two resulted in the recovery of
the patients.^ Alluding to which, Mr. Fergusson remarks: "An
amount of mortality which may well incline the surgeon to act upon
the doctrine inculcated by Sir Astley Cooper" (to attempt to save

» Edinb. Med. Monthly, Aug. 1844.

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the limb by reduction). But Mr. Fergusson has added a sentiment
Avhich accords very closely with my own experience and opinions.
"I fear, however, that in the attempts which have been made to save
the foot (by reduction), the results in all the cases have not met with
the same publicity — that the instances where amputation has been
afterwards necessary, or where death has been the consequence, have
not always been recorded ; and, from what I have myself seen, I would
caution the inexperienced practitioner from being over-sanguine in
anticipating a happy result in every example."

By Tenotomy. — As a means of overcoming the resistance of the
muscles, and for the purpose especially of facilitating the reduction,
tenotomy has been proposed. First by Dieflfenbach in cases of ancient
unreduced luxations ; but Wm. Hey, Jr., was the first to make a prac-
tical application of this suggestion in a case of compound dislocation.
After cutting the tendo-Achillis, the ankle being dislocated, the re-
duction was easily effected, but a strong tendency to displacement
backwards remained, and be was obliged afterwards to cut the ten-
dons of the tibialis posticus and flexor longus digitorum.^

This method, based in some degree upon a very correct notion of
the principal sources of difi&culty, I regard as totally impracticable,
at least to any useful or adequate extent. In order to be efficient, all
the tendons passing the articulations must be cut, or nearly all of
them ; and I doubt whether the judgment of any discreet surgeon
will ever sanction such an extreme, I might almost say such an ab-
surd, measure. Nor do I think that in the point of view in which we
are now considering this subject, having reference only to the ques-
tion of danger, if the cutting of the tendons was sufficiently extensive
to have any real effect in facilitating the reduction, the practice would
be found to have any advantage over other methods known to be
eminently dangerous.

By Resection. — Finally, resection presents itself for our considera-
tion as the only remaining surgical expedient.

We have seen that most of the early writers understood the effects
of a constant strain upon the muscles in increasing the danger of
spasms, inflammation, and death ; but in general they have suggested
no remedy but non-reduction or amputation. Hippocrates, however,
uses the following language, after speaking of resection of protruding
bones in accidental amputations or in fractures of the fingers : ** Com-
plete resection of bones at the joints, whether the foot, the hand, the
leg, the ankle, the forearm, the wrist, for the most part, are not at-
tended with danger, unless one be cut off at once by deliquium animi,
or if continued fever supervene on the fourth day." To which pas-
sage the translator adds the following note : " This paragraph on re-
section of the bones in compound dislocations and fractures contains
almost all the information on the subject which is to be found in the
works of ancient medicine." Celsus notices the practice of resection
in compound dislocations very briefly, as follows : " Si nudum os emi-

> Hey, Trans, of Provinc. Med. and Surg. Assoc, vol. xii. p. 171, 1844.

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net, impedimentum semper futurum est; ideo quod excedit^ abscin-
dendum est."

Mr. Hey, of Leeds, was the first of modem surgeons who called
especial attention to the value of resection in compound dislocationa.

Subsequently, Mr. Parks, of Liverpool, in an "Account of a New
Method of treating Diseases of the Joints of the Knee and Elbow,^
advocates the practice of resection in certain cases of diseases of these
joints, but especially in "affections of the joints produced by external

Mr. Lev^ille, in France, also following, as he affirms, the guidance
of Hippocrates, has advocated a similar practice.

Velpeau, Syme, Fergusson, Erichsen, Miller, Liston, Chelius, Liaars,
Gibson, Norris, under certain circumstances, and especially where the
bones cannot otherwise be reduced, and where the dislocations occur
in certain joints, and especially the elbow and ankle joints, recommend
resection. To which names we may add that of Sir Astley Cooper,
who has considered the subject, as applied to the ankle joint, quite at
length, and who says : " I have known no case of death when the ex-
tremities of the bone" (tibia, at the ankle) "have been sawed off,
although I shall have occasion to mention some cases which termi-
nated fatally when this was not done."

Why resection should diminish the danger to life, by placing at
rest the injured muscles, has been already sufficiently considered ; but
it seems not improbable that, if synovial membranes are actually
more susceptible of violent and dangerous inflammations than the
other tissues about the joints, then would this source of danger be
removed just in proportion as the synovial membranes themselves are
removed. Such, indeed, was the argument used by Sir Astley ; and
Mr. South, in a note to Ohelius, when referring to this fact, has made
the following statement : —

" In compound dislocations of the ankle-joint, with protrusion of
the shin-bone through the wound, most English surgeons saw off the
joint end, not merely to render reduction more easy, but also, accord-
ing to Sir Astley Cooper's opinions, to lessen the suppurative process,
by diminishing the synovial surface. This mode of practice is cer-
tainly not commonly followed in reference to other joints, and the
younger Cline was always opposed to its being resorted to in dislo-
cated ankle."

The following case, having occurred under my own eye, will serve
to illustrate the value of the principle which I have been endeavoring
to establish : —

Samuel Adamson, of Buffalo, sat. 24, was caught by the cable of a
vessel, June 17, 1855, dislocating the left tibia at its lower end in-
wards, and breaking the fibula two inches above the ankle. I was
immediately called, and found the tibia protruding through the skin
about three inches. The periosteum was torn up, and the cartilagi-
nous surface of the end of the bone was roughened. His thigh was
also severely bruised and lacerated, but the bone was not broken*

Dr. Boardman assisting me, we attempted to reduce the bones, but
with our hands we found it impossible to do so. I proceeded imme-

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cliatelj to remove abont one inch and a half of the lower end of the
ti'bia with the saw. The remaining portion was then brought easily
into place, and the woand dressed with sutures, adhesive straps, band-
ages, and light splints. On the same day he became an inmate of the

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 87 of 100)