Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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H. S., aged six years, was thrown from a horse, partially breaking
his left clavicle, near its middle. Dr. Sprague, of Bufl'alo, was em-
ployed. The projection in front was for several days very apparent,
and was examined by myself at Dr. Sprague's request. The bone did
not seem to be out of line. Five years after the (iccident, I examined
the lad, and could not find any trace of the original injury.

September 25, 1855. Mrs. T. 0. brought to me her infant child,
then but two weeks old. Upon the left clavicle, at a point a little
nearer the acromion process than the sternum, was an oblong swelling,
three-quarters of an inch in length, smooth and hard like callus ; the
skin was not reddened, nor tender. There was no motion or crepitus,
and the line of the axis of the bone was perfect. The mother, who
had been put to bed by a midwife, thinks the injury occurred in the
act of birth, although she did not notice the swelling until a week

October 20. Nearly one month later, I found no change in the con-
dition of the bone ; the hard lump remained, but it was still entirely
free from tenderness. I have not seen the child since.

An infant boy, three years old, fell, August 12, 1857, from the hands
of the nurse. The child cried, but the point of injury was not de-
tected until the third or fourth day, although the mother examined the
shoulders and neck carefully at the time. She is quite certain that if
any swelling or discoloration had been present, she would have seen it
then, or oh the subsequent days, while washing and dressing the child.
When first seen it was very distinct, but not so large as at present.

August 19. The child was brought to me. A little to the sternal
side of the middle of the right clavicle there was an oblong node-like
swelling, of the size of the half of a pigeon's egg, hard, smooth, and
feeling like bone; there was no discoloration or swelling of the integu-
ments ; no crepitus or motion ; the line of the clavicle seemed nearly
or quite unchanged.

I have not noticed this variety of accident in -any other bone except
the clavicle, yet it is not improbable that it happens occasionally, and
perhaps quite as often, in other long bones, but that its existence is
not elsewhere so easily recognized.

Of one hundred and five fractures of the clavicle recorded by me,
twenty-two were partial fractures ; and of these six were spontaneously
and immediately restored to their natural axes.

In explanation of the fact that hospital surgeons have not observed
so large a proportion of partial fractures of the clavicle, it must be
stated that nearly all these cases of partial fracture were drawn from
private practice. Accidents of this class may be often met with in
dispensaries, but they are seldom found in hospitals.

ilxperitnenL — In fourteen experiments upon the bones of chickens,
a partial fracture, with immediate and spontaneous restoration, has
occurred but once. In nine of these cases the bones were only bent,
and in five they were partially broken ; an immediate restoration has

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occurred, therefore, in one case out of five of partial fraciare ; while
in my reported examples of partial fracture of the clavicle it has been
noticed about once in every three or four cases. The following is the
experiment to which I have referred : —

I produced a partial fracture of the tibia in a chicken six weeks old.
The fracture was near ^ the middle of the bone. I felt it break under
my finger; but on removing the pressure, it immediately and spon-
taneously resumed the straight position.

I dissected the limb on the tenth day. The line of the axis of the
bone was perfect; but on the fractured side was a node-like enlarge-
ment, sufficient to be distinctly felt and seen before the soft parts were

Pathology, — ^In no case,-except in my single experiment upon the
bone of a chicken, has the actual condition been determined by dis-
section, and if any question has existed heretofore as to the possibility
of an immediate and spontaneous restoration after a partial fracture,
this experiment ought to decide it in the affirmative ; but then.the first
nine experiments already quoted have shown that a mere bending with
immediate restoration leaves no such traces or signs as have been de-
scribed as following these accidents. We have, therefore, the negative
argument that, since a bending with restoration leaves no signs, these
examples reported by myself and others as having occurred, and as
having been followed by a node-like swelling, etc., must have been
partial fractures. Moreover, in one of the cases of immediate resto-
ration reported by Blandin, there was a feeble crepitus: and in
another, the subsequent displacement proved the correctness of his
di agn osis.

We conclude, then, that these are examples of partial fracture, but
that the number of bony fibres which have given way are too incon-
siderable, as compared with those not broken, to affect materially the
elasticity of the bone.

Diagnosis. — The diagnosis will depend somewhat upon the history
of the accident as well as upon the present symptoms. In no instance,
where I could ascertain the cause, have I known an incomplete frac-
ture of this variety produced by any other than an indirect blow; and
where the clavicle has been the seat of the fracture the counter-blow
has been received upon the end of the shoulder. The fact possesses,
therefore, equal significance in its relation to either of the varieties of
partial fracture ; but in the case of a partial fracture with a permanent
curvature, the diagnosis would be complete without the history, while
in this case it might not be, and a knowle4ge of the manner in which
the accident occurred would, therefore, be of great importance.

The signs, then, after a knowledge of the fact that a blow has been
received upon the shoulder, are a node-like swelling upon the anterior
or upper face of the clavicle, generally in its middle tnird, this swell-
ing being hard, smooth, oblong ; the skin only slightly or not at all
swollen or tender, and in no way discolored, as it would have been
had the swelling upon the bone been the. result of a direct blow, and
the line of the axis of the bone unchanged. I have never detected
motion or crepitus at the point of injury, yet we have seen that Blan-

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din was able to detect both in one instance ; nor has it ever occurred
to me to see the swelling upon the bone until two or three days after
the injury was received. We are not likely, therefore, to recognize
this accident immediately after its occurrence.

IVeatment. — In the case of the clavicle, neither bandages, slings,
compresses, nor lotions can be of much service. Yet no harm can
arise from employing a simple sling and roller to confine the arm ;
and it is always proper to enjoin some degree of care in using the arm
of the injured side. The consolidation will be speedily accomplished,
and after a time the ensheathing callus will wholly disappear.

If a similar accident should occur in any other of the long bones,
as retentive and precautionary means, splints ought to be applied, at
least for a few days.

2. Partial Fracture without immediate and spontaneous restoration of
the bone to its natural form. — The causes of this accident are the same
with those which produce simple bending, or partial fracture with im*
mediate and spontaneous restoration, from which latter they diflfer
probably in the greater extent of the bony lesion. Perhaps, also, they
difier sometimes in the peculiar form and degree of the denticulation
at the seat of the fracture; in consequence of which an antagonism of

Fig. 22. Pig. 23,

PartUL fraetare of the claTicle wlthoat sponUneous restoration. From
nature ; taken three weeke after the accident

the fibres takes place, preventing a restoration of
the bone to its original form.

They constitute a large majority of those ex-
amples of partial fracture which come under our
observation in the various long bones. In one hun-
dred and five fractures of the clavicle, it has been
Partial fracture witt- otg^ryed by mc sixtccu timcs. In two hundred

out re«loration . of the - , r '^ ^ r a.i- J* J i -^ i.

bone to lu natural form, and uinc fracturcs of the radius and ulna, it has
occurred twelve times.
It has not happened to me to meet with this fracture in any other
bone ; but examples have been mentioned as having occurred in the
humerus, ribs, femur, tibia, and fibula.

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Very few surgeons have spoken of partial fractures in the clavicle,
while Jurine, Syme, Liston, Miller, Norris, and many others, have
declared that it is much more frequent in the bones of the forearm
than elsewhere. This does not agree with my experience, according
to which it occurs oftener in the clavicle than in the forearm ; a
discrepancy which I cannot very well explain, except by supposing
that, in the case of the clavicle, the accident has either been over-
looked entirely or misapprehended. Blandin, who, we have seen, has
reported five cases of partial fracture of the clavicle with immediate
restoration, states distinctly that in two of these cases distinguished
surgeons of Hdpital Beaujon and Hotel Dieu failed to recognize it.

Says Turner : " The next I shall descend to is that of the clavicle or
coUaj^-bone, which I have found the most frequently overlooked, I
think, of any other, till it has been sometimes too late to remedy,
especially among the children of poor people ; for, though they find
these little ones to wince, scream, or cry, upon the taking off or putting
on their clothes, yet, seeing that they suffer the handling of their
wrists and arms, though it hd with pain, they suspect only some sprain
or wrench, that will go away of itself, without regarding anything
further or looking out for help; whereas, this fracture discovers
itself as easily as most others. For not only the eye, in examining
or taking a view of the part, may plainly perceive a bunching out or
protuberance of the bones when the neck is bared for that purpose,
with a sinking down in the middle or on one side thereof, which will
be still more obvious on comparing it with its fellow on the other
side ; but when it is more obscure, and the bone, as it were, cracked
only — a semi-fracture^ as we say — ^yet, by pressing hard upon the part,
from one extremity to the other, you will find your patient crying
out when you come upon the place ; and by your fingers, so examining,
sometimes perceive a sinking farther down, with a crackling of the
bone itself."^

Erichsen, who regards all of these cases as mere bendings of the
bones, remarks that it "most commonly occurs in the long bones,
especially the clavicle, the radius, and the femur."' He says, more-
over, " Fracture of the clavicle in infants not unfrequently occurs, and
is apt to be overlooked. The child cries and suffers pain whenever
the arm is moved. On examination, an irregularitv, with some
protuberance, will be felt about the centre of the bone."* The reader
will not fail to recognize in these symptoms the incomplete fracture
of which we are now speaking, although Erichsen evidently believes
them to be examples of complete fracture.

In addition to this testimony as to the frequency of thqse fractures
in the clavicle, I will only mention that Johnson, in his review of
Markham's Observations on the Surgical Practice of Paris, says that
" many surgeons have noticed the incomplete fracture of the clavicle,
as of other bones, which takes place in the young."^

> Art of Sorgery, by Daniel Turner, London, 1742, yol. ii. p. 256.

> Science and Art of Surgery, Phila. ed., 1854, p. 180.

> Science and Art of Surgery, Phila. ed., 1854, p. 205.
* Lond. Med..Chir. Rev., vol. xxxiv. p. 474, 1841.

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Fig. 34. Pathology, — The following experiment will assist

in the elucidation of this point of our subject: —

ExperimenL — I bent the leg of a chicken five
weeks old. It cracked under my fingers, and re-
mained bent. Having waited a few seconds, and
finding that it was not restored to position, I pressed
upon it and made it straight. The chicken walked
oflF without any limp.

On the fourth day, before dissection, the bone
looked as if it was still bent ; but on removing the
soft parts, the line of the axis of the bone was found
to be straight. The areolar tissue under the skin
was infiltrated with lymph, which was most i^bun-
dant near the fracture, and gradually diminished
towards each extremity of the limb. This eflFusion
was confined almost entirely to the front of the limb,
or to that side which had been broken, and consti-
tuted the greater part of the enlargement which I
had noticed before the dissection was commenced,
and which then felt like bone.

On the front of the bone, also, underneath the pe-
riosteum, there was a loose, honeycomb deposit of
ensheathing callus, about one line in thickness, and
extending upward and downward about half an inch.
This callus surrounded the bone in three-fourths of
Partial fracture after j^ circumfereucc I but thcrc was no callus on its

nnlon is oonsammated. ^. « '-.^ ij/*-^ ,ii

posterior surface. It was also deficient exactly along
the line of fracture, in front and on the sides, in consequence pf which
an oblique groove remained, indicating the seat of the fracture.

In three other experiments, the particulars of which are detailed in
the earlier editions of this book, similar results were obtained.

So early as the year 1673, a dissection made by Glaser demon-
stratea incontestably the existence of partial fractures in the shafb,
and in the direction of the diameter of long bones.^ Camper, in
1765, again described a specimen which he had seen;' and Bonn,
in 1783, added a third positive observation.*

M. Gimele is, therefore, in error when he ascribes to Campaignac
the credit of having first proven by dissection their existence, in a
paper communicated to the Academy of Medicine at Paris, in 1826.
Campaignac, however, seems to have been the first who described
very particularly the condition of this fracture. He has recorded the
history and dissection of two cases, one of which occurred in the
fibula, and one in the tibia. The first of these cases was a girl twelve
years old, who survived the accident just eight weeks. The fracture
had occured near the middle of the bone, and upon the interior and
internal side ; in which direction, resting against the tibia, the bone

* Malgalgne, op. cit., p. 44, from Th. Boneti Sepulchretum, 1700, torn. iil. p. 424.

• Essays and Obs. Phys. and Lit. of Soc. of Edlnburflrh, 1771, vol. ill. p. 537.

' Malgalgne, op. cit., p. 44, from Descrlpt. Tlies. Ossium Morb. Hoviani, 1783.

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was found incliDed. "The bony fibres bad been broken at different
lengths, almost exactly like what takes place in the branch of a tree
which has been partially broken ; and, as we see sometimes in this
latter case, the bundles of splintered bony fibres abutted upon them-
selves, and did not take their places when we endeavored to restore
them ; so the abnormal angle which the fibula represented could not
be efiaced, the ends of the divided fasciculi not restoring themselves
to their respective places. This disposition might be especially seen
toward the anterior part of the internal face, where a packet of fibres,
coming from below, was braced against the upper lip of the division,
which it thus held open. This opening at first made me think that
the fragments could not have been well consolidated; but I assured
myself that it was, and the fact was subsequently confirmed by the
Academy of Medicine; all the points which were in contact were
found intimately united."*

Diagnosis. — The diagnosis is not difficult. The distortion indicates
sufficiently the existence of a fracture, while the complete absence of
crepitus in nearly all cases, and of either overlapping or lateral dis-
placement^ must, generally, especially where the accident has occurred
in a child, sufficiently indicate that the fracture is incomplete. It will
assist the diagnosis also to notice that these accidents are almost con-
fined to the middle third of the long bones ; and they are produced
usually by a bending of the bones, the forces operating upon the
extremities, and not directly upon the point which is broken.

In complete fractures, also, preternatural mobility is so constant a
sign as to be regarded as diagnostic, while here there is almost' always
a great degree of immobility at the seat of fracture. The angle made
by the projecting extremities is usually rather gentle and smooth ;
at other times it is abrupt, indicating a greater amount of fracture, or
that the outer fibres are broken more irregularly. The power of using
the limb is generally sensibly impaired, but ubt completely lost.

Treatment. — Jurine, Murat, Oampaignac, Gulliver, Malgaigne, with
some others, have noticed the fact that it is often difficult, and some-
times quite impossible, to restore these bones to position; a cir-
cumstance which they have justly ascribed to that condition of the
fragments described by Campaignac. The broken extremities of the
&sciculi become braced against each other, and effectually resist all
efforts to straighten the bone ; unless, indeed, so much force is used as
to render the fracture complete : a result which, if it should chance to
happen, need not occasion any alarm, since, while it enables us at once
to restore the bone to line, it does not much increase the danger of
lateral displacement and overlapping. That the fracture has become
complete we may know by a sudden sensation of cracking, by the in-
creased mobility, and by the crepitus which is now easily developed.

But we need not, on the other hand, be over-anxious to straighten
the hone completely, since experience has shown that after the lapse
of a few weeks or months the natural form is usually restored spon-

^ Des Fractures Incompletes et des Fractures Longitudinales des Os des Membres ;
par J. A. J. Campaignac. Paris, 1829, pp. 9-10.

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taneously. I am not now speaking of those cases in which the resto-
ration occurs immediately, where it is probable that the splintered
fibres offer no resistance to the restoration ; but only of those in which
the bone straightens so gradually as to induce a belief that the broken
ends are the cause of the resistance. To this variety of accident belong
cases one, five, six, seven, and eight, published in my Report on De-
formities after Fractures;* in one of which the natural axis was resumed
in less than four weeks. In a case mentioned by Gulliver, it required
about the same time to render the bones of the forearm perfectly
straight; and in one case mentioned by Jurine, at the end of si3C
months it was " diflScult to say which arm had been broken, and at
the end of one year it was impossible."

Jurine attributes this restoration to "muscular action, or more
especially to the reaction of the compressed bony plates;" but while
it is easy to understand how the reaction of the compressed fibres
may accomplish the gradual restoration, I am unable to understand in
what manner muscular action contributes to this result, since most of
the muscles attached to the long bones operate so much more ener-
getically in the direction of their axes than in the direction of their
diameters. Indeed, we have often seen these bones bent after com-
plete fractures, and before the union was consummated, by muscular
action alone.

I repeat, then, that the gradual restoration of these bones is due to
the same circumstance which produces at other times an immediate
restoration, namely, the elasticity of the unbroken fibres, but which
elasticity, in this latter instance, is, for a time, efiectually resisted by
the bracing of the broken fibres. At length, however, in consequence
of the gradual absorption of the broken ends, the resistance is removed,
and the bone becomes straight. If this absorption refuses to take
place, and the fibres continue pressed forcibly against each other, as
in the case described bjr Campaignac, then the bone remains perma-
nently bent.

Having straightened the bone as far as is practicable, it only re-
mains to secure the fragments in place by suitable bandages or splints.
If the restoration is incomplete, these means may assist the efforts of
nature in accomplishing a gradual restoration.

It is scarcely necessary to say that extension and counter-extension
avail nothing in partial fractures.

§ 3. Fissures.

These constitute the second principal form of incomplete fractures,
or those in which the fracture is accompanied with no appreciable
bending, which occur almost exclusively in inflexible bones, such as
the compact bones of adults, and more often in the direction of their
axes than of their diameters. They are complete so far as they extend,
but they do not completely sever the bone so as to form two distinct
fragments. They have been most frequently observed in the flat

> Trans. Am. Med. Assoc, vol. vlil., 1855, pp. 892-5.

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bones, such as the bones of the skull, and in the upper bones of the
face ; occasionally in the long bones, both in their diaphyses and epi-
physes, and rarely in the short bones.

M. Gariel has reported, in the Bulletins de la Sociite Anat., for 1835,
a case of fissure of the inferior maxilla, occurring in a lad sixteen or
eighteen years old. Falletta found a fissure extending partly through
the third dorsal vertebra, in a man who had fallen upon his back
eleven days before ; and M. Lisfranc has mentioned a remarkable
case of fissure and partial fracture, with bending of five ribs in the
same person.^ Malgaigne believes that he has seen one example of
this variety of incomplete fracture of the scapula, occurring through
a portion of the infra-spinous region. I have myself elsewhere re-
corded another, as having been found in the skeleton of Nimham, an
Oneida Indian, who was a great fighter, and who died when about
forty-five years old, in consequence of severe injuries received in a
street brawl ; but his death did not occur until four or five months
after the receipt of the injuries.

In addition to this fracture of the right scapula, five of his ribs
were broken, and both legs, all of which, except the scapula, had
united completely by intermediate and ensheathing callus.

The scapula was broken nearly transversely, the fracture com-
mencing upon the posterior margin at a point about three-quarters of
an inch below the spine, and extending across the body of the bone
one inch and three-quarters, in a direction inclining a little upwards,
being irregularly denticulate and without comminution. The frag-
ments were in exact apposition, and, throughout most of their extent,
in immediate contact. They were, however, not consolidated at any
point, but upon either side of the fissure there was a ridge of en-
sheathing callus, of from one to three or four lines in breadth, and of
half a line or less in thickness along the broken margin, from which
point it subsided gradually to the level of the sound bone. The same
was observed upon the inner as well as upon the outer surface of the
scapula. This callus had assumed the character of complete bone,
but it was more light and spongy than the natural tissue, and the
outer surface had not yet become lamellated. Its blood -canals and
bone-cells opened everywhere upon the surface.

Directly over the fracture, and between its opposing edges, no callus
existed, but as the bone had lain some time in tne earth before it was
exhumed, it is probable that a less completely organized intermediate
callus had occupied this space, and that, owing to the less proportion
of earthy matter which it contained, it had become decomposed and
had been removed.

M. Voillemier found the head of the humerus penetrated by two or
three fissures f and M. Campaignac has reported the case of a lad ten
or twelve years old, who was compelled to submit to amputation of
his arm at the shoulder-joint, in consequence of a severe injury, in
which the humerus was found fissured from the insertion of the del-

1 Des Fract. Incomplet. et des FisBUres, par J. A. J. Campaignac, 1829, p. 20.

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 9 of 100)