treatment fractures and dislocations, · [from themedicaland surgical reporterofoctober 26, 1861.]...

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  • [ From the Medical and Surgical Reporter of October 26, 1861. ]



    By JOHN SWINBURNE, M.D.,Of Albany, N. Y.

    The object of this paper is more fully toelucidate the treatment of fractures and dis-locations of the elbow-joint, and particularlyin children.

    I had supposed that the subject matter ofthe mode of treatment by simple extension,counter extension, and maintenance of thesame, had been so fully demonstrated in mypaper read before the New York State MedicalSociety, for the year 1861, as not to require anymore demonstration. I find, however, thatmany of the profession are still in doubt as tothe mode ofapplication. I propose not only tosimplify the treatment, but also the apparatus,which can be readily made with the appliancesalmost always on hand. The material requiredis a piece of shingle, cigar-box, or anythin stripof wood readily procured.—See Plate No. 1,Fig. 3.

    [Plate No. I.]Fig. 1. Fig. 2.

    Fig-, 'i.

    Figs. 1 arid 2.1. Splint with joint.2. Adhesive plasters.

    Fig. 3.1. Board without cover. 2. Adhesive plaster.3. Joint to be made by adhesiveplaster.

    3. Joint of instrument.4. Compress.

    Some adhesive plaster—Fig. 3, No. 2—or itsequivalent, some adhesive material like Bur-gundy pitch, or black wax, etc., with which apiece of leather or cloth can be covered, the bitsof splints encircled or enveloped, so as to form ahinge.—Fig. 1, No. 1. One end of the splintcan extend to about the termination or insertionof the deltoid muscle, and the other portionmay extend to near the wrist.—No. 2, 2, Fig. 1.

    This must be applied to the arm in the ex-tended position; the ends are secured to thearm and fore-arm severally by strips of ad-hesive plaster, applied in a serpentine or spiraldirection, to secure the ends of the apparatusfrom slipping up or down,—Fig. 1, No. 2, 2then flex the fore-arm upon the arm, and therequired degree of extension is affected, afterwhich the elbow can be secured to the appara-tus.—Nos. 2, 2, 2, 2, Fig. 2.

    The hinge—-No. 3, Figs. 1, 2, 3—can be re-lieved from too much angular pressure by asmall compress on either side of the sharpangle, formed by the joint of the apparatus.—No. 4, Fig. 2. The flexion of this apparatusproduces extension and counter-extension and atthe same time presses the humerus posteriorly,while the radius and ulna are forced downwards,replacing the fractured bones.

    As an experiment, apply the same withoutfixing the ends of the angular apparatus, (Day’s,or the Rose splint,) with a bandage; flex thearm, and it will be found that the ends aremoved up on the arm and drawn on the fore-arm, thereby losing all the extension whichwould otherwise be obtained by the change inthe relative position of the hinge in the ap-paratus and the bones of the arm.

    The following diagrams illustrate the princi-ple of extension by means of this apparatus:


    Fig. 1.

    Fig. 2.

    a. Fig. 1 anrl 2, is the joint of the instrument; b is the elbow-joint. The joint A is about one or one and a half inches abovethe joint n, and from one and a quarter to three inches in frontof it. The end of the instrument and the fore arm extend tothe same point. Now, semifiex the fore-arm, and the splint willextend farther than the fingersby the distance c d, Fig. 2, andwhen the flexion extends to a right angle, the difference is G I.

    It is plain, therefore, that if the hand bemade fast to the end of the instrument whileextended, then, when it is flexed, the hand andthe end of the instrument will describe thesame circle, and both extend to the point g, thefore-arm being forcibly extended, the amountof extension being proportional to the diameterof the arm—in other words, the vertical dis-tance between the joints of the arm and instru-ment respectively, and also the horizontal dis-tance between them, so that, by means of thissimple arrangement, sufficient extension ismade to continue prolonged reductive efforts inold standing dislocations, and to keep recentones reduced, which might otherwise be trouble-some.

    The principle involved may be illustratedvery easily by simply placing a bit of board onthe fore-arm, from the fingers to the elbow,fixing it at the joint with the other hand, andthen flexing, when it will be seen that the splintextends two inches or more beyond the fingers,as seen in Fig. 2, compared with Fig. 1,

    The following sketch will demonstrate theprinciple more fully;—

    Fig. 1, No. 1,represents the distorted fracture;Fig. 1, Nos. 2, 3, 4, and 5, represents the ap-

    paratus and dressings applied; Fig. 2, No. 1,represents the fracture reduced by the flexion;Fig. 2, Nos. 2, 3, 4, and 5, apparatus and dres-sings.

    [Plate No. 3.]Fig. 1.

    Fig. 2.

    No. 1,Fig. 1 Fracture and displacement.No. 1,Fig. 2. “ “ “ replaced by flexion.No. 2, Figs. 1 and 2. Extension and counter-extension.No. 3, Figs. 1 and 2. Splint.No. 4, Figs. 1 and 2. Joint of Splint.Nos. 5, 5, 5, 5, Figs. 1 and 2. Adhesive plaster.The form of accident to which this apparatus

    is especially applicable are those occuring in ornear the elbow-joint, sometimes accompaniedwith distortion, and a continued disposition torecurrence of the same displacement. I willdivide this form of accident into

    Ist. Fracture of the humerus, near and intothe elbow-joint, where the spasmodic action ofthe biceps and triceps muscles are acting con-stantly as distorters.

    2d. Fracture of the external condyle, carry-ing with it the head of the radius, and extend-ing through the coronoid and olecranon fossm,thus allowing the radius to become displaced,with its fragment, and drag with it the ulnawhich is unloosed from its natural connections.

    3d. Fracture of the internal (or even both)condyles and displacement of the radius andulna.

    4th. Fracture of the ulna with dislocation ofthe head of the radius, where there is a con-stant tendency to dislocation of the radius.This was exemplified a few days since in theperson of a neighboring physician who met withthis accident, and it was reduced by an ablesurgeon; but instead of applying some reten-tive apparatus, he merely carried the hand of the


    dislocated arm over the shoulder of the sameside, and maintained it in that position ; subse-quently radius re-dislocated ; theulna shortenedleaving deformity for life.

    See also case reported of old accident, Medi-cal and Surgical Reporter, Vol. 3d, No. 11,new series.

    It will be seen at a glance that the elbow-joint is surrounded by powerful muscles whichare brought spasmodically into action as soon asthe integrity of the joint is destroyed, andhence the absolute necessity of some antagonis-tic force to overcome this abnormal condition,and restore the parts to their normal positionas nearly as possible, and maintain them sountil union is effected. Before I had testedthis plan of treatment faithfully, I must confessthat the elbow-joint presented more horriblevisions of bad results and suits for mal-practicethan any other fracture.

    The prophetic words of Prof. S. I). Gross, ofPhiladelphia, were constantly ringing in myears, for if such surgeons approach this class offracture with “ doubt and misgiving,” whatwould the young and perhaps inexperiencedsurgeon do ? They would be bold, indeed, toapproach with less trepidation.

    In reference to fractures of the lower portionof the humerus and involving the joint, hesays: “ I know of no fractures which I ap-proach with more doubt and misgiving thanthose of the inferior extremity of the humerus,involving the elbow-joint. I know of nonewhich are more liable to be followed by severeinflammation of the synovial membrane—ex-tensive effusion, anchylosis and deformity.Even in the more simple forms of these injuriesand where the treatment has been most skil-fully conducted there is generally great risk ofan unfavorable result; at all events a long timewill be sure to elapse before there will be any-thing like good use of the. articulation. Theprudent surgeon will, therefore, inform his pa-tient at the commencement of the attendance, ofthe nature and probable consequences of thecase. From five to six weeks is the averageperiod necessary for the reunion. The natureof the deformity in badly treated fracture ofthe condyles of the humerus, may exhibit itselfin quite a variety of ways depending upon thepeculiar mode of treatment. Sometimes a pos-terior projection remains, caused by the dis-placement of the lower end of the bone back-wards; notunfrequently the limb has a strange-ly twisted appearance, either in the direction

    of pronation or supination ; occasionally it ispermanently flexed or extended, and some-times again the limb is greatly increased inbreadth.”

    I will quote one case to illustrate this me-thod by extension and counter-extension ofdressings, as well as the speedy and happy re-sults which followed;

    J. Me , aged ten, fell from the top of theprivy—eight feet—producing a fracture of thehumerus, extending from above the externalcondyle of the humerus obliquely through theolecranon and coronoid fossae, and effectuallydestroying the humeral connections of both theradius and ulna, producing great distortion. Idrew the arm down to its normal condition, butfound it diffiucult by ordinary means (angularsplints) to retain it in its place. I then ap-plied the apparatus, above described, when ap-position of the fragments was effected. Duringthe three weeks that the dressings were con-tinued, the arm was not re-dressed, except thata few additional pieces of straps may have beenadded to keep the apparatus in its place, andduringthat time I saw him not more than four orfive times. At three weeks all dressings were re-moved, passive motion allowed, and at the endof six weeks the motion of the elbow was per-fect, though the bony callus left an appearanceof deformity. My friends and myself have nowtreated fifteen cases of this class of accident, in-volving -deformity of the elbow-joint, withmuch better results than I have been able toobtain by the mere retentive splints. This planonly requires a fair trial to be fully appreciated.It is merely the extension and counter-extensionapplied to. the joint, but by a different mode ofprocedure.

    Now, for all these accidents or resultsthere must be some reason, and one is led natu-rally to inquire its real nature, and why unionis delayed jive or six weeks. Is it the close proxi-mity of the joint? The presence of synovia?The cancelated structure of the bone ? Thesmallness of the fragments, and its consequentslight vitality ? Or, is it not rather an insuffi-cient reduction and extension of its severalparts ?

    If the bones were properly reduced and re-tained, there would be little distortion whenunion is complete; and certainly there is littledifficulty of extending the limb to its normalcondition, and when so extended, nearly all de-formity ceases, and who can pretend that itthis position of extension^was,main,tained, the


    limb would not be quite natural, and all the de-formities, above spoken of, made to disappear.

    If these indications are fulfilled can anyone,for a moment, suppose that “from five to sixweeks as an average 'period would be necessary forreunion

    The nearer the fragments of bone are in ap-position the sooner they will unite, and unlessbony deposit shall be thrown out, there is abso-lutely little or no callus at the end of threemonths where apposition is perfect.

    Lately I have had eminent surgeons examinecarefully fractures of the femur, humerus, tibiaand fibula, Collis fracture of the radius, and inmost of them they were unable to discover anycallus, or to distinguish the broken from theunbroken limb. The Collis fracture was ex-amined by Doctor Elisha Harris, of New York,(when on a visit to this city in connection withhis Sanitary Mission by order of United StatesGovernment,) and though at the time of theaccident there wr as great contusion and distor-tion, no redressing from the time of the acci-dent to the 22d day when all dressings werediscontinued, union being perfect and fair mo-tion.

    Six months after the accident the Doctor ex-amined it, and found it so perfect that he wasabsolutely unable to state which had beenbroken, there being no callus. Then, as amaxim, we can state that the less distortion,the less callus, and visa versa. So that if wecan obtain absolute apposition of the fragmentsof bones entering into the joints, we can as wellavoid excessive bony callus in this position, asin the radius, tibia, femur, or any other bone.Take for example, a simple transverse fracturewithout distortion, and who ever expected ex-cessive bony callus, or a retardation ot bonyunion. On the contrary, talce an over-lappedfracture of any angle, and let it unite in thatposition, the union would be slow, and thebonycallus would be great, and would absolutelyconstitute a deformity. Then to avoid deformityand immobility of joints place them in apposi-tion as nearly as possible and keep them thereuntil they are consolidated firmly together.This cannot be effected until spasmodic muscu-

    lar contraction is overcome. There are twoways of effecting this end, compression by ban-daging, and overcoming the spasm by perma-nent extension, without compression with ban-danges. Experience tells me which of the two tochoose.

    The advantages of this mode of placing thefracture in place, and retaining it, can be brieflysummed up as follows :

    Ist. The dressing (splints) is easily andreadily made, and hence not expensive ; and al-ways at hand.

    2d. Extension and Counter-extension is effectedby simple flexion of the forearm upon the arm,i.e., changing the relation of the joints of thearm and splint respectively by simple flexion.(See cuts.)

    3d. It can be examined at pleasure, while lo-tions do not disturb the dressings.

    4th. The swelling is much less than wherethe parts are constricted by bandaging, and ifthere is too much swelling, the plaster can becut down the back of the arm so as to allowit to accommodate itself to the swelling,during the subsidence of which others can beadded at pleasure, without removing the oldplaster or apparatus, and hence no entirere-dressings of the limb becomes imperative;in fact, it is better not to disturb the relationsof the parts, when once replaced, until uniontakes place, when motion is gradually madeaccording to rules laid down in all works onsurgery.

    sth. The ultimate restoration of the joint toits normal usefulness is obtained much sooner,for this reason, that there is less infiltrationand subsequent inflammation where there islittle pressure from the apparatus and bandages,than where compression is the means used toprevent re-distortion of the joint or fracture.

    Gth. The swelling which may ensue does notchange the relation of the dressings, or jeopard-ize the vitality of the parts.

    7th. There is no slipping of the apparatusfrom shortening and distortion of the joint, asin the case where a simple angular apparatusis used without the two fixed points designatedin the annexed cuts.

    A new method for the treatment of fractures and dislocations :MAINChapterUntitledUntitledUntitledUntitledUntitledUntitledUntitled