within downwards and outwards, or from without downwards and inwards; even this obliquity, however, is always trifling, and scarcely ever sufficiently great to invalidate the truth of the general proposition (first maintained, I believe, by Monsier Voillemier), that when the radius is broken within an inch of its lower extremity, the direction of the fracture is transverse, the direction which we would expect it to follow, from reflecting upon the manner in which the accident happens, and in which the force which breaks the bone is applied; for, when the fracture takes place from a fall upon the palm of the hand, as it usually does, the force, though principally and ultimately transmitted to the posterior surface of the lower end of the radius, yet is applied in a direction nearly parallel to the plane of the carpal surface of the bone." P. 142.

It appears that Voillemier, a writer in the Archives Générales de Medicine, regards all fractures of the lower end of the radius as examples of impacted fracture, and his views are given in the work before us at some length, and afterwards very fully discussed. This opinion is founded upon the fact that, in nearly all specimens of fracture of the lower end of the radius examined long after the occurrence of the injury, a line of compact tissue is found, continuous with the posterior wall of the shaft, and extending to a greater or less distance into the reticular structure of the lower fragment. Mr. Smith's attention having been directed to the subject by the memoir above referred to, he examined numerous sections of this fracture, and, for reasons which we have not sufficient space to quote, he considers that the doctrine" of fracture with penetration" is untenable. He believes that "the impaction is only apparent, and that the compact tissue of the shaft is not found enveloped in bone, from its having penetrated the lower fragment at the time of the occurrence of the injury, but because it becomes subsequently incased in osseous matter during the process by which the bony union of the fracture is accomplished." We are disposed to agree with Mr. Smith on this subject, but we think that he has discussed the point at greater length than its importance would seem to require.

Mr. Smith describes a very rare injury, viz. "fracture of the lower extremity of the radius, with displacement of the lower fragment forwards." It generally occurs in consequence of a fall upon the back of the hand.

"It is accompanied by great deformity, the principal features of which are a dorsal and a palmar tuinour, and a striking projection of the head of the ulna at the posterior and inner part of the fore-arm; the dorsal tumour occupies the entire breadth of the fore-arm, but is most conspicuous internally, where it is constituted by the lower extremity of the ulna displaced backwards; from this point, the inferior outline of the tumour passes obliquely upwards and outwards, corresponding in the latter direction to the lower end of the superior fragment of the radius. Immediately below the dorsal swelling there is a well-marked sulcus, deepest internally below the head of the ulna, directed nearly transversely, but ascending a little as it approaches the radial border of the fore-arm.

"The palmar is less remarkable than the dorsal tumour; formed principally by the lower fragment of the radius, it is obscured by the thick mass of flexor tendons which cross the front of the carpus, but towards the ulnar border of the limb there is a considerable projection, which marks the situation of the pisiform bone, passing down to its attachment into which, can be seen the tendon of the flexor carpi ulnaris thrown forwards in strong relief. The transverse diameter of the fore-arm is not much altered, but the antero-posterior is considerably increased, and the radial border of the limb becomes concave at its lower part."

P. 163.

1847]

Fracture of the Lower-end of the Radius.

145

Mr. Smith has never had an opportunity of ascertaining the anatomical characters of this fracture. He is quite satisfied, however, of the nature of the injury, and believes that it has not unfrequently been mistaken for dislocation of the carpus forwards.

"The facility, however, with which the deformity can be removed, its liability to recur when the extending force ceases to act, the production of crepitus when the limb is extended, and a motion of rotation given to the hand, and our being able to feel the irregular margin of the upper fragment of the radius posteriorly, are sufficient to enable us to distinguish this accident from luxation of the bones of the wrist forwards." 163.

Another form of injury occurring in the vicinity of the wrist is "a separation of the inferior epiphysis of the radius, with fracture of the lower extremity of the ulna." This accident is very liable to be mistaken for dislocation of the wrist backwards, but cannot be confounded with the ordinary fracture of the radius; the dorsal tumour is transverse, and the limb presents none of the peculiar deformity arising from the displacement of the lower fragment of the radius towards the side of supination which distinguishes the more common form of fracture.

Although this injury assumes very much the appearance of dislocation of the carpus backwards, it may yet be distinguished from it without any considerable difficulty, more especially should we be fortunate enough to see it, before the occurrence of tumefaction has obscured the diagnostic signs. The styloid processes of the radius and ulna can be felt, still holding their normal relations to the carpus, and, as has been remarked by Boyer, these processes move with the hand when any motion is imparted to the latter. If the distance between the superior margin of the dorsal tumour, and the extremity of the middle finger of the injured limb, be measured and compared with that between the corresponding point of the hand and the upper edge of the carpus of the sound limb, the former measurement will be found to exceed the latter by at least half-an-inch; sometimes the difference is greater; but if the case should be one of dislocation of the wrist backwards, this measurement will give the same results upon each side, and the styloid processes will be found to remain at rest when the hand is moved; if we add crepitation, the easy reduction of the deformity by extension, and its liability to recur when the extending power is removed, we are at once furnished with a group of symptoms, quite sufficient to enable us to distinguish this injury from that very rare accident, luxation of the wrist." P. 166.

With respect to the treatment of the ordinary fracture of the lower end of the radius with displacement of the lower fragment backwards, the object most difficult to be accomplished is to restore to the carpal surface of the bone its normal direction forwards, and this is not effected by the means recommended by Dupuytren. Mr. Smith has found the following mode of treatment to answer remarkably well, and to fulfil all the more important indications.

"The deformity having been, as far as possible, removed by extension and counter-extension, and the hand moderately adducted, a cushion is to be placed upon the posterior surface of the limb, of sufficient length to extend from the elbow to the fingers; the portion of this cushion which corresponds to the lower fragment of the radius and to the carpus should be thicker than any other part, and from its ulnar to its radial border, should gradually increase in thickness. A transverse section of this portion of the cushion would represent an isosceles triangle, the base of which would correspond to the radial border of the limb.

NEW SERIES, NO. XI.-VI.

L

The objects proposed to be attained by constructing the pad of this form are, to press the lower fragment of the radius forwards, and to direct its external border towards the side of pronation.

"A second cushion, thicker below than above, is to be placed upon the front of the limb, but should not descend below the margin of the superior fragment, for otherwise it would, to a certain extent, counteract the influence of the dorsal cushion, and would tend to maintain the displacement backwards of the inferior fragment. An anterior and a posterior splint are then applied, each of which should be at least an inch broader than the fore-arm; the posterior should extend from the elbow to the fingers, and should be curved from the wrist downwards, to receive the adducted hand; the anterior need not descend below the palm of the hand: a roller is then to be carried around the splints in the ordinary manner.

By constructing and placing the cushions in the manner above described, the two fragments are pressed in opposite directions, and the carpal surface of the inferior is directed forwards, while the curved splint, by maintaining the hand moderately adducted, tends to restore to the articulating surface its natural direction inwards, quite as effectually as the ulnar splint of Dupuytren, and with much less uneasiness to the patient. It is scarcely necessary to mention, that the form which I have recommended can be readily given to that portion of the dorsal cushion which corresponds to the lower fragment, by the employment of graduated compresses." P. 168.

"During the application of the apparatus, as well as during the subsequent treatment, the fore-arm should be maintained in a position intermediate between pronation and supination, for it is in this position that the co-aptation of the fragments can be most easily and most perfectly accomplished, in consequence of the relaxation of the pronator and supinator muscles.'

P. 169.

We may here add the description of the plan of treatment in these cases recommended by Professor Fenger of Copenhagen, and recently communicated to the Royal Medical and Chirurgical Society.* He states that, as the deviation occurs in a curve, with its centre upon the fracture, it is desirable to counteract the deformity by extension acting in a direction according to the tangent of that curve. This end he thinks is best attained by acting through the medium of the hand and of the capsular ligament which is attached to the lower end of the radius. The hand is first to be brought into a position of strong flexion, and the fore-arm is then placed on an oblique plane, with the carpus highest, the hand being permitted to hang freely down the perpendicular end of the plane. The tendons of the extensor muscles are thus brought into a position which enables them to assist in keeping the reduced fragments of the bone in proper relation. Where the deformity requires it, the displaced lower fragment is to be pressed into its position by the thumb of the operator, after sufficient extension has been made, and when the hand is bent on the fore-arm. The patient is to be kept in bed, but the hand is not confined, the seat of fracture being covered only by an evaporating lotion.

Mr. Smith's views are summed up in a number of general corollaries, which we regret that we are unable to find room for. This chapter presents the clearest view of the anatomical characters, symptoms, and diagnosis of the common fracture of the lower end of the radius that we know

The Lancet, Vol I., 1847, p. 487.

1847)

Fractures of the Humerus.

147

of, and its obscure nature and the difficulty of managing it, perhaps justify the length with which it is treated.

Chapter IV. treats of "Fractures of the Humerus, in the vicinity of the Shoulder-joint." On the subject of Fractures of the greater tuberosity of the humerus we find nothing particularly deserving for notice. Mr. Smith has had but one opportunity of observing the anatomical characters of the injury. The accident had occurred many years before death, and the history connected with it could not be precisely ascertained.

Our author describes two varieties of impacted fracture of the neck of the humerus. In one, the upper extremity of the lower fragment penetrates the reticular tissue of the head of the bone; "this is an extracapsular fracture, and occupies the situation which, in the young subject, marks the junction of the epiphysis with the shaft; in the other, the superior fragment is forced downwards into the cancellated structure between the tubercles, the greater of which processes is, in almost every such instance, split off from the shaft of the humerus; in this case the fracture is intracapsular, and occurs through the anatomical neck of the bone." Both these injuries are fractures of the true anatomical neck of the humerus, which, our experience would lead us to say, are of very rare occurrence. They have been confounded with fractures through the tuberosities, or through the line of junction of the epiphysis with the shaft of the bone.

"In the latter, the deformity is considerable, in consequence of the lower fragment being drawn inwards by the muscles which constitute the folds of the axilla; but in the former there is scarcely any displacement of the inferior fragment, the influence of these muscles being counteracted by the supra-spinatus, infra-spinatus, and teres minor, attached to the greater tubercle; the bone being thus placed between two opposing forces, suffers very little displacement, and the deformity is slight in proportion; hence the diagnosis of fracture of the anatomical neck of the humerus is, comparatively speaking, obscure. The impairment of the motions of the joint and crepitus are, in fact, almost the only symptoms upon which we can depend, in forming our opinion as to the nature of the injury which the bone has sustained." P. 185.

Notwithstanding the unfavourable circumstances in which the head of the humerus is placed as regards bony union, osseous consolidation takes place, the impaction serving to maintain the parts in contact. Mr. Smith describes some interesting cases and specimens of the injuries in question. "Separation of the superior epiphysis from the shaft of the humerus, is an accident which Mr. Smith states not unfrequently occurs in early life. Our experience would lead us to say that it was a rare form of injury. It is attended by a considerable degree of deformity, but of so striking a character, that there is no great difficulty in recognising the true nature of the injury.

"The axis of the arm is directed from above, within, and before, downwards, outwards, and backwards; the elbow, however, projects but little from the side, and can be brought into contact with it with facility; the head of the bone can be distinctly felt in the glenoid cavity; a slight depression is seen beneath it, and it remains motionless, when the shaft of the humerus is rotated.

"The most remarkable feature, however, of this injury, is a striking and abrupt projection, situated beneath the coracoid process, and caused by the upper

*

L

extremity of the lower fragment or shaft of the bone, drawn inwards by the muscles which constitute the folds of the axilla: there is but little displacement as regards the length of the bone, for the extremity of the inferior fragment is seldom drawn so far inwards as to enable it to clear completely the surface of the superior. Were this to occur, the humerus would, of course, be drawn upwards by the muscles passing from the shoulder to the arm, in a direction parallel, or nearly so, to the axis of the humerus, and a corresponding diminution in the length of the limb would result.

"This remarkable and abrupt projection does not present the sharp, irregular margin of an ordinary fracture; on the contrary, it feels rounded, and its supe rior surface is smooth and slightly convex. The latter can be felt as plainly as the cup-like cavity of the head of the radius, in cases of luxation of that bone backwards at the elbow-joint. By pressing the upper end of the lower fragment outwards, and directing the elbow inwards, during extension and counter-extension, crepitus can be perceived, and the deformity removed without much difficulty; but the moment the parts are abandoned to the uncontrolled action of the muscles, the deformity recurs.' P. 201.

دو

Fractures of the Acromial Extremity of the Clavicle are considered in Chapter V. The chief point of interest in relation to this inquiry adduced by our author, is the occurrence of displacement of the outer fragment of the clavicle in cases of fracture between the trapezoid ligament and the acromio-clavicular articulation, which, he says, is, in general, considerable, its inner extremity being drawn inwards. This displacement is frequently carried to such an extent that the fragments form a right angle with each other; and it is principally due to the action of the clavicular portion of the trapezius muscle. In consequence of the displacement the clavicle is shortened.

In Chapter VI. Mr. Smith treats of Dislocations of the Bones of the Foot. After briefly alluding to the displacements with which surgeons are already familiar, he remarks that the instances of luxation he is about to describe are different from any that have yet been recorded. They are instances of dislocation of the metatarsus and internal cuneiform bone, upwards and backwards upon the tarsus. Its external characters are said to be very striking, and clearly to indicate the nature of the accident.

"The foot is greatly deformed, but it is at first sight obvious, that the relations which the bones composing the ankle-joint bear to each other, are undisturbed. There is, it is true, a remarkable fore-shortening of the foot, but we are not likely, on this account, to confound the accident with displacement of the tibia forwards, for there is no corresponding elongation of the heel: the foot, in front of the ankle-joint, is shortened to the extent of an inch or more, but the heel preserves its natural relations to the bones of the leg.

"The foot likewise appears to be rotated upon its long axis, in such a manner that the aspect of the dorsal region is directed outwards, and that of the plantar inwards; the inner edge of the foot is elevated and the outer depressed. These alterations resemble those which are the results of the dislocation of the tibia outwards; but in the latter accident the outer edge of the foot is applied to the ground throughout its whole length, whereas in the injury under consideration, it is only the central third of the external margin of the foot, which is presented to the ground in walking.

“The next remarkable symptom which attracts observation, is the alteration