A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

REMARKS ON COMPLICATED FRACTURES.

27. Complicated fractures of the neck of the humerus are to be classed with all other accidents of a similar nature, and it would be difficult here to lay down such general rules as would be applicable to every case. The practitioner must be always governed by circumstances. The necessity of the case sometimes urges him to the adoption of daring measures, which, in developing the resources of the art, do honour to the talents of him who exercises it. Of this the following case is a proof.

Case III. Pierre Lena, aged fifteen, as he was at work on a scaffold, forty feet from the ground, fell from that height on the corner of a stone. He experienced instantly such severe pains, that he was unable to rise. He was carried to the house of a surgeon, who, believing that he had suffered a luxation, made fruitless attempts to reduce it, produced in the part an enormous swelling, augmented his pains, and all to no purpose.

The patient was carried to the Hospital of Charity, where Desault at the time was surgeon in chief. A fracture of the neck of the humerus was discovered, through the tumefaction and echymosis, which had overspread the whole shoulder. A suitable bandage was applied.

A few days afterwards, a manifest fluctuation, an evidence of an effusion of blood, disclosed the necessity of making an opening. This was accordingly done, and the fingers being introduced into the part, several large splinters were discovered, and a sharp-pointed bone, the end of the lower fragment, pricking the deltoid muscle, and occasioning, no doubt, the pains which had hitherto continued without intermission.

The indication was evident. To give vent to all the splinters, and cut off the point of the bone, or to amputate the limb, was the only alternative that was left. Most of the practitioners that were consulted were in favour of the last measure. But Desault ventured to repose a hope in the first, the successful issue of which would be the certain preservation of the limb. He performed the operation as follows.

A large incision made in the posterior, and one still larger in the anterior part of the arm, enabled him to remove with ease all the splinters. Then taking hold of the pointed extremity of the inferior fragment, he drew it through the anterior opening, and cut it off with a saw and a pair of cutting forceps. He then replaced it with his fingers, and fixing the head of the bone in its proper position, applied an apparatus somewhat similar to that intended for the retention of fractures.

A suppuration taking place, the patient was dressed every day. Several abscesses were formed during the course of the treatment; each time the pus was discharged by means of an incision.

At the end of four months, the bone was perceived to be in a state of necrosis. The dressings were regularly continued; but the patient, becoming tired of his residence in the hospital, left it, being able to move without difficulty, and having, in the upper part of his arm, a deep fistula, from whence there was a constant escape of ichorous matter, and through which several splinters were discharged, in the space of six months which he passed at his own house.

About the expiration of this period he returned to the Hospital of Charity. Desault had, in the mean time, left this institution to take charge of the Hotel-Dieu. Amputation was proposed to the patient as his only resource. He refused to comply, and went to Desault, who, examining the state of the parts, found an irregular callus formed, which he removed, together with a portion of the soft parts corresponding to the fracture. At the end of two months and a half, the patient was discharged perfectly cured, except a weakness in the limb, which disqualified him for hard labour.