[Extracted from The American Journal of the Medical Sciences for July, 1859.] 
SUCCESSFUL TREATMENT 
OP A 
CASE OF LIGAMENTOUS UNION OF FRACTURED 
RADIUS AND ULNA 
DRILLING AND WIRING, AFTER FAILURE BY OTHER MEANS. 
E. K. SANBORN, M. D., 
BBOFESSOR OF SURGERY IN CASTLETON MEDICAL COLLEGE. 
Although cases of non-union or ligamentous union of fractured bones 
are of considerable frequency, and, when occurring, are of most serious 
consequence to both patient and surgeon, it would probably be the feeling 
of most surgeons, if expressed, that there is no class of surgical cases in 
which they would operate with less certainty of success, or be more embar- 
rassed in the selection of the best method of operation, than the one under 
consideration; for, notwithstanding a varying degree of success has followed 
a great variety of operations for ununited fracture, the very multiplicity 
of methods recommended by distinguished authorities is a virtual confession 
of the inadequacy of any operation yet devised to safely meet in all cases 
the surgical exigency of a confirmed non-union. 
The seton has been successful in many cases; but it has also failed in 
more cases, probably, than any other means, because, on account of the 
comparative ease with which the operation is performed, and its apparent 
freedom from danger, it has been performed more frequently than any other 
operation. But, aside from the uncertainty attending the introduction of 
the seton, the recovery, if it takes place, is prolonged and tedious, and the 
operation is not always free from danger, particularly from erysipelatous 
inflammation, induced by the presence of so large a foz-eign body in the 
cellular tissue. 
Resection has also had its triumphs; but it has also signally failed; and, 
where recovery takes place, it is not a restoration of the strength and pro- 
portions of the limb, on account of the shortening which is necessarily 
involved in this operation. It is also a dangerous operation; and a fail- 
1 2 
ure, if it is not accompanied by loss of the limb, generally precludes all 
chance of success from any subsequent operation. 
The method of drilling the ends of the fractured bones, to induce adhe- 
sive inflammation, which has been introduced within a few years, though 
not a difficult or dangerous operation, and in many cases a successful one, is 
still unreliable, for it has failed, after thorough trial, in repeated instances. 
Dieffenbach’s operation, of introducing ivory pegs, and Langenbeck’s modi- 
fication of it, the substitution of iron screws for the pegs, are severe ope- 
rations, and the former, at least, uncertain. During the winter of 1854 I 
had the pleasure of seeing the distinguished Berlin surgeon, Langenbeck, 
perform his peculiar operation in two cases with success; and he informed 
me that it had never failed in his hands, though he had not applied it in 
the femur. 
On returning home, I recommended the operation in a case of ununited 
fracture of the humerus, and assisted to perform it. On the second day it 
became necessary to remove the screws, in consequence of the violence of 
the inflammatory action, which soon took the form of phlebitis, and re- 
sulted in destruction of the head of the humerus, abscess, and finally anchy- 
losis of the shoulder-joint. Although the patient’s life was endangered by 
this operation, yet the union of the bone was perfect, and the arm is now 
strong and useful. 
Though strongly impressed in favour of the German operation by the 
results I saw from it in the hands of its skilful originator, my experience 
in the above-mentioned case has not inclined me to repeat it; though I am 
fully of the belief that the complication of phlebitis, &c., in the case arose 
from accidental causes, which could be avoided in another operation. 
A case of ligamentous union in both bones of the forearm has been 
treated by me within the last few months, with such satisfactory results as 
greatly to increase my confidence in the efficacy of surgery in these cases, 
and also to confirm my belief in the “law of tolerance of living structures 
for the presence of foreign metallic bodies.” 
Case. Mr. J. H. P., of Vermont, aged 33, of lymphatic temperament, and 
inclined to corpulency, broke his forearm in January, 1858, while at work 
in the woods. The points of fracture were—radius, upper third; ulna, 
junction of middle and lower third, or about three inches below the upper 
fracture. The fracture was simple, and presented no extraordinary features 
in any respect. The limb was dressed by a neighbouring physician without 
any delay; four plain splints being used, according to the patient’s account, 
and the arm being suspended by a sling in a prone position. After the lapse 
of four or five \yeeks it was ascertained that no union had taken place, and, 
by the advice of another physician, a single splint (Goodwin’s spoon splint) 
was substituted for those originally adjusted. Subsequently a starch band- 
age was applied over the splint. The fracture still giving no signs of con- 
solidation, several attempts at inducing union by rubbing the ends of the 
bones together, &c., were made during the three following months, but with 
no effect. In September, eight months subsequent to the accident, the pa- 3 
tient went to Albany for advice and assistance, and finally placed himself in 
the hospital for treatment. A seton was introduced at the point of fracture 
in the radius, the fractured ends of the ulna were drilled, and the liga- 
mentous union lacerated subcutaneously. On the third day symptoms of 
erysipelatous inflammation appeared about the upper wound; and on the 
fourth day the seton was removed, in consequence of the violence of the 
local and general disturbance. The inflammation soon subsided, and the 
patient, after remaining in the hospital three and a half weeks, returned 
home with the arm in splints, with some appearance of commencing union, 
at least in the upper fracture. These appearances, however, were fallacious, 
and in November the patient returned to Albany, where the operation of 
drilling, &c., was repeated. No perceptible effect followed the second ope- 
ration, and the patient soon returned to his home. 
In December—a year, within a few days, from the time of the accident— 
the patient presented himself to me for examination and advice. The limb 
then presented the usual features of false joint. There was no soreness of 
any part; the limb was, however, entirely powerless—not strong enough to 
sustain its own weight—while the ends of the fractured bones could be rea- 
dily felt as the arm bent by the weight of the hand. 
The patient was naturally very much discouraged, and had little faith in 
any further attempts on the arm. I proposed and explained the operation 
that I finally performed, after his assurance that he should not, at any rate, 
return to the hospital. He left, undecided as to his course. In about two 
weeks he returned, and placed himself under my charge; and on the 23d of 
December I performed the following 
Operation.—Having previously decided to operate on but one fracture 
at a time, I selected the upper one, or the radius, for the first trial. I first 
made an incision, about four inches in length, on the radial side of the fore- 
arm, directly over the fracture. The incision was then extended down to 
the bone, and the broken ends displayed. A knife was then passed through 
the fracture, separating the connecting ligament readily. The ligamentous 
covering was then carefully dissected from the end of each fragment. The 
fracture was found to be oblique, the lower fragment lying by the side of 
the upper, and separated from it about half an inch. The wedge-shaped 
end of each fragment was then bored through with a small gimlet, at a dis- 
tance of three-quarters of an inch from the end, and through these holes a 
stout silver wire was passed, and the ends twisted with strong clasp forceps 
until the broken ends were firmly held together in the loop. The external 
wound was then loosely brought together by adhesive strips, the twisted 
ends of the wire projecting an inch or more from the middle of the wound. 
The limb was placed in an elbow-splint—made of tin, for the purpose—ex- 
tending from the axilla to the fingers. The splint was placed on the inside 
of the arm and forearm, and was deep enough to embrace one-half the cir- 
cumference of the limb, while the wound was left free for dressing, &c., 
without disturbing the arm. The wound was finally dressed with lint and 
cold water. 
The patient underwent the operation without any anesthetic, by prefer- 
ence. One small artery only was ligatured. 
Dec. 24. Saw the patient at 9A. M. Found him in bed, with some 
febrile symptoms. Pulse 100; face slightly flushed. Chiefly complained of 
pain in the head and back, which prevented him from sleeping the latter 
part of the night. No pain of consequence in the arm. Changed the 
dressings. Found the limb swollen below the elbow, with bloody serum 4 
discharging pretty copiously from the wound. Ordered a saline cathartic, 
with mucilaginous drinks. 
25th. Patient passed a better night than the one before, though com- 
plains still of pain in head and back. Pulse 90. Is sitting up, and makes 
no complaint of the arm. 
Jan. 2. Nothing worthy of mention has occurred up to the present time. 
The wound commenced discharging freely on the fourth day, and the swell- 
ing has rather increased, though there has been no particular pain in the 
limb. Last night there was a sudden recurrence of pain in the head and 
back, accompanied with difficulty of breathing, and cough. The limb was 
observed also to be hot, and more painful, with an erysipelatous blush ex- 
tending up to the elbow. At eight in the evening I applied a solution of 
sulphate of iron as a lotion to the limb, and gave directions for its assidu- 
ous application during the night; also administered a diaphoretic mixture. 
This morning I found the patient relieved, with scarcely a trace of inflam- 
mation in the skin, which is yellow and shrivelled under the application of 
the iron. 
25th. The patient has been progressing favourably. There is now no 
soreness. The wound has healed up, as far as the projecting wire will allow 
it. Very little discharge from the wound. No swelling in the limb gene- 
rally, and very little about the fracture. Took the arm out of the splint, 
and found no evidence of union. The wire was loose in the bones, and 
could be handled without giving pain. The arm was carefully replaced in 
the splint, and with strong clasp forceps the wire was twisted as tightly as 
the patient could bear. 
22d. The operation of twisting the wire has been followed by pain and 
swelling, and increased discharge. The pain, however, is up and down the 
radius. At the point of fracture, also, the bone is extremely sensitive, and 
the least touch of the wire gives great pain. Patient is now taking phos. 
lime and chalk in considerable quantity. 
24th. The swelling and sensitiveness in the region of the fracture have 
greatly diminished. The wire has also become slightly loose in the bone. 
Something like an ensheathing callus is observable at the point embraced 
by the wire. The wire is again twisted until the patient exclaims from 
pain. 
Feb. 1. The operation of twisting has been continued every alternate day 
up to the present time. A temporary discharge has been produced, but the 
increase of the callus is quite evident. This morning, while twisting the 
wire as usual, the small neck of bone that held it gave way, and the wire 
was wholly removed. 
2d. Removed the arm from the tin splint, and made a careful examina- 
tion. The union is evident, though it is not firm. As the swelling has 
nearly subsided, I substituted the gum and chalk bandage for the splint, 
enveloping the limb from the axilla to the fingers with several layers of 
bandage smeared with a thick mucilage of acacia, thickened to the consist- 
ence of white paint with pulverized chalk, leaving a small open space 
opposite the small wound whence the wire was removed. 
15th. Removed the gum bandage, and found the union quite firm. A 
small abscess occurred, just over the point of fracture, a week since, but it 
is now closed. The patient having the impression that the lower fracture 
is also consolidating under the influence of the stiff bandage, it is reapplied, 
and Mr. P. goes home to await the result. 
March 16. The expectations of the patient in regard to the fracture of 5 
the ulna have not been realized. Although the arm is quite strong, and 
the use of the thumb and first and second fingers is recovered, the condition 
of the false joint in the ulna remains unchanged. Accordingly to-day I 
performed on the ulna precisely the same operation that I previously did in 
the case of the radius. I will not go over the details of the second ope- 
ration, which would be merely a repetition of the first account. The con- 
dition and situation of the bones were nearly the same as in the radius. A 
little more difficulty was experienced in introducing the wire than in the 
first instance, on account of the inability to turn out the ends of the bones 
from the wound, as was, readily done in the operation on the radius. The 
same splint and dressings were used as in the previous operation. 
April 1. No unfavourable symptom has been manifested since the second 
operation. The wound has nearly closed. A large node or callus has been 
thrown out about the wire, and union is evidently taking place. The pa- 
tient is out of doors daily, and has nat been confined to bed since the 
operation. 
12Hi. The wire was to-day removed by gentle twisting and traction, and 
the union found to be quite firm. The arm was replaced in the splint. 
20th. The wound in the arm has been closed several days. The patient 
is gradually beginning to use the arm. Both fractures are perfectly con- 
solidated. The power of pronation and supination is possessed to a con- 
siderable degree, and it is quite evident that a little use is all that is required 
for the complete restoration of the motions of the arm. 
May 21. Asa completion of the somewhat extended history of this case, 
I will only add that I have had frequent reports, up to the present date, of 
the daily improvement of my patient’s arm under the influence of daily 
exercise about the farm. 
Remarks.—The wire used in these operations was composed of four 
threads of silver wire, of the size recommended by Dr. Simms for sutures. 
Being closely twisted, they made a wire of the size of a small knitting- 
needle ; and, from its perfect flexibility and strength, I found it much easier 
of introduction, and more manageable afterwards, than would have been a 
single wire of similar size and strength. 
The difference in the time of union in the two fractures will have been 
noticed by the reader. In the radius there were no signs of union on the 
thirtieth day after the operation. 
In the ulna union was quite evident as early as the sixteenth day after 
the operation, and apparently firm in twenty-eight days. 
In the radius the wire was so firmly held in the bones as to be removed 
with great difficulty, and after repeated trials of the twisting process. 
In the ulna the wire was removed, without force, after once twisting 
with the forceps. 
Undoubtedly one reason why the second fracture united so readily was 
the immobility secured by the previously united radius. But still another 
cause, I think, may be found in the fact that in the last operation, besides 
the holes bored for the reception of the wire, I made several other perfo- 
rations with the gimlet in each fragment, a feature in the operation which 
I should be careful not to omit in another case. 6 
I am aware that the wire has been used before in treating ununited frac- 
ture ; but, as far as I know, it has been to secure coaptation of resected 
hones, as in Rodgers’s case (N. Y. Hospital), and Brainerd’s case (Am. 
Journ. Med. Sciences). In the latter case the wire embraced the circum- 
ference of the broken shaft, and in both resection was the operation, and 
the wire was used as an auxiliary. 
If it shall be found that the dangers and deformity of resection can be 
avoided, and that the metallic wire alone, through its instrumentality in 
procuring apposition of separate fragments, but more particularly in its 
peculiar property of exciting adhesive inflammation in living tissues, is 
the safer and surer means, it will not be one of the least of modern im- 
provements in surgery. 
In concluding, I take pleasure in referring to the valuable assistance 
received, in treating the above case, from Prof. Woodward, of Castleton; 
Dr. Griswold, of this town; also Dr. Page, brother-in-law of the patient, 
to whose immediate and constant supervision of the case the success is in a 
great measure, undoubtedly, due. 
Rutland, Yt., May 23,1859.