REPRINTED PROM 
ANNALS 
SURGERY 
AU*DNTHLVIR?VaW.OP BUROICAC PRACTICE 
EDITED BY 
PILCHER. AM. KLDi J. WILLIAM WHITE; M.D. 
FREDERICK TRSVES.--F-R.CSt. WILLIAM MACEWENrMJ?, 
Table of contents. 
ORIGINAL'MEMOIRS. 
. 
TRANSACTIONS OP THE HEW TORE 
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'EDITORIAL. ARTICLE. 
INDEX OP SURGICAL PROGRESS- 
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BOOK REVIEWS. 
ANNOUNCEMENTS. 
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UNIVERSITY- OF PENNSYLVANIA PRESS. 
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Great Britain: Cassell and Company. London. 
Oae Oolaca a Vent In SAvmaoo. 
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JVtAY, 1808 
FURTHER OBSERVATIONS REGARDING THE USE OF THE 
BONE-CLAMP IN UNUNITED FRACTURES, FRACTURES 
WITH MALUNION, AND RECENT FRACTURES WITH 
A TENDENCY TO DISPLACEMENT. 
BY CLAYTON PARKHILL, M.D., 
OF DENVER, COL. FURTHER OBSERVATIONS REGARDING THE 
USE OF THE BONE-CLAMP IN UNUNITED 
FRACTURES, FRACTURES WITH MALUNION, 
AND RECENT FRACTURES WITH A TEN- 
DENCY TO DISPLACEMENT. 
CLAYTON PARKHILL, M.D., 
OF DENVER, COL. 
In the history of our profession a very important chap- 
ter has been devoted to the fracture of bones. No subject, 
perhaps, has received more attention. No department of our 
art has demanded a more ready and accurate anatomical 
knowledge, or such finished mechanical skill. No surgeon, 
however accomplished, but has met with cases the treatment 
of which has taxed his ability to the utmost, and few with 
any extended experience, but have left monuments to their 
want of success. Many conditions, such as muscular action, 
interposition of tissue fragments, blood-clots, irregular, ob- 
lique, and multiple lines of fracture militate against accurate 
approximation of the fragments in fractures of the long 
bones. These may not only prevent adjustment in the re- 
duction of the fractures, but also their sound and symmetri- 
cal union. Accurate adjustment and perfect fixation are the 
ends sought for in treatment. The numerous cases of pseu- 
darthrosis and malunion show how inefficient the treatment 
has been. No result can be more mortifying to a surgeon 
than the failure to get union, and none can proclaim so 
loudly and persistently his lack of skill as a union with de- 
formity, External appliances, in the way of splints and fixed 
dressings, such as plaster of Paris, etc., have formed the usual CL A YTON PARKHILL. 
2 
procedure for the fixation of fractures with a tendency to 
displacement, until recent years. Even in compound frac- 
tures with large openings through the soft tissues, depen- 
dence has been placed to a very large extent upon these 
methods of treatment. Modern surgical technique should 
now be sufficiently perfect to warrant a bolder method when 
necessary, and the securing of accurate and permanent fixa- 
Fig. i.—Separate pieces of clamp. 
tion of the fragments. In certain selected cases this should 
apply to simple as well as compound injuries. 
The great number of mechanical appliances for securing 
fixation in cases of pseudarthrosis is sufficient in itself to 
show how imperfectly any of the methods have answered the 
purpose. These might, for convenience of study, be ar- 
ranged in three classes. 
In the first class we would put those which contemplate 
leaving the materials used for uniting the fragments perma- BONE-CLAMP IN FRACTURES. 
3 
Fig. 2.—Side view of clamp in tibia. 
Fig. 3.—Top view of clamp in tibia. 
Fig. 4.—Appearance presented at first dressing, six weeks after application of clamp 
to a fracture of the tibia. 4 
CLA YTON PARKHILL. 
nently in place, either expecting them to become absorbed 
or ensheathed. In this category we would find the various 
forms of ligatures, such as catgut, kangaroo tendon, silk, and 
silver wire. The first objection that has been found to these 
is that they imperfectly fix the fragments, and dependence 
must be placed on external dressings. The second is that 
the non-absorbable materials not infrequently prove an irri- 
tant to the tissues, lowering their vitality, and leading to 
subsequent infection. This condition, in many cases, neces- 
sitates secondary operation for their removal, whether union 
be secured or not. In fact, save in exceptional cases, they act 
only as a stimulant to bone-production without either se- 
Fig. 5.—Clamp applied to a fracture of the neck of the femur 
curing fixation or retention. In the same list should be 
placed bone-ferrules; ivory, bone, and metallic plugs, for 
insertion into the medullary cavities, and ivory and bone 
nails and pins. The objection to these is that their mechani- 
cal presence in many cases has led to infection, and necessi- 
tated secondary operative measures for their removal, while 
at the same time the fixation of the fragments was imperfect 
and insecure. 
In the second class should be placed those instruments 
which tend more accurately to fix the fragments, such as 
metallic nails and screws, and the instrument of Keetley, BONE-CLAMP IN IRACTURES. 
5 
which are of sufficient size to project beyond the soft tissues. 
These, if used in connection with the “ stepped” method of 
resection of Langenbeck, making what is known in me- 
chanics as the “ fish joint,” are sufficient to fix the frag- 
ments. When this method of resection is used, however, it 
is at the expense of the length of the bone, and if any other 
form of resection be used, lateral motion is not prevented, 
except by means of external appliances. 
In the third class we would place the buried metallic 
screw, the metallic double staple of Gussenbauer, and the 
plate and screws of Agnew. All of these are open to the ob- 
jection of necessitating secondary operation for their re- 
moval, even if union does take place. 
I desire again to call attention to a method for the fixa- 
tion of the fragments in recent fractures with a tendency to 
displacement, in ununited fractures after resection, and in 
fractures with malunion after resection, which I had the 
honor to bring before the profession in a paper read before 
the American Surgical Association at its last meeting in 
Washington. I desire to add a number of cases to those em- 
bodied in that report, together with the additional experi- 
ence gained in their treatment. The instrument shown in 
Figs, i, 2, and 3 is adapted for use in all parts of the femur, 
except the neck. The intermediate size is smaller and is 
adapted for the tibia, humerus, and patella. The smallest size 
is for use in the bones of the forearm, fibula, and clavicle. 
The instrument is simple in construction, easy and accurate 
of adjustment, and when properly used secures absolute fixa- 
tion of the fragments. Neither lateral nor longitudinal motion 
is possible. It is of steel, heavily plated with silver, in order to 
secure the antiseptic action of this metal. It consists essen- 
tially of four shafts, each with a thread cut on the lower end, 
and also one near the upper end. The extreme upper end, 
however, is made square so that the shaft may be governed 
by a clock-key. Two sets of curved wing plates are attached 
to these shafts, the longer pair corresponding to the outer 
ones and the shorter pair to the inner. Each wing plate is 6 
CL A YTON PARKHILL. 
fixed to its shaft by two nuts running upon the upper thread, 
one above the plate and the other below, for accuracy of ad- 
justment. When in position one wing plate overlies the 
other in each half of the instrument, and when clamped, the 
pair lie side by side. They are fastened together by a steel 
clamp with a screw in each end. These screws and shafts are 
controlled by the same clock-key, and the nuts by a small 
wrench. The parts composing the apparatus are shown in 
Fig. I. 
Fig. 6.—Pseudarthrosis of femur 
Any method of resection of the bony fragments which 
may be found desirable in the particular case may be used. 
The transverse is probably the most easy of execution and 
generally the most desirable. The periosteum may or may 
not be separated from the fragments. In the forearm and in 
the leg, if one bone is intact while its fellow demands opera- 
tion, it should be shortened to a corresponding degree, and B ONE- CLAMP IN FRA CTURFS. 
7 
clamped in a similar manner. Each fragment is drilled trans- 
versely to the longitudinal axis of the bone, and a small steel 
pin is thrust into the first hole, while the second is being 
drilled in order that they may be made parallel. The dis- 
tance these holes should be from each other and from the 
ends of the fragments should be determined by the bone 
under operation, and the size of the clamp to be used. The 
Fig. 7.—Fracture of leg with delayed union in tibia 
drill selected should be a trifle smaller than the shaft of the 
instrument, in order that the threads may take a firm hold on 
the bone. The shafts are screwed in place by means of the 
clock-key. This is more rapidly accomplished by means of 
the clock-key attachment fitted to a Langenbeck brace. The 
shafts being, in place, their corresponding wing plates are 8 
CL A YTON PARKHILL. 
adjusted and fixed by means of their nuts. While the frag- 
ments are held in accurate apposition the wing plates are 
clamped together. The instrument is long enough to pro- 
ject through the incision in the soft tissues, in order to allow 
for the accurate suturing of the wound between the shafts 
and also for the interposition of a dressing. When possible 
the wound should be sutured without drainage. The part 
operated upon should be enclosed in a fixed dressing of plas- 
ter of Paris, or something of a similar nature. The instru- 
ment should be removed in from four to eight weeks (Fig. 4), 
depending upon the bone operated upon and the conditions 
of the particular case. 
Fig. B.—Pseudarthrosis of bones of forearm. 
I made a special form of wing plate for patellar cases, 
but find it is unnecessary. By reversing one wing plate in 
each half of the instrument adapted for the humerus and 
clamping the plates longitudinally while the shafts are in- 
serted in the form of a quadrangle every indication is met. 
I have also a special form of clamp which I believe will 
be useful in fractures of the neck of the femur. (Fig. 5.) it 
has not been tried, however. It would seem to fix the head 
of the bone more accurately than any other instrument. BONE-CLAMP IN FRACTURES. 
9 
The following is a brief abstract of the histories of the 
cases upon which this instrument has been used. 
Case I.—(Operator, Parkhill.)—W. S., aged nineteen years, 
was sent from Walsenburg to St. Luke’s Hospital, Denver, No- 
vember 20, 1894. Pseudarthrosis of the right humerus as the 
result of a gunshot fracture eleven months previous. An open 
infected wound communicated with the upper fragment. On 
November 22 this wound was scraped out, removing all the in- 
fected tissue. It healed kindly, and on January 3, 1895, the clamp 
was used for uniting the fragments. The bones were found 
separated a distance of two inches. The upper fragment had a 
Fig. 9.—Pseudarthrosis of humerus. 
length of one and a half inches, including the head, and was 
very soft. Transverse resection. The wound was closed about 
the clamp without drainage. The extremity, including the chest, 
was enclosed in a plaster-of-Paris dressing. No reaction. The 
dressing was removed February 7, 1895, when the wound was 
entirely healed. No infection. The clamp screws were lifted out 
without force. The sutures were removed. A dressing and cast 
applied. This was removed at the end of four weeks. Perfect 
union was observed. 
Case II.—(Operator, Parkhill.)—M. M., aged forty years, 
was sent from Victor, Col. Pseudarthrosis of nine months’ stand- 
ing, at the junction of the lower and middle thirds of the right 10 
CLAYTON PARKHILL. 
femur. There was great deformity with retrodisplacement of the 
lower fragment, customary in such fractures. Operated July 7, 
1896. An anterior section of the soft tissues showed the lower 
end of the upper fragment resting upon the anterior surface of 
the lower. No attempt at osseous union. A large amount of 
fibrous tissue was removed with the scissors. The oblique ends 
of the fragments were freshened by means of the rongeur and 
Volkmann spoon. A large size femur clamp was applied. 
Fig. 10.—Pseudarthrosis of humerus, 
Wound sutured about clamp without drainage. Sterilized dress- 
ing applied, and extremity enclosed in plaster of Paris. No re- 
action from operation. Dressing removed at the end of eight 
weeks. Perfect union of fragments. No infection of wound. 
Small dressing applied and plaster-of-Paris splint for three weeks 
longer. Present condition: Perfectly useful extremity. 
Case lll.—(Operator, Parkhill. Delayed union.)—Dr. S. J., 
aged twenty-six years, on July 1, 1896, suffered oblique fracture BONE-CLAMP IN FRACTURES. 
11 
of both bones of the leg, at the junction of the lower and middle 
third, in a run-away accident. Temporary dressing in a fracture- 
box. Later, when the swelling had subsided, in plaster of Paris. 
At the end of six weeks some evidence of union, but far from 
perfect. Very impatient to secure union and get about his work. 
Operated August 15. Considerable amount of new osseous 
Fig. 11.—Mai union of femur. 
Fig. 12.—Nonunion of frac- 
ture of tibia; resection of 
fibula. 
tissue filling the gap between the fragments. Also some fibrous 
tissue. Latter removed with a Volkmann spoon. Fragments 
drawn into accurate apposition and secured by a clamp. Wound 
sutured about clamp without drainage. Antiseptic dressing. 
Leg enclosed in plaster of Paris. No reaction. Clamp removed 
at the end of five weeks. No infection. Perfect union. Anti- 
septic dressing applied. Was given crutches. Perfect result at 
this time. 12 
CL A YTON PARKHILL. 
Case IV.—(Operator, Parkhill.)—A. S., aged twenty-three 
years. Pseudarthrosis of both bones of the forearm as the result 
of a gunshot injury received in Utah, eight months previous. 
Sent to operator from Aspen, Col. Admitted to St. Luke’s Hos- 
pital, August 12, 1896. Operated August 14. Fracture in the 
Fig. 13.—Malunion of fracture of femur, 
middle of the forearm. Fragments separated about one inch. 
Large amount of fibrous tissue between the bones. Transverse 
resection of all the fragments so as to secure a symmetrical fore- 
arm. A small clamp used for each bone. Wound sutured about 
clamp without drainage. Antiseptic dressing applied. The fore- 
arm enclosed in plaster-of-Paris splint. No reaction. Dressing 
removed at the end of six weeks. Clamps taken out. No infec- 
tion. Good union of both bones. Small antiseptic dressing ap- 
plied. Forearm placed in anterior metallic splint. When seen, BONE-CLAMP IN FRACTURES. 
13 
two months later, had regained considerable amount of motion in 
the fingers, and the hand promised to be a very useful one. 
Case V.—(Operator, Mager, Recent fracture with a ten- 
dency to displacement.)—A. D., aged thirty-two years, a travel- 
ling salesman. Steady drinker for some years. On December 24, 
1895, while driving in the mountains, the horses became 
frightened and ran away. He was thrown from the buggy. 
Right leg was caught in wheel, causing compound comminuted 
fracture of both bones in the middle third. Admitted to the hos- 
pital the same evening. Wound cleansed mechanically and anti- 
septically. Small fragments of bone removed. Resection of 
fragments of tibia. Union by silver wire. Aside from normal 
aseptic fever no reaction. At the end of a week, during sleep, 
a violent muscular contraction broke the wire and again fractured 
the lower end of the upper fragment. On January 5 the second 
operation was performed. Second resection of upper fragment. 
Parkhill clamp used. Antiseptic dressing. Plaster-of-Paris cast. 
At the end of seven weeks the dressings were removed. Union, 
but not strong. Antiseptic dressing reapplied. Perfect union at 
the end of ten weeks. Useful extremity. 
Case VI.—(Operator, McNaught. Pseudarthrosis of the 
right humerus.)—G. 8., aged thirty-five years. Railroad accident. 
November 2, 1895, car-wheel passed over upper fourth of the 
right humerus, producing compound comminuted fracture. 
Great destruction of the soft tissues and bone. Lack of union 
after the wound had healed. Operated February 2, 1897, at St. 
Luke’s Hospital. Transverse section. Parkhill clamp used. 
Wound closed about the clamp without drainage. Antiseptic 
dressing. Plaster-of-Paris cast. Clamp removed at the end of 
six weeks. Good union, with useful extremity. 
Case VII.—(Operator, McNaught. Pseudarthrosis of the 
left humerus one and a half inches from elbow-joint.)—Pl. H., 
aged sixty years. Operated May 21, 1896. Parkhill clamp used. 
At the end of six weeks the clamp was removed. Good union. 
Discharged from hospital. The night following discharge the 
patient, in a drunken spree, refractured the arm. The following 
November again presented himself for treatment, requesting that 
the same instrument be used. Clamp applied, and at the end of 
six weeks perfect union was obtained. 
Case Vlll.—(Operator, Freeman. Pseudarthrosis of the 
left humerus.)—A. C., aged thirty-five years. Eighteen months 14 
CLA YTON PARKHILL. 
previous to operation received comminuted fracture of the left 
humerus at the junction of the upper and middle thirds. In 
May, 1896, admitted to Arapahoe County Hospital, Denver, 
Fibrous union and a small sinus. Operated by surgeon on duty. 
Fig. 14.—Fractures of bones of leg, involving ankle-joint, united in deformity. 
Resection of ends and suture by silver wire. Failure. Operated 
September 30, 1896. Ends again resected and united by Parkhill 
clamp. Upper fragment of shaft not more than one-quarter of an 
inch in length. Practically nothing but head of bone remaining. BONE-CLAMP IN FRACTURES. 
15 
Clamp applied, size for femur instead of humerus, so that appli- 
cation was difficult. Much oozing from the wound. Impossible 
to entirely check it. This necessitated frequent changes of dress- 
ing for considerable length of time. Infection lasting about three 
weeks. Clamp removed November 3. Perfect union with motion 
at shoulder-joint. Patient could place hand to top of head. Use- 
ful extremity. 
Case IX.—(Operator, Parkhill.)—W. M., aged thirteen 
years. Malunion of the left femur of about ten months’ standing, 
fracture having occurred at junction of upper with middle third. 
Upper fragment tilted upward and outward. Lower fragment 
united with it at an angle producing great deformity and much 
shortening. Operated February 5, 1897. Anterior incision. 
Fragments separated with difficulty by means of saw and chisel. 
Transverse section of ends. Extremity extended, and a gain in 
length secured amounting to an inch or an inch and a half. 
Clamp applied. Wound sutured about instrument without drain- 
age. Antiseptic dressing and entire extremity and pelvis en- 
closed in plaster cast. Dressing removed at the end of seven 
weeks. Perfect union and perfect symmetry of bone. No infec- 
tion. A light dressing with external and posterior light splint. 
Dressing taken off at end of nine weeks and splints removed. 
Was given crutches and is now walking on extremity. 
Case X.—(Operator, Parkhill. Pseudarthrosis.)—O. 0., 
aged twenty-eight years, has led a dissipated life and been a more 
or less heavy drinker until two years ago, when he contracted 
syphilis. Since that time he has been a periodical drinker. He 
has had practically no treatment for syphilis. On the 30th of 
March, 1897, he sustained a fracture of the left tibia at the junc- 
tion of the lower with the middle third, in a railroad accident in 
the State of Washington. Non-union. First operation June 18, 
1897. Oblique fracture from above downward and forward. 
Space between the fractured ends filled with dense fibrous tissue. 
Fragments freshened with scissors and Volkmann spoon. 
Clamped. At the end of six weeks the instrument was removed. 
No union. Operated the second time on September 28, 1897. 
Resection of the tibial fragments with saw in the line of fracture; 
corresponding portion of the fibula removed. Clamp adjusted in 
each bone. Wound sutured without drainage. Extremity en- 
closed in a plaster cast. First dressing made and clamp removed 16 
CL A YTON PARKHILL. 
at the end of seven weeks. Perfect union of both bones. No 
infection. 
Case XL—(Operator, Parkhill. Malunion.)—R. H., a 
healthy miner who had been a hard drinker. Left femur fractured 
in the middle third by the kick of a man posteriorly, on May 7, 
1897, at Creede, Col. Treated in that city. Was in splint five 
Fig. 15.—Pseudarthrosis of radius 
weeks. On presenting himself, in October, union was firm but 
with deformity, the upper fragment overlying the lower and over- 
riding at least three inches. The thigh bowed anteriorly and 
externally, crippling him seriously. Operated October 29. An- 
terior incision. Fragments separated with great difficulty, by 
means of a chisel and mallet. Ends resected transversely. Strong 
extension made on extremity and a gain of at least two inches 
in length was secured. Clamped in place. Extremity including 
the pelvis enclosed in an external dressing of plaster of Paris. 
Wound was dressed at the end of a month. Light grade of infec- 
tion found, probably due to imperfect preparation of the thigh for 
operation. Instrument removed at the end of forty days. Good 
union secured without deformity. BONE-CLAMP IN FRACTURES. 
17 
Case Xll.—(Operator, Parkhill. Malunion.)—Mrs. S., 
aged forty-six. Fracture of both bones of the left leg by a fall 
from a wagon, August 3, 1897. Treated at her home at Buffalo 
Park, Col. In splint three weeks. On presenting herself to 
operator, union was found with great deformity, the foot being 
inverted and resting upon its outer border. Operated November 
6, 1897. Incision on the inner surface of the tibia discovered 
that there had been an oblique fracture from below upward and 
inward, splitting off the inner malleolus with a small portion of 
the adjoining articular surface of the tibia, the fracture line ex- 
tending upward to a distance of about one and a half inches. 
The fracture united with great deformity. An incision over the 
fibular side of the ankle showed a multiple fracture of the lower 
end of the fibula. These fractures had united, but with the outer 
malleolus displaced strongly inward. Resection of each bone, 
and replacement of fragment in normal position. A clamp used 
for each bone. Three shafts of each clamp fixed in the upper 
fragment and one in the lower. Sutured without drainage. Ex- 
tremity enclosed in external dressing of plaster of Paris. Clamp 
removed December 18, 1897. Good union with perfect sym- 
metry. No infection. 
Case XIII.—(Operator, Parkhill. Pseudarthrosis.)—C. 
McC., aged fifty-eight. Fracture of right radius at junction of the 
lower with the middle third March 1, 1897. Treated in splints at 
Cripple Creek, Col. Non-union. Operated in Cripple Creek in 
June, 1897. Fragments wired with silver. Failed to unite. Pre- 
sented himself to operator early in November with pseu- 
darthrosis. Operated November 13. Incision over the outer 
margin of the radius. Fragments resected transversely. Incision 
over the inner margin of the ulna, and removal of three-fourths 
of an inch of bone, making a symmetrical forearm. Clamp used 
in each bone. Sutured without drainage. Extremity enclosed in 
external dressing of plaster of Paris, reaching above the elbow- 
joint and fixing the forearm at a right angle. Clamp removed 
December 28. Good union with perfect symmetry. 
Case XIV.—(Operator, McNaught. Recent fracture with 
displacement.)—W. W., aged thirty. Received a fracture of the 
patella while mounting a moving train, September 11, 1897. The 
fracture was probably due to muscular action, as he recollects no 
injury. The fracture was transverse. He was treated on an 18 
CLA YTON PARKHILL. 
Agnew splint, and apparently good union was obtained. Was 
discharged from the hospital on December 2, 1897. Slipped on 
the icy pavement the same day and refractured the patella. Re- 
turned to the hospital and was operated December 10. The 
fragments were found separated about one inch, the fractured 
surfaces freshened by the Volkmann spoon and cutting forceps. 
The Parkhill clamp applied, the shafts being inserted into the 
fragments in the form of a quadrangle. Perfect apposition. 
Wound closed without drainage. Progress until the present time 
uneventful. Good union obtained. 
Fig. 16.—Recent fracture of patella. 
We claim for this instrument: 
(1) That union has been secured in every case in which 
it has been used, as against 56 per cent, of cures by all me- 
chanical means, according to the statistics of Bruns and 
Gurlt, 
(3) That it prevents both longitudinal and lateral mo- 
tion between the fragments. 
(2) That it is easily and accurately adjusted. 
(4) That the presence of the shafts in the bone stimu- 
lates the production of osseous tissue. 
(5) That nothing is left in the tissue that might reduce 
their vitality or lead to pain and infection. 
(6) That no secondary operation is necessitated