(Extracted from The American Journal of the Medical Sciences for April, 1860.] 
THE 
SILYER WIRE IN UNUNITED FRACTURE, 
WITH A CASE. 
By E. K. SANBORN, M.D., 
'"’TRMTfRQERY IN CASTLETON MEDICAL COLLEGE AND BERKSHIRE MEDICAL COLLEGE, MASSACHUSETTS. 
In a late number of this journal (July, 1859) I reported the history of 
a case of “ununited fracture of the radius and ulna successfully treated by 
drilling and wiring,” the case having previously resisted the means ordi- 
narily used by surgeons to procure union, including simple drilling and the 
seton. 
Since the publication of the above case I have made further trial of the 
wire, in a case of false joint of three years’ standing, and the result goes far 
to confirm the opinion there expressed, that the operation, both in safety 
and certainty, was superior to the operations generally practised in such 
cases. 
The necessity of freely exposing the ends of the fragments, and of dis- 
secting away ligamentous connections or coverings, in order to insert the 
wire satisfactorily, makes the operation appear somewhat formidable, in 
comparison with the so-called milder methods, as the introduction of the 
seton, drilling, acupuncture, &c. But it has appeared in the three cases in 
which I have performed the operation, that both the local and constitutional 
disturbance was very much less than that produced by the seton in the same 
cases. For in each case in which I have introduced the wire, the seton and 
the operation of drilling had been unsuccessfully tried—the seton especially 
being followed by erysipelatous inflammation of a dangerous character in 
one case, and long-continued suppuration in another. The testimony of 
my patients is conclusive to the fact, that wiring is less severe than the 
seton. And it will be noticed in the report of the case below given, that 
the seton had been worn thirteen weeks, occasioning at times severe suffer- 
ing, from inflammation and abscess; while, in the operation by the wire, 
the external wound was healed and the union of the fracture quite firm in 2 
forty-two days, and the inflammatory symptoms were altogether of a trivial 
character. 
Wiring, as I have performed the operation, is in fact the application of 
the “silver suture” on a large scale to fractured bones ; and it will be quite 
evident to any one familiar with the action of metallic sutures in the soft 
tissues, that they fulfil quite closely the conditions required for the union 
of unrepaired fracture, which are immovable, and close coaptation of the 
fracture ends of the broken bone, for a considerable length of time, asso- 
ciated with a continued and gentle stimulus to the vessels of the hone and 
periosteum at the point of fracture. It is also essential, for the speedy 
and perfect progress of the reparative action in the bone, that the surround- 
ing soft tissues should be free from the higher stages of inflammation. 
According to my observations, if the wire is properly inserted, and is allowed 
to remain undisturbed, the bone in a few days becomes passive to the pre- 
sence of the foreign body; while the wound in the soft tissues closes up 
around the projecting wire almost as speedily as in a simple cut. Even 
under considerable tension, produced by daily tightening the “loop,” the 
separation of the wire in my cases has been a slow process—not being 
accomplished under twenty or thirty days. 
Case.—L. T., Enfield, IST. H., 33 years old, married, and healthy—un- 
united fracture of the lower third of the right humerus. According to the 
patient’s account the accident occurred in 1856, or about three years since. 
The fracture was received while at work with a threshing-machine, and was 
compound. 
The case was under the care of a skilful surgeon, but without any appa- 
rent reason the bones failed to unite. 
Seven months after the accident the patient went before the clinic of 
Dartmouth Medical College, where the operation of drilling (after Brai- 
nerd’s method) was performed. 
Getting no benefit from this operation, the patient, six weeks afterwards, 
went to Boston, where he placed himself under the care of Dr. Warren, in 
the Massachusetts General Hospital. Here a seton was introduced, which 
was retained thirteen weeks. The irritation produced by the seton was 
severe, and at last suppuration was so extensive and the pain so great that 
it was removed. 
This operation was also unsuccessful, and in view of the failures, and the 
fact that the patient while young had suffered from necrosis of several of 
the bones of the lower extremities, an unfavourable prognosis was given, 
and the young man returned to his home. 
Since that time nothing has been done in the case. At the present time 
(June, 1859) the limb presents the usual features of confirmed false joint. 
The arm is nearly useless, and is carried in a sling. The upper arm is very 
much shrunken, and somewhat scarred by operations and abscesses. The 3 
ends of the fragments can be freely felt, and they slip by each other to the 
extent of an inch and a half, in any attempt to move the limb. 
The forearm is well developed, and in some positions, when a leather 
bracelet is worn about the fracture, the hand is useful. The general health 
of the patient is perfectly good. 
Seeing nothing in the present condition or previous history of the case 
that could interfere with the success of the wiring operation, I suggested 
the plan, and on the 16th June the operation was performed in presence of 
numerous medical gentlemen of this town and neighbourhood. 
Operation.—The patient being fully etherized, an incision about five 
inches in length was made over the fracture, on the outside of the arm, 
extending down to the bone. The ends of the fragments were found to be 
inclosed in a strong capsular ligament, which, on being opened, discharged 
about half an ounce of clear synovial fluid, having about the consistence 
and appearance of lamp-oil. This capsular envelop was dissected away, 
and the ends of the bones fully disclosed. This capsule was interspersed 
with numerous small osseous scales, which made it somewhat difficult to 
cut; and at the point where the membrane was attached to the bone were 
numerous rough projecting bony points, and ridges which probably marked 
the sites of the drill-holes formerly made. The end of each fragment was 
covered with smooth cartilage—the upper fragment exhibiting a sort of 
shallow cavity on its broken end, in which played the rounded end of the 
lower fragment, after the manner of a ball-and-socket joint. The cartila- 
ginous covering was dissected from the ends of the bones, and the surfaces 
deeply scarified with the bone-forceps. From the lower fragment a pro- 
jecting spike of bone was also removed. With a common small sized gimlet 
several holes were then bored obliquely through each fragment. The 
instrument entering on the periosteal surface about an inch from the extre- 
mity, and coming out at the end. 
Through one set of these holes was then inserted a stout wire (made by 
twisting together four strands of the largest silver wire as used by Simms), 
the extremities of which being twisted by strong clasp forceps, brought the 
ends tightly together in the loop, with the wire projecting from the 
wound. 
The external wound was then brought loosely together by adhesive 
plaster, and the limb laid into a right-angle gutter splint, made of tin for 
the purpose, and extending from the axilla to the fingers. Water-dressing 
was applied over the wound. 
June IY. Saw the patient at 9A. M.; complains of some pain in the 
arm and shoulder. Some heat and swelling in the neighbourhood of the 
wound. Passed rather a restless night, although he took half a grain of 
morphia in the evening. Pulse, 105. Added infusion of opium to water- 
dressing, and prescribed rigid diet, mucilaginous drinks, and morphia— 
p. r. n. 4 
ISth. General febrile symptoms abated. Patient comfortable. Changed 
dressings. Arm considerably swollen; but wound looking well. Treat- 
ment continued. 
28th. The case has progressed favourably. The wound is nowr discharg- 
ing freely about the wire, and is closing at the extremities. The swelling in 
the limb generally has much diminished, though a prominent ridge has 
been thrown out at the part embraced in the wire-loop. The wire having 
become somewdiat loose, it is twisted as much as the patient can easily 
bear. 
July 25. To-day, while tightening the wire, it became detached, and was 
removed with the loop unbroken. The external wound has closed, except- 
ing at the point where the wire projected. A well-formed callus seems to 
embrace the fracture, and the arm can be lifted from the splint without 
displacement, though the connection is yielding. 
August 6. Since the last record, two or three small bits of bone have 
been discharged from the wound. Swelling has nearly disappeared, and 
the wound has closed, excepting a mere point. The prominent callus is 
also disappearing, though the consolidation is now so great that the bone 
will sustain the weight of the forearm without bending. Removed the 
splint and applied a gum and chalk bandage from the hand to the axilla, 
cutting a small aperture in the bandage opposite the wound for the purpose 
of dressing, &c. 
Bth. Having ascertained that the stiff bandage is well borne, dismissed 
the patient, with directions to begin to use the hand after two wreeks, and 
to wear the bandage as long as it fitted closely, or the arm needed support. 
The present condition of the limb will be seen by the following extract 
from a letter, dated December 7th, from Dr. B. T\ Skinner, his attending 
physician : 
“I examined T.’s arm day before yesterday. It is evidently firmly 
united. He has worked constantly with a one-horse team for two months 
or more, drawing wood, gravel, goods from the depot, &c. He says the 
arm feels as strong as the other. lam unable to see why the cure is not 
complete.” 
Rutland, Yt., January 7, 1860.