Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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about twenty miles from town, and was occasioned by the kick of a
horse. This was also a compound fracture. It does not appear that
his surgeon discovered the dislocation of the radius, but supposed that
it was a fracture of both bones. On the ninth day the patient became
dissatisfied and dismissed his surgeon, but employed no other.

Oct. 1, 1849, eleven weeks after the accident, he called upon me. I
found the ulna united with a manifest displacement, but I could not
discover that there had been any fracture of the radius. The head
of the radius was in front of the external condyle, and a depression
existed where it formerly articulated. When the arm was flexed, the
head did not strike the humerus so as to arrest the flexion, but it
glided upwards and outwards along the inclined base of the external
condyle. He had already begun to use his arm considerably in labor.
The forearm was shortened one inch.

Three times I have noticed after the lapse of several years that the
forearm could not be perfectly supinated ; but pronation was never
permanently imp^^ir^. I think, also, that the motions of flexion and
extension have always, except where the radius has remained dislo-
cated, been completely restored soon after the splints were removed ;
and even in these latter cases, it is only extreme flexion which has
been hindered.

Treatment. — In simple fracture we must look carefully to the lateral
deviation of the fragments; and if they are found to be salient forwards
or backwards, pressure made directly upon or near their extremities,
restores them to place, but it often requires considerable force to ac-
complish this. A gentleman feir and broke the right ulna near its
middle. He came immediately to me, and I found the fragments dis-
placed backwards. Pressing strongly with my fingers, they sprung
forwards with a distinct crepitus, and I thought they were now in
exact line. A broad and well-padded splint was applied to the fore-
arm, and I took especial pains with compresses nicely adjusted, from
day to day, to keep everything in place. The arm was placed in a
sling. Eight months after the accident this gentleman died of cholera,
and I was permitted to dissect the arm. I found the fragments well
united, but with a very palpable projection of the fragments back-
wards, in the direction in which they were at first.

If the displacement is in the direction of the radius, it is more diffi-
cult to overcome, but its necessity is much more urgent, since, if the
fragments fall completely against the radius, a bony union may take
place, occasioning a complete loss of the power of pronation and of
supination

While moderate extension is being made, and the hand is well
supinated, the fingers of the surgeon should be pressed firmly, and in
spite sometimes of the complaints of the patient, between the radius



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800 FRACTURES OF THE ULNA.

and ulna, and the fragments of the broken ulna fairly pushed out from
the radius.

The forearm may now be laid in the usual position against the front
of the chest; midway between supination and pronation, and the same
splints applied and in the manner which we shall hereafter describe
for fractures of the shaft of both bones.

We ought, however, especially to bear in mind the danger of thrust-
ing the fragments against the radius, by allowing the sling or the
bandage to rest against the middle of the ulnar side of the bone. To
prevent this, the sling ought to support the arm by passing only under
the hand and wrist, or the forearm may be laid in a firm gutter which
will touch the forearm only at the elbow and wrist, or it may be laid
upon its back as suggested and practised by Scott, and also bv Fleary,
the latter of whom, according to Malgaigne, had a case which had
been treated in the position of semi-pronation, and which remained
not only displaced, but refused to unite ; but when the arm was supi-
nated, the fragments came at once into contact and bony union speedily
took place. This position may be adopted whenever it is found to be
practicable; but the position of semi-pronation is generally much
more comfortable to the patient, at least when the forearm is laid
across the chest, and I have found very few patients who would sub-
mit to a position of complete supination.

In fractures accompanied with dislocation of the head of the radius
forwards or backwards, nothing should prevent the immediate reduc-
tion of the dislocation but a demonstration of its impossibility, or a
condition of the limb which would render manipulation hazardous.
It can be reduced, generally, by pushing forcibly upon the head of the
bone in the direction of the socket, while the arm is moderately flexed
so as to relax the biceps, and while extension is being made at the
forearm by an assistant. In making the counter-extension, care should
be taken to seize the lower end of the humerus by the condyles, rather
than by its anterior aspect, by which precaution we shall avoid press-
ing upon and rendering tense the tendon of the biceps.

July 29, 1845, a lad, set. 9, fell from his bed, breaking the ulna
and dislocating the head of the radius. i)r. Austin Flint was called
on the following morning, and at his request I was invited to see the
patient with him. We found the ulna broken obliquely near its mid-
dle, and the head of the radius dislocated forwards. While Dr. Flint
seized the elbow in front of the condyles, I made extension from the
. hand, the forearm being slightly flexed upon the arm, and at the same
moment I pushed forcibly the head of the radius back to its socket.
The reduction was accomplished easily and completely.

We then dressed the arm with an angular splint, constructed with
a joint opposite the elbow. This was laid upon the palmar surface,
and the whole was nicely padded, especially in front of the head of
the radius. In two weeks pasteboard was substituted for the angular
splint. At the end of six weeks I was permitted to examine the arm,
and found the head of the radius perfectly in place, but the points of
fracture slightly salient. All of the motions of the arm were fully
restored.



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CORONOID PROCESS OP THE ULNA. 801

June 2, 1845. C. C, eet. 9, fell upon his arm, breaking the ulna
obliquely near its middle, and dislocating the head of the radius for-
wards. Dr. J. P. White being called, requested me to visit the patient
also with him. We found one of the broken fragments protruding
through the skin, on the inside of the arm.

With great ease, and by simply pressing with considerable force
upon the head of the radius, it was made to slide into its socket. The
case was left in charge of Dr. White.

Five weeks after, I found all of the motions of the forearm com-
pletely restored, except that he could not extend it petfectly. The
head of the radius was also a little more prominent in front than in
the opposite arm.

Four or five years later, the projection of the head of the radius had
disappeared, an^ the functions of the arm were perfect.

§ 2. CoRONOiD Process of thb Ulna.

Dissections^ have established the possibility of this fracture as a
simple accident in the living subject ; but I have not myself seen any
example of which I can speak positively. In the two following cases,
the existence of such a fracture was at first suspected, but I have now
very little doubt but that my diagnosis was incorrect. I shall relate
them, however, as examples of those accidents which are likely to be
mistaken for fracture of this process.

A laboring man, aged about twenty-five years, had been seen and
treated by another surgeon, for what was supposed to be a simple
dislocation of the radius and ulna backwards. The surgeon thought
he had reduced the dislocation very soon after the accident. On the
following day he found the dislocation reproduced, and he requested
me to see the patient with him. The arm was then much swollen,
but the character of the dislocation was apparent. By moderate ex-
tension, applied while the arm was slightly flexed, and continued for
a few seconds, reduction was again effected, the bones returning to
their places with a distinct sensation; but on releasing the arm the dis-
location was immediately reproduced. These attempts to reduce and
retain in place the dislocated bones were repeated several times during
this day, and on subsequent days, but to no purpose, and the patient
was dismissed after about two weeks with the bones unreduced.

The impossibility of retaining the bones in place, and the existence
of an occasional crepitus during the manipulation, inclined me to be-
lieve at the time that the dislocation was accompanied with a fracture
of the coronoid process.

Another similar case has since presented itself in a child nine years
old, and in which the subsequent examinations not only demonstrated
the non-existence of a fracture^ but also rendered doubtful the justness
of the conclusions which I had drawn in the case just related.

This lad fell, Nov. 4, 1855, and his parents immediately brought
him to me; but as he lived many miles from town, I did not see him



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302 rEAOTURES OP THE ULNA.

until eighteen hours after the injury was received. I found the arm
much swollen, slightly flexed, and pronated. Flexion and extension
of the arm were very painful, the pain being referred chiefly to the
front of the joint, near the situation of the coronoid process ; and at this




« Fracture of the coronoid proceM.

point also there was a discoloration of the size of a twenty -five cent
piece. Flexing the forearm moderately upon the arm and making
extension, the bones came readily into place, but without sensation of
any kjnd, either a snap or a crepitus. That the bones had now re-
sumed their position, however, I made certain by a very careful exami-
nation with the hand and by measurement, yet they would not remain
in place one moment when the extension was discontinued. The
reduction was made several times, and constantly with the same result.
We then applied a right-angled splint to the arm, having first reduced
the bones, and thus were able to retain them in position. I believed
that the coronoid process was broken, and so informed the surgeon to
whose care the boy was returned.

Five months after, he was brought again to me, and I then found
that the radius and ulna had been kept in place; the motions of the
joint were perfect, and if the coronoid process had ever been broken it
was now again in its natural position, and with every structure about it
in a condition as complete as it was before the accident. For myself,
I do not believe that so perfect a union of this process can happen —
at least in a case where, as must have been the fact in this example,
the separation and displacement of the process are such that it no
longer offers an obstacle to the dislocation of the ulna backwards and
upwards.

Malgaigne thinks that the fracture is more frequent than the small
number of reported examples would lead us to suppose, especially
because he has noticed how often the summit of the process is broken
ofi^, when dislocation of the radius and ulna backwards is produced
artificially on the dead subject. In three or four cases, also, of dis-
locations of these bones backwards and inwards, which had come
under his notice, he was unable to feel this process, and he therefore
thought it probable that it was broken oft* Other surgeons have
thought, also, that it was a not infrequent accident; and they have
constantly made use of this supposition to explain those cases in
which the radius and ulna having been dislocated backwards, would
not afterward remain in place when well reduced. Fergusson has
indeed made the extraordinary statement in relation to dislocations of
the radius and ulna backwards generally, that in these cases " the
coronoid process will probably be broken."

But, in my opinion, these fractures are exceedingly rare; and I think
these gentlemen need to have furnished some more conclusive evi-



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CORONOID PROCESS OF THE ULNA, 803

dence of the correctness of their opinions than can be found in their
writings, or in the writings of any other surgeons which I have seen.

Malgaigne mentions three reported examples, namely: one pub-
lished by Combes Brassard, an Italian surgeon, in 1311, which Bras-
sard saw only after a lapse of three months ; one seen by Pennock, and
published in the Lancet in 1828, the patient then being sixty years
old, and the accident having occurred when he was a young man ; the
third was seen by Sir Astley Cooper, several months after the accident,
and is reported by himself in his excellent treatise on Fractures and
Dislocations. Says Mr. Cooper : " It was thought, at the consultation
which was held about him in London, that the coronoid process was
detached from the ulna." This was the only living example seen by
Mr. Cooper in his long and immensely varied surgical practice ; and
even here we cannot fail to notice the apparent reserve with which he
expresses his opinion — " It was thought at the consultation."

To these examples our own researches have added a few others.

Dorsey says that Dr. Physick once saw a fracture of the coronoid
process. The symptoms resembled a luxation of the forearm back-
wards, " except that when the reduction was effected, the dislocation
was repeated, and by careful examination, crepitation was discovered.
The forearm was kept flexed at a right angle with the humerus. The
tendency of the brachieus internus to draw up the superior fragment
was counteracted in some measure by the pressure of the roller above
the elbow. A perfect cure was readily obtained."* In 1830, Dr. Wm.
M. Fahnestock repotted a case occurring in a boy, who, having fallen
from a haymow, received the whole weight of his body ** on the back
part of the palm of the left hand," while the arm was extended for-
wards. It seemed to be a dislocation of the forearm backwards, but
when reduced it was again immediately displaced, with an evident
crepitus. The arm was secured in the angular splint of Dr. Physick
and " recovered very speedily."* Dr. Couper, of the Glasgow Infirm-
ary, also has reported a dislocation of the forearm backwards and out-
wards, occurring in a young man aged seventeen, and which he thinks
was accompanied with this fracture. The dislocation was easily re-
duced, but returned again immediately on ceasing the extention. The
fragment was not felt, nor does he speak of crepitus ; the existence of
the fracture being inferred from the fact that the bones would not
remain in place without help. The forearm was placed across the
chest, with the fingers pointing toward the opposite shoulder, and
secured in this position with splints and a bandage. At the end of
four weeks union had taken place, with only slight deformity, although
with some stiffness of the joint.

In relation to this example, the editor remarks that the symptoms
were not to his mind conclusive in determining the existence of a
fracture of the coronoid process, and he inclines to the belief that it
was rather an oblique fracture of the lower extremity of the humerus.
" In cases like these," he adds, " where very rare accidents are sus-

» Dorsey, Elements of Surgery, vol. u p. 152. Philadelphia, 1818.
« Fahnestock, Amer. Joum. ited. Sci., vol. vi. p. 267.



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804 FRACTURES OF THE ULNA.



pected, we think that unless the diagnosis is clear, the leaning should
always be the other way : we mean that, cseteris paribus, the symptoms
should rather be referred to the common than the extraordinary
injury. The contrary practice introduces a dangerous laxity in diag-
nosis."^

Dr. Duer, of Philadelphia, has reported a case which occurred in a
boy six years old, and in which he felt and moved the fragment with
his fingers. It was complicated with a dislocation, which remains un-
reduced. This case was last seen about seven weeks after the accident*
If at a later period we could be permitted to examine the patient, it
is probable that the diagnosis might be rendered certain.

In the American Medical Monthly for October, 1855, also, I find the
report of a trial for malpractice, in which a lad nine years old re-
ceived some injury about the elbow -joint which resulted in a maiming.
The defendant claimed tHat there had been a dislocation of the fore-
arm backwards, accompanied either with a fracture of the trochlea
of the humerus, or of the coronoid process of the ulna.

Dr. Crosby, of Dartmouth College, testified that he had never met
with a fracture of this process, yet he would not say that it did not
exist in this case. He was not able to decide positively. Dr. Peaslee,
of the same college, thought it altogether probable that it had been
broken, and Dr. Spaulding was of the opinion fully that it had been
broken.

The jury did not agree, and a nonsuit was finally allowed by the court.

The defendant, in his report of the trial, seems tb me to have justly
complained that Mr. Fergusson has said, that in a dislocation of the
forearm backwards " the coronoid process will probably be broken."
This was urged in the trial by the plaintifiTs counsel as contradicting
the medical testimony, and as evidence of a conspiracy on the part of
the surgeons to defeat the ends of justice ; since they constantly affirmed
that the accident was so rare as not to have been reasonably expected,
and that a failure to look for or to discover it did not imply a lack of
ordinary skill or care.'

Says Mr. Listen : " The coronoid process is occasionally pulled or
pushed oflf from the shaft, more especially in young subjects. I saw
a case of it lately, in which the injury arose in consequence of the
patient, a boy of eight years, having hung for a long time from the
top of a wall by one hand, afraid to drop down ;"* after whom Miller,
Erichsen, Skey, Lonsdale, and most of the Scotch and English sur-
geons have repeated the assertion that this process may be broken in
this manner by the action of the brachialis anticus alone, yet no one
of them has to this day seen another example.

The explanation of the accident in the case of the boy, given by
Liston, implies two anatomical errors : first, that the coronoid process
is an epiphysis during childhood ; and second, that the brachialis anti-
cus is inserted upon its summit. The coronoid process is never an epi-
physis, but is formed from a common point of ossification with the

» Couper, Lond. Med.-Chir Rev., new ser., vol. xl, p. 509.

« Duer, Amer. Joum. Med. Sci., Oct. 1883, p. 890.

» Op. cit., vol. iv. p. 889. * Liston, Practical Surgery, p. 55.



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CORONOID PBOCESS OF THE ULNA.



805



shaft ; the olecranon process and the lower extremity of Fig- 100.
the ulna having also separate points of ossification : the
olecranon becoming united to the shaft at the sixteenth
year, and the lower epiphysis at the twentieth. Moreover,
the brachialis anticus has its insertion at the base of the
process and partly upon the body of the ulna, but in no
part upon its summit; indeed, the process seems rather to
be intended as a pulley over which the brachialis anticus
may play ; resembling also somewhat, in its function, the
patella ; serving to protect the joint and perhaps the muscle
itself from becoming compressed in the motions of the
joint. Certainly it could never have been broken by the
action of this muscle, and the case mentioned by Mr. Liston
must find some other explanation. It may have been a
rupture of the brachialis anticus itself, or of the biceps,
or possibly a forward luxation of the head of the radius.
Either of these suppositions is more rational than the state-
ment made by Mr. Liston, because either one of them is
possible, while his supposition is impossible.

I have already quoted Dr. Hodges as saying that he had
found the coronoid process broken off three times in con-
nection with longitudinal fractures of the head of the
radius.

These, if I except my own, constitute all of the supposed
examples seen in the living subject, of which I find any
record ; twelve in all.

It is true, however, that at least two other cases have been reported
to me by letter, of which the writers speak with great confidence, and
the authenticity of which lam unable to dispute ; but in neither case
is the testimony to me satisfactory, and as they are not upon record, I
shall be excused from discussing their merits.

The two first of the twelve above enumerated, were not entirely satis-
factory to Malgaigne ; the third is spoken of cautiously by Sir Astley
Cooper, as if it needed, in addition to his own great name, the indorse-
ment of the " London council." Dorsey reports his case upon hearsay,
and the result is quite too satisfactory to give it much claim to credi-
bility. Fahnestock's case is to our mind far from being fully proven.
Couper's case is doubted by Dr. Johnson ; and the New Hampshire
case was not made out satisfactorily to either the jury or the medical
men. Listbn's case was simply impossible. Duer's case could have
been better verified at a later period. Having never seen a report
of the three cases referred to by Dr. Hodges, I am unable to form any
opinion as to their claims. His well-known reputation, however, dis-
poses me to accept of them as authentic.

Certainly it is not upon such testimony as this that we can rely to sus-
tain Mr. Fergusson's opinion that this fracture is likely to occur in all
dislocations of the forearm backward, or of Malgaigne's conjecture that
it is of more frequent occurrence than the published cases would
seem to show. Nor will it be regarded as conclusive, that the beak
of the process is often found broken after luxations made upon the



Uloa, with
epiphyses.
(From Gray.)



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806 FRACTURES OP THE ULNA.

subject ; since between laxations thus produced, and luxations occur-
ring in the living subject there exists this important differenoe : that
in the case of the latter, muscular action is the principal agent in the
production of the dislocation, while in the former it is the external
force alone which drives the bone from its soclcet.

The fact, therefore, that so few cases have ever been reported, and
that most of these are far from having been clearly made out, remains
presumptive evidence that the actual cases are exceedingly rare ; but
if to this we add such negative evidence as is furnished by actual dis-
sections, and by examinations of the pathological cabinets of the
world, we think the testimony is almost conclusive.

Only four specimens have been mentioned by any of the surgical
writers known to me. Sir Astley Cooper says that a person was
brought to the dissecting-room at St. Thomas's Hospital, who had been
the subject of this accident. " The coronoid process, which had been
broken off within the joint, had united by a ligament only, so as to
move readily upon the ulna, and thus alter the sigmoid cavity of the
ulna^o much as to allow in extension that bone to glide backwards
upon the condyles of the humerus."* Mr. Bransby Cooper adds in a
note that the external condyle of the humerus was also broken and
united by ligament.

Samuel Cooper describes, rather obscurely, a specimen contained in
the University College Museum, "in which the ulna is broken at the
elbow, the posterior fragment being displaced backwards by the action
of the triceps ; the coronoid process is broken off; the upper head of
the radius is also dislocated from the lesser sigmoid cavity of the
ulna, and drawn upwards by the action of the biceps. In this com-
plicated accident, the ulna is broken in two places."

Malgaigne says that Yelpeau has also established by an autopsy
the existence of a fracture of the coronoid apophysis, but without
having given any further particulars in relation to the case.

In addition to these examples, Charles Gibson, of Bichmond, Ya.,
has stated to me, by letter, that he has in his possession a specimen of
this fracture, evidently belonging to an adult. The process was broken
transversely near its extremity, and has united again quite closely
and without any displacement, and without ensheathing callus.

We must subject these specimens to analysis also. The first two
were complicated with other fractures, and the second, especially,
seems to have been a general crushing of all'the bones concerned in
the formation of the elbow-joint ; neither of them could have been
occasioned by contractions of the brachialis anticus, while only that
one described by Sir Astley Cooper could have been the result of a



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 36 of 100)