Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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dislocation of the forearm backwards. Of the specimen said to have
been seen by Yelpeau, I am unable to speak without more circum-
stantial knowledge of its condition. Nor can I speak very confidently
of that belonging to my distinguished friend, Dr. Gibson, of Yirginia.
Notwithstanding the respect which I entertain for his opinion, I can-
not avoid a suspicion that the bone was never broken at all, since i

> A. Cooper, Dislocations and Fractures, p. 411.

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find it more easy to believe that he is deceived by certain appearances,
than that it should have united by bone again, and so perfectly as not
to leave any line of separation or degree of displacement. Certainly
the fracture was too high to have been produced- by the action of the
muscle, if such a thing were ever possible; and if broken by a dislo-
cation, which must have forced it violently from its position, as the
ulna was driven upwards, it is to me incredible that 'it should ever be
made to unite again so perfectly.

We are therefore left as before, with no evidence that the coronoid
process was ever broken by the action of a muscle, and with only one
example in which it is probable that a fracture occurred as a conse-
quence of a dislocation of the radius and ulna backwards. If then it
does happen that in this dislocation it is pretty often found difficult
or impossible to retain the bones in place without aid, it will be the
part of prudence to ascribe this troublesome circumstance to some
more common accident than a fracture of the coronoid process; per-
haps to a fracture of some portion of the lower end of the humerus,
or to a disruption, more or less complete, of the tendons of the biceps
and brachialis anticus^ together with the ligaments which surround
the joint

(Just as this volume is ready for the press my attention is called
by Dr. Castle, of this city, to a review by Zeis of a paper on fractures
of this apophysis, published by Lotzbeck, of Munich, in 1866.^ The
original paper furnishes five cases, to which the reviewer has added
four more, one of which, Pennock's case, I have already spoken of.
After a careful reading of the review, I fail to find conclusive evidence
that the coronoid process was broken in either case. The evidence
may be, indeed, in some of the cases probable, but never conclusive,
since other explanations of the phenomena presented than those which
are here offered, would prove to me equally satisfactory.)

CavL8€8. — ^It is probable that this process will be sometimes broken
in a fall upon the palm of the hand ; the force of the blow being
received directly upon the lower end of the radiusi, and, through its
numerous muscles and ligamentous attachments, being indirectly con-
veyed to the ulna, producing a violent concussion of the coronoid
process against the trochlea of the humerus, and resulting finally in
a fracture of this process and a dislocation of both bones of the fore-
arm backwards. The gentleman seen by Sir Astley had fallen upon
his extended hand while in the act of running. Brassard's patient
had fallen also upon his hand with his arm extended in front. Pen-
nock's patient, an old man of sixty years, had fallen upon the palm of
his hand, and Fahnestock's fell upon the '^ back of the palm." In no
other case is the point upon which the blow was received particularly
mentioned. In two of the examples mentioned by Malgaigne there
was a luxation' of the forearm backwards ; such was also the fact in
the case seen by Fahnestock ; in Couper's case it was dislocated back-
wards and outwards, and in Sir Astley's case I infer that there was
only a subluxation of the ulna backwards.

1 Schmidt's Jahrbuch for 1866, vol. 139, p. 184 et Mq,

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We know of no other causes, therefore, than such as equally tend
to produce dislocations at the elbow-joint, unless we except direct
crushing blows, which of course may break the bones at any point
upon which the force happens to be applied.

Symptoms. — Partial or complete displacement of the ulna, or of the
radius and ulna backwards, accompanied with the usual signs of these
luxations ; to whibh may be possibly added crepitus ; and it is fair to
presume that in some examples the fragment carried forwards by being
driven against the trochlea, may be felt displaced and movable in the
bend of the elbow. Brassard affirms that it was so with the patient
whom he saw. If only the summit is broken off, the brachialis anticua
could have no influence upon it; but if it were broken fairly through
the base, it might be displaced slightly in the direction of the action
of this muscle.

The symptoms, however, which .have been regarded as most diag-
nostic, are the disposition to re-luxation manifested in most of these
examples when the extension has been discontinued; and especially
the fact that the olecranon was particularly prominent when the arm
was extended, but that it resumed its natural position when the arm
was flexed to a right angle. But I am unable to understand how
either of these circumstances can be better explained upon the suppo-
sition of a fracture of this apophysis, than without such a supposition.
If the reduction of both bones is once effected, even though the sup-
port of the coronoid process is completely lost, the head of the radius
ought to prevent a re-luxation unless the arm is disturbed again; nor
can I understand why, when the elbow is bent, the re-luxation is less
likely to occur ; since, although in this position the humerus bears
less directly upon the process, the difference in this respect must be
very little, for in whatever position the arm is placed, so long as the
radius retains its position the ulna cannot be drawn very forcibly
against the hqmerus ; while, on the other hand, by flexing the arm
the power of the biceps and of such fibres of the brachialis as remain
attached to the ulna, to aid in the maintenance of reduction, is com-
pletely lost ; and at the same moment the resistance, and consequent
power of the triceps to produce the luxation, are greatly increased.

In short, we must confess that we are here, also, notwithstanding
the confidence with which writers have spoken of the signs of this
accident, very much in doubt; nor do we see how these doubts can
be removed until we have in detail the symptoms of at least one
example, the indubitable existence of which has been subsequently
verified by dissection.

Prognosis. — In the case of Oooper^s patient, seen several months
after the accident, the ulna projected backwards while the arm was
extended, but it was without much difficulty drawn forwards and bent,
and then the deformity disappeared. He thought that during exten-
sion the ulna slipped back behind the inner condyle of the humerus.
Brassard's patient, seen after three months, retained the power of pro-
nation and supination, with also extension, but flexion was completely
impossible, the forearm being arrested in this direction by the small,
slightly-movable fragment of bone in front of the elbow-joint, and

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which was supposed to be the process itself, Pennock's old man, who
had met with the accident in boyhood, had still the radius luxated
forwards and outwards, and the olecranon more salient backwards than
in the sound arm. Extension and flexion were nearly but not quite
complete. Fahnestock informs us that his patient " recovered com-
pletely," but whether without deformity or maiming we are not told.
Couper says the bone was united in four weeks, and that only a slight
deformity and a little stiffness remained. Physick's patient made a
perfect recovery.

Let us come again to the dissections. Bejecting the doubtful
specimen belonging to Dr. Gibson, we have an exact account of only
two, and, indeed. Sir Astley Cooper alone has described the mode of
union. Samuel Cooper says that in the ease of the University College
specimen the radius is dislocated forwards and upwards, and the ole-
cranon is displaced backwards, but he does not say whether the
coronoid process has united, nor described its position ; but Sir Astley
informs us that in the example seen and dissected by him the process
was united by ligament, which was sufiBiciently long and flexible to
allow the fragment to move upwards and downwards in the motions
of flexion and extension.

In tl^ absence of any other testimony, we may be allowed to ex-
press an opinion that when the fracture has taken place across the
summit or above the insertion of the brachialis anticus, nothing but a
ligamentous union can be regarded as possible, since the fragment
can only derive nourishment from a few untorn fibres of the capsule
and perhaps of the internal lateral ligaments; and although it may
not be displaced, it cannot have the advantage of impaction, upon
which alone, I suspect, a fracture of the neck of the femur within the
capsule must rely for a bony union, if it ever does so unite. If, how-
ever the fracture has taken place at the base, and fortunately it has
not become much displaced by the force of the concussion against the
humerus, it does not seem to me so impossible that under favorable
circumstances a bony union might now and then occur. It will be
remembered that a good portion of the attachment of the brachialis
anticus is still below the fracture, and the remaining fibres are not
therefore very likely to displace the fragment, especially when the arm
is sufficiently flexed, so as to properly relax this muscle.

It will be of small importance, however, whether the union is bony
or ligamentous, provided only there is not great displacement.

Treatment. — Whatever view we take of the pathology of this acci-
dent, the rational mode of treatment would seem to consist in flexing
the arm at a right angle, and retaining it a sufficient length of time in
that position ; not forgetting, however, the danger of anchylosis from
long-continued confinement in one position.

An angular splint may be useful in preventing motion at first, but
I think it ought not to be continued beyond seven or ten days at the
most. After this, a simple sling is all that can be necessary, since
from this period some motion must be given to the joint if we would
take the proper precautions to prevent stiffness. Sir Astley Cooper
thought the limb ought to be kept immovable three weeks, and Vel-

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peau preferred four; but I cannot agree with them, believing that the
question of the future mobility of the elbow-joint is vastly more im-
portant than the question of a bony or ligamentous union between
the fragments. Couper says that he* adopted in the treatment of the
case reported by him, extreme flexion; but both Physick and Fahne-
stock placed the arm at right angles, and Sir Astley Cooper has re-
commended the same position. The latter position has always the
advantage in case permanent anchylosis occurs, and the former cannot
add much to the chance of complete replacement of the fragment.

Bandages are only serviceable to retain the splint in place, and they
may be thrown aside as soon as the splint is removed.

§ 8. Fractures of the Olecranon Process.

Causes. — My records furnish me with accounts of only twelve of these
fractures, and, so far as I have been able to ascertain, all were occa-
sioned by falls upon the elbow, or by blows inflicted directly upon
the part. Malgaigne has, however, been able to collect accounts of
six examples of fracture of the olecranon, produced, as is affirmed, by
the violent action of the triceps; as in pushing witji the arm slightly
flexed, in throwing a ball, in plunging into the water with the arms
extended, etc. ; but only four of these reported examples does he think
are sufficiently authenticated to entitle them to be received as facts ;
nor do I think it possible to affirm positively that in any instance,
where the whole process is broken oflF, the triceps alone has occasioned
the separation. For example, Capiomont reports the case of a cavalier,
who, being intoxicated, was thrown head foremost from his horse, and,
striking probably upon his head, was found to have broken the
olecranon process. We do not, in this example, see evidence alone
of a forcible contraction of the triceps, but also of violent pressure
against the hand and in the direction of the axis of the forearm toward
the elbow-joint, by which the olecranon process might have been so
thrown forwards against the fossa of the humerus as to cause its
separation. The same explanation might apply to several of the
other examples.

Point and Direction of Fracture ; Displacement, etc, — The process may
be broken at its summit, at its base, or intermediate between these two
extremes, the last of which is the most common.

It is probable that when the action of the triceps alone has produced
the fracture, it will be found that only that portion which receives the
insertion of the triceps has been broken off. Malgaigne, who has
been able to find upon record only two cases of a fracture of the ex-
treme end of the process, declares that they were both occasioned by
muscular action.

Fractures of the middle are generally transverse, or only slightly
oblique, occurring in the line of the junction of the epiphysis with
the diaphysis.

Fractures through the base are generally quite oblique, the line
of fracture extending from before downwards and backwards, so that

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not only the whole of the process, ^ig. lOl.

bat a portion of the back of the
shaft is carried away ; and this ac-
cident can scarcely happen, except
by a blow received upon the lower
end of the humerus, directly in
front of the process ; or, what would
amount to the same thing, by a
blow from behind, received upon
the ulna just below the olecranon
process, or by wrenching the fore-
arm violently back, while the hume- Fractuwa at the ba»e.
rus is fixed.

The only displacement to which the upper fragment seems to be
liable, is in the direction of the triceps; and the degree of this dis-
placement does not depend so much upon the point at which the
fracture has taken place as upon the violence which has occasioned it,
the extent of the disruption of the ligaments, aponeurosis of the triceps
and of the capsule, and upon whether, since the accident, the arm has
been flexed or kept extended.

In three instances, I have found distinct crepitus immediately after
the fracture had occurred, produced by only moving the fragment
laterally, showing plainly that little or no displacement had taken
place. The following example will show also that this displacement
does not always happen even after the lapse of several days, and where
no surgical treatment has been adopted.

Samuel Duckett, aat. 14, fell upon the point of the elbow, and two
days after was admitted to the Buffalo Hospital of the Sisters of
Charity. The elbow was then much swollen, but no crepitus could
be detected, and he could nearly straighten his arm by the action of
the triceps. On the sixth day, the swelling having sufficiently sub-
sided, a distinct crepitus was discovered when the olecranon process
was seized between the fingers, and moved laterally. We extended
the arm immediately, and applied a long gutta-percha splint to the
whole front of the arm and forearm, securing it in place with a roller.
On the eleventh day, five days after the first dressing, the splint was
taken off, and its an^e at the elbow-joint slightly changed ; and this
was repeated every day until the twenty -second from the time of the
accident. The splint was then finally removed, when the fragment
was found to be united without any perceptible displacement, and the
motions of the joint were unimpaired.

It must not be inferred, however, that it is always prudent to leave
this fracture thus unsupported, since it has occasionally happened
that the displacement, which did not exist at first, has taken place to
the extent of half an inch or more, after the lapse of several days.
Mr. Earle mentions a case in which .the separation did not take place
until the sixth day, when it was occasioned by the patient's attempting
to tie his neckcloth.

Symptoms. — The usual signs of a fracture of the olecranon process
are, when the fragments are not separated, crepitus discovered espe-

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cially by seizing the process, and moving it laterally ; or, when dis-
placement has actually taken place, the crepitus may be discovered
sometimes by extending the forearm, and pressing the upper fragment
downwards until it is made to touch the lower fragment ; the existence
of a palpable depression between the fragments, partial flexion of the
forearm, and total inability, on the part of the patient, to straighten
it completely^ or even to flex the arm in some cases. If the fragments
do not separate, gentle flexion and extension of the arm, while the
finger rests upon the process, may enable us to detect the fracture.

It will sometimes happen that, owing to the rapid occurrence of
tumefaction, the evidences of a fracture will be quite equivocal ; but,
in all cases where a severe injury has been inflicted upon the point
of the elbow, it will be well to suspend judgment until, by repeated
examinations, made on successive days, the question is determined.
Meanwhile, the arm ought to be kept constantly in an extended posi-
tion, as if a fracture was known to exist.

Prognosis, — In a large majority of cases, this process becomes re-
united to the shaft by ligament^ which may vary in length from a
line to an inch or more, and which is more or bss perfect in different
cases. Sometimes it is composed of two separate bands, with an
intermediate space, or the ligament may have several holes in it ; at
other times it is composed in part of bone and in part of fibrous tissue ;
but most frequently it is a single, firm, fibrous cord, whose breadth and
thickness are less than that of the process to which it is attached.

Tf the fragments are maintained in perfect apposition, a bony union
may occur, yet it is not invariably found to have taken place, even
under these circumstances. Malgaigne thinks, also, he has seen one
case in which there was neither bone nor fibrous tissue deposited be-
tween the fragments. This was an ancient fracture at the base of the
olecranon; the superior fragment remained immovable during the
flexion and extension of the arm, yet it could be moved easily from
side to side.

In my own cases, I have five times found the fragments united
without any appreciable separation, and have presumed that the union
was bony. One of these examples I have already mentioned ; the
second, was in the person of a lady aged about forty years, who,
having fallen down a flight of steps on the Stl? of September, 1857,
sent for me immediately. I found a large bloody tumor covering the
elbow joint, but there was no difficulty in detecting a fracture of the
olecranon process. It was easily moved from side to side, and this
motion was accompanied with a distinct crepitus. During the first
week, the arm was only laid upon a pillow, but as it was found to
become gradually more flexed, and the swelling having in a great
measure subsided, the arm was nearly, but not quite, straightened,
and a long gutta-percha splint applied to the palmar surface of the
forearm and arm. The fragments united in about twenty or twenty-
five days, and without separation, so far as could be discovered in a
very careful examination.

The third example to which I have referred, occurred in a b<gr
fourteen years old, and was treated by Dr. Benjamin Smith, of Berk-

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shire, Massachusetts. Sixty-nine years after, he being then eighty-
three years old, I found the olecranon process united apparently by
bone, but to that day he had been unable to straighten
the arm completely, or to supine it freely. ^ff- 1^2.

In one instance I found the fragment, after the lapse
of one year, united by a ligament, which seemed to be
about one-quarter of an inch in length, and the arm
appeared to be in all respects as perfect as the other.
He could flex and extend it freely.

In the two following examples, also, the bond of union
was ligamentous : —

John Carbony, set. 18, having broken the olecranon,
it was treated with a straight splint. Nine years after,
I found the process united by a ligament half an inch in
length, and he could nearly, but not entirely, straighten
the arm. In all other respects the functions and motions
of the arm were perfect.

A lad, 89t. 15, was brought to me by Dr. Lauderdale,
a very excellent surgeon in the town of Geneseo, Liv-
ingston Co., N. Y., whose olecranon process had been
broken by a fall six months before, and at the same "* ment"**
time the head of the radius had been dislocated for-
wards. I found the radius in place, and the olecranon process united
by a ligament about half an inch in length. He was not able to
straighten the arm completely, the forearm remaining at an angle of
45° with the arm.

Treatment. — It will surprise the student who is yet unacquainted
with the literature of our science, to learn that in relation to the treat-
ment of a fracture of the olecranon process, a wide difference of opinion
has been entertained as to what ought to be the position of the arm
and the forearm, in order to the accomplishment of the most favorable
results ; and that, while some insist upon the straight position as essen-
tial to success, others prefer a slightly flexed position, and still others
have advocated the right-angled position. Thus, Hippocrates, and
nearly all of the earlier surgeons, down to a period so late as the latter
part of the last century, directed that the arm should be placed in a
position of semi-flexion ; Boyer, Desault, and, after them, most of the
French surgeons of our own day, prefer a position in which the fore-
arm is very slightly bent upon the arm ; while Sir Astley Cooper, and
a large majority of the English* and American surgeons, employ com-
plete or extreme extension.

The arguments presented by the advocates and antagonists of these
various plans deserve a moment's consideration.

In favor of the position of semi-flexion, requiring no splints, and,
in the opinion of some writers, not even a bandage, but only a sling
to support the forearm, it is claimed that it leaves the patient at liberty
at once to walk about and to move the elbow-joint freely, so soon at
least as the subsidence of the swelling and pain will permit, and that
in this way the danger of anchylosis is greatly diminished ; that, more-
over, if anchylosis should unfortunately occur, the limb is in a much

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better position for the proper performance of its most ordinary func-
tions than if it were extended. Some have also added to this arma-
ment a statement that a fibrous union, under any circumstances, is
inevitable, and that it is a matter of little consequence whether the
ligament thus formed is long or short, since in either condition it will
be equally serviceable.

In reply to these statements, it may be said briefly that they are
nearly all based upon false premises, or that they have been proven
in themselves to be essentially erroneous.

Anchylosis is always a serious event, which by all possible means
the surgeon will seek to prevent, but position has nothing to do with
determining this result ; when it does occur, it may usually be ascribed
either to the severity and complications of the original injury, to the
violence of the consequent inflammation, or to having neglected, at a
proper period and with sufficient perseverance, to move the joint.

That a fibrous union is inevitable under any circumstances, has
been fully proven to be an error ; and it has been equally proven that
the functions of the arm are generally impaired in proportion to the
length of the uniting medium.

The only argument which remains, and which really possesses any
weight, is, that, if permanent anchylosis does actually occur, the arm,
when semi-flexed, is in a better position for the performance of its
ordinary functions ; and this, considered as an argument in favor of
the universal or even general adoption of the flexed position, is suc-
cessfully met by a statement of the infrequency of permanent anchy-

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 37 of 100)