Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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motions of the arm are not generally so much impaired as in either
of the other dislocations ; and finally, as in all other dislocations of
the humerus, the hand cannot be laid upon the opposite shoulder
while the elbow touches the front or side of the chest. In Parker's
case the elbow was thrown outwards, although the arm was carried
very much across the chest. Desclaux's patient held his hand upon
his head, with his arm horizontally across his body.

Usually the diagnosis will be easily made ; in my own case the
position of the head of the bone was easily recognized, but Sir Astley
relates one case in which, on the morning following the accident, a
surgeon was unable to discover the dislocation, and on the seventeenth
day Bransby Cooper failed to make the diagnosis; nor, indeed, on the
twenty-third day did Sir Astley himself determine that it was a
dislocation, until he had unexpectedly reduced it while manipulating
upon the arm. In a second example, Sir Astley at first believed it
to be a fracture, but a more careful examination showed it to be a dis-
location backwards. In this instance the limb could not be rotated
outwards, as the subscapularis was not torn, and continued to offer
resistance when the arm was moved in this direction ; he was also
suffering much more pain than did the other patients, owing, as Sir
Astley thinks, to pressure upon the articular nerves. In the case of
Mr. Collinson, also mentioned by Mr. Cooper, a surgeon, who saw the
patient immediately after the accident, failed to discover the true
nature of the injury; and Trowbridge's patient had suffered a dislo-
cation several weeks before the nature of the accident was fully

Prognosis. — The reduction has always been sooner or later accom-
plished, except in one instance ; in this case we have seen that the arm
never recovered any considerable degree of usefulness. Mr. CoUinson's
arm, reduced on the second day, was restored to all of its functions

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"^writhin one month. Dr. Parker's patient had nearly recovered the.
<5omplete use of her arm at the end of four weeks, although it was not
X'educed until it had been out fourteen days. Sedillot succeeded in
X'educing the dislocation in the case of his patient, at the end of one
year and fifteen days. Lepelletier, after forty-five days. Trowbridge,
sifler forty days ; and in this latter case we are informed that the arm
'was restored to usefulness.

TVeatment. — In the first case mentioned by Sir Astley Cooper, "the
l>andages were applied in the same manner as if the head of the hume-
Tus had been in the axilla, and the extension was made in the same
direction as in that accident" (downwards and a little outwards). In
less than five minutes the bone slipped into its socket with a loud snap.
The second case was treated successfully in the same way. Mr. Dunn
also having failed to reduce by pulling upwards, finally succeeded by
palling at the wrist downwards and forwards, while an assistant pushed
the head of the bone toward the socket; the heel was not placed in
the axilla, which Mr. Bransby Cooper thinks would have only retarded
the reduction. Mr. Key also, failed to accomplish reduction while car-
rying the arm upwards and backwards, but when the patient had be-
come faint, by placing the heel in the axilla and pulling downwards a
minute or two, the bone was reduced. Vidal (de Cassis) recommends
the same plan, namely, that we shall pull in the direction in which we
find the limb; Trowbridge employed the pulleys successfully, the ex-
tension being made downwards and forwards; while Dr. Parker suc-
ceeded equally well with his patient, by " pulling the arm outwards,
downwards, and slightly forwards." Counter-extension was at the
same time made by a sheet in the axilla, and the head of the humerus
was pushed toward the socket by the hand. In Mr. Collinson's case,
the scapula was supported by a towel, while ''gradual extension of the
limb was made directly outwards, and then the arm being moved
slowly forwards, the head of the bone was distinctly heard to snap into
its socket." The time occupied was not more than two or three
minutes. Rogers succeeded by N. R. Smith's method. Sir Astley,
however, seems to give the preference to the method which succeeded
so happily in the case of Mr. G., while he was still manipulating with
a view to determine the character of the accident. " I readily reduced
the bone," he remarks, " by raising the hand and arm, and by turning
the hand backwards behind the head." In one other instance, having
failed to reduce it by slight extension outwards, he raised the arm
perpendicularly, at the same time forced it backwards behind the
patient's head, and the reduction was promptly effected. In the case
of Kretner, I first attempted reduction by pressure directly upon the
head of the humerus; but failing, I proceeded to pull the arm with
moderate force outwards and downwards, which procedure was
attended with immediate success. The patient was under the influence
of chloroform.

After the reduction, a compress should be placed against the head
of the bone, and underneath the spine of the scapula, and this should
be secured in its place by several turns of a roller. The forearm

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ought also to be placed in a sling, with the elbow thrown a little back
of the centre of the body, so as to direct the head of the hameras
forwards. '

§ 4. Partial Dislocations op the HuMSRua

Sir Astley Cooper has related in his treatise two cases of supposed
incomplete luxation of the head of the humerus forwards; and in con-
firmation of his views he has added an account of the appearaooes
presented on dissection in the body of a subject brought into the
rooms of St. Thomas's Hospital. Bransby Cooper, in his edition of
the same work, furnishes the report of a similar case which cajne
under the observation of Mr. Douglass, of Glasgow. Hargrave and
Dupuytren have each reported one example of this species of dislo-
cation, in which its existence was said to be confirmed by dissection.

Petit, Duverney, Chopart, Sedillot, Miller, Gibson, Malgaigne, and
many others, have admitted its possibility ; Malgaigne, however, only
admits its existence when the capsule remains entire.

Without intending to discuss very much at length the value of
these opinions, I shall content myself with declaring that the exist-
ence of this or of any other form of partial luxation of the shoulder-
joint, as a traumatic accident, has not up to this moment been fairly
established ; and that the anatomical structure of the joint renders its
occurrence exceedingly improbable, if not absolutely impossible.

The only example mentioned by Sir Astley Cooper, in which a
dissection was made, showed that the long head of the biceps bad
been ruptured, and that the capsule was torn, while the head of the
humerus was resting under the coracoid process. We shall have no
difficulty, therefore, in assigning it to its proper place as a complete
subcoracoid dislocation. In Mr. Etargrave's case, also, the tendon of
the biceps was torn ; while Dupuytren omits to mention what was the
actual fact in relation to this tendon in the case seen by him, but it is
distinctly stated that the head of the bone rested upon the ribs. Mr.
Hargrave seems, therefore, to have described a case of rupture of the
long head of the biceps, and it is probable that Dupuytren, who knew
nothing of the previous history of the subject, has given us a faithful
account of a pathological dislocation, a result of disease, and not of a
direct injury.

If the head of the humerus is driven from its socket by violence,
and remains thus displaced, it is, we assume, a complete luxation;
since it is only by having placed the semi-diameter of the head of the
bone outside of the margin of the glenoid fossa that it can be made
for one moment to retain its abnormal position. To accomplish this
amount of displacement upwards, or upwards and forwards, or directly
forwards, the acromion or the coracoid process must be broken;
while its occurrence in any other direction must involve at least a
most extraordinary extension, if not an actual laceration, of the cap-
sule. If we admit, with Malgaigne, that occasionally the capsule has
been found capable of such extraordinary extension without actual
rupture, we still are unwilling to regard this as a fair example of a

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partial dislocation, since the head of the bone no longer moves in its
socket, being at no point in actual contact with the articular surface
of the glenoid fossa. It is essentially a complete dislocation, accord-
ing to all the admitted definitions of this term.

It is quite probable that a majority of these accidents were examples
of rupture or of displacement of the tendon of the long head of the
"biceps, the eflFect of which, as Mr. John G. Smith^ and Mr. Soden* have
shown by a number of dissections, is to allow the head of the humerus
to be drawn upwards and forwards in its socket, until it is arrested by
the two processes, and by the coraco-acromial ligament. Says Mr.
Soden, "To enable the bone to maintain its equilibrium, it is necessary
that the capsular muscles should exactly counterbalance each other ;
and as there is no muscle from the ribs to the humerus to antagonize
the upper capsular muscles" (that is, to draw the head of the humerus
downwards), ''it is suggested that this office is performed by the sin-
gular course of the long tendon of the biceps, which, by passing over
the head of the bone, when the muscle is put in action, tends to throw
the head downwards and backwards ; it follows, therefore, that, the
tendon being removed, the head of the bone would rise upwards and

The drawing (Fig. 250) represents the case of displacement of the
tendon of the biceps seen by Mr. Soden, and of which he had been
permitted to make a dissection.*

I have myself frequently observed, and I have before, when speaking
of the prognosis or results of dislocations, called attention to the fact,
that the head of the humerus some-
times remains for a long time after ^S- ^50.
the reduction has been effected slight-
ly advanced in its socket, so as to lead
to a suspicion that it is not properly
reduced. Quite recently I have been
consulted in the case of a lad about
fourteen years of age, who had been
subjected to the pulleys during four
consecutive hours to accomplish a
more complete reduction.

The same thing, also, has been
noticed by me occasionally where
the shoulder had been subjected to
& violent wrench, but no actual dis-
location had ever occurred. In either

case the explanation is perhaps the Displacement of the long head of the biceps.

same, the long head of the biceps has

been broken or displaced ; or, when it follows a dislocation, some of the
muscles inserted into the greater tuberosity have been torn from their
attachments. I mean to say that in these circumstances we may find

' Amer. Joum. Med. Sci., vol. xvi. p. 219, May, 1835, from Lond. Med. Gaz.
« Ibid., vol, xxlx. p. 480, from Lond. Med. Gaz., July, 1841.
' Pirrie's System of Surg., Amer. ed., p. 255 ; also, Sir Astley Cooper, edited
by BraDsby Cooper, Amer. ed,, p. 368.

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a sufficient and perhaps the most frequent explanation ; yet it is quite
probable that, in a considerable number pf cases, the laceration of the
capsule, and the action of the muscles, are alone concerned in the
production of this phenomenon. I have seen one example in the
person of Mr. Craig, of Brooklyn, in which the tendon of the bicej^
suddenly resumed its position after the lapse of several days, and the
prominence of the head of the humerus at once disappeared.

Alfred Mercer, of Syracuse, N. Y., in a very interesting paper on
this same subject, relates several examples of forward displacement
after injuries to the shoulder-joint, one of which, as being exceedingly
pertinent, I shall take the liberty of quoting.

"Mrs. B, a well-developed woman, of full habit, aged fifty-six, seven
years since was thrown from a carriage, dislocating her right shoulder,
which was reduced a short time after the accident, but the shoulder
was painful, and tender to the touch, and almost useless for months
after. She could carry the arm forwards and backwards, but could
not raise it from the side, or carry the hand behind her, or raise it to
her head, for fourteen months. She has gradually gained better use
of her arm, but now, July, 1858, she cannot raise her elbow from the
side more than half-way to a horizontal position without assistance;
but with assistance, the arm may be carried into any position without
pain or resistance. Measurement shows no appreciable difference in
the size or length of the arm, or size of the shoulder ; but the point of
the shoulder is still tender to the touch, is prominent in fronts and
correspondingly flattened behind. The head of the humerus appears
to rest against the outride of the coracoid process, but the fulness of
habit obscures the diagnosis, compared with the other cases. Several
doctors, at different times, have examined the shoulder; some have
said it was not properly reduced, and advised a suit for malpractice.

" I examined the shoulder again in November last ; it presented the
same general appearance, although the patient was much thinner ia
flesh from recent sickness. Some six weeks previous to this exami-
nation, in a sudden and thoughtless effort to raise the arm above the
head, the muscles unexpectedly obeyed the will ; since which time
she has had perfect use of it, though the deformity still remains. She
thinks she felt or heard a snap when the arm went up, but it was
followed by no pain, soreness, or swelling."*

There can be no doubt, we think, that in this case, at least, the
deformity and maiming were due in a great measure to a displace-
ment of the long head of the biceps.*

» Mercer, Buffalo Med. Joum., vol. xiv. p. 641, April, 1859.
« Broomfield's Chirurg. Observ., vol. ii. p. 76.

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I HAVE met with twenty-three examples of traumatic dislocation of
tlie head of the radius ; of which nineteen were dislocated forwards,
or forwards and outwards, and only four backwards : or, rejecting
those cases which were complicated with fracture, I have recorded
nine cases of simple forward luxation, and two of simple backward
luxation. My experience, therefore, does not correspond with the
experience of Boyer, Velpeau, Vidal (de Cassis), Chelius, B. Cooper,
Guthrie, Gibson, and some others, who declare that the dislocation
backwards is the more frequent of the two. Indeed, I ought to say
of both of the examples of backward luxation of the radius which
have come under my notice, and which I have marked as simple, that
they were ancient luxations, and I am not entirely certain, therefore,
that they had not been originally complicated with a fracture, although
at the time of my examination they presented no such evidence. I
have seen one congenital dislocation of the head of the radius outward
and forward, which I will describe more particularly in the chapter
on congenital dislocations.

§ 1. Dislocations of the Head of the Radius Forwards.

Games, — A fall upon the elbow, the blow being received directly
upon the posterior face of the head of the radius ; a fall upon the
hand with the forearm extended and pronated ; extreme pronation of
the forearm ; or, according to Denuc^, a blow upon the inside of the
elbow, which is equivalent to a violent adduction of the forearm.

In children, and especially in those of a strumous habit, whose
ligaments are feeble, a subluxation forwards, or even a complete luxa-
tion, is occasionally produced by being lifted suddenly from the floor
by the hand, or by an attempt to sustain the child when he is about
to fall. I have seen examples of this dislocation produced in this
way. Batchelder,^ Sylvester,^ Goyrand,' and many other surgeons,
have mentioned similar cases. In the case of Lydia Merton, four years
old, brought to me in May, 1868, the dislocation was caused by hold-
ing on by the hands after having fallen from a swing. •

Dr. Krackowizer related to the New York Academy, in 1856, a
case of complete dislocation forwards, produced, as was supposed, in

» New York Joum. Med., May, 1856, p. 833.

* Amer. Joum. Med. Sci., vol. xxxi. p. 206, Jan. 1843.

» Ibid., vol. xxxii. p. 228, July, 1843.

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the act of turning the child in delivery. The arm was ecchymosed,

and the dislocation was very distinct.*

Pathological Anatomy, — The head of the radius is carried forwards

upon the humerus, and generally a little outwards. In the case of

Lydia Merton, already mentioned,
Fig. 251. the head of the radius, on the nine-

ty-fourth day after the accident,
was nearly in the centre of the
humerus. The anterior and ex-
ternal lateral ligaments, with the
annular, are in most cases more or
less broken. Sometimes the ante-
rior and external lateral are alone
broken, the annular ligament being
then sufficiently stretched to allowr
of the complete dislocation ; or the
anterior and annular having given
way, the external lateral may re-
main intact.

Symptoms. — ^The head of the
radius can in general be distinctly
felt in its new situation, rotating
under the finger when the hand is
pronated and supinated; we may
sometimes also recognize a depres-
sion corresponding to its naturaJ
situation, behind and below the

Head of radios forwardi. Anatomical reUtiooi. little head of the humcrUS. Tbo

external border of the forearm is
slightly shortened, and the arm inclines unnaturally outwards. The
tendon of the biceps is relaxed. The forearm is generally pronated,
sometimes it is in a position midway between supination and prona-
tion, but I have never seen it supinated. I have particularly noticed
this fact in my report made to the New York State Medical Society
in 1855 ; and Denucd, who has also examined these cases carefully,
affirms that it is seldom supinated, notwithstanding the general state-
ments of surgeons to the contrary.

The arm is usually a little flexed, and cannot be perfectly extended
without causing pain. In some cases, especially when the dislocation
has existed for a considerable length of time, the arm is capable of
extreme and unnatural extension. This was the case with Lydia
Merton. There is usually preternatural lateral motion; but, except
in old cases, the forearm cannot be flexed upon the arm beyond a
right angle. »

Prognosis, — Denucd says : " The reduction is often impossible ; more
frequently still, difficult to maintain." In proof of which he refers io
the observations of Danyau and Robert. In the case of recent luxa-
tion related by Bobert, it was found impossible to maintain a reduc-

* Erackowizer, New York Joum. Med., March, 1857, p. 263.

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Fig. 252.

'fcion which he thought he had several times accomplished, and he
T>elieved that the difficalty consisted in a portion of the torn annular
ligament having become entangled between the head of the radius and
^he condyle of the humerus.*

Sir Astley Cooper was unable to accomplish the reduction in two
xecent cases; and of the six cases which came under his immediate
observation, only two were ever re-
duced. In Bransby Cooper's edition
of Sir Astley's work, other similar
examples of non-reduction are re-

Malgaigne says that in a collec-
tion of twenty-five cases which he
has made, the accident was unrecog-
nized or neglected in six, and in-
efifectual efforts at reduction had been
made in eleven ; so that only eight
of the whole number were reduced.
I have myself met with six of
these simple dislocations which were
not reduced, three of which, however,
had not been recognized, and no
attempts at reduction had ever been
made ; one had been treated by an
empiric, Sweet, a " natural bone-set-
ter," but without success; one had
been reduced, but it had become
reluxated, and in the remaining
example I was myself unable to
reduce the dislocation on the seventh

The following are brief notes of
four of these cases : —

A young man, aet. 28, presented
himself at my office, to whom the

accident had occurred about one year before. The surgeon who was
first called did not recognize the dislocation, and no attempt had ever
been made to replace the bones. The forearm was forcibly pronated
and could not be supinated, but he could extend it completely, and
fiex it somewhat beyond a right angle. It was strong, and nearly as
useful as before.

H. H. B., 8Bt. 6 ; dislocation produced by a fall upon the elbow.
The surgeon who was called did not detect the nature of the injury.
Eighteen years after, I found the head of the radius lying in front of
the old socket, having formed a new socket in which it moved freely.
From the elbow to the hand the arm inclined outwards, or to the
radial side; pronation and supination were perfect. He could fiex

Head of radias forwards,
anoe of limb.

External appear

1 M^moire sur lea Luxations da Goude, par Paul Denuc^. Paris, 1854.

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the arm to an acute angle, but not so completely as the other. The
arm was as strong as the other, but it was frequently hurt by lifting.

Ira E. Irish, set. 12. ** Sweet" was at first employed, but failed to
reduce it. Thirty-nine years after, when Mr. Irish was fifty-one years
old, I examined the arm. He could not flex the forearm upon the
arm beyond a right angle ; and when the attempt was made, the radius
struck against the humerus. Complete supination was impossible.
The arm was as strong as the other, except in raising a weight above
his head. Occasionally he was annoyed with slight pains in this limb.

Urias Lett, a colored barber of BuflFalo, aged forty -eight years, was
thrown from a carriage, producing dislocation of the right radios, and
severely bruising the elbow-joint. He drove a couple of spirited
horses several miles after the accident, and did not see Dr. K., a highly
accomplished young surgeon, until six hours had elapsed. The elbow
Wits then much swollen, and exquisitely tender, and Lett would not
permit much if any examination, to enable Dr. K. to determine his
condition. The doctor applied simple dressings, and the next day re-
quested me to see him. The whole arm was then swollen and tender,
and very little examination was admissible. The dressings were,
therefore, not completely removed, but only laid open sufficiently to
enable us to see the joint. We suspected a forward luxation of the
head of the radius, but could not positively determine the point — ^the
patient not permitting any kind or degree of manipulation. We
decided, therefore, to wait a few days until the inflammation had
somewhat abated, and then, if the existence of a dislocation was ascer-
tained, to attempt its reduction. On the seventh day the swelling had
measurably subsided, and the diagnosis became satisfactory. We
immediately placed him under the complete influence of chloroform,
and made long-continued and violent efforts at reduction, but without
success. Severe inflammation again followed these efforts, and Lett
would never consent to another trial. After four years, I find the
bone still out. He can flex the forearm upon the arm almost as far
as he can the opposite limb ; he can carry it nearly to his mouth ; the
head of the radius sliding off upon the outer face of the humerus, and
not resting plumply against it; indeed, the radius seems to have been
gradually pushed outwards as well as forwards. The hand is forcibly
pronated, and cannot be supinated. The attempt to supine produces
a click in the neighborhood of the head of the radius, as if it struck
against a bone. The arm is as strong as the other, and not wasted.
He has constantly pursued his occupation as a barber, aft;er only a few
weeks' confinement.

If the dislocation is accompanied with a fracture of the ulna, unless
the fracture is transverse or incomplete, reduction is not generally
accomplished. When speaking of fractures of the shaft of the ulna, I
have related several examples illustrative of this remark. Norris

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 67 of 100)