Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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has made the same observation.^ I have, however, three times met
with this accident thus complicated in children, in the treatment of
which a much better result has been obtained. In the first example,

1 Norris, Amer. Joam. Med. Sci., vol. xzzi. p. 21.

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a lad aged nioe years had broken the ulna in its upper third and dis-
located the radius forwards. Dr. White, of Buffalo, and myself were
in immediate attendance. Both the fracture and dislocation were
easily reduced, and in a few weeks the limb was sound and perfect,
except that a slight fulness remained in front of the head of the radius,
and this continued for several years. In the second example, a lad, of
the same age as the other, was treated by Dr. Austin Flint and my-
self. We reduced both the fracture and the dislocation by extending
the arm from the wrist, while at the same moment pressure was made
upon the head of the radius from before backwards. A right-angled
splint was applied and continued during a period of four weeks, being
removed daily for the purpose of giving to the joint gentle, passive
motion, &c. After this the arm was permitted to straighten gradually,
and at the end of a month more the joint was moving freely, and with
no degree of displacement at the point of fracture or dislocation. ,

It is quite probable that in each of the above cases the separation
was not complete, although crepitus was distinct, and the displacement
of the broken ends was very marked. In the following case the frac-
ture was certainly incomplete: —

Elizabeth Carmody, est. 4, was brought to me, August 6, 1851, with
a fracture of the ulna, two inches below its upper end, the fragments
being inclined backwards, while the radius was dislocated forwards.
Both bones were easily replaced, and the functions of the arm were
soon completely restored.^

Where the restoration has been promptly effected and maintained
steadily, the motions of the joint are soon restored ; but in one case
the head of the radius has been found to play very freely and loosely
after the lapse of two years, and in others it has remained slightly
prominent in front, as if it was a little in advance of its socket.

Treatment, — Extension and counter-extension should be made in the
direction in which we already find the limb, namely, with the forearm
slightly bent upon the arm, while at the same moment the surgeon
should seize the elbow with his hands, and press the head of the radius
back with his two thumbs.

Other methods will often succeed ; but by this we relax the biceps,
and put the parts in the best position to accomplish the reduction
easily and promptly. Sir Astley directed to supine the forearm while
the extension was being made from the hand, but Denuc^ prefers that
the forearm should be in a position of pronation.

After the reduction is effected it is never safe to straighten the arm
completely at once, nor indeed for some weeks ; not until the ligaments
have been sufficiently restored to resist the action of the biceps. The
arm must therefore be flexed and placed in a sling, or, if the radius is
disposed to become reluxated, a right-angled splint ought to be placed
upon the back of the arm and forearm, and, by the aid of a compress
and roller, an attempt should be made to retain it in place.
Nor will it be found safe at any period to compel the arm by force

» This case was erroneously reported to the N. Y. State Medical Society as an
example of fracture of the radius, with dislocation.

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to resume the straight position, since this bone, when it has once been
dislocated, will for a long time be liable to luxation.

A boy, aged about four ye^rs, was presented at my clinic by his
father, having a forward dislocation of the head of the radius. The
dislocation had existed several months. The father's purpose ia bring-
ing the child was to ascertain whether he could not claim damages
for malpractice. The account which he gave was as follows: The
surgeon called it a dislocation forwards, and pretended to reduce it,
A right-angled splint was applied with a roller. At the end of three
weeks the father removed the splint, but did not discover anything out
of place. Finding, however, that the elbow was stiff, he took measures
to straighten it forcibly. In a few days he discovered the head of the
bone out of place, and so it has remained ever since.

I explained to him that there was much reason to suppose that the
surgeon had properly reduced the dislocation, and that be had himself
reproduced the accident, by straightening the arm, through the action
of the biceps upon the upper end of the radius. The father declined
any further surgical interference, and no prosecution has followed.

The late Dr. Batchelder, of this city, in a very excellent paper on
dislocations of the head of the radius, has described a method of
reduction suggested to him first by Dr. Goodhue, of Chester, Vermont,
and which he had himself found more successful than any other
method ; indeed, he says it never fails, yet he does not inform us in
precisely how many cases he had made the trial. The plan suggested
by Dr. Goodhue consists essentially in first making extension from
the hand, and pressing at the same time downwards and backwards
upon the head of the radius until it has descended to a level with the
articulating surface of the humerus. As soon as this is accomplished,
the forearm is to be suddenly fiexed upon the arm in such a direction
as that the hand shall pass outside of the shoulder; at the same
moment, also, the pressure must be continued vigorously upon, the
head of the radius.^

§ 2. Dislocation of the Head of the Radius Backwards.

Denuc^ has collected fourteen examples of this luxation ; bat Mai-
gaigne, who rejects a portion of the cases, and adds one or two more,
admits only twelve. In addition to those mentioned by these two
writers, I have found recorded, or incidentally noticed, one by May,'
one by Bransby Cooper,' one by Lawrence,* one by Liston,* two by
Case,* two by Gibson,^ one by Parker,* three by Markoe,* and to these
my own observations have added four more, in all twenty-eight sup-
posed examples.

» Goodhue, New York Joum. of Med., May, 1856, p. 883.
* May, Sir Astley Cooper on Dislocations, &c., by B. Cooper, op. cit., p. 403.
8 B. Cooper, ibid., p. 404. * Lawrence, Pime's System of Surgery, p. 259.

8 Listen, Practical Surgery, p. 88.

*^ Case, Amer. Joum. of Med. Sci., vol. yi. p. 354, from 11th No. of ProYmdal
Med. Gazette.
' Gibson, Institutes and Practice of Surgery, 6th ed., vol. i. p. 379.
8 Parker, New York Joum. of Med., March, 1852, p. 188.
» Markoe, ibid.. May, 1855, p. 382.

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Of the examples brought under my own notice I have already in
'the preceding section affirmed that two of them were accompanied
^with fracture, and I am not entirely certain but that they all were,
^arkoe, of New York, whom we have mentioned as having reported
three cases, found in each case a fracture of the internal condyle of
the humerus, and, after an examination of a number of the reported
examples, he does not find any evidence that this dislocation ever
occurs as a simple uncomplicated accident. I am unable to complete
the critical analysis which Dr. Markoe has undertaken ; yet I confess
that, so far as I have been able to do so, the testimony strongly con-
firms his conclusion. While I am prepared to admit the possibility
of the luxation without either a fracture of the lower end of the
humerus or of the ulna, I have found no written account of any case,
nor have I seen an example, which was absolutely conclusive.

The example reported by Parker as having occurred in the practice
of N. K. Freeman, of this city, is one of the few which seems to admit
of but very little doubt.

In July, 1850, Dr. Freeman was called to see a gentleman, est. 37,
who was seriously injured by jumping from the railroad cars while
they were in motion, and found a backward luxation of the head of
the radius of the right arm. "The symptoms," says Dr. Freeman,
''were marked; the hand and forearm were prone, and the attempt to
place them in the supine position caused great pain ; while the head of
the radius formed a considerable projection posterior to the external
condyle of the humerus, where the cavity on its extremity could be dis-
tinctly felt. Assisted by Dr. Walsh, of Fordham, who firmly grasped
the humerus, I was enabled to reduce it by extending the forearm and
flexing it upon the arm, at the same time pronating the hand, and
pressing forwards the head of the radius with my thumb. After the
reduction was eifected, I requested Dr. Walsh to examine it; when,
upon slight extension being made upon the forearm, with supination
of the hand, the bone was again dislocated. I immediately reduced
it in the same manner as before, and directed the patient to keep the
forearm flexed and the hand prone, and, laying it upon a pillow, apply
cold water. He complained of severe pain for two days, which gradu-
ally subsided, and on the fourth day he was able to move and extend
the forearm."

Oauses.-'A direct blow upon the front and upper part of the radius;
a fall upon the elbow, or upon the hand; a violent effort to supinate
the forearm while it is grasped and held firmly in a state of pronation;
probably, also, sometimes it is occasioned by a twisting of the arm in
machinery, &c.

Pathological Anatomy. — In the only example of which a dissection
has been made, reported by Sir Astley Cooper, "the coronary liga-
ment was found to be torn through at its forepart, and the oblique
bad given way. The capsular ligament was partially torn, and the
head would have receded much more, had it not been supported by
the fascia which extends over the muscles of the forearm." The head
of the radius was thrown behind the external condyle of the humerus,
and rather to the outer side. This was an ancient luxation found in

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the dissecting-room of St. Thomas's Hospital, and the accompanjing
drawing is copied from the sketch made at the time.

If the luxation is not complete, as occasionally happens with chil-
dren, the annular ligament may not be torn.

Symptoms, — The head of the bone is felt rotating behind the outer

condyle, and a depression exists corresponding to its original' poeition.

The forearm is slightly flexed and prone; and the

Fig. 253. whole arm is deflected outwards from the elbow

downwards ; flexion and extension are difficult, while

supination is impossible.

Treatment. — Most surgeons have agreed that while
extension and counter-extension are being made, the
forearm should be forcibly supinated. At the ^me
time, also, the head of the radius must be strongly
pushed forwards. Martin recommends to extend
forcibly, and then suddenly flex the arm, in a manner
very similar to the plan recommended by Batchelder
in dislocations forwards. In Dr. Freeman's case, jast
quoted, the reduction was effected while the forearm .
was pronated, and supination seemed to throw it
again out of place.

According to Markoe, where the accident is oam-
plicated with a fracture of the inner condyle, when
the reduction is accomplished the arm sboald be
placed in a position about ten degrees less than a
right angle, and supported by a splint with hand-

Dislocation of the agCS, 4pC.

Swkwlrd!!'' '*^*" ^^ ^^® dislocation is simple, however, I can see do
objections to its being nearly or quite extended, since
in this dislocation the action of the biceps would only tend to retain
the head of the radius in place.

§ 3. Dislocation of the Head of the Radius Outwards.

Denuc^ has collected four examples of this accident, unaccompanied
with a fracture, and he proceeds to speak of it as a distinct form of
dislocation. In two of the examples, however, mentioned by him, it
was consecutive upon a forward luxation, and I have several times
seen the head of the radius very much inclined outwards in what are
properly termed forward dislocations. For these reasons it is not very
plain to me that we ought to consider this as a distinct form of pri-
mary dislocation, but rather as a consecutive luxation, or at least as
only a modification of the forward or backward luxation. Indeed, I
think the radius never will be found thrown directly outwards, but
always in a direction inclining forwards or backwards.

Parker, of this city, mentions a case which came under his notice,
in a child four years old, who, six weeks before, had fallen down stairs
" backwardly, with the right arm twisted behind the back, in such a
position that the whole weight of her body came upon her arm." No
attempt was ever made to reduce the bone, and the head of the radius

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continued to project externally. By pressure it was easily reduced,
but 'became immediately displaced when the forearm was either flexed
or extended. The motions of the joint were completely restored. Dr.
Parker recommended no treatment.^



This accident, the existence of which, as a simple luxation, is placed
beyond doubt, has nevertheless been described so variously, and often
indefinitely, that it is impossible to declare its history, except in a few
points, with any degree of accuracy. No doubt many of the cases
which have been reported were examples only of a subluxation of
both radius and ulna backwards. In other cases, the radius or the
external condyle of the humerus being broken, the ulna has been ac-
tually displaced, not only backwards, but upwards; indeed, it is vfery
certain that without either a luxation of the radius, or a fracture with
displacement of the external condyle of the humerus, or a fracture or
bending of the radius, an upward displacement of the ulna, to the
degree represented by the reporters of these cases, could never have
occurred. The example mentioned by Sir Astley Cooper, and of which
a dissection was made, is plainly a case of subluxation of both bones ;
or if the luxation of the ulna may be regarded as having been com-
plete, the head of the radius was also displaced more or less upwards
from its original socket, a new socket, Sir Astley himself informs
us, having been formed for its reception, upon the external condyle.
But this is the only example, the actual condition of which has been
proven by an autopsy.

Nevertheless, it seems probable that a simple luxation or subluxa-
tion of the ulna backwards may occur without either of the above-
Fig. 254.

DislooatioD of the npper end of the ulna bmekwardi.

mentioned complications, and that, to the extent of a few lines, it may
be made to pass upwards upon the back of the humerus, by the

Parker, New York Joum. Med., March, 1852, p. 189.

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falling of the forearm to the ulnar side ; in which case the character
of the accident would probably be recognized by the projection of
the olecranon process, while the head of the radius might he felt
moving in its socket — by the partial flexion and complete pronation
of the forearm, and by the general immobility of the joint In a case
reported by Dr. Waterman, caused by a fall on the hand, the arm was
at a right angle, and pronated.*

Its reduction ought to be accomplished easily, one would think, by
the same measures which have been found successful in reducing a
dislocation of both bones backwards; but in Waterman's case this
method failed, and the reduction was promptly effected by bending
the forearm forcibly back.

Pirrie says that in a case occurring in the practice of Mr. Gosset,
in which the coronoid process rested on the internal condyle, and the
pain on bending the arm was insupportable, owing, it was supposed,
to the pressure of the coronoid process against the ulnar nerve, " re-
duction was accomplished by extension and counter-extension applied
by two persons pulling in opposite directions, and by the pressure of
the olecranon process downwards and outwards, while the forearm
was suddenly flexed."*



The radius and ulna may be dislocated at the elbow-joint back-
wards ; laterally, that is, either inwards or outwards ; and forwards.

§ 1. Dislocations of the Radius and Ulna Backwards.

Games. — In fifty-six cases observed by me, the average age is
about twenty years; the youngest being four years old, and the
oldest fifty-three. Twenty-two of this number occurred in children
under fourteen years of age.

Generally the dislocation has been produced by a fall upon the
palm of the hand, as when in running a person has fallen forwards
with the forearm extended in front of the body, or he may have fallen
from a height ; once I have known it produced by a blow received
upon the back and lower part of the humerus; and in several in-
stances the patients have declared that they had fallen upon the elbow ;
it is produced, occasionally, by twisting the forearm violently, as when
the limb has been caught and wrenched about by machinery, by a
blow upon the front and upper part of the forearm, and by forced

* Boston Med. and Surg. Joum., vol. iv., new series.

* GoBset, Pirrie*8 Surg., Amer. ed., p. 359.

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Pathology. — The radius and ulna are not only carried backwards
T^ehind the articulating surface of the humerus, but they are also,
tlirough the action of the triceps, almost always drawn more or less
-upwards, so that often the coronoid process of the ulna rests in the
olecranon fossa. In some cases it has been
Isnown to mount even higher, while in Fig. 255.

others it is arrested short of this point. The
radius still retaining its relative position to
the ulna, lies upon the back of the humerus^
or rather upon the posterior margin of its
articulating surface.

The anterior and two lateral ligaments
are generally more or less completely torn
asunder ; but the posterior ligament and the
annular do not usually suffer disruption.

The biceps muscle is drawn over the
lower articulating surface of the humerus,
but is in a condition of only moderate ten-
sion, while the brachialis anticus is forcibly

stretched, or even torn. Dislocation of the radlaa and ulna

The median nerve is also pressed upon backwards.
in front by the humerus, and the ulnar is occa-
sionally painfully stretched over the projecting extremity of the ulna
from behind.

Symptoms. — Sir Astley Cooper does not mention particularly the
position of the arm as to flexion or extension, except to say that " the
flexion of the joint is in a great degree lost; nor, in his original work,
published in London in 1823, is there any illustration accompanying
the text to indicate in what position he had usually seen the limb;
but in the later editions, edited by Mr. Bransby Cooper, is found a
drawing which represents the forearm at a right angle with the arm.
It is very certain that Sir Astley never sanctioned this error by any-
thing which he had written or communicated to others. It is very
certain, I say, because the fact that it seldom, if ever, occupies this
position, could not have escaped the notice of one whose experience
was so large, and whose habits of observation were generally so accu-
rate. The truth is that it is almost constantly found only slightly
flexed, or forming an angle in front of about 120°.

This fact is especially noticed in my records twenty -six times, and
if it had ever been found in any other position, it would certainly
have been stated. Once, where the dislocation was accompanied with
a fracture of the outer condyle of the humerus, the arm was at first
straight, a position in which it is said to be found occasionally with
children: and in the case of a patient admitted to Bellevue Hospital,
on the l4th of December, 1864, the dislocation having existed thirty-
one days, but unaccompanied with a fracture, I found the arm straight,
and there existed also a preternatural lateral mobility of the elbow-
joint; but never, in any case of a recent dislocation, and but once in
an old dislocation, have I found it flexed to a right angle; yet I will
not deny that such unusual phenomena are possible in recent disloca-

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tioQs ; indeed, it is certain that they have occasionally been presented,
but they must be regarded as only exceptional; and as by no means
diagnostic of this accident.

Sir Astley Cooper and Miller declare that in this dislocation the
forearm is usually supinated; Pirrie says "the hand is between prona-
tion and supination, but more inclined to the latter;" Desault thinks it
is sometimes in supination and sometimes in pronation ; Denuo^ con-
cludes that it will occupy that position, whatever it may be, in which
the force of the blow has thrown it ; while by most surgical writers
no allusion is made to the position of the forearm in reference to pro-
nation or supination. For myself, I can only say that I have found
the forearm and hand almost constantly in a position of moderate but
positive pronation, and I am compelled to regard it, therefor^ as one
of the usual signs of a backward dislocation of these bones.

The limb can be neither flexed nor extended without force, and
such motion is almost always accompanied with pain. It is, however,
possible in most cases to give to the arm a slight lateral motion, such
as does not belong to it in its natural condition.

In front, and deep in the fold of the elbow, is felt the lower end of
the humerus, forming a hard, broad, and somewhat irregular projec-
tion, over which the integuments and muscles are swollen, and tender
to pressure. Behind, the head of the radius may be felt, when not
much tumefaction exists, rotating or moving under the finger when
the forearm is supinated and pronated ; while the olecranon proems
projects strongly backwards and upwards. If now we flex the arm
slightly, this projection of the olecranon process will be sensibly in-
creased ; but if an attempt is made to straighten the arm, it will be
diminished, the reverse of what we have seen to happen in cases of
fracture of the lower end of the humerus (at the base of the condyles).
This circumstance becomes, therefore, an important diagnostic mark
between these two accidents.

The relation of the olecranon process, also, to the condyles is changed,
and the upper end of this process, instead of being a little below the
internal condyle, as it would be naturally when the arm is slightly
flexed, is found generally carried upwards toward the shoulder, from
half an inch to one inch or more above the condyle.

Measuring from the internal condyle to the styloid process of the
ulna, the forearm is shortened ; the same result will be obtained also
by measuring from the acromion process to either of the styloid pro-
cesses ; while from the acromion process to the condyle, the length
will be the same in both arms.

The signs which have now been enumerated will be sufficient to
enable us to make the diagnosis promptly in the great majority of
cases, but if considerable swelling has already taken place, the diag-
nosis may be rendered exceedingly difficult, if not impossible; and in
such cases we should confine the patient at once to his bed. and pro-
ceed to reduce the tumefaction oy cold water lotions as rapidly as
possible, examining the limb carefully from day to day in order that
we may seize the earliest opportunity to ascertain its actual condition
and apply the proper remedy.

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lu relation to the difficulty of diagnosis in certain examples of this
accident) and under certain circumstances, Mr. Skey, in his Operative
jSurgery, has made some very judicious remarks.

"Severe injuries of the elbow-joint, whether in the form of fracture,
dislocation, or a compound of the two, are frequently followed, at a
short interval, by swelling of a formidable kind, in wliich it is impos-
sible, but by the aid of a perfect intimacy with the anatomical struc-
ture of the jointy to detect the relations of one part with another ; but
even under this difficulty, the two points in question are readily dis-

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 68 of 100)