Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

. (page 69 of 100)
Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 69 of 100)
Font size
QR-code for this ebook


tinguishable. In such forms of swelling, the arm, including the length
of six inches both above and below the joint, may be involved in the
extravasation, and this swelling may distend the arm to a circumfer-
ence of one-third beyond its natural size. • In such circumstances, in
which it is impossible to determine with any certainty whether any,
or what bones are broken, or whether or not dislocated, the difficulty
of the case should at once be stated to the friends of the patient."

Prognosis, — If the luxation is recent, reduction is in general easily
effected; but if considerable time has elapsed, the reduction is often
accomplished with difficulty. As to the probability of its reluxation,
I have already spoken when considering the subject of fractures of the
coronoid process. Unless this process is broken, it is not likely to
occur except where some violence has again been applied. It has
happened to me, however, to find these bones unreduced in several
instances. In some of these examples surgeons recognized the acci-
dent and supposed that they had accomplished reduction, while in
others the dislocation was mistaken for a fracture.

A lad, W. F., twelve years old, residing in Brie County, N. Y., was
brought to me six weeks after the accident had occurred. The surgeon
who was first called declared it to be a dislocation, and told the parents
he had reduced it ; but the dislocation was dow complete, and the arm
immovably fixed in its abnormal position.

On the 10th of May, 1850, J. P., of Canada West, 89t. 25, was thrown
from a load of hay, striking upon his left hand, and producing a dis-
location backwards of both bones at the elbow-joint A Canadian
surgeon, who saw the patient within three hours, recognized the dislo-
cation, and by pulling the arm straight forwards he supposed he had
reduced it ; the patient also thought he felt the bones slip into place.
No attempt was made subsequently to fiex the arm, and it was imme-
diately dressed with a straight splint laid along the palmar surface.
On the sixth day it was found to be unreduced, and the surgeon again
attempted to reduce it as before, and thought he had succeeded. The
same splint was reapplied. At about the end of six weeks three
surgeons, residing in Canada also, placed the patient under the com-
plete influence of chloroforn, and attempted the reduction. They first
made extension for half an hour in a straight line, then five men
seized upon the arm and forearm, bending it with great force to a right
angle. It was now believed that the ulna was reduced, but not the
radius. Four days after, the attempt was renewed. Three months
lifter the accident the young man called upon me, and I found the arm
nearly straight, with almost complete anchylosis at the elbow-joint.



Digitized by VjOOQIC



592 DISLOCATIONS OP THE RADIUS AND ULNA.

Both the radius and ulna were displaced backwards, but not opwards.
Tbe arm was of the sancie length with the other, and the relation of
the condyles to the olecranon was so manifest, that the absence of tbe
usual displacement upwards was easily determined. I was anirilling
to make any further attempts at reduction, not believing that I should
succeed after so much time had elapsed, and after so man j ineffectnal
attempts had been made by clever surgeons.

In the following examples the dislocation was supposed to have
been a fracture of the lower end of the humerus.

A man, residing in Pittsfield, Mass., dislocated his left arm by Sail-
ing from a horse.* The surgeon who was called regarded it as a frac-
ture at the base of the condyles, and treated it accordingly. Ten
weeks after, the error was discovered and an attempt was made u>
reduce it, but without success. A second attempt was also made, with
the same result.

The patient was brought to me eight months after the accident, with
the bones still unreduced. The forearm hung at a very obtuse angle
with the arm, and there was very slight motion at the elbow-joint. I
discouraged any further attempts at reduction.

Mr. W., of Alleghany Co., N. Y., aet. 43, fell from a load of hay,
striking upon his left arm, Feb. 16, 1853. Four hours after, he was
seen by a young but very intelligent surgeon, who thought the hume-
rus was broken just above the condyles. After eight weeks, the fact
that it was a dislocation having become apparent, three surgeons, well
known to me as men of large experience, attempted its redaction,
aided by pulleys and chloroform. The patient was also bled, and
nauseated with antimony. The eflforts were protracted through many
hours, and frequently varied. A second attempt made by these same
gentlemen, a few days after, was equally unsuccessful.

On the ninth week Mr. W. came to me, and I placed him at once
in the Buffalo Hospital of the Sisters of Charity, where, assisted by
my friend Prof. Moore, of Eochester, I renewed the attempt at re-
duction. The patient was placed under the influence of chloroform,
and during a great portion of the time occupied the pulleys were
in use. The elbow was pulled upon, twisted, flexed, and extended,
until there seemed to be neither adhesions, nor ligaments, nor capsule
to prevent the reduction. We could move the joint in every direction,
even laterally, as well as forwards and backwards. Still the bones
would not return to their sockets. Section of the triceps seemed to
be the only remaining expedient, but the injury already done to the
joint was so great that we did not deem it prudent to prosecute the
attempt any further. We had occupied two hours in the various pro-
cedures. Violent inflammation supervened, but he was able to retom
home in about two weeks. Two years after, I learned that the arm
still remained unreduced, and nearly anchylosed ; the whole limb was
also much atrophied and very weak.

John Sharkie, aet. 63, fell on the 4th of Aug. 1854. A botanic doctor,
who saw him on the same day, and a regular physician, who saw him
on tbe third day, thought he had broken his arm. About six weeks
after this he came under the charge of an almshouse doctor, who



Digitized by



Google



DISIiOCATION OP RADIUS AND ULNA BACKWARDS. 598

" rebroke" it, supposing it to be a fracture; and two months later he
" broke" it again ; but as the arm was not improved by these operations,
he finally urged the poor fellow to submit to amputation ; and it was
in reference to this last proposition that Sharkie consulted me. I found
the radius and ulna dislocated backwards and upwards one inch; the
arni p)erfectly straight and the elbow anchylosed ; no pronation or supi-
nation. I did not think it prudent to make any attempt to reduce it,
but assured him that if let alone it would ultimately be quite useful
in many ways, and that he should never think of having it cut off.

In at least eight additional cases, according to my records, the acci-
dent bas been overlooked by reputable surgeons; the injury having
been supposed to be either a fracture or a mere contusion. Two of
these bad been examined by house surgeons at Bellevue. In one
other case my house surgeon supposed he had reduced the dislocation,
when he had not.

In three or four instances, also, the accident has been overlooked
by the patient himself, or by some empiric, no surgeon having been
called to see the case until after the lapse of several days or weeks.

In general, when the reduction has been effected promptly, the
patients have recovered the complete use of the elbow-joint within a
few weeks; but many exceptions have from time to time come under
my notice.

A lad eight years old was brought to me, whose arm had been dis-
located six months before, and the reduction of which had been ac-
complished easily and promptly by
Sir Astley Cooper's method. At Fig. 356.

this time the arm was bent to a right
angle, and quite stiff at the elbow-
joint. Four years later I learned that
the stiffness still continued in a great
measure, with only slight improve-
ment.

Treatment. — Sir Astley Cooper thus
describes his own method of reducing
this dislocation : "The patient is made
to sit upon a chair, and the surgeon,
placing his knee on the inner side of
the elbow-joint, in the bend of the
arm, takes hold of the patient's wrist,
and bends the arm. At the same
time he presses on the radius and
ulna with his knee, so as to separate
them from the os humeri, and thus
the coronoid process is thrown from
the posterior fossa of the humerus ;
and whilst this pressure is supported
by the knee, the arm is to be forcibly

but slowly bent, and the reduction is ^^^^^^^^^ ^^^ ^^^ ^^^ i^ t^, t,„^ .^ ,^^
soon effected." eibow.



Digitized by



Google



694 DISLOCATIONS OP THE RADIUS AND ULNA. ,

The same practice bas been recommended by Ericbsen, Gibson,
Samuel Cooper, and others. The plan recommended bj Doraej is
nearly identical with that just described, only that, instead of the knee,
he advises that the surgeon "interlock his fingers in front of the arm,
just above the elbow, and draw it backwards."

On the other hand, Liston and Miller recommend, as a better mode
of procedure, that the patient shall be seated upon a chair, and that
the arm and forearm shall be pulled directly backwards, so as to relax
as completely as possible the triceps muscle, while counter-extension
is made against the scapula.

Skey says : ** Extension of the forearm should be made from the
hand or wrist in a straight direction downwards^ as if for the purpose
of simply elongating the arm."

Pirrie prefers that an assistant shall grasp the forearm near its mid-
dle, instead of the wrist, and pull the arm straight forwards, while at
the same moment the surgeon seizes upon the olecranon process with
the fingers of one hand, and, placing the palm of the other against
the front and upper part of the forearm, pulls forcibly backwards^ so
as to draw out the coronoid process from the olecranon fossa. Water-
man recommends forced extension; that is, bending the forearm
forcibly back, as preliminary to flexion, with the view of lifting the
coronoid process from the olecranon fossa.^

For myself, having generally practised the method recommended
by Sir Astley, and having usually succeeded in the first attempt and
with the employment of only moderate force, I confess that my pre-
dilections are in its favor ; yet I am not entirely certain but that an
equal experience with either of the other modes recommended might
have changed these convictions. The truth is, I think, that in recent
cases very little force is generally requisite to accomplish the reduc-
tion, and that it is not very material which of these several modes we
adopt ; but in case of a failure by one mode, we ought immediately
and without hesitation to resort to another, as the following case of
failure by flexion will illustrate: —

A lad, 89t. 11, fell in a gymnasium from a height of six feet^ striking
probably upon his hand. I saw him within twenty minutes, and
found the arm in the usual position. I attempted immediately to re-
duce it by Sir Astley's method, but after a fair yet unsuocessfol trial,
I extended the forearm upon the arm until it was nearly straight,
and then, with only moderate force, drew it promptly into place.

If we still continue to encounter difficulties, the patient ought at
once to be placed under the influence of an anaesthetic, and, if neoes^
sary, the pulleys should be employed.

When the reduction is accomplished, which is indicated generally
by the sudden slipping of the bones and by the restoration of the
natural form to the elbow-joint, the surgeon, in order to confirm his
opinion, must flex the forearm upon the arm to a right angle. If the
bones are in place, and there is not much swelling, this can generally

> New Method of Reduction of the Elbow, by Thomas Waterman, M.D., Boston
Med. and Burg. Joum., vol. iy., Nos. 12-13, new series, 1869.



Digitized by



Google



PISLOCATION OP RADIUS AND ULNA BACKWARDS. 595



'be done Mrithout causing much, if any, pain ; but if it cannot be done,
ttis fact furnishes presumptive evidence that the reduction is not
effected. In one instance, however, of recent luxation, this rule has
not held good. A girl, sat. 10, fell from a tree upon her hand. I was
in attendance within half an hour, and found the usual signs charac-
terizing this accident Reduction was accomplished readily by pulling
at the hand moderately, with the forearm flexed, while my left hand
pressed back the lower part of the humerus. After the reduction it
^was found impossible to flex the arm to a right angle without causing
severe pain, and it became necessary, after placing it in a sling, to
allow the hand to drop very low beside the body. A good deal of
inflammation followed ; but in a few weeks the arm was well, only that
for a period of two years or more the elbow remained very tender.

On the other hand, an omission to apply this rule has often led the
surgeon to believe the reduction accomplished when it was not. This
same thing has happened to myself, and as it is the' only instance in
which I have omitted to adopt this test, and the only one also in which
I have left a bone unreduced which I believed to have been reduced,
it will be proper to state the case and its results more fully.

A lad, set. 11, fell from a fence on the 22d of December, 1858, and
dislocated both bones backwards. I saw him within two hours from
the occurrence of the accident. The elbow was already considerably
swollen and quite tender, but the signs of dislocation were very mani-
fest. Seizing the wrist with one hand, and placing my knee against
the front and lower part of the humerus, I pulled steadily for some
time, and with much more force than is usually necessary, until at
length two distinct and successive snaps were felt, such as one often
feels when the two bones resume their sockets. Relinquishing my
grasp, it was observed by myself and the parents that the deformity
had disappeared. The reduction seemed to be complete, and so I
announced. I then requested the lad to permit me to bend the elbow,
and place it in a sling, but this he peremptorily refused to do, and ran
away from me, nor would any arguments or entreaties persuade him
to allow me again to touch it. I reassured the parents and child, how-
ever, that all was right, and left the house. During several successive
days I saw the little patient, but although the arm remained swollen
and very tender, I did not suspect the cause until the ninth day ; and
on the tenth day, having placed him under the influence of chloroform,
the reduction was easily and satisfactorily accomplished. The recovery
has been slow. At the end of six weeks I found the motions of the
elbow-joint not completely restored, and the forefinger was partially
paralyzed ; but from this condition it has gradually recovered, and
two months later the functions of the arm and hand were completely
restored.

The mistake in this instance was the more mortifying because I had
just seen a case in a lad only a little older, in which another surgeon
had committed the same error, and after the lapse of twelve or four-
teen days I had myself made the reduction ; and I was fully awake,
therefore, to the possibility of the mistake.



Digitized by



Google



596 J)ISLOCATIONS OF THE RADIUS AND ULNA.

The circumstance of the diminution, and apparent disappearance of
the deformity, and the sensation of a double click, can only be explained
by assuming that originally the coronoid process was resting in the
olecranon fossa, and that by manipulation the bones had been removed
nearer their sockets, yet not actually reduced. The swelling, also,
rendered more difficult a diagnosis which, now, nothing but the flexion
of the forearm could have determined positively.

If much time has elapsed since the occurrence of the dislocation the
reduction is accomplished with difficulty, if, indeed, it can be redaced
at all. There are many cases upon record, however, in which surgeons
have been successful after the lapse of many weeks, or even months.
Boyer thought it was not possible to effect the reduction after four or
six weeks; but Capelletti, of Trieste, succeeded after seventy days;'
Sir Astley Cooper, at three months;* Malgaigne, after three months
and twenty-one days.' Boux succeeded in a case of a young nuin
twenty-two years of age, whose elbow had been dislocated five months.*
Blackman, of Cincinnati, informs me that be has reduced a lateral luxa-
tion after five months. Brainard, of Chicago, reduced a dislocated
elbow in a boy of nineteen years, after five months and thirteen daysw
In this case the surgeon who had first seen the patient supposed that
he had reduced the dislocation.* Gorre, Gerdy, and Drake succeeded
in four cases after six months f and finally. Starch claims to have
been successful after two years and one month.^ To which enamera-
tion Denuc^ has added seventeen other examples^ said to have been
reduced at various periods, ranging from one month to one handr^
and fourteen days.®

I have reduced quite a number of these old luxations, the five last
of which will be briefly recorded.

Thomas Robertson, set. 85, was admitted to Bellevue Hospital, Dec.
14th, 1864, with a simple dislocation of the radius and ulna backwards,
which had existed thirty-one days, but which had not been up to this
moment recognized by his surgeon. I reduced it before the class, by
Sir Astley*s method, the patient being under the influence of ether.
Considerable force was required.

J. G., »t. 7, was brought to me in Nov. 1865, with a backward dis-
location of the right radius and ulna which had existed nine weeks.
The arm was nearly straight and fixed. Having placed him under
the influence of ether, assisted by Dr. Gurdon Buck, of this city, I
proceeded to flex the arm slowly, and after a few seconds, and when
the elbow was bent about ten or fifteen degrees, the olecranon process
separated at the line of epiphyseal union. In a few moments the
reduction was completed, and the arm brought to an acute angle, but
the olecranon had separated full half an inch. We were quite certain

> Capelletti, Am. Joum. Med., vol. xix., from Annal. Univ. deMM. for Oct. 1835.
« Sir Astley Cooper, On Dislocations and Fractures, Amer. ed., p. 888.
3 Malgaigne, Amer. Joum. Med. Scl., vol. xxiii. p. 238, from Revue M^., Dec
1837.
* Houx, Amer. Joum. Med. Sci., vol. xvi. p. 538, from Archives Q6n., Dec. 1834.
s Brainard, Illinois and Indiana Med. Joum., 1847.

6 M^moire sur les luxations du coude, par Paul Denuc6, Paris, 1854, pp. 86, 87.
' Denuc^, op. cit., p. 87. • Op. cit.



Digitized by



Google



DISLOCATION OP BADIUS AND ULNA BACKWARDS. 697

tliat the ulna was perfectly reduced, but the head of the radius did not
eeem to occupy its origiual position fully. Only moderate infiam-
Tnation ensued. Passive motion was soon commenced and consider-
able motion of the joint was finally obtained.

In April, 1869, a gentleman, set. 30, consulted me on account of a
dislocation which had then existed ten weeks, and which had not been
recognized by his surgeon. In attempting to reduce the dislocation
I fractured the olecranon, and brought the ulna into position ; but I
could not reduce the radius. Almost complete anchylosis of the elbow
remains.

In 1870, a man was brought to me whose elbow had been dislocated
eight weeks. Under ether, I succeeded in reducing the dislocation,
but fractured the olecranon process in doing so. He has recovered
very good use of the joint.

October 22, 1869, before the class of medical students at Bellevue,
I reduced a dislocation in the case of a woman set. 87, which had ex-
isted since the 10th of the preceding March, a little more than seven
months. I have seen her often since; she has a somewhat limited
but very useful motion of the joint.

Dr. W. F. Westmoreland, of Atlanta, Ga., has reported a case in
which he succeeded readily in reducing a dislocation of the elbow
backwards of five months' standing in a woman aged 22 years. The
reduction was followed by great pain, a good deal of swelling, tempo-
rary improvement of circulation in the radial artery, complete para-
lysis of the little finger, and partial paralysis of the middle and ring
fingers. On the fourteenth day, at which period the history of the
case closes, all these symptoms were rapidly disappearing.^

Nevertheless, the fact is in the main as stated by Boyer ; and if so
many cases can be found in which surgeons have succeeded at a late
period, they are not probably in the proportion of one to five as com-
pared with the failures : but the failures have not received the same
publicity. Nor, indeed, have all the severe accidents, such as violent
inflammation, suppuration, gangrene, and even death, been faithfully
declared. Denuc^ says he has been able to trace out five or six ex-
amples in which, although the arm was reduced, grave accidents
resulted, and Velpeau's patient actually died in consequence.

Dixi Crosby, of New Hampshire, has treated two cases of ancient
dislocation of the forearm backwards, by bending the elbow forcibly
so as to break the olecranon process, after which the reduction was
easily accomplished by extension. R. D. Mussey, of Cincinnati, has
succeeded once in the same manner.' I have reported three similar
examples.

The dislocation being reduced, it may be a matter of prudence, some-
times, to apply a right-angled splint, first carefully padded, to the
palmar surface of the arm and forearm ; remembering, however, that
considerable swelling will soon occur, and that it ought not therefore
to be bandaged to the limb very tightly. At least once a day it should
be removed, and the arm examined ; and in very few cases can it be

> Westmoreland, Atlanta Med. and Surg. Joam., May, 1S66.
« Crosby, Mussey, Trans. Amer. Med. Assoc, vol. iii. p. 857.



Digitized by



Google



598 DISLOCATIONS OF THE RADIUS AND ULNA.

necessary or judicious to continue its application beyond one ^week.
At the same time, if there is any especial tendency in the radios to
become displaced backwards, owing to a rupture of its annular liga-
ment, this must be prevented, if possible, by a compress and bandage.
Some surgeons regard these precautions as necessary in all cases, but
I have seldom employed any splint or bandage whatever, nor have I
ever had reason to regret this omission.

Finally, we are to place the arm in a sling, and adopt such measures
as are calculated at first to reduce the inflammation ; and at a very
early day we ought to begin to move the elbow-joint, in order to
prevent anchylosis.

§ 2. Dislocations of the Radius and Ulna Outwards (to the Radial

Side.)

The large majority of outward dislocations of the forearm are in-
complete ; indeed, only nine examples of a complete dislocation have
been collected by Denuc^, including two seen by himself. Malgaigne
has since added two more, making in all eleven cases. All these
examples have occurred in the practice of French surgeons. So far
as I am able to discover, no American or English surgeon has ever
reported a single example.

Incomplete dislocations must, therefore, in this case be regarded as
typical ; but even these are by no means frequent.

Causes. — A careful examination of a large number of recorded ex-
amples, and of those which have come under my own eye, renders it
certain that a majority of these accidents result
Fig. 257. from a blow received directly upon the inner side

of the forearm or upon the outer side of the humerus,
or from the action of two forces pressing in an
opposite direction. Of course those forces mast
act upon the bones somewhere in the neighborhood
of the elbow-joint. Occasionally it has been pro-
duced by a fall upon the hand ; sometimes by a
violent twist of the arm, as when the hand is caught
in machinery ; and in other cases it has been found
consecutive upon a dislocation backwards, being
produced in the attempts made to accomplish re-
duction of thb latter form of dislocation.

Pathology. — In most of the examples of simple
incomplete outward luxation of the forearm, the
great sigmoid cavity of the ulna still embraces the
lower end of the humerus, but instead of reposing
upon the trochlea, it is carried outwards half an
inch or more> so as to rest its central crest upon
the depression which separates the condyle from
the trochlea. If the annular ligament remains
I unbroken, the radius is displaced in the same di-

Moit f^eqneat fora of yection and to the same extent, its head resting

incomplete outward dUlo- ., jj« ^ii_i ^i • ji

cation of the fbrearm. agamst and dircctly below the epicondyle.



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 69 of 100)