Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

. (page 70 of 100)
Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 70 of 100)
Font size
QR-code for this ebook


Digitized by



Google



DISLOCATION OF RADIUS AND ULNA OUTWARDS. 599

Occasionally, however, where the violence has been greater, the cen-
tral crest of the great sigmoid cavity rests fairly upon the condyle, or
upon the articulating surface of the humerus where the head of the
radius was formerly applied, and the dislocation approaches more nearly
to the character of a complete luxation. At the same time, owing
perhaps to the resistance afforded by the skin, or some of the liga-
ments, the head of the radius may be thrown either forwards or back-
wards, so as to be out of line with the ulna. Such a displacement
generally implies a rupture of the annular ligament.

We have now only to suppose the action of a more considerable
force in the same direction to render the dislocation complete ; in
which case the upper end of the radius is sometimes thrown com-
pletely forwards, and its head may even be found resting in front of
the ulna, occasioning an extreme pronation of the forearm and hand.

The anconeus and brachialis anticus are the only muscles in either
of these dislocations whose fibres are generally much disturbed ; the
biceps and triceps being only made to traverse the articulation a little
more obliquely.

Denuc^, Malgaigne, A. Cooper, and others have preferred to speak
of the dislocation backwards and outwards as a distinct form or species
of dislocation. I prefer to regard it as only a variety of the outward
luxation, since it may, and no doubt often does, occur consecutively
upon a simple incomplete outward dislocation ; and if the dislocation
outward is complete, the bones of the forearm can scarcely fail to be
drawn more or less upwards. Sometimes also it has been consecutive
upon a simple backward dislocation, or upon unsuccessful attempts at
reduction where the form of dislocation was originally backwards ;
yet, as it does not so naturally follow upon a complete backward dis-
location as upon a complete outward luxation, I find sufficient reason
for studying its mechanism in this place.

The beak of the olecranon process not only, but a large portion of
the body of this process, now lies above and behind the condyle; the
brachialis anticus becomes more stretched, if not actually torn; and the
biceps is laid against the articulating surface of the humerus ; but the
triceps becomes again relaxed, as in simple dislocation backwards and
upwards.

In all these dislocations the capsular ligaments are more or less ex-
tensively torn, but the principal arteries and nerves do not generally
Buflfer greatly, if at all.

ISympUyma. — The forearm is usually flexed to about the same angle
at which we have found it in dislocations backwards; once I have
found it nearly or quite straight ; occasionally it is flexed to a right
angle. In all the cases seen by me the forearm has been pronated,
and the elbow-joint has been very immovable. The most striking
diagnostic sign, however, consists in the unnatural form of the elbow-
joint, which is so remarkable as not to be easily misunderstood. The
internal condyle of the humerus (epitrochlea) projects strongly to the
inner side, leaving a deep depression below; while upon the other
side, the head of the radius, with its cup-like extremity, can be dis-
tinctly felt, and made to rotate outside of its socket. The olecranon



Digitized by



Google



600 DISLOCATIONS OF THE RADIUS AND ULN'A.

process, driven from its fossa, projects mora or less posteriorly, aod
even the fossa itself may sometimes be plainly felt.

A girl, twelve years old, had fallen upon the inside of her elbov^
producing a dislocation outwards of the forearm. I saw her within
half an hour. The forearm was bent upon the arm about fifteen de-
grees, and immovably fixed. The head of the radius ooQid be dis-
tinitly felt external to and a little in front of the outer condyle, while
the olecranon process of the ulna, which rested upon the back and
outer surface of the humerus, was less distinctly felt than in the oppo-
site arm. The inner condyle projected sharply to the inside, and the
olecranon fossa was plainly felt with the fingers. The child was suf-
fering very little pain.

Seizing the wrist with my right hand and the lower end of the
humerus with the left, and making moderate extension in these oppo-
site directions, the bones easily, and after only a moment's efforty re-
sumed their places. Her recovery was rapid and complete.

James O'Neil, set. 16, was admitted to Bellevue Hospital in Dec.
1865, with a dislocation caused by the kick of a horse, the blow
having been received on the ulnar side of the forearm near the elbow-
joint. When he came under my notice the dislocation bad existed
three weeks. I found the head of the radius reposing upon the radial
and posterior side of the humerus. The ulna was displaced one inch
to the radial side. The forearm was not at all, or but very slightly,
fiexed upon the arm. The natural deflection of the forearm to the
radial side was a little exaggerated: forearm pronated: elbow-joint
admitting of a little motion; but motion caused great pain.

This patient was not in my service, and I have not learned the
result of the attempt at reduction.

If the dislocation is complete, the position of the arm is usually the
same, but the pronation of the hand is greater, and the projection of
the inner condyle more striking.

If now the bones, by a continuance of the original force, or by the
action of the triceps, are drawn upwards also, the arm becomes a little
more fiexed, and the olecranon process more prominent^ while the
length of the whole limb is sensibly diminished.

Prognosis. — In recent cases of incomplete outward luxation, and
where no complications exist, the reduction is generally easily effected;
and M. Thierry claims to have reduced an outward and backward
luxation after eight months. A patient of whom Debruyn has spokea
was not so fortunate. On the 16th of April, 1841, a lad, ast. 18, fell
upon the palm of his hand and dislocated both bones outwards and
backwards; on the following morning a surgeon attempted to redooe
the dislocation, and the attempt was repeated on the next day by an-
other surgeon ; but on the day following this last attempt^ gangrene
ensued in consequence of the great violence employed by the surgeons,
and, although the limb was amputated, the patient died. The autopsy
showed that both the brachial artery and the median nerve were torn
asunder, and that the tendons of the biceps and the brachialis anticoa
were slipped behind the outer condyle, probably having been thrown



Digitized by



Google



DISLOCATION OF RADIUS AND ULNA OUTWARDS. 601

into this position during the violent twistings to which the arm had
T>een subjected.^

I have seen three examples of dislocations upwards and outwards
which the medical attendants had failed to reduce. The first was in
the case of a lad, Wm. Kinkaid, fourteen years old, who had fallen
from a wagon and struck upon the palm of his left hand. The sur-
geon who was immediately called made extension, and supposed that
the reduction was accomplished. The lad was brought to me a few
months after the accident. The arm was slightly flexed, and neither
prone nor supine. There existed only a slight motion at the elbow-
joint. I did not think it worth while to make any attempt at reduc-
tion. Several years after this, in the month of February, 1859, 1 had
an opportunity of examining the arm again. He had now recovered
considerable motion in the joint, but he could not tie his cravat.
Pronation and supination were perfect.

In the second example, a lady, ast. 33, had fallen upon the inside of
her elbow, and reduction not having been accomplished, I found her,
nine weeks after the accident, with scarcely any motion at the elbow-
joint, and complaining of a numbness in the forearm and hand.

The third instance of unreduced dislocation I will relate more at
length.

Francis Banfield, aged twenty-two years, a resident of Alleghany
County, N. Y., on the 31st of September, 1857, fell from the sweep of a
threshing-machine to the grounu, a distance of about five feet, striking
upon the palm of his hand, his arm being extended in front of him. On
rising, he found his arm forcibly flexed and abducted. He straight-
ened it without difficulty, and it assumed the position it now occupies.
A physician was called and saw the patient an hour and a half after
the accident, who pronounced it a case of dislocation of the radius and
ulna, and made efforts at reduction, which he continued from 8} A. M.
until 2 P. M., a period of five and a half hours, to no purpose, when
he abandoned the attempt. During the attempt at reduction, the ex-
tension was made at times with the arm flexed, and at others extended.
At 9 P. M. another physician was called, who made efforts at reduc-
tion until 8 A. M., upwards of six hours, at which time he also aban-
doned the attempt. On the third day another physician, the patient
being under the influence of ether, made efforts at reduction for twenty
minutes, when he pronounced it in place, and applied a bandage.
From the patient's account, the arm was swollen to such an extent as
to render this point difficult to determine. On the fifth day the first
physician was called, and believing that he discovered a grating,
pronounced it a fracture of the external condyle.

Four months after the accident, when the patient applied to me, the
limb presented the following appearances: **The forearm extended
upon the arm ; looking at the limb along its radial margin, we notice
a gentle outward inclination of the forearm from the elbow down, but
by manipulation this may be greatly increased ; the power of prona-
tion and supination is not affected; the inner condyle projects an

> Denned, op. cit., p. 108.
89



Digitized by



Google



602 DISLOCATIONS OF THE BADIUS AND ULN-A.

inch to the ulnar side ; the head of the radius, completely removed
from its socket, projects to an equal extent on the radial side. The
top of the olecranon process is an inch higher than the top of the inner
condyle, so that the radius and ulna are carried upwards as well as
outwards"

I believe that the external condyle was not broken, as in that case
the arm would be permanently deflected outwards to a much greater
extent. For, although this arm may be deflected outwards bj the
surgeon to an angle of 135^, still the degree of mobility which exists
would be adverse to the supposition of its being a fracture of the
external condyle. The condyles alse can be plainly felt in their
natural situations, which would not be the case if a fracture of the
external condyle existed. The patient was advised not to submit to
any further attempts at reduction.

The following will serve as an illustration of a recent accident of
this character : —

John Collins, of Bufialo, 8Bt. 8, fell while wrestling, his companion
falling upon his arm. I found the forearm slightly flexed, pronated,
and both radius and ulna thrown over to the radial side and carried
upwards. Pressing firmly upon the radius from the outside, the bones
assumed suddenly the position of a backward and upward dislocation,
from which position they were readily reduced to their original sockets
by simple extension.

Treatment. — In relation to the treatment of these accidents we have
little to add to what has already been said of the treatment of dislo-
cations backwards. The reduction, if eflFected at all, has generally
been accomplished by moderate extension, or by extension combined
with lateral pressure. If the head of the radius is in front of the
humerus, or of the ulna, the hand should be first supined, and then
the extension should be applied. In some cases the reduction has
been efiected by placing the knee in the bend of the elbow and flexing
the forearm, while the surgeon was making extension from the hand.

§ 3. Dislocation op the Radius and Ulna Inwards (to thb Ulnar Side).

This form of dislocation is much more rare than the dislocation
outwards, a fact which may perhaps find a sufficient explanation in
the peculiar form of the trochlea, the inner half of which rises mach
higher than the outer, forming thus an elevated inclined plane, over
which the articulating surface of the ulna must rise before the dislo-
cation can occur.

Like the opposite dislocation, the typical form of the accident is
that in which the displacement is incomplete; indeed, no example of
a complete inward dislocation has, we think, been yet recorded.

Causes. — A fall upon the hand or forearm, a blow upon the radial
side of the forearm near its upper end, or upon the ulnar side of the
arm near its lower end, a violent wrenching of the limb are among
th6 causes which may occasion this dislocation.

Pathology. — The ridge which divides antero-posteriorly the greater
sigmoid cavity of the ulna, having been driven over the elevated



Digitized by



Google



DISLOCATION OP RADIUS AND ULNA INWARDS. 608

inner margin of the trochlea, falls down upon the epitrochlea, so as,
in some sense, to embrace it instead of the trochlea ; while the head
of the radius passes inwards also, and is made to occupy the trochlea,
from which the ulna has escaped. Generally the head of the radius
is found in the same line with the ulna (Fig. 258),
but it may suffer a luxation and be found a little ^^S- 25S.

in advance of the ulna, or possibly a little in the
rear.

I choose also to regard the dislocation inwards
and upwards as only a variety of the dislocation
inwards; in which form of the accident the coronoid
process of the ulna is thrust upwards above the
epicondyle, and the head of the radius occupies the
olecranon fossa, or rests upon the back of the
humerus somewhere in this vicinity.

In addition to the injury suffered by the liga-
ments and muscles, the ulnar nerve in both varieties
of inward dislocation is peculiarly liable to contu-
sion, in consequence of its being crushed between
the olecranon process and the epitrochlea.

Symptoms. — If the dislocation is only inwards,
the olecranon process can be felt projecting upon
the inner side, and completely concealing the epi-
condyle ; while the head of the radius, having aban-
doned its socket, may be felt indistinctly in the
bend of the arm. The external condyle (epicon-
dyle) is remarkably prominent. The forearm is Mott frequent form of

u \ n J 3a1_-lj/»' Incomplete Inward dlilo-

generally more or less flexed, and the hand forci- c»uon of the forearm,
bly pronated. The natural outward deflexion of
the forearm is also lost, or it may be even inclined slightly inwards.
This phenomenon is explained by the position of the epicondyle, upon
which the greater sigmoid cavity now rests, allowing the ulna to
overlap a little upon the humerus; rendering the forearm actually
somewhat shorter along its ulnar margin, although the head of the
radius may still occupy the summit of the trochlea.

If the bones are displaced upwards as well as inwards, a consider-
able shortening is declared, and the head of the radius may now be
felt behind the trochlea, or over the olecranon fossa. In three of the
four examples seen by Malgaigne, all of them ancient, the forearm was
in a state of supination. Other sargeons have met with cases in which
the forearm was supine, but they must be considered as exceptions to
the rule.

The following example of this dislocation, unreduced after the lapse
of fourteen years, is reported to me by Dr. T. H. Squier, of Elmira,
N. Y. : Thomas Cook, now in his nineteenth year, was four years and
ten months old when he fell from a pile of boards about as high as
a man's shoulder. According to his statement, given at the time, his
right arm caught betweeii the boards, and, in falling, he turned a
summersault. The mother, to whom the child immediately ran,
grasped his arm which he said was brolcen, and found that it would



Digitized by



Google



604 DISLOCATIONS OF THE RADIUS AND ULNA.

roll and turn in various ways. When the surgeon arrived, tbrec
hours afterwards, the arm was very much swollen and the accident
was supposed to be a fracture. At present flexion and extenaaon are
perfect. The forearm has an inward deflection of a hand's breadth
more than the other. The power of pronation is complete, bnt the
forearm and hand cannot be supinated entirely. The external con-
dyle is very prominent, but the internal is almost hid by the olecranon,
which projects inwards nearly as far as the point of the epioondjleL
The finger can be laid in the olecranon fossa behind, and all the back
part of the trochlea can be distinctly traced. By flexing the forearm
slowly as it approaches a right angle, the tendon of the triceps may
be felt, lodged, as it were, on the back part of the point of the epicon-
dyle; and by continuing the flexion, the tendon suddenly slips over this
point and places itself on the anterior aspect of the arm. When the
forearm is fully flexed, the tendon is advanced full three-quarters of
an inch in front of the epicondyle. The arm is very serviceable^ bat
invariably pains him* after a hard day's work.

Prognosis. — Malgaigne was unable to reduce the dislocation in a
recent case of incomplete internal dislocation, which came under his
own notice. Triquet succeeded in a child seven years old, on the
fifteenth day, after many trials ; but the movements of the elbow-joint
were never restored. Dubruyn succeeded on the fiflh day, but not
without difficulty; the case reported by Squier was mistaken for a
fracture, and no attempt at reduction was made ; and in the only re-
maining example which has been put upon record, the precise cha-
racter of the accident having been determined by Yelpeau, reduction
was easily accomplished, and on the eighth day the patient was
dismissed.^

Of the four examples of inward and backward luxation seen by
Malgaigne, not one was ever reduced ; but as the history of them all
is not complete, it is by no means to be inferred that reduction could
not have been easily accomplished, at least in some of them, at the
first. Nor, with such imperfect details before us, can we understand
fully what complications may have existed, such as would perhaps
render these exceptional, rather than illustrative examples.

One of these patients had a completely anchylosed elbow at the
end of two years, but pronation and supination were preserved. In
the case of another, however, even flexion and extension were as per-
fect as in the normal condition.

Treatment. — The indications of treatment are the same as in dislo-
cations outwards, with only such slight modifications as the judgment
of every surgeon must naturally suggest. I prefer to employ by way
of illustration the example diagnosticated by Yelpeau.

On the 10th of May, 1848, Alexandrine Guyot, sBt. 22, entered the
Hospital of La Gharit^, with an incomplete inward dislocation of the
forearm which had just occurred. The hand and forearm were in a
state of forced pronation, half-flexed, and the whole limb from the
elbow downwards was deflected inwards. There were present also

' Denue^, op. cit., pp. 154-156.



Digitized by



Google



DISLOCATION OP RADIUS AND ULNA FORWARDS. 605

all the other usual signs of this dislocation, and Velpeau had no doubt
as to its true character.

In order to accomplish reduction, one assistant made counter-exten-
sion upon the arm, while a second made direct extension upon the
forearm. At first the tractions were made in the direction of the fore-
arm (flexed and prone), but gradually the arm w^as straightened and
supinated. Then the surgeon, seizing with one hand the superior ex-
tremity of the forearm, and with the other the inferior extremity of
the arm, acted forcibly upon the two portions in opposite directions,
and immediately the reduction was effected with a noise.^

§ 4. Dislocation of thx Radius and Ulna Forwards.

Sir Astley Cooper, Vidal (de Cassis); and others have denied that
this dislocation was possible without a fracture of the olecranon pro-
cess ; but Monin, Prior, Velpeau, Canton,* and Denucd have each re-
ported one example, so that its existence may now be considered as
established. Nevertheless, it is only as a result of very violent and
extraordinary accidents, by which the forearm is forcibly flexed, or
greatly extended, or twisted, or in some other utusual and indirect
way the olecranon is placed in front of the humerus.

Fig. 259.



S. Canton's case of dislocation of the radios and nlna forwards.

The following is a summary of the facts in Velpeau's case. Alex-
andrine Carelli, »t. ^8, was knocked down by a carriage, on the first

> Denned, op. clt., p. 155. « Dub. Quart. Joum. of Med. 8ci., Aug. 1860.

Digitized by VjOOQIC



606 DISLOCATIONS OP THE WRIST.

of July, 1848, the wheel passing over the right arm. The arm was
found in a right-angled position, and it could neither be flexed nor
extended; the forearm was strongly supinated; the projecting angle
usually made by the olecranon process was replaced by the irregular
extremity of the humerus; the forearm was shortened upon the arm;
the head of the radius resting in the coronoid fossa, and the olecranon
process being also carried upwards and a little outwards. Beductioa
was easily accomplished, and the patient left on the mneteenth day
with only a slight remaining stiffness in the joint.'

A case is reported to have come under the observation of Mr. J. W.
Langmore, house surgeon at the University College Hospital, London.
It was occasioned by a fall upon the elbow. The reduction of the
ulna was easily accomplished by placing the knee in the bend of the
elbow and flexing the arm. The radius was then reduced by pressure
and extension.'

Chapel has reported a case of dislocation forwards and outwards,
which he readily reduced soon after it occurred, while Colson, Leva,
and Guyot have each reported one example of 5u&-luxation forwards,
in which the extremity of the olecranon process has been found rest-
ing upon the extremity of the humeral trochlea.'

TreatmenL — If the dislocation is complete, and the forearm is short-
ened and flexed upon the arm, the reduction should be first attempted
by violent flexion, or by flexion combined with extension from the
wrist, and counter-extension from the lower portion of the humerus.
If the dislocation is incomplete, and the forearm is extended upon the
arm, the reduction may be readily accomplished by extension alone,
or by moderate flexion.



CHAPTER X.

DISLOCATIONS OF THE WRIST (RADIO-CARPAL ARTICULATION).

Begabded as an accident of not unusual occurrence by Hippocrates,
J. L. Petit, Duverney, Boyer, and by most if not all of the older writers,
its frequency began to be questioned by Pouteau, and finally its ex-
istence was almost absolutely denied by Dupuytren, who remarks:
" I have for a long time publicly taught that fractures of the carpal
end of the radius are extremely common; that I had always found
these supposed dislocations of the wrist turn out to be fractures ; and
that, in spite of all which has been said upon the subject, I have never
met with, or heard of, one single well-authenticated and convincing
case of the dislocation in question." Dupuytren subsequently de-
clared that he would not positively deny the possibility of the aoci-

» Denuc6, op. cit., p. 110. •

< New York Med. Record, March 1, 1867, fh)m the London Lancet.

» Denuc6, p. 120.



Digitized by



Google



DISLOCATIONS OF THE WBIST. 607

dent, yet that " it must at least be admitted that the accident is an
extremely rare one." Wishing to explain this infrequency, he says :
'* In examining the structure of the soft parts, one cannot fail to per-
cseive that it is not the ligaments which prevent the displacement of
"fche articular surface forwards, but that this effect is especially due to
the multitude of flexor tendons, deprived as they are at this point of
fill the fleshy parts, and reduced to the simple flbrous tissue which
composes them. These tendons are bound together beneath the ante-
rior annular ligament of the wrist, and thus offer so efScient a resist-
ance that severe falls are insuflicient to tear them through ; the hand
is forced into a state of extreme tension, and the tendons are flrmly
applied on the anterior part of the radio-carpal articulation. If the
extension is still further augmented, the wrist-joint is yet more closely
clasped by these parts, and their power of resistance is incalculable ;
I am convinced that a force equivalent to one thousand pounds weight
would be inadequate to overcome it; and the known power of the



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 70 of 100)