Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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tendo Achillis is suf&cient to prove that this computation is not ex-

" The risk of dislocation backwards by a fall on the dorsal surface
of the hand is equally precluded by the tendons of the extensor mus-
cles. Their arrangement and relations at the back of the joint are
similar; it is true, they are not quite so strong; but we must admit
that their power of resistance is very considerable, when we take into
consideration how they are inclosed in sheaths as they cross beneath
the posterior annular ligament of the wrist. I have not alluded to the
ulna, for it has really little or nothing to do with these movements, as
it does not articulate (directly) with the hand.

" To sum up, then, the extreme rarity of dislocation forwards or
backwards is owing to the obstacles opposed by the flexor or extensor

The opinion of such a writer as Dupuytren, whose experience was
very great, and who described only what he had seen, is always en-
titled to profound respect ; yet it has been the practice of nearly all
who have made any reference to his opinions in this matter to speak
of them lightly, and not a few have falsely represented him as saying
that such a dislocation was "impossible." The fact is, that surgeons
do still constantly mistake fractures of the lower end of the radius
for dislocations, as my own personal observation can attest ; and not-
withstanding examples have been reported by Ben^, Marjolin, Padieu,
Cruveilhier,Voillemier, Boinot, Malgaigne,Scoutetten, Bransby Cooper,
Fergusson, W. Parker, and others, yet the whole number of cases for
which the distinction is claimed is, to this day, so inconsiderable as
only to establish the value and accuracy of Dupuytren's opinion that
the " accident is an extremely rare one." But it is, perhaps, most re-
markable that while very few of these supposed examples have been
verified by an autopsy, in every instance in which the autopsy has
been made, the dislocation has been found to be complicated with a
fracture, generally of the lower extremity of the radius or of the
styloid apophysis of the ulna.

The existence of a complication, however, does not render the acci-

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dent any the less a dislocation, although it may render the diagnosis
more difficulty and modify somewhat the indications of treatment. A
knowledge of the fact, also, that such complications have always been
observed in the autopsy, may leave us in doubt as to what is the nata-
ral history of a simple, uncomplicated dislocation, if, indeed, it does
not warrant a suspicion that such a case never occurs. We shall,
nevertheless, after a careful analysis of the cases as they have been
reported, and by a consideration of the anatomy of this articulation,
be able to determine with some degree of accuracy, perhaps, what
are, or what ought to be, the usual causes, signs, treatment, &c^ of these

Partial luxations have also been frequently described by sargeons.
I have never met with an example, but the following case, related to
me by the patient himself, I believe to have been a case in point.

Lewis C, of Buffalo, eet. 18, by a fall upon his hand, broke the left
forearm below the middle, and at the same time, as he affirms, par-
tially dislocated the carpal bones backwards. Dr. Spaulding, of
Williamsville, N. Y., took charge of the limb, and pronounced it a
fracture with partial dislocation, and for more than a year after the
accident the bones had a tendency to become displaced in the same
direction. Whenever he attempted to lift even the weight of half a
pound, with his hand supinatea and his forearm extended horizon-
tally, the lower end of the radius would spring suddenly forwards,
and all power in the arm would be lost. When this happened, as it
did quite often, he always reduced the bones himself, by simplj push-
ing upon- them in the direction of the articulation.

Fourteen years after the accident, I examined the arm and found it
in all respects perfect, except that the forearm was shortened about
one-third of an inch, which shortening was due, no doubt, to the
overlapping of the broken bones.

§ 1. Dislocations of the Carpal Bones Backwards.

Causes. — The same casualty, namely, a fall upon the palm of the
hand, which, as we have elsewhere noticed, produces frequently a frac-
ture of the lower end of the radius, occasionally a dislocation of the
radius and ulna backwards, at the elbow-joint, may also, it is believed,
occasion sometimes a dislocation of the carpal bones backwards. In
several of the cases reported, this cause has been assigned ; but in the
only example of simple dislocation which has ever come under my
notice, and which I have every reason to believe was a simple dislo-
cation unaccompanied with a fracture, the carpal bones were thrown
back by a fall upon the back of the hand. The following is a brief
account of the case : —

The Rev. Stephen Porter, of Geneva, N. Y., set. 75, while walking
with his son after dark, and holding in his right hand a satchel, slipped
and fell. In the effi>rt to save himself, and still retaining his grasp
upon the satchel, his right hand struck the side-walk flexed, and in
such a way as that the whole force of the fall was received upon the
back of the hand and wrist, thus throwing the hand into a state of

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extreme flexion. In less than twenty minutes he was at my house.
I^o swelling had yet occurred, and the moment I looked at the wrist
I said to him, "You have broken your arm;" so much did it resemble
& fracture of the lower end of the radius. A further examination led
»xie to a diflferent conclusion. The palmar surfe^ce of the wrist pre-
sented an abrupt rising near the radio-carpal articulation, the summit
of which was on the same plane and continuous with the bones of the
forearm, and a corresponding elevation existed upon the dorsal surface
terminating in the carpal bones and hand ; the hand was slightly
inclined backwards, but the fingers were moderately flexed upon the
palm. To this extent the accident bore the features of a fracture of
the radius; but the hand did not fall to the radial side; the projec-
tions upon the palmar and dorsal surfaces were more abrupt than I
lad ever seen in a case of fractifre, and which, if it were a fracture,
would imply that the broken extremities had been driven off from
each other completely ; the most salient angles of these projections
were abrupt, but not sharp or ragged ; the styloid apophyses could be
distinctly felt, and I was not only able to determine that they were
not broken, but, by observing their relations to the palmar and dorsal
eminences, it was easy to see that these latter corresponded to the
situation of the articulation.

In addition to these evidences that I had to deal with a dislocation,
and not a fracture, we had the testimony furnished by the reduction,
which was not made, however, until by every possible means the
diagnosis was definitely settled. Seizing the hand of the gentleman
with my own hand, palm to palm, and making moderate but steady
extension in a straight line, the bones suddenly resumed their places
with the usual sensation or sound accompanying reductions. There
was no grating, or chafing, or crushing, nor was the reduction accom-
plished gradually, but suddenly. To test still further the accuracy
of the diagnosis, I now pressed forcibly upon the wrist from before
back, but without producing any degree of displacement, nor could
any crepitus still be detected. No splint was applied, and on the fol-
lowing morning Mr. Porter preached from one of the pulpits in the
city, only retaining his arm in a sling.

Sixteen months after the accident, Sept. 16, 1858, this gentleman
again called upon me, and I found the arm perfect in all respects,
except that it was not quite as strong as before ; the lower extremity
of the ulna was preternatu rally movable, and occasionally he felt a
sudden slipping in the radio-carpal articulation.

Pathological Anatomy. — In the examples of compound or compli-
cated dislocations, which alone have been exposed by dissections, the
posterior and lateral ligaments have been found extensively torn, as
also frequently the anterior ligament, with or without separation of
the radial or ulnar apophyses ; the extensor muscles torn up from the
lower part of the forearm and displaced ; the first row of the carpal
bones lying underneath the tendons^ and upon the bones of the fore-
arm, sometimes having been carried directly upwards, sometimes up-
wards and a little inwards, and at other times upwards and outwards ;
the arteries and nerves have occasionally escaped serious injury, but
more often they have been displaced^ bruised, or torn asunder.

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Fig. 260.

Dialoeation of the eupal bonei bickwardfl. (From FerfOMon.)

Such are, briefly, the pathological circamatances which may be
supposed to exist, also, in a lesser or greater degree, in nearly ail
cases of simple dislocations.

In compound dislocations, however, the muscles, or rather the ten-
dons, are twisted, torn, and thrust aside, producing very extensive
lesions among the deeper structures of the forearm and hand before
the integuments can be made to yield.

On the 2d of May, 1852, Silas Usher, set. 54, had his right arm
caught between the bumpers of two cars, bruising the hand and dis-
locating the carpal bones backwards, the radius and ulna being thrown
forwards and pushed completely through the skin into the palm of the
hand. Most of the flexor tendons had been merely thrust aside, but
one or two were torn asunder ; the median nerve was torn oS| bat the
radial and ulnar nerves were apparently uninjured, and there was
no fracture. The patient being a temperate man, in perfect health,
and the bones having been easily replaced by moderate extension, it
was determined to make an effort to save the arm. The limb was
therefore laid on a carefully padded splint^ and cool water lotions dili-
gently applied. Phlegmonous erysipelas began to develop itself on
the third day; and on the ninth, gangrene having attacked the limb,
I amputated a little above the middle of the humerus. On the four-
teenth day hemorrhage occurred suddenly from the stump, and when
I reached him he was pulseless and dying.

The result demonstrated the error of the attempt to save the limb
without resection of the lower ends of the bones of the forearm.

Symptoms, — The usual signs have already been sufficiently stated
in the example which we have given. The most important diagnostic

marks are found in the abruptness
* Fig. 261. of the angles formed by the pro-

jecting bones ; the relation of these
prominences to the styloid apopbj-
ses ; in the total absence of crepi-
tus ; and in the reduction, which is
accomplished easily, suddenly, and
with a characteristic sensation. H
Duiocauon of the carpal bonaa backwards, a fracturc compHcates the accident,

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crepitus may also be present. It should be remembered, moreover,
that when the styloid process of the radius is broken, if the hand is
moved backwards and forwards this process will move also, which
might lead to the supposition that the radius was broken higher up,
ana that it was not a aislocation at all.

Prognosis. — In compound dislocations the prognosis is exceedingly
grave, unless the surgeon determines to resort to amputation, or, what
is generally much preferable, to resection. In dislocations complicated
with fracture of the posterior edge of the articulating surface of the
radius ("Barton's fracture"')* some difficulty may be experienced in
retaining the bones in place ; but when this fracture does not exist,
the posterior margin of the articulation, considerably elevated above
its anterior margin, constitutes a sufficient protection against a reluxa-
tion in that direction. In all cases, also complicated with fracture,
even of an apophysis, intense inflammation and swelling are likely to
follow, and the danger of a permanent anchylosis is greatly increased.

Treatment — Extension in a straight line has generally been found
sufficient to accomplish the reduction ; to which may be added a slight
rocking or lateral motion, if necessary.

The reduction may be effected also by pressing the hand backwards,
while the surgeon pushes the carpus downwards from behind and
above, in the direction of the articulation.

Unless a tendency to displacement exists, no splints or bandages
of any kind ought to be applied, but it should be treated by rest and
cool water lotions until all aanger from inflammation has passed.

§ 2. Dislocations of the Carpal Bones Forwards.

The causes, mechanism, symp- Fig. 263.

toms, pathology, treatment, &c.,
of this accident resemble in so
many points those of the pre-
ceding dislocation, with only
the differences necessarily due
to a change in the direction of
the bones, that I find it not worth
while to do more than to relate
one single example contained in
Bransby Cooper's edition of Sir
Astley's work on Fractures and
Dislocations. The case did not
come under the observation of

Mr. Cooper himself, but was re- Dislocation of the carpal bonei forwards.

lated to him by Mr. Haydon, a

surgeon residing in London. It is especially interesting as furnishing
an example of a dislocation of both wrists at the same moment, and
from similar causes, but in opposite directions.
A lad, aged about thirteen years, was thrown violently from a horse

« Philadelphia Medical Examiner, 1888.

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on the 11th of Jane, 1840, striking upon the palms of botb hands
and upon his forehead. The left carpus was found to be dislocated
backwards, the radius lying in front and upon the scaphoides and
trapezium. The right carpus was dislocated forwards, the radius and
ulna projecting posteriorly, and the bones of the carpus forming an
" irregular knotty tumor, terminating abruptly" anteriorly.

A very careful examination was made to determine what parts
came in contact with, the resisting force, but although the palms of
both hands were extensively bruised, there was not the slightest

bruise on the back of either hand.
Fig. 2«8. Nor were the gentlemen present

able to find any evidence what-

/^ ' — '"' ever that the dislocation was ac-

i^L^^^ companied with a fracture. "More-

\w|^I^V ^ over," says Mr. Haydon, " we were

^\5^ ^ " strengthened in our opinion that

DUloeaUon of the carpia boa., forward.. ^hls WaS a CaSC of dislocatlOH, 00-

attended with any fracture, because
the dislocations appeared so perfect ; the two tumors in each member
60 distinct ; the reduction so complete ; the strength of the parts after
reduction so great ; and lastly, by the very trifling pain felt after
reduction, for within an hour after, the patient could rotate the band,
and supinate it when pronated — this could not> we believe, have
been done had there existed a fracture."



In connection with fractures of the lower end of the radius this
accident is not very uncommon. I have myself met with it ander
these circumstances several times ; but without a fracture it is quite
rare. Dupuytren met with but two cases in his long and extensive
practice. Sir Astley Cooper does not record a single instance, and
many surgeons affirm that they have never seen the dislocation in

§ 1. Dislocations ov the Lowsb End of the Ulna Backwards.

To the eleven or twelve examples collected and referred to by
Malgaigne, I am only able to add two cases of ancient luxation seen
by myself.

Causes. — Duges mentions the case of a little girl in whom the acci-
dent occurred in both arms, but at different periods^ by being lift^
by the hands. One of the patients seen by Desault, a child five years
old, had the ulna dislocated backwards by extension accompanied with

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forced pronation, and in another example, cited by him, forced prona-
t;ion alone, as in wringing wet clothes, was foand to have been sufficient.
!ln Hurteaux's case the patient had fallen upon her wrist.

Pathological Anatomy, — Rupture of the synovial membrane (sacci-
ibrm ligament), and also of the ligament which binds the ulna to the
cuneiform bone : the little head or lower extremity of the ulna aban-
doning its socket in the radius, and being thrown backwards, or in
some cases backwards and outwards so as to cross obliquely the lower
end of the radius; or it may incline inwards as well as backwards.

House Surgeon Owen, of Bellevue Hospital, called my attention,
April 4, 1869, to an example of this dislocation in ward 28. The
patient, Mary Fay, aet. 27, having puerperal mania, was confined,
some time in February, in a strait-jacket, and the accident happened
during this confinement, about six weeks before she came under my
notice. I found the right ulna displaced backwards so that its artic-
ular surfaces were completely separated ; but it did not override the
radius, and with moderate pressure it was returned to place. The
dislocation and reduction, which had been frequently made by the
house stafiP since the accident, caused no pain, but was accompanied
with a slight grating sensation.

Dr. Moore, of Bochester, has found this dislocation existing in con-
nection with a Colles fracture. In the chapter on fractures of the
radius I have made especial reference to the views of this distinguished
surgeon upon this subject.

Several examples are mentioned also in which the end of the bone
has been thrust completely through the integuments.

Prognosis. — In recent cases the reduction has generally been accom-
plished without difficulty, and in only three or four instances has the
bone become spontaneously displac^. .

Loder reduced the ulna after eight weeks, and Bognetta after sixty
days. In one of the examples to which I have already referred as
having been seen by myself, the dislocation had existed twenty years,
the accident having occurred in Ireland when the person was fifteen
years old. When I examined the arm, July 21, 1850, the right ulna
projected backwards and a little outwards, about half an inch. He
said he had been lame with it for several years, but the motions of the
wrist-joint were now completely restored, and both pronation and
supination were perfect.

Symptoms. — The hand is usually fixed in a position midway between
supination and pronation. Boyer, however, found the hand in a state
of extreme pronation. The extremity of the ulna is felt and seen
distinctly upon the back of the wrist, prominent and movable ; and
the styloid process is no longer in a line with the metacarpal bone of
the little finger ; the fingers, hand, and forearm are slightly flexed.

Ih-eatment. — The reduction may be accomplished by holding firmly
upon the radius and at the same moment pushing the ulna forcibly
toward its sQcket ; or by simply supinating the hand strongly. Some
cases demand also extension and counter-extension.

Generally the bone has been found to remain in its place without
assistance, yet in three or four of the examples upon record the con-

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stant tendeocj to displacement when the pressure was removed lias
rendered it necessary to employ splints and compresses.

§ 2. Dislocations of the Lower End of the Ulna Forwards.

The dislocation forwards is said by Malgaigne to be more rare tban
the dislocation backwards. In addition to the nine cases collected by
him, I have been able to add one reported by Parker, of LiverpKX)! ;
leaving, therefore, a diflFerence of only three or four in favor of the
lazation backwards ; and not sufficient, I think, to warrant any posi-
tive conclusions as to the relative frequency of the two accidents.

While the dislocation backwards is usually caused by violent pro*
nation of the hand, this dislocation is most often occasioned by violent
supination. The hand is therefore generally found to be snpinated
forcibly, and the projection formed by the end of the bone is seen upon
the front of the wrist instead of the back.

By pushing the ulna toward its socket while an attempt is made to
flex the hand, or by extension, supination, &c., it is made to resume its
position readily. In the case reported by Parker, however, the re-
duction was effected only while the hand was pronated.

Parker's case, already referred to, is thus related : —

"John Dalton, aged forty, applied to the hospital Aug. 9th, 1841,
under the following circumstances : —

" States that he is a carter, and falling down, the shaft of the cart
fell upon his hand and forearm, in such a way as to supinate them
forcibly. He complains of pain in the left wrist. The forearm is
supinated, and cannot be pronated, the attempt causing much suffering.
The wrist-joint can be flexed or extended without much pain. On
looking at the back of the wrist, the appearance is characteristic; the
natural prominence of the ulna is wanting ; an evident depression ex-
ists, as if the lower end of the ulna had been dissected out ; it can be
traced, however, on a plane anterior to the radius, its button-like head
being distinctly felt under the flexor tendons. Several ineffectual and
very painful attempts were made to accomplish the reduction, by

f)ushing the head of the ulna into its natural situation. This was at
ast effected by seizing the hand to make extension (counter-extension
being made at the elbow), then forcibly pronating the hand, at the
same time pressing backwards the dislocated head of the bone with
the fingers of the left hand. After persevering for a short time, the
bone was felt to assume its natural position, the wrist acquired its
usual appearance, and the ordinary movements of the joint could be
readily performed. There was no tendency to redislocation, and the
man was dismissed with directions to keep the bone quiet^ and to
foment it. He attended as an out-patient for two or three days, after
which, complaining of nothing but a little weakness in the part, a
bandage was applied, and ordered to be worn for a short time."*

> Parker, Amer. Joum. Med. 8ci., April, 1848, p. 470; finom Lond. and Edin.
Month. Joum. Med. Sci., Dec. 1842.

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Bound together on all sides by strong ligaments, and enjoying
only a very limited degree of motion among themselves, the carpal
l)ones seldom become displaced except in gunshot wounds, or in con-
nection with extensive lacerations and fractures of the neighboring
parts. Simple dislocations, or rather subluxations of these bones, do,
lowever, occasionally take place, but, so far as we have been able to
ascertain, only in one direction, namely, backwards.

The bones of the carpus, which are said occasionally to have suf-
fered simple backward subluxation, are the semilunar, cuneiform, and
pisiform of the first row, and the magnum of the second row.

Bicherand, the editor of Boyer's Lectures, says that he once met
with a subluxation of the os magnum backwards, of which he has
given us the following account : " Mrs. B., in a labor pain, seized vio-
lently the edge of her mattress, and squeezed it forcibly, turning her
wrist forwards; she instantly heard a slight crack, and felt some pain,
to which her other sufferings did not allow her to attend. Fifteen
days afterwards, happily delivered, and recovered by the care of Pro-
fessor Baudelocque, she showed her left hand to this celebrated ac-
coucheur, and expressed her disquietude about the tumor which
appeared on it, especially when much bent. I was called to visit the
lisidy. I found that this hard circumscribed tumor, which disappeared
almost totally by extending the hand, was formed by the head of the
OS magnum, luxated backwards; I replaced it entirely by extending
the hand, and making gentle pressure on it. As the affection did not
impede the motion of the part, as the tumor disappeared on extend-
ing the hand, and as it would have been but little apparent in any
state of the band had Mrs. B. been more in flesh, I advised her not
to be uneasy about it, and to apply no remedy to it."^

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 71 of 100)