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Southern Medical and Surgical Journal, the Undersigned Is Apprehen- Sive That the Loss of the Judicious and Able Management of His Pre- Decessor May Be Seriously Felt

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Southern Medical and Surgical Journal, the Undersigned Is Apprehen- Sive That the Loss of the Judicious and Able Management of His Pre- Decessor May Be Seriously Felt SOUTHERN MEDICAL AND SURGICAL JOURNAL. EDITED BY L. A. DUGAS, M. D., PROFESSOR OF SURGERY IN THE MEDICAL COLLEGE OF GEORGIA. Medical College of Georgia. "Je prends Ic bien ouje le trouve.^^ VOL. VIL—1851.—NEW SERIES. ^ngnsta, ©a. JAMES McCAFFERTY, PRINTER AND PUBLISHER. 1851. — CA/' ^3 9 SOUTHERN i MEDICAL AND SURGICAL j JOURNAL. j =====_================. ! Vol. 7.] NEW SERIES.—JANUARY, 1851. [No. 1. ! ' 'i PART FIRST. 1 4 ©riginal fflommtTnicattona. ARTICLE I. Remarks upon the Dislocation of the Radius and Ulna hack- . wards at the Elbow—icith Cases. By L. A. Dugas, M. D., Professor of Surgery in the Medical College of Georgia. H The object of this paper is to direct attention to a species of dislocation, which, although not so common as some others, i occurs sufficiently often, and is attended with consequences so serious, when upreduced, as to make its study a matter of .1 great importance to every practitioner, and to the community who rely upon his skill. The cases to be subsequently report- -i ed will demonstrate the correctness of these premises. Errors 1 of diagnosis are, however, not peculiar to our country, for I Listen observes that, "many cases of unreduced luxation are j with ; I it met have seen in both elbows of the same person ; i ' and I have had a dozen of cases, in as many months, of unre- duced elbows shown too late for attempts at reduction. The frequent occurrence of such blunders is the more lamentable, as it is almost impossible to replace the bones after three or four weeks ; indeed I have been foiled at the end of two weeks." (Elem. Surg.) The bones constituting the elbow-joint are held in their nor- mal position by the capsular, the two lateral, the coronary and the oblique ligaments, neither of which, individually, nor all combined, are sufficiently strong to resist the violence to which they are sometimes subjected. On the posterior aspect of the joint we find the great triceps extensor cubiti, inserted into the N. S. VOL. VII. NO. I. 1 ^^ 4i^ Dugas, on Dislocation of the Radius and [January, ^ " ' olecranon process, and the anconeus, into the upper portion of the body of the ulna,— both of which muscles tend to strengthen the capsular ligament by their attachments to it. Anteriorly, the biceps flexor cubiti is implanted into the tuber- cle of the radius, and the brachialis internus into the coronoid process of the ulna and a portion of the bone below this point, being also attached to the capsular ligament. The displace- ment of such extensive articular surfaces, the rupture of the capsular and lateral ligaments, and the strong traction to which the biceps and brachialis internus are subjected, (the latter be- ing sometimes lacerated,) will, especially when viewed in con- nection with the tension of the median nen'e and brachial artery, sufficiently account for the painfulness of the injury and the seriousness of its character. This accident is usually the effect of a fall from horse-back, from a vehicle, or from some other elevated position, during which the hands are thrown forwards for protection, receive the principal force of the shock, and transmit it to the elbow-joint. The bones of the fore-arm, being thus suddenly and violently forced upwards and backwards, rupture their attachments to the humerus and slip up behind the lower end of this bone. The displacement is sometimes effected with such force as to cause the extremity of the humerus to protrude through the soft parts, and thus to constitute a compound dislocation, which is then readily recognized by the exposed bone in the bend of the arm. In simple dislocations, however, tumefaction takes place very soon, and becomes so considerable as not unfre- quently to obscure very materially the means of diagnosis. It " is true that, in the language of Sir Astley Cooper, this dislo- cation is strongly marked by the great change which is pro- duced in the form of the joint, and by its partial loss of motion." But when the case is presented to the surgeon, the form of the joint is often so much changed by the swelling, as to make it difficult to determine how much of the change belongs to this and how much should be attributed to a displacement of the bones. Indeed we find in the valuable work from which we have just quoted,* the narrative of a case under the Editor's * A treatise oa Dislocations and Fractures of the Joints. By Sir Astley Cooper. Edited by Bransby B. Cooper, Philad., 1844. ; 1851.] Ulna backwards at the Elbow, care, in Guy's Hospital, the true nature of which was not de» tected until the third day after its first examination, nor reduced until the fifth or sixth day. The patient was admitted on the 12th January, when *' the tumefaction was so great as to prevent a very minute examination." * * * " Thirty leeches were appli- ed, and afterwards the spirit lotion. The next day the swelling was still very great ; twenty leeches w^ere ordered ; purgative medicine was administered, and the lotion continued. On the next day (Jan. 14th) the swelling was very much reduced, and the nature of the injury became apparent.'' * * * * *' 15th. The sw^elling being much diminished, I made an attempt at reduction, but unsuccessfully, in consequence of the great pain it occasioned. Sir Astley Cooper corroborated my opin- ion as to the nature of the accident. A day or two after, I succeeded in reducing the dislocation." (Op. cit., p. 386.) We doubt not that every surgeon of experience has met wnth cases in which the diagnosis was obscured, as it was in this instance. It is therefore important that we possess ourselves of every means by which the nature of such accidents mav be determined, even when the joint is swollen to the uttermost. Let us then dwell a little upon the symptoms and diagnosis. The first circumstance calculated to awaken suspicion that the case may be one of dislocation backwards of the radius and ulna, is the position in which the limb is- found. The fore-arm is in a state of semi-flexion and the palm of the hand turned up- wards. Pronation is impracticable, save in a very slight degree. Any attempt to extend the fore-arm completely is attended with pain and great traction of the bicipital tendon and if it be attempted to Jlex the fore-arm beyond a right ano^le with the axis of the humerus, pain will also be occasioned and the tension of the triceps be materially increased. The fore- arm may, however, be flexed and extended within the limits just mentioned, without much inconvenience. The wrist may be moved laterally, or carried from side to side, an inch or more beyond the axis of the humerus without much pain. If we now extend the fore-arm as much as may be, and examine the anterior aspect of the joint, a considerable prominence will be found in lieu of the depression which usually exists in the bend of the arm. This resisting tumour terminates abruptly at its Dugas, 071 Dislocation of the Radius and [January, lower margin, is formed by the inferior extremity of the hume- rus resting in front of the radius and ulna, and may generally be easily traced by the fingers to be continuous with the shaft of the humerus. The brachial artery is found in front of the tumor, is unusually superficial and beats with great force. The tendon of the biceps is also very prominent and tense, as well as the belly of this muscle. The lateral surfaces of the joint are much thicker than in the normal state, because of the great increase in the antero-poste- rior diameter. When the fore-arm is semi-flexed, there exists a depression on either side of the olecranon, occasioned by the increased prominence and distance of this process from the humerus. If the joint be examined posteriorly whilst the limb is extend- ed as much as possible, and a line be drawm across it from one condyle to the other, the olecranon will be found considerably above this line. In the adult, it ascends from an inch to an inch and a half beyond its usual position. In females and younger subjects, this displacement will be less marked. In the normal state, the external condyle is said to be on a level with the upper end of the olecranon, and the internal condyle a little above it. The head of the radius may also be felt (if the tume- faction be not very great) on the external side of, and a little below the point of the olecranon, and its identity as well as the integrity of the bone determined by attempting to rotate the wrist w^ith one hand, whilst a finger of the other is pressed upon the bead of the radius. If the radius be unbroken, its head will be found to follow the movements of the wrist. The diagnosis will be materially facilitated by comparing the tw^o arms placed in the same position, and by measuring in each the distance from the lower end oftheulnato the internal condyle, or to the point of the acromion process. The dislo- cated limb will be the shorter of the two. Some of the symptoms just enumerated may be presented in other injuries of the joint or of its adjacent structures. The dislocation of the ulna and radius may be lateral and backward, in which case the coronoid process of the ulna will be found resting upon the posterior surface of the external or internal condyle, instead of lodging in the fossa of the humerus, as it 1851.] Vina backwards at the Elbow.
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