Part 13

57. To the bandage which we have just described, Desault added formerly a strip of linen, to be placed all along the posterior part of the arm, secured first at its upper end by circular casts, which began above; this strip was secured afterwards by oblique casts, as far as to the place where it met the olecranon, separated from the ulna. Here, the surgeon quitting the roller, took hold of the bit of linen, and drew it downwards, and along with it the circular casts of the roller, together with the muscles on which these casts were applied, and also the fragment which the muscles drew upwards. An assistant then secured it here, while the surgeon, after having made some casts in form of the figure of 8, descended to the inferior part of the fore-arm, where the end of the strip was made fast by tight circular turns. (See fracture of the rotula.)

58. The intention of this additional piece of apparatus, was to draw down the superior fragment, to prevent the circular casts of the roller from separating by their relaxation, and, by that means, to retain the fragments in apposition. But, on the one hand, may not the superior fragment be drawn by the hand, as well as by a roller employed for the purpose? And, on the other, if the circular casts of the roller be liable to become relaxed, why not the strip of linen also? These considerations induced Desault to lay it aside, and use the bandage in the form just described.

59. The advantages it offers are far from being equivocal. 1st, The limb is kept in a state of invariable extension by the anterior splint, and, on this account, there can be no displacement on the part of the inferior fragment. 2dly, The bandage, which accurately envelopes the whole limb, restrains the action of the muscles by compressing them, and prevents in part the contractions of the triceps; while the casts in the form of the figure of 8, applied with skill and precision, hold down the superior fragment, and render it difficult for it to be displaced. 3dly, Without the application of a roller over the whole limb, a swelling, more or less considerable, would probably be the effect of the constriction at the elbow, which must necessarily be somewhat tight, because, as the turns of the roller, in form of the figure of 8, act on the olecranon obliquely, if they be too loose, they will slip and not perform the office of retention.

60. Like all kinds of apparatus composed of rollers, this ought to be frequently examined, lest, by becoming relaxed, it should not make sufficient resistance to the triceps, which is always disposed to draw itself upwards. There can be no period fixed on for the reapplication of the apparatus; the moment it begins to become slack, it ought to be renewed: three or four times during the course of the treatment are generally sufficient. Should a considerable swelling give reason to suspect that the constriction is too great, it will be necessary to remove the bandage in order to apply it anew.

61. The period necessary for the reunion of fractures of the olecranon varies, according as the bandage is more or less exactly kept in its place. Among ten cases of this kind, collected in the Hotel-Dieu, four united in twenty-four days, three in twenty-eight, and three in thirty-two. Hence, taking the mean term, all other circumstances being alike, the process of cure requires about twenty-six days.

62. When this is completed, it is necessary to impress on the limb motions of flexion and extension, gradually increased every day. This is, as David properly observes, the most certain method of avoiding a stiffness, and even an anchylosis, too often the consequence of this fracture.

63. But that illustrious practitioner, in recommending this salutary remedy, has erred with regard to the mode in which it operates. To consume, by degrees, a superabundant callus in the interior of the articulation, and thus reduce it to a level with the articulating surfaces, is not, as he conceives, the effect which these motions produce. This opinion, founded on the ancient doctrine of an osseous juice, is refuted by the dissection of many bodies of patients that died during the treatment, and in which Desault discovered no trace, either of an effusion of osseous juice, during the reunion, or of its superabundance after this reunion had been completed.

The exercise communicated to the limb, appears to act principally by removing the congestion of the tendons and membranes surrounding the joint, which, being at first irritated by the fracture, are thrown into a state of _engorgement_; and further by dissipating a kind of numbness which affects the muscles after they have remained too long in a state of rest.

64. But whatever may be its mode of action, it ought to be gradually increased, according to the state of the parts, and continued for at least twenty days, a period sufficiently long to restore to the limb, in general, its natural motions.

65. It is seldom that after this methodical treatment, the patient is exposed to an anchylosis, a thing inevitable in such cases, according to most authors, A celebrated surgeon, believing the long continued extension of the fore-arm to be the cause of this accident, has advised here to abandon every kind of bandage, and to commit the cure entirely to nature. But this doctrine, contrary to the general principles of the reunion of divided parts, has not in its favour the result of experience, which proves that, under such neglect, the stiffness in the parts near to the joint is always as great as in other cases, that the reunion is more tedious and more deformed, and that sometimes it cannot be accomplished at all. The analogy of the inconveniences and disadvantages attributed to the method of Foubert, in fractures of the neck of the os femoris, constitutes another argument against this method, which is now almost entirely abandoned.

66. To the cases already published, proving the success of that which we have proposed, let us add one more, reported by Maublanc.

CASE IV. Silvan de la Noue, aged thirty, fell on his elbow, having his fore-arm bent, while the shoulder of the same side supported a heavy load. Acute pains at the instant of the fall; a sudden inability to extend the fore-arm; a considerable swelling appears almost immediately, around the joint; and a superficial echymosis at the hind part.

During the night the pains were augmented, the swelling increased, and, on the day following, February 9th, 1791, the patient was received into the Hotel-Dieu.

From the presence of the signs formerly mentioned (43), Desault recognized the fracture, and applied the apparatus (56), notwithstanding the swelling and echymosis, persuaded that the compression made by this apparatus on the tumefied parts, was the most effectual mode to remove the enlargement.

Next day, pains almost gone; swelling diminished; on the fifth day, the bandage become loose, by the almost entire disappearance of the swelling; a new application of it; the joint wet frequently with vegeto-mineral water.

Seventh day, usual regimen allowed; ninth day, a slightly bilious disposition; evacuants somewhat active administered, to remove it.

Thirteenth day, a third application of the apparatus; echymosis entirely gone.

Thirtieth day, the consolidation complete; the apparatus laid aside; from this time motions gradually impressed on the limb.

Fifty-eighth day, the patient discharged, free in all his motions, except a little stiffness, which exercise will soon remove. Since that time, it has been understood that the limb had completely recovered its natural functions.

MEMOIR IX.

ON THE LUXATION OF THE FORE-ARM.

§ I.

1. The solidity and security of joints are increased in proportion as the extent of their motions is diminished. This inverse proportion of these two properties to each other, is in a particular manner remarkable in the upper extremities, where the connexion of the humerus with the scapula, of the fore-arm with the humerus, and of the bones of the wrist among themselves, appear, in regular gradation, to acquire the one as they lose the other: hence, their predisposition to luxations is extremely different. We will examine those to which the fore-arm is subject.

2. An angular ginglymus unites to the humerus the bones of the fore-arm, which are again connected with each other by a double lateral ginglymus. Eminences and depressions, reciprocally receiving and received, constitute the first kind of articulation, where, proceeding from without inwardly, we find, 1st, the small head of the humerus, entering or rather joining the upper articular cavity of the radius, which moves on it: 2dly, the external groove of the humerus, receiving the rim of the same cavity of the radius: 3dly, a projection which, rising from the external edge of the coronoide[19] cavity, extends to the corresponding edge of that of the olecranon, and is received into the external depression of the sigmoid cavity:[20] 4thly, the large groove of the humerus, receiving the middle eminence of this same cavity: 5thly, a considerable projection, obliquely applied to the internal depression which receives it.

[19] Not generally named in English works of anatomy.

[20] _Echancrure sigmoide._

3. These numerous connexions secure the solidity of the joint, which is still farther strengthened before by the coronoid apophysis, together with the fleshy and tendinous extremities of the biceps, and brachialis muscles, and by the olecranon behind; at the inferior part, by the anconeus; on the sides by two ligaments which descend from the two tuberosities, and strong muscular fasciæ running from the same parts. The whole articulation is also surrounded by a thick capsule, strengthened by numerous accessory fibres. With such powers of resistance, how can this joint suffer a luxation? Yet next to that of the os humeri, it is perhaps most frequently subject to this accident.

§ II.

OF THE KINDS AND CAUSES OF DISPLACEMENT.

4. Writers have admitted in general four kinds of displacement; backward, forward, outward, and inward. But all these are not alike frequent, as is proved by experience, and demonstrated by the relative situation of the parts.

5. In a backward direction the olecranon and the radius may pass up behind the humerus, as the coronoid apophysis offers but little resistance in consequence of its slight curvature. On the other hand, the kind of hook formed by the olecranon, prevents it and the radius from passing before the lower articulating extremity of the humerus, and therefore, without a fracture of the olecranon, a luxation in that direction is impracticable: at the sides, the two lateral ligaments, but more particularly the reciprocal joining or interlocking of the uneven articulating surfaces, present almost insurmountable obstacles to luxations laterally. Whence it follows, that luxation backward is much more frequent than the others; compared to lateral luxations, it is, at least, in the proportion of ten to one: with luxations forward, no comparison can be made; neither Petit nor Desault having ever met with such.

6. An external force produces the whole of these luxations, but according to each, this force must vary. In a fall sideways, suppose the hand be applied to the ground, with the arm extended, to save the body. It is evident that the resistance of the ground will tend to make the bones of the fore-arm pass upwards over the humerus, while the weight of the body pushing that bone downward and forward, will make it glide over the coronoid apophysis. Thus, the capsule, being distended before by the humerus, and behind by the bones of the fore-arm, will give way in one or the other place, or in both, as Desault observed in a man, who fell on his side, as he was carrying a heavy load: the weight of the body increased by the load, had such an effect, that the bones overlapped each other nearly two inches.

7. It appears from this, that a state of extension is the position most favourable to a displacement backwards; a doctrine by no means conformable to that of most practitioners, who consider a state of flexion as necessary to the accident. But, then, in what direction should the fall take place, in order that the olecranon may pass upwards? Applied as it is against the side of the cavity that receives it when the arm is extended, would not this apophysis prevent such passage? Whatever may be the mode of displacement, the olecranon, in passing upward and backward, may incline a little to the one or the other side.

8. I have already said, that without a fracture of the olecranon, no luxation forward can occur (5). But what cause can act with sufficient power on the parts to produce both accidents at the same time? It would be necessary that a fall which had produced a fracture should be succeeded by another fall; but in such a case, the fore-arm would be half-bent, and it is in a state of extension alone (7) that the luxation can take place.

9. Lateral luxations, that is, luxations at the sides have been divided into complete, when the two articular ranges of the arm and fore-arm, have lost their connexion entirely, and incomplete, when only one bone or one part of a bone has been separated from its natural connexion with the humerus. But what cause can act with sufficient force to produce the first kind of luxation, namely, that which is complete? In such an accident so great would be the extent of the wreck and ruin of the part, that without doubt amputation would be the only resource.

10. The second kind of lateral displacement is the result of a stroke which forces violently the extremity of the fore-arm outward or inward. A footman, says Petit, in falling from a carriage, had his arm entangled between the spokes of the wheel, and suffered in consequence a luxation outwards. Another produced one inwardly, by being thrown from his horse, and falling with his arm under him, on rough ground. Strokes of this kind may, as that author remarks, vary in a singular manner. But, in general, in all of them, the fore-arm must represent a lever of the first kind, where the power acts on the end next the hand; the resistance being in the joint, and the fulcrum in the middle.

§ III.

OF THE SIGNS.

11. To form an idea of the signs or appearances of a luxation backwards, let us examine, for a moment, the natural situation of the olecranon, and the condyls of the humerus. As these eminences are easily felt under the skin, a knowledge and recollection of their situation will serve as a standard of comparison, to judge of the changes they experience in a luxation. When the fore-arm is extended, the olecranon is on a level with the internal condyl, and a little above the external one. In a state of flexion, it descends below this level, and is then farther below the internal than the external condyl. In either situation, it is nearer to the first than to the second, the radius separating it from the latter.

12. But, when a luxation has taken place, this apophysis, still remaining on a level with the two condyls, even although the fore-arm be half-bent, is oftentimes separated from the internal one, and driven towards the other: a preternatural protuberance announces this change of position of the olecranon. The coronoid apophysis, whose posterior surface glides in the large groove of the humerus, corresponds to this groove now only with its anterior surface: sometimes the olecranon cavity[21] receives its extremity. The radius passes backward over the small head of the humerus. At the fold of the arm, a transverse protuberance, more perceptible on the internal side, announces the presence of the displaced articular extremity of the os humeri. Over this extremity are reflected the biceps and the brachialis muscles in a state of violent distension. These muscles, greatly irritated by such distension, continue in a state of habitual contraction, in consequence of which, they keep the fore-arm half-bent. Nor can the anconeus muscle, which is necessarily relaxed, act so as to prevent this semiflection. Severe pains would be the consequence of attempts to extend the fore-arm; the limb is in a state of pronation; yet I find among the cases collected by Desault, several examples where supination existed; this state is explained by the relaxed condition of the pronator muscles. At the level of or opposite to the coronoid cavity is a depression or hollow manifesting the absence of the apophysis of that name.

[21] That deep depression in the os humeri, which, in a natural state of the parts, receives the upper end of the olecranon process. TRANS.

13. Should chance give rise to a luxation forward, an anterior projection of the two bones of the forearm, and above all, of the coronoid eminence, a depression corresponding to the olecranon cavity, the extremity of the humerus carried backward and downward, the rigid extension of the fore-arm, a protuberance behind formed by the fractured olecranon (5), and severe pains, necessarily resulting from attempts to bend the limb, &c. would constitute the principal characteristic signs of the displacement.

14. In lateral luxations, a protuberance at the internal or external side of the articulation, always shows of what kind it is. If the displacement be to the internal side, the olecranon is then situated behind the small tuberosity: the middle protuberance of the os humeri bears on the radius, which is sometimes placed even behind the internal articular eminence of that bone, which then rests on the external depression of the great sigmoid cavity. Hence, as Petit judiciously observes, arises the direction of the fore-arm outward, the above eminence presenting a manifest obliquity in that direction. In this luxation, the ulna has been known to lose entirely its connexion with the humerus, and the radius to be brought into contact with the internal condyl of that bone. This is what some authors call a complete luxation. Others reserve that name for cases where, the two articular ranges have lost their correspondence or apposition entirely.

15. In a luxation outwards, the olecranon corresponds to the external condyl; the middle projection of the humerus, to the internal depression of the great sigmoid cavity; the small head of this bone, to the external depression; the radius projects outwards; and the humerus makes a protuberance inwardly.

16. After all, these changes of situation vary remarkably, and it belongs to theory rather than practice, to trace their history, with precision. In general, luxations outwardly happen more frequently than those inwardly, a circumstance which is fully explained by the structure of the joint. In both, the lateral ligaments are almost always lacerated.

A swelling more or less considerable accompanies all the different kinds of luxation, and is sometimes carried so far as to involve the diagnosis in great uncertainty, particularly when the displacement is not very great. This phenomenon (the swelling), seems, in general, to correspond, in a direct ratio, to the force with which the articulation resists. Indeed the violence, and consequently the irritation, are always in proportion to the resistance of the parts.

§ IV.

OF THE REDUCTION.

17. The means of reduction vary according to the different kinds of displacement. They are all, however, founded on nearly the same principles, and it will be easy to form proper ideas of them, when we shall have given an account of the means necessary to be employed in luxations backward, of which the others are only modifications.

Here genius seems to have been as prodigal of resources, as nature has been of obstacles. Indeed, to accomplish the reduction, we sometimes see the surgeon placing his elbow in the fold of the affected arm, interlocking his fingers with those of the same limb, and, then, bending with his whole force, both his own fore-arm, and that of the patient, to effect at the same time extension, counter-extension, and reduction or conformation: at another time we see him fixing the fold of the injured arm against some resisting body, such as a bed-post; and while an assistant, then, pushes the displaced olecranon against this body, he himself, pressing on the shoulder with one hand, and grasping the fore-arm with the other, bends it forcibly, in order, by that means, to produce a replacement: again, a body of some size, being placed in the fold of the arm, serves as a fulcrum, on which the fore-arm, being suddenly flexed, moves and acts like a lever of the first kind, of which the power, being applied at the extremity next the hand, draws it backward and upward, and by that means pushes in a contrary direction its luxated end, where the resistance is made. On some occasions, the fore-arm of the diseased side, bent at a right angle, is placed on a horizontal table, and, while the lower extremity of the humerus is thus resting on the table, the surgeon pushes it backward with one hand, and with the other, taking hold of the extremity of the fore-arm, draws it in a contrary direction.

18. The ancients employed the three first modes. Pare has had engravings of them made: Scultel has also given figures of them as practised by Hippocrates. The Arabians knew of no other modes, nor did their descendants, who were only compilers from them. The practitioners of our own day still continue their use. But, in general, they are chargeable with the numerous inconveniences and faults of producing intense pain, of not being completely under the direction of the surgeon, of bringing the point of luxation too near to the place on which counter-extension is made, and of bruising and doing violence to the parts: nor do they disengage, by means of previous extension, the luxated ends of the bones, to facilitate their replacement in their natural situations.

This last charge is not applicable to the last of the processes proposed by Petit. But, here, the extending forces are most commonly insufficient; the surgeon, having both his hands engaged, is not able to act on the joint to assist in the replacement: and the counter-extension made is too near to the point of luxation.

19. In common cases, Desault employed a method as simple and more efficacious, which few writers have recommended, and none have described with accuracy.

The patient is, indifferently, either seated or standing. The fore-arm being half-bent, an assistant takes hold of the extremity next the hand, to make extension; another, to make counter-extension, takes hold of the humerus a little below its middle, with both hands, the fingers crossing before, and the thumbs behind. The extension is made gradually, and when it begins to move the olecranon, and draw it from the place it accidentally occupies, the surgeon, to aid in the reduction, grasps the lower end of the humerus with both hands, crosses his fingers in the fold of the arm, applies his thumbs to the olecranon, and drawing the first backward, pushes at the same time the latter forward; thus, he favours, on the one hand extension, and on the other counter-extension, and in that way finishes the reduction.

20. This method is most commonly practised with success, in recent luxations, where we have oftentimes seen the reduction effected at the Hotel-Dieu, by the simple process of pushing, as just mentioned, the olecranon forward, the humerus being held backward, without any previous extension, while the fore-arm was merely supported by the assistants.