Denucé's case (Fig. 82) the olecranon projected nearly an inch behind the humerus, the arm could be fully extended and flexed nearly to a right angle. In Nélaton's case there was flexion nearly at a right angle. It is also noteworthy that in no case were there symptoms of interference with the circulation, and in only one case (Mears) were there symptoms of injury to the nerves. In his there was pain in the fingers and numbness in the distribution of the median nerve. Treatment. Reduction has been effected without difficulty in all the recent cases by extension and direct manipulation of the upper ends of the radius and ulna. The laceration of the ligaments and muscles is so great that the bones are freely movable, and special manoeuvres intended to relax opposing bands are seldom necessary. Exceptions to this may be found sometimes in the first and second varieties; in the first the head of the radius may pass through and be caught, as apparently happened in Puech's case, between two muscular bundles which may then need to be relaxed by flexing and abducting the forearm; in the second, which appears sometimes, as has been said, to differ from the incomplete outward dislocations only in the addition of pronation of the forearm, the external lateral ligament remaining untorn, the first movement must be to supinate the limb and thus turn the sigmoid cavity under the capitellum and bring the head of the radius to the outer side; the dislocation is then an incomplete outward one, and is reduced accordingly. The only reported case in which the attempt to reduce has been followed by grave consequences is that of Michaux,' quoted in Chapter VIII. p. 80, and generally called a dislocation backward and outward. The reason for thinking that it may have been primarily a dislocation outward is that after amputation the tendons of the biceps and brachialis anticus. were found behind the external condyle, and also that during the efforts to make reduction the ulna and radius always moved toward the outer side. The second attempt to reduce was followed by arrest of pulsation in the radial and ulnar arteries and gangrene of the limb. The brachial artery and median nerve had been ruptured and lay behind the external condyle. The patient was ten years old. DISLOCATIONS OF THE FOREARM FORWARD. Although mentioned by Hippocrates and characterized by him as the most painful of all and fatal in a few days, and admitted by all subsequent writers, the first recorded case (and that a questionable one) of this dislocation was published only a hundred years ago, and the number has now barely reached 20.2 1 Reported by Debruyn, Annales de la Chir. Franç. et Etrangère, 1843, vol. 9, p. 66. 2 The bibliography is as follows: Evers, Monin, Guyot, Wittlinger, quoted by Streubel in Prager Vierteljahrschrift, 1850, 2, p. 37, and by Malgaigne, loc. cit., p. 626; Guerre, quoted by Pingaud in Dict. Encyclopédique, 1st. ser. vol. 21, p. 708; Chapel, quoted by Malgaigne, loc. cit., p. 617, as a dislocation outward; Colson, Leva, quoted by Debruyn in Annales de la Chirurgie Française et Etrangère, 1843, vol. 9, p. 44 and 45, and by Streubel; Richet, Archives générales, 1839, vol. 6, p. 472; Prior, Lancet, 1844, ii. p. 366; Ancelon, L'Union Médicale, 1859, vol. 3, p. 394; Canton, Dublin Medical Journal, 1860, ii. p. 24; Secrestan, Gazette des Of the 11 cases in which the age is mentioned, 1 was 6 years old, 2 were 8, 1 was 14, 2 were 15, and 1 each 18, 20, 34, 38, and 40 years old; another was an "adult." The cause in the greater number of cases appears to have been a fall upon the flexed elbow; in one (Prior) it was a blow by the handle of a crane upon the back of the elbow; in one certainly (Date), and probably in others, it was a fall upon the palm of the hand; in one (Caussin) the patient's hand was caught between two cogwheels and both bones of the forearm were broken at the middle as well as dislocated; and in one (Morel-Lavallée) the patient fell from a wagon and was run over, the wheel passing across the elbow and breaking the olecranon and coronoid process. In 6 of the cases the olecranon was broken, and in these the mechanism of the dislocation is easily understood, for, the resistance of the olecranon being removed, the two bones can be easily displaced forward and upward along the front of the humerus by a force acting upon the back of the forearm. In the case of a fall or of a blow upon the flexed elbow the direction of the force is probably inclined somewhat away from the axis of the forearm and is more nearly parallel with the posterior portion of the articular surface of the olecranon, and it must be great enough to rupture the lateral ligaments without the aid of leverage, unless the flexion of the elbow is at the same time carried so far that the tip of the coronoid process and the anterior edge of the head of the radius are brought into contact with the anterior surface of the humerus above the joint, and a fulcrum thus created by the aid of which the ligaments may be ruptured. All attempts to reproduce the dislocation upon the cadaver by this mechanism, forced flexion and direct impulsion, have failed, except after preliminary division of the lateral ligaments. The small size of the projecting part of the olecranon and its cartilaginous character in children favor displacement by this mechanism. In the case of a fall upon the hand there is clinical evidence to show that this form is closely allied to the lateral dislocations, and that it is produced by lateral outward flexion supplemented by sufficient torsion (supination) of the limb to bring the olecranon forward under the trochlea; in several of the cases the displacement was outward as well as forward; in Chapel's so far outward that the case has been classed with the lateral dislocations. It has also been claimed that the dislocation may be produced by exaggerated hyperextension, bringing the upper surface of the olecranon down along the back and under surface of the trochlea, but Guérin's experiments failed to confirm this, even when the dorsal flexion was Hôpitaux, 1860, p. 598; Caussin, L'Union Médicale, 1861, vol. 11, p. 475, and Bulletins de la Société de Chirrgie, 1861, vol. 2, p. 451; Richet, Bull. de la. Soc. de Chirurgie, 1859, vol. 9, p. 110; Morel-Lavallée, Idem, p. 107; Greenaway, quoted by Hutchinson, Med. Times and Gazette, 1866, i. p. 409; Langmore, Lancet, Abstract in New York Medical Record, 1867, vol. 2, p. 10; Rigaud, Bulletins de la Société Anatomique, 1870, p. 15; Date, Lancet, 1872, ii. p. 597; Mons, Deutsche Mil. Zeitschrift, 1877, p. 401; quoted by Poinsot, loc. cit., p. 951; Krönlein, Deutsche Chirurgie, Lief. 26, p. 30 References have also been made to a case by Ferguson, Surgery, 3d. ed. p. 241, one by Roser, Chirur. Anat., 1844, p. 477, and one by Flaubert. carried so far that the whole length of the forearm rested against the back of the arm; he found the posterior portion of the lateral ligament remained untorn and effectually opposed the displacement forward. 66 Pathology. One autopsy (Richet), three amputations (Canton, MorelLavallée, Rigaud), two compound fractures of the olecranon without amputation (Richet, Guerre), one compound dislocation without fracture (Prior), and experiments upon the cadaver show how great the laceration sometimes is. In Prior's case, in which the patient was struck upon the "under side of the left arm at the elbow-joint" by the rapidly revolving handle of a crane, there was a large wound at the point where the blow was received, " occasioning a general disconnexion of its parts, muscular and otherwise, excepting immediately in front." The radius and ulna were driven upward and forward on the humerus; the condyles of the latter and its shaft for two and a half or three inches projected through the wound nearly at right angles with the forearm, as completely stripped as if cleaned with a knife. There was no fracture. Reduction was made; the patient recovered after much suppuration in and around the joint, and the final result was good, "the limb gaining in freedom and power." In Canton's case, the patient, a man forty years old, was thrown from a wagon; apparently he struck upon the extended hand, but the forearm was immediately flexed and twisted under his chest. The forearm was flexed, the hand supinated, the swelling very great, and the skin tense and threatening to slough over the internal condyle. The antero-posterior FIG. 84. Forward dislocation of the elbow ; and lateral diameters of the joint were increased, and the head of the radius could be indistinctly felt externally and anteriorly. The diagnosis was not made, and "attempts to correct the maladjustment" failed; after a delay of forty-eight hours, during which the swelling increased and sloughing was established, amputation well above the condyles was resorted to. Examination of the limb showed (Fig. 84) that the upper surface of the olecranon rested against the front of the capitellum; the annular and interosseous ligaments were whole, the anterior ligament was ruptured except in its centre, the posterior and both lateral ligaments ruptured. The triceps was completely detached from the olecranon. The two radial extensor muscles and all the muscles arising from the epicondyle except the supinator brevis and the anconeus were detached, as was also the epitrochlear head of the flexor carpi ulnaris. The ulnar nerve was torn behind the condyle. The other large nerves and the main vessels were uninjured. Morel-Lavallée's patient was a man thirty-eight years old who had fallen from and been run over by a wagon, the wheel passing across the front of the elbow from the outer to the inner side. There was a compound fracture of the olecranon, and the skin was broken on each side of the joint. There was great swelling; passive movements were very free. The olecranon remained in place; the radius and ulna were displaced forward and outward. Amputation was done on the fourteenth day. The coronoid process was found to have been broken off parallel to the anterior surface of the ulna and turned outward; it remained attached to the ulna by the soft parts. The truncated end of the ulna rested against the capitellum. Richet's first patient was eighteen years old and had fallen from a height of forty-five feet. The forearm was slightly flexed and in supination, and was immovable; it was shortened an inch, measuring from the epicondyles to the lower ends of the radius and ulna. The olecranon was in place and movable; two inches below it was a large wound through which the lower end of this fragment projected. The head of the radius and the broken end of the ulna were recognizable in the fold of the elbow a fingerbreadth above the condyles. Reduction was easy by traction, but recurrence at once followed. The patient died three hours later. The autopsy showed the annular ligament to be intact. In addition to these two varieties, dislocation with and without fracture of the olecranon, the difference between which is so important, there is another, based upon clinical and experimental evidence to which the name incomplete is given; in it the upper end of the olecranon rests against the under and anterior surface of the humerus instead of passing upward in front of it. So far as can be inferred from the reported cases it is the most common form. The use of the terms first and second degree, to distinguish between the two forms, is, I think, to be preferred to that of incomplete and complete. In Chapel's case the additional outward dislocation, which is noted in several of the others, was so great that Malgaigne classes it with the outward dislocations. The patient was a boy fourteen years old. The radius formed a marked prominence under the skin on the outer side; on its inner side could be felt the olecranon and its sigmoid cavity, with the coronoid process in front. The two bones overrode the humerus in front about two centimetres; the epicondyle lay behind the ulna. Mons's case seems to me to be of the same kind. It is quoted by Poinsot as a unique example of divergent dislocation, ulna forward and radius outward. The description is limited to this statement and does not definitely exclude the possibility that the ulna may have been displaced outward as well as forward. This supposition seems justified by the fact that the injury was caused by direct violence upon the completely flexed elbow. Fracture of the epitrochlea has been observed in one case, Date's, a boy fourteen years old, and this is the one in which the evidence that the dislocation was produced by external lateral flexion in a fall upon the hand is most complete. The head of the radius was prominent outside of and below the outer condyle; above it was a deep depression in which the condyle could be obscurely felt; the olecranon was below its usual position, resting with its extreme end against the trochlea (first degree, or incomplete.) The limb was semi-flexed. Reduction was easy under chloroform; the radius first, and then the ulna, going back into place with a distinct snap. If this account of the positions of the two bones is accurate the annular ligament was probably torn. Symptoms. In five of the cases uncomplicated by fracture it is stated that the forearm was lengthened, more than an inch in one of them, and with this coincided a position of the limb which is mentioned in several others, namely slight or partial flexion, which could generally be changed somewhat in either direction. In one in which the range of motion is specified, Longmore, the limb was held at an angle of 130°, could be flexed to a right angle, and extended to 160°; in another, Colson, hyperextension could be made without causing pain, and during the movement the olecranon passed forward between the biceps and pronator teres. In correspondence with this lengthening there is flattening of each side and of the back of the elbow, unless the swelling is sufficient to mask it, with prominence of the inner and sometimes of the outer condyle, and the formation of a transverse sulcus appreciable by the touch behind between the humerus and the olecranon. In one case the forearm was also abducted. In Canton's case the forearm was flexed beyond a right angle; the olecranon rested against the capitellum, and the triceps was torn completely from it. It seems probable that detachment or rupture of the triceps is a necessary condition of the passage of the olecranon to any distance along the front of the humerus, and that the existence or absence of the detachment may constitute the essential difference between the complete and incomplete forms, or the first and second degrees. The clinical features which differentiate the two forms are that in the lesser form the olecranon is prominent below the humerus when the elbow is flexed, and the forearm is lengthened when it is extended or but slightly flexed. In the second, "complete" form, the forearm is more or less shortened when extended, but is lengthened when flexed at or near a right angle, and its antero-posterior diameter is increased because of the projection of the coronoid process in the fold of the elbow. The biceps tendon can be recognized on the outer side of the latter, and beyond it the head of the radius. Posteriorly, in both forms, the olecranon fossa is empty; the direction of the ulna also plainly indicates the change in the position of its upper end unless the swelling is great. Course and Prognosis. In only one case, Canton, did the dislocation. remain unreduced, and, as in this the diagnosis was not made because of the swelling, there is no reason to suppose that a suitable attempt to reduce would have been less successful than it proved in the others. It was also the only case, of those uncomplicated by a compound fracture of the olecranon, that did badly and in which amputation was thought to be necessary. The history of the case, moreover, suggests that the decision was reached rather hastily and on grounds that might be deemed insufficient. With this exception, there is nothing to show that an uncomplicated dislocation of this kind is more likely to be followed by grave consequences than one of another form in which the displacement is marked and the laceration notable. Of the 7 compound dislocations, of which 6 were complicated by fracture of the olecranon, 3 recovered, 2 underwent amputation after the joint had suppurated, 1 died three hours after the accident, which was a |