SECT. CXV.—ON THE ELBOW.
Inasmuch as the elbow-joint is more complicated than that of the shoulder, so, in like manner, are its dislocations more difficult to manage; for they are less readily occasioned, and more difficultly reduced, owing to the number of its processes and cavities. Sometimes it undergoes sub-luxation only, but often it is completely dislocated in every direction, and more especially forwards and backwards. It is easily recognised even by the sight, and the dislocated bone may be felt in the place to which it has been removed, while a hollow appears in the place whence it was moved. A comparison with the sound arm particularly discloses the nature of the accident. Reduction then must be made immediately before inflammation comes on, for, if this has supervened, it is difficult to cure, and some such cases become utterly irremediable, more especially if the dislocation was backwards; for of all the dislocations at the elbow-joint, that backwards is the most painful and dangerous. Small displacements then may be restored by a moderate degree of extension, the assistants keeping the hand extended, pulling, and making counter-extension at the fore-arm and arm, while the surgeon with the palm of his hand pushes the dislocated bone into its natural place. Hippocrates rectifies the dislocation forwards by bending the hand suddenly so as to force the palm straight to the shoulder of the same side; and that backwards again by frequent and strong extension; inasmuch as dislocations forwards are produced by violent extension, and those backwards by violent flexion. If the dislocation has continued long unreduced, we must have recourse to stronger extension, such in particular as that described by Hippocrates for a fractured arm, where he has recourse to the piece of wood adapted to a spade. Some of the moderns manage the matter thus: Two assistants stretching the arm as aforesaid, the one holding at the armpit, and the other below at the wrist, the surgeon, standing opposite the patient, grasps the arm with the palms of both his hands near the joint, and giving orders to bind a long folded robe or broad swathe round his hands and the arm of the patient, and to pull outwards and downwards towards the hand, whilst he, following the same course, drags the parts with his hands thus secured until they pass the articulation of the joint. The arm should be first anointed with oil, to render the part slippery and easily moved with the palms of the surgeon’s hands. Thus the dislocated parts being violently pulled by the hands of the assistants will return to their proper place. After the reduction the arm is to be bent to an angular position, and treated with oblong compresses and suitable bandages.
Commentary. No author, ancient nor modern, has given so complete a view of the accidents to which the elbow-joint is subject as Hippocrates. In his works (De Fracturis, De Articulis, and Mochlicus,) he has treated of this subject with surprising accuracy and skill. He describes the following injuries of the elbow-joint: 1st. Complete luxations, laterally, anteriorly, and posteriorly. 2d. Luxations of the radius, anteriorly, posteriorly, and laterally. 3d. Fracture of the olecranon. 4th. Fracture of the apophysis of the humerus. We must give his description of the last-mentioned injury in his own words: “It sometimes happens that the head of the humerus is broken at its apophysis; and this, although it appear a more serious accident, is, in fact, less so than many other injuries of the joint.” It is singular that this distinct account of a very common injury of the joint should have been overlooked or misunderstood by all his commentators and the surgical authorities down to the present day. We have often met with it in our own practice, and seen many instances in which it had been misapprehended in the practice of other surgeons. It is only within the last five or six years that it has been described in any modern work on surgery. Lateral luxation of the radius is described by him under the name of diastasis. (De Fracturis, 44; De Articulis, 20.) The Commentaries of Apollonius Citiensis and Galen are worth consulting although they contain no new matter. Galen remarks that in dislocations of the radius, the power of flexion and extension is often not much impaired; and this, we may add, is confirmed by modern observation. Galen’s account of fractures of the olecranon is remarkable for its precision and accuracy. (Chirurg. Vet. 84.)
Celsus describes four different kinds of dislocation at the elbow, namely, forwards, backwards, and to either side. He also mentions that rare variety, in which there is a dislocation of the ulna, while the radius remains in its place. (See Sir Astley Cooper’s Lectures.) The other varieties are all well described, and suitable methods of treatment recommended. When there is a dislocation forwards the arm is extended, but cannot be bent; when backwards, on the contrary, it cannot be extended, and is shorter than natural. When to either side, the arm is somewhat bent towards that side from which the bone has been moved. He lays it down as a general rule for treating all such dislocations, to extend both the members concerned in different directions, until the bones are separated from one another, and then to push them into their right position. When the dislocation is forwards, he directs us to make strong extension with the hands or with thongs, and then placing some round body upon the anterior part of the arm, to push the fore-arm over it suddenly to the shoulder. This method is well described by Hippocrates, but rather indistinctly by Paulus. In all the other cases, the best method, he says, is to make reduction in the same way that it is performed for the replacement of fractures.
Oribasius mentions the four ordinary kinds of dislocation at the elbow-joint, and describes methods of reducing them by machines. He has likewise described the separate dislocation of the radius from the humerus, and he is the only Greek authority, as far as we know, who has described the separate luxation of the ulna, but which, as stated above, had been noticed by Celsus. We need scarcely remark that a few cases of this uncommon accident have been reported of late years.
Albucasis says that the fore-arm is dislocated in all directions, but more especially backwards and forwards. His description of the mode of reduction is evidently copied from Paulus. Avicenna likewise borrows his whole account from our author.
Rhases and Haly Abbas describe the ordinary cases of complete luxation at the elbow-joint, but we believe that neither they nor any of the Arabians take notice of the dislocation of the radius from the ulna, nor the abruption of the apophysis of the humerus.