A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

MEMOIR VIII.

ON THE FRACTURE OF THE BONES OF THE FORE-ARM.

§ I.

1. The fore-arm, composed of two bones, neither of them very strong, and covered below by a small quantity of soft parts, is exposed still more than the humerus, to the action of external bodies, and is articulated at the upper end in such a manner, as not to yield, like it, in every direction to the impulses which it receives. From these considerations, it is one of those parts where fractures most frequently occur, and, in a comparative view of affections of this kind in the Hotel-Dieu, it has oftentimes held the first place.

2. It would be useless to mention here the disposition of the bones which compose the fore-arm, their irregularly prismatical form, their thickness unequally distributed, their direction obviously different, and their motions differently combined. It is sufficient to observe, that, for the perfection of one part of these motions, a space, wide in the middle, and narrow at the ends, must separate the two bones, that, without this space the radius, impeded in its movements on the cubitus, would compress the muscles, restrain their action, and would be unable to perform the motions of pronation and supination; whence the fore-arm, being confined, as it were, to mere flexion and extension, would not, in its uses, correspond to our wants.

These things being premised, we will observe, that fractures of the fore-arm may have their seat, 1st, in both bones at the same time; 2dly, they may occupy but one of them: hence three kinds of fractures more or less different in their phenomena, their consequences, and their treatment.

FRACTURE OF THE FORE-ARM.

§ II.

OF THE VARIETIES AND THE CAUSES.

3. Fractures of both bones of the fore-arm, may occur either at the ends, or in the middle of the limb. Frequent in the middle, and somewhat common below, they seldom occur in its upper part, where the fleshy portions of numerous muscles, combined with a considerable thickness of the ulna, resist the motions which tend to produce them. The two bones, though most commonly broken on the same line, are, however, sometimes broken on different ones. The fracture is almost always single: at times, however, it is double, and Desault, in particular, was once called to a patient, over whose fore-arm the wheels of a carriage had passed, and had broken it both in the middle and at the lower end, so that it evidently exhibited six fragments distinct from each other. The two middle ones, though completely insulated, united again to the others with but very little deformity. Like all other similar affections, these may be rendered compound by wounds, splinters, &c. circumstances which, as they fall within the general class of such injuries, will not be treated of at present.

14. They occur, in general, in two ways, being the result, sometimes of the action of external bodies, immediately applied, and at other times of the same action, operating by way of a counter-stroke. The occasional percussion of a body on the fore-arm, furnishes an example of the first mode of fracture. This is much more frequent, in general, than the other, which usually arises from a fall on the wrist; but, in such a case, as it is the large lower end of the radius that forms the principal point of articulation with the hand, that bone alone sustains almost all the force of the stroke, and is very generally the exclusive seat of the fracture.

§ III.

OF THE SIGNS OR APPEARANCES.

It is in general difficult to be mistaken with respect to the signs which characterize fractures of the fore-arm. A mobility of the limb where it was before inflexible; a crepitation almost always easily perceived; a depression, sometimes evident, at the place of division; a protuberance sometimes formed under the skin by the fragments; pain produced by the motion of the part; a crack sometimes heard by the patient, at the moment of the accident; an inability to perform the motions of pronation and supination; the almost constant semi-flexion of the fore-arm; such, together with the phenomena common to all fractures, are those which essentially characterize this, and which must generally remove all doubts which the swelling of the limb may temporarily create respecting its existence.

6. There is a circumstance, however, where a fracture near to the joint of the wrist, may give rise to appearances similar to a luxation of that part. In both cases, indeed, a convexity behind, and a depression before, or the reverse, are perceived, and are the effect of a displacement of the fragments. But the styloid apophysis being carefully examined, will always determine, according as it is found above or below the deformity, from which of the two causes the deformity arises. Besides, a greater mobility in one than in the other affection, and a crepitation, will guard the practitioner from an error, into which I saw a surgeon fall in the presence of Desault, whom he called on to consult, in the case of a child six years old, which laboured under a supposed luxation.

§ IV.

OF DISPLACEMENT.

7. Most of the phenomena which accompany fractures of the fore-arm (5), are evidently the result of a displacement of the fragments; a displacement, not, in general, very perceptible in the longitudinal direction of the bones, because the muscular action, tending to produce it in that direction, is not very powerful. When it does occur in this way, it is most frequently the immediate effect of the stroke that produced the fracture.

8. But it is different with respect to a displacement in the cross direction of the bone. Here the cause of the separation of the broken ends, may be the same with the cause of their fracture, as happens in the passage of a carriage wheel over the limb, or in the falling of some body against it; and then, 1st, the fragments are separated from before backward, or contrarywise, and hence, a protuberance on the one side of the limb, and a depression on the other; 2dly, or else they are pressed against each other laterally from without inwards. From this latter cause arises that inequality which the limb exhibits at the place of the fracture; the slight depression which it manifests on its sides; and the protrusion or bulging out of its anterior and posterior surfaces, by means of the mass of muscles which are pushed in these directions, by the approximation of the fragments to each other.

9. A proper reduction removes the first kind of displacement, namely, that which occurs in the cross direction of the bone backward or forward (8); and unless an external force be applied anew, it does not again return. On the contrary, how exact soever the reduction may be, in the second kind, namely, that which takes place laterally from without inwards, the fragments are soon found to have approached each other again. Above, the pronator teres presses the superior fragment of the radius against that of the ulna; below, the two fractured extremities are pressed against each other, by the contractions of the pronator quadratus. From this double cause arises, unless something prevent it, the contact of the four fractured ends, which have been sometimes found united together by a common callus, as is proven by several cases sent to Desault, and by the cases of different patients admitted into the Hotel-Dieu, after having undergone an improper treatment. In such cases, the movements of pronation and supination being entirely destroyed, are but imperfectly supplied, as Duverney remarks, by those of a rotation of the arm.

But if the four broken ends should not even be joined together by a common callus, still the space between the bones being evidently diminished, impedes muscular action and the motions of the limb depending thereon.

§ V.

OF THE REDUCTION.

10. It follows from what has been said on the displacement of the fragments (8), and on the causes which have a constant tendency to re-produce this displacement (9), that the extending forces, intended to remove it, should be, in general, less powerful than in most other fractures, because their principal object is, to restore to the limb its natural length, which is here but very little affected.

11. Previously to the application of these, it is necessary, according to the precept of Hippocrates, to place the fore-arm in a middle state between pronation and supination, flexion and extension. This position is highly favourable to the relaxation of the muscles, and is that, above all others, as the father of medicine observes, which those who have sustained a fracture naturally assume, and which alone they can, for a long time, retain, without experiencing any inconvenience.

12. The fore-arm being thus placed, an assistant makes extension, by taking hold of the four fingers; a mode to be adopted in preference to that of Petit, who directs us to make extension at the wrist; for the real momentum or force of a power is in the inverse ratio of its distance from the place of resistance. At the same time, another assistant makes counter-extension on the humerus, which he grasps with both his hands, in such a manner, that his thumbs correspond to the back part of it, while his fingers cross each other anteriorly.

13. It further follows, from what was said (8 and 9), that the process of conformation, so often useless and even injurious, in other fractures of bones, is necessary here, to restore to the fragments that exact contact which they have lost, in a transverse direction. If the displacement be forward, the surgeon pushes both fragments backward, while the assistants maintain the extension. If the bones project backwards, they must be pushed in the contrary direction. As to a lateral displacement (8) in which the broken ends approach each other, it is not altogether useless, as Petit observes, to endeavour to remove it, by forcing the muscles into the space between the bones. This is done by making a moderate pressure on the anterior and posterior surfaces of the fore-arm, in order that the bones, being thus removed from each other, may come in contact with their broken ends. If this be done, when the apparatus is first applied, the reduction is attended with but little difficulty, and the ends of the fragments are easily retained in apposition.

§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

14. Our forms of apparatus are nothing but means of continuing, for a long time, that state of things, which extension and the process of conformation temporarily produce at the time of reduction. This principle, though generally acknowledged, was particularly neglected in such fractures, as that now under consideration, till the time of Petit, who made it the basis of his practice. Before him, there was a common inconvenience attached to every kind of bandage. The two bones being pressed against each other, by circular rollers applied externally, were thus drawn in that very direction, in which the action of the pronator muscles already tended to displace them; because, the form of the fore-arm being irregular, made these rollers act more powerfully on its lateral parts, where it is very convex, than either behind or before, where it is very flat. It is well known that bandages will make the greatest pressure on the most projecting parts of the limbs round which they are applied; so that, if the fore-arm be bound or pressed on behind and before with a force equal to one, it will sustain laterally, that is, on its sides or edges, a pressure equal to two. Hence results, not only a tendency in the radius to approach the ulna, but also, a want of resistance in the muscles situated on the posterior and anterior sides of the fore-arm. For these muscles being, from their flatness, less compressed than the bones, give way, and do not, by forcing themselves between them, oppose the approach of the bones to each other.

15. Such was the disadvantage of the apparatus of Hippocrates, consisting of one roller applied immediately on the skin, of a many-tailed bandage intended to retain this, and of four splints, applied on the seventh day, and secured by another roller. Such was also the inconvenience of several bandages, proposed after the time of Hippocrates, by different authors, who modified his without improving it, and who, in attempting to alter it, even added to its imperfections. Thus, the compresses with which the limb was first covered, previously to the application of the rollers, served only, by becoming wrinkled, to render the compression unequal, fatiguing, and even painful to the patient. In like manner the pasteboard, which many authors, particularly Duverney, have substituted for splints, and which a majority of practitioners employ, even at the present day, soon becoming softened by moisture, bends without resistance, becomes incapable of preventing a displacement, and has at least the inconvenience of being useless.[18]

16. Is it to be wondered at then that a perfect cure of fractures of the fore-arm has been regarded as a thing of so much difficulty, and that most authors should have advised practitioners, as a thing of prudence, to warn the patient of its being impracticable to cure him, without the loss of the motions of pronation and supination? Thus, in like manner, it was formerly declared, that a constant deformity was the necessary consequence of fractures of the clavicle.

17. Petit first conceived, that he discovered, in the very means destined to prevent the displacement, the cause of its being continued, and that, in order to be effective, the bandage ought to do constantly what the hands of the surgeon do at the time of reduction (13); that is, it ought to oppose to the unremitting action of the pronators, a resistance equally unremitting, by pressing the muscles into the interstice between the bones. But, after having discovered the end to be attained, he accomplished it only in an imperfect manner. For by first applying a roller immediately round the fore-arm, he reproduced, in part, the very inconveniences and disadvantages he wished to prevent, by placing anteriorly and posteriorly two long and thick graduated compresses, intended to keep the bones asunder, by forcing the muscles between them.

18. Duverney, more judicious, proposed to place the graduated compresses of Petit on two circular compresses, previously applied round the fore-arm. But what availed these circular compresses? If they be drawn tight, will they not produce that approximation of the bones which the surgeon wishes to avoid? And if they be not tight, they will, in consequence of their loose and pliable state, form troublesome and inconvenient wrinkles, without being productive of any good to counterbalance this inconvenience.

19. It was from these different considerations, that Desault modified, as I am about to mention, the apparatus for fractures of the fore-arm. To a great degree of simplicity, this apparatus unites, when thus improved, great ease to the patient, and its advantages are proven by the freedom in the different movements of the arm always experienced by the numerous patients, whom he was called to attend. The pieces of the apparatus are, 1st, Two graduated compresses, one of them of such a length as to extend from the elbow to the wrist, and the other from the wrist to the fold of the arm on the inside. They are to be formed each of a single piece of linen, folded seven or eight times on itself, in such a manner, that the lower fold may be an inch wide, while the others, laid on top of each other, gradually diminish in width to the last. The thickness of these compresses ought to be less in very fat persons, where the anterior and posterior surfaces of the arm are more convex. 2dly, A roller about four yards and a half long, and four inches wide. 3dly, Four thin but stiff wooden splints, long enough to reach, one, from the fold of the arm to the wrist, the second, from the interval or hollow space between the olecranon and the condyl to the same part, the third from the internal condyl of the humerus to the styloid process of the ulna, and the fourth from the eternal condyl to the styloid apophysis of the radius. The breadth of the two first ought to be double that of the other two, as the latter occupy a space of but half the width of that occupied by the former.

20. Every thing being arranged, the reduction is to be executed as already directed (11–13); and while the extensions are still continued, the surgeon wets with vegeto-mineral water, or some other discutient liquid, the graduated compresses, and places them on the anterior and posterior part of the fore-arm, (which must be firmly supported in a state between that of pronation and supination, 11), in such a manner, that their broadest part or base may be in immediate contact with the limb. He then secures them with a roller wet with the same liquid, the casts of which, being first fixed at the place of the fracture, descend obliquely to the wrist, and are secured at the hand by being passed between the thumb and the fore-finger. Running across the back of the hand, the roller then reascends, either by oblique or reverse turns, according to the inequalities of the fore-arm, till it reaches the elbow. Here the surgeon relinquishes the roller, giving it into the hand of an assistant, and places the four splints on the parts already mentioned (19), while the hands of a second assistant secures them, by grasping them all at their lower end, next to the wrist. The surgeon then resumes the roller, and, in order to fix the splints immoveably, descends with it along the fore-arm by circular casts, till he reaches the hand, where he finishes.

There is, in the application of this bandage, an essential precaution to be observed; which is, that as each turn of the roller passes over the graduated compresses, the surgeon ought to press on these compresses with the thumb and fore-finger of his left hand, in order that the muscles, by being forced into the interstice between the radius and ulna may prevent their approximation, which would produce an inequality in the compression made by the apparatus.

21. After the application of the apparatus, if the patient be obliged to keep his bed, the fore-arm is to be extended on a pillow, taking care to keep it always half-bent, and guarded by hoops from the weight of the bed-clothes. But if the fracture be not a compound one, and if the fall has done no injury to the system in general, it is unnecessary to confine the patient to a position wearisome, and oftentimes insupportable to many persons. Then the limb is to be suspended in a sling, which is always sufficient to support it, without having recourse to the kind of hollow case recommended by Bell, which is seldom at hand, and the use of which must be extremely inconvenient.

22. The subsequent treatment to be adopted in such fractures is simple and easy: to wet the apparatus daily, for a few days, with vegeto-mineral water, to obviate, by proper means, the accidents that may occur; to renew the application of the roller at the end of eight days, or perhaps later, according to the degree of its relaxation; to repeat this application two or three times during the course of the treatment; to allow, at first, but light diet, which may be afterwards more solid, and given in larger quantity, and to admit finally of a return to the patient’s usual mode of living: such was, in cases of fracture, the practice of Desault, which was always attended with happy effects.

23. Sometimes a considerable swelling occurs, after the application of the bandage, on the back and face of the hand; small blisters appear between the fingers; the patient experiences sharp pains along the fore-arm; and other small blisters rise on its surface. It is then necessary to remove the apparatus, to open the blisters by pricking the cuticle, and dress the part with cerate spread on linen rags; replace the apparatus, making it less tight than before, taking care to renew it every day, till the excoriation be entirely gone. This accident, of no great consequence in itself, has frequently occurred to Desault, although the rollers were applied at first with but a moderate degree of tightness.

24. The consolidation being completed generally in twenty-four or twenty-five days, leaves, at this time, a little stiffness in the joints, in consequence of their having remained so long without motion: the movements of pronation and supination are performed but imperfectly. Their return is facilitated and hastened by frequent exercise of the limb, as well at its junction with the os humeri, as in its own proper joints; and, in general, by the fifteenth or twentieth day from the removal of the apparatus, things are in the same state in which they stood before the fracture.

FRACTURE OF THE RADIUS.

§ VII.

OF THE CAUSES AND THE DISPLACEMENT.

25. The radius, which is the moveable and almost the only support or abutment of the hand, receives, in falls on that part, a much greater share of the shock than the ulna, which is joined to the hand by only a small surface. Hence, without doubt, arises the greater frequency of the fractures of the radius; fractures which, when produced by falls on the hand, are evidently the result of a counter-stroke. Oftentimes also this bone is broken by the immediate action of external bodies, because it is defended below with but a thin covering of muscles.

In whatever way the fracture may be produced, it occurs in the middle or at the extremities of the bone; very rare near its articulation with the os humeri, it is more common in its middle; but more frequent still at its lower end. The difference arises probably from this circumstance, that, in falls on the wrist or hand, the shock is weakened and lost in proportion as it is propagated upwards.

26. In such fractures, displacement is almost constantly observable in the thickness or cross direction of the bone and fore-arm, and is produced by the action of the pronator muscles, which, by forcing the fragments of the radius towards the ulna, tend to diminish the interval between the bones. The ulna remaining unbroken, always prevents any displacement in a longitudinal direction. The first kind of displacement is the more perceptible, in proportion as the fracture is nearer to the middle part of the radius, where the bones are at the greatest distance from each other. This displacement is seldom outwards, because the interosseous ligament prevents that: yet experience furnishes some exceptions to this rule.

Case I. Desault was called, in the month of July, 1781, to visit a mason, who, sleeping at the foot of a wall, with his fore-arm stretched out, received on the anterior part of it, a round stone, of the size of a bowl, which, falling from a scaffold, fractured the radius in its middle, and produced a large contusion, accompanied by an enormous swelling, to which the usual discutient remedies were applied. On the fifth day the swelling had in part disappeared; but then there was discovered a very evident protuberance of the inferior fragment, which, by pointing outwards, separated itself from the superior one, which remained nearly in its place. The interval between the bones was evidently increased below.

The fracture was reduced by pressing the lower fragment inwards, and, instead of employing graduated compresses the whole length of the limb, they reached only to its middle, along the part corresponding to the superior fragment. The roller was drawn a little tighter below than above, in order to keep the inferior part of the radius near to the ulna.

By being treated afterwards in the usual mode, the fracture was cured. But, in consequence of being over-stretched by the separation of the bones, the ligaments of the wrist became the seat of a tedious lymphatic swelling, which left behind it some degree of stiffness.

27. Examples of this kind occur too rarely to affect the general law relative to the direction of the displacement of a fractured radius, a displacement which, if not properly treated, makes the fragments unite in such a manner as to form an angle pointing inwardly towards the ulna, as is evinced by a perceptible depression under the cuticle. In such a case, from this contraction or narrowing of the interval between the bones, arise the inconveniencies already mentioned (9).

§ VIII.

OF THE SIGNS.

28. The diagnosis of fractures of the radius is in general easy, when they occur at the lower end, or in the middle (25). In these two cases, a depression more or less perceptible, on the external side of the fore-arm; an inability to perform pronation or supination, by the action of the muscles alone; and a severe pain, necessarily resulting from moving the bone in this two-fold direction. Such are the particular signs or appearances which first disclose the existence and the place of the fracture. The reality of the accident is afterwards more fully confirmed by the signs common to all fractures, namely, the flexibility of the bone, the crepitation perceived by moving it in different directions, &c.

29. Desault cautioned his pupils not to confound this last sign or symptom with a kind of noise, sometimes heard in the sheaths of the tendons of the extensor longus, extensor brevis, and abductor longus; a noise resulting from a filtration of synovial fluid into the sheaths, or produced by some other cause. But, besides this crepitus in the sheaths being a very rare occurrence, it is always easy to distinguish it from a crepitation of the bone, by this circumstance, that the first is heard on merely pressing the parts, but the latter only by making the bony surfaces rub against each other. Besides, by an experienced ear there is no danger of any mistake being committed.

30. If the fracture exist at the upper end, the thick muscular covering which there surrounds the radius, renders the diagnosis more difficult. Petit has, however, thrown some light on the subject, by judiciously advising to place one hand on the upper extremity of the radius, and with the other to make the fore-arm rotate on this bone. The solution of continuity or fracture will be rendered evident, if, in the midst of these motions, the head remain stationary. But if, on the other hand, it rotate, it has sustained no injury. These two circumstances can be easily explained; but, it is not so easy for the practitioner to avail himself of them in every case. This precept may also be applied in cases where a considerable swelling, occupying the whole fore-arm, conceals from the touch of the surgeon the fragments of the bone, even when broken in the middle.

§ IX.

OF THE REDUCTION, AND THE MEANS OF MAINTAINING IT.

31. The reduction of a fracture of the radius is effected in nearly the manner already described for that of the two bones of the fore-arm (10–13), except that, here, the extension must be less, because there exists no displacement in a longitudinal direction (26).

To remove that which exists in a cross direction, an assistant whose business it is to make extension, places the hand in a state of adduction, for the purpose of removing the inferior fragment outwards. This precept cannot be applied to much advantage, if the division exist towards the upper end, on account of the interosseous ligament.

At the same time the surgeon endeavours to bring the ends of the bone into perfect contact, by pushing them in a direction opposite to that of their displacement; and when he has attained this end, he begins the application of a bandage or apparatus the same as that already described (19 and 20), with this difference, that as the ulna is here sound, and performs, in relation to the fractured radius, the office of a natural splint, it is unnecessary to place an artificial one between the internal condyl of the humerus, and the styloid apophysis of the ulna.

32. The consolidation or cure is here always more speedy than in the preceding cases, where nature, with the same amount of means and resources, has twice the quantum of labour to perform, and where she supplies her deficiency of power, by the greater length of the time which she employs. In general the bone is united by the twentieth or twenty-fourth day.

33. When the fracture exists at the superior part of the radius, it is essential, after the removal of the apparatus, to make the limb very frequently perform all its natural motions. In such a case, indeed, the parts sometimes swell, become stiff, and an anchylosis of the fore-arm may be the consequence, as Ambrose Pare observes, in his book on fractures, where he says he has seen many accidents of this kind. Galen has remarked the same thing before him. The following case reported by Jeo. Dol**, confirms the truth of it.

Case II. Jane Rene was received into the Hotel-Dieu, in consequence of a fracture of the upper extremity of the radius, produced by a fall on that part, for which she was subjected to the treatment already described (31). The apparatus being removed at the expiration of twenty-five days, the consolidation was perceived to be complete. The motions of pronation and supination were impracticable; those of flexion and extension very much impeded. The patient was now ordered to have the fore-arm moved daily, in these several directions, for the space of an hour, and this space was even increased morning and evening, notwithstanding the pains which, at first, accompanied the exercise. On the eighth day pronation and supination could already be performed in a small degree; they became more and more free, in proportion as the exercise of the limb was longer continued; finally, on the twenty-second day from the removal of the apparatus, the patient was conducted, according to custom, to the amphitheatre, where all the pupils witnessed the perfect freedom of the motions.

Case III. A few days after this, a man, who had left the Hotel-Dieu about eight months before, while under treatment for a similar fracture, returned, to be the subject of a public consultation in consequence of a different disease.

Desault, on interrogating him, learnt from him that the treatment for the fracture had been continued at his own house (31), but that, when the apparatus was removed, no motion had been impressed on the limb, and that the surgeon had even kept it in a sling. The fore-arm was then examined; it was half bent, constantly in a state of pronation, and could not, by any force, be brought into a state of supination. The motions of flexion and extension, were so limited as to be scarcely sufficient for the common wants of the patient, who, under proper treatment, might have been cured like the preceding one, as Desault remarked to his pupils at the time.

34. The patient who was the subject of this second case, was sent to the mineral springs, but derived no benefit from the use of the waters. If this were a proper occasion, I could mention many instances where this remedy, so highly spoken of by many physicians of the present time, has had no effect, except to deprive the patient of more efficacious means, by making him lose that time, during which exercise frequently repeated, would have effected a cure, but which, coming too late, could be of no avail.

FRACTURE OF THE ULNA.

§ X.

OF THE CAUSES AND THE SIGNS.

35. The ulna, less frequently broken, in general, than the radius, scarcely ever suffers alone from falls on the wrist or hand. Most commonly its fracture is direct, and occurs, in particular, in cases where a person in falling, extends the fore-arm for the purpose of supporting himself, and strikes its internal part against some resisting body.

The division, though it does take place occasionally in all parts of the bone, occurs most frequently near to the lower end, where its slender size, compared to that of its upper end, its more projecting situation, and its thinner covering of soft parts, act as predisposing causes.

36. In whatever part it may exist, the touch must readily detect it, when the fingers are drawn along the internal surface of the ulna, which lies almost immediately under the skin. If moved in contrary directions, the fragments will also, by their mobility and crepitation, disclose the nature of the injury. A depression more or less perceptible is observed on the internal part of the fore-arm, produced by a displacement of the fragments, which are carried towards the radius, more particularly of the inferior fragment, as Petit has well observed, the superior one remaining almost immoveable.

§ XI.

OF THE REDUCTION, AND THE MEANS OF MAINTAINING IT.

37. The reduction does not differ from that of the radius (31), except in this, that the assistant who makes the extension, must place the hand in the opposite state, namely, that of abduction, in order that the fragments may be brought into contact, while the surgeon assists in this process, by pushing the broken ends of the bone in a direction opposite to that of their displacement.

As in the foregoing case, three splints are sufficient for the apparatus, where the radius, being unbroken, performs the office of a fourth.

The exercise of the limb, after the consolidation of the bone, is in general less necessary here, than in fractures of the radius (34), because the ulna, being an immoveable point of support for the motions of rotation, concurs in them only in a passive manner.

FRACTURE OF THE OLECRANON.

§ XII.

REMARKS ON THE OLECRANON.

38. The ulna is surmounted, at its upper end, by a considerable appendix, curved before, where it corresponds to the articulation of the fore-arm, and is covered with cartilage; convex behind, where there is nothing to separate it from the external integuments, and is attached at its upper end to the strong tendon of the triceps muscle, which appears to be incorporated with it. This appendix resembles greatly, in its structure, form, and uses, the rotula, from which it would differ in nothing, if the inferior ligament of the latter were ossified, so as to form a bony continuity between it and the tibia. It is exposed to fractures, perfectly similar to those of the rotula, but which differs so essentially from the other fractures of the ulna, as to call for a separate examination.

39. The ancients appear to have had but little knowledge of fractures of the olecranon, respecting which they have transmitted nothing to us, unless with Dalechamps, we find cause to recognize a reference to this affection in the following passage of Paul of Egina: Cubitus frangitur . . . circa partem ad cubiti gilbum.

Most of the moderns have spoken of it only in a vague manner; no one has described with accuracy the signs which characterize it; and few have given satisfactory ideas on its treatment. Petit has not spoken of it separately, and Duverney, who concludes with it his article respecting fractures of the fore-arm, has but imperfectly described for it a bandage which is in itself equally imperfect. Bell does not give us, on this point, an exposition of either his opinions or his practice.

Yet this fracture is by no means so rare as to justify the silence of authors, and its treatment merits a degree of attention beyond that which is requisite in most other fractures.

§ XIII.

OF THE VARIETIES AND CAUSES.

40. The olecranon suffers fractures at its base and at its summit, but more frequently in the first, than in the second situation. The division, though very generally transverse, is sometimes oblique. Desault met with an instance of an oblique fracture of the olecranon in a man, who had sustained a violent blow on his fore-arm from a club.

41. The causes which produce it are, either muscular action, a circumstance that very rarely occurs, or the direct action of external bodies, which is by far the most common case. The reverse of this is true with regard to fractures of the rotula, which are almost always produced by the contraction of the muscles attached to that bone.

42. The olecranon has been at times separated from the ulna, by the act of throwing a stone with great force. In such cases, the fracture has been produced by the immediate action of the triceps muscle. This is the first mode of division.

The second occurs when a violent blow is received on the elbow, or, more particularly, from falls on that part: for example, if, when descending a flight of stairs, our heel slip and we fall backwards, the arm is suddenly thrown behind to save the body. In such a case, the olecranon striking forcibly against one of the steps, and being pressed between it and the weight of the body, is broken. In this way was the disease produced in a majority of the patients attended by Desault for fractures of the olecranon.

§ XIV.

OF THE SIGNS.

43. We meet here with the same appearances and state of things, which constantly occur in fractures of the rotula. The triceps extensor, finding no longer in the continuity or sound state of the ulna, a resistance to its contractions, draws upwards the short fragment to which it adheres, produces between it and the lower one an interval more or less perceptible, and gives rise to the greater part of the other characteristic signs of the affection: these are, 1st, An interval or space between the fragments, corresponding to the posterior part of the articulation. This interval may be increased at pleasure, by increasing the flexion of the fore-arm, or by making the patient contract the triceps muscle, and may be again diminished, by bringing the arm into a state of extension: 2dly, An inability in the patient to extend the fore-arm spontaneously, which is the necessary result of the separation of the triceps from the ulna: 3dly, A constant semiflexion or half-bent state of the fore-arm, produced by the contractions of the biceps and brachialis internus muscles, to which no antagonists are now opposed: 4thly, An elevation, more or less perceptible, of the olecranon above the condyls, which, on the contrary, rise above it, when, in a natural state of the parts, the fore-arm is half-bent: 5thly, A facility of moving the upper fragment in every direction, without communicating any motion to the ulna; 6thly, A peculiar sensation experienced by the patient, to whom it seems, when he makes an effort to extend the fore-arm, as if some body or substance were detached or broken off from his elbow, and carried upwards. The patient may realize the justness of this sign, by comparing it with what he feels on attempting to extend the opposite fore-arm, placed in the same position.

44. If to these signs be added the circumstances which accompany the accident, the severe pain that is always felt, the crack which is sometimes heard by the patient, and the possibility of producing a perceptible crepitation, by rubbing the fragments in contrary directions, after having first brought them together, it will be difficult to be mistaken respecting the existence of the fracture, which indeed the swelling of the part alone can conceal from the practitioner, if, as sometimes happens, it be considerable. But then, being soon dispersed, either spontaneously, or by the action of discutients, it leaves the accident unmasked, accompanied by the signs just enumerated.

45. To the swelling is oftentimes added, an echymosis more or less considerable, when the accident has been produced by a fall on the elbow. But by this, no change is effected in the essential characters, which are always sufficient to distinguish a fracture from a luxation backwards, with which it has been sometimes confounded, as appears from many examples recorded in different works.

§ XV.

OF THE PROGNOSIS.

46. I will not dwell on the question, so much agitated of late, namely, whether or not the olecranon be susceptible of consolidation or reunion. Already has it been hundreds of times answered by experience. What could theory add to the conviction already impressed on us from that quarter? It was by exhibiting to the crowd of pupils who attended his clinical lectures, fractures of this kind perfectly reunited, that Desault refuted the weak arguments, of the periosteum not being able, in consequence of not covering the anterior surface of the olecranon, to produce a union between its fragments, of the synovia mixing with the matter of callus, diluting it, weakening it, preventing it from becoming sufficiently hard for the purpose of reunion, &c. We will only observe, that these ideas are borrowed from a theory which modern experiments have proven to be unfounded, and which, were it true, would be applied in the present case quite unphilosophically, since it would deny to certain parts of man the power or property of restoration or being healed, a property common to all the component parts of beings endowed with life, and which even constitutes one of their essential and discriminative characters.

47. Is the consolidation of the olecranon effected in the same mode as in other bones? The observations of many practitioners, Camper in particular, seem to prove that a ligamento-cartilaginous substance is always the medium of the union of fragments. Desault once found this substance in a corpse, but it was in a case where the fracture had been improperly treated, and where, of course, no inference could be drawn with regard to ordinary cases.

48. But of what import to us are the means which nature employs? The indication is still the same. The fragments must be always kept in contact, that the reunion may be immediate, and that, as David observes, in his memoir on motion and rest in surgical diseases, the apophysis may not, by becoming too long in consequence of the space occupied by the callus, impede the extension of the forearm on the os humeri.

§ XVI.

OF THE MEANS OF CONTACT BETWEEN THE FRAGMENTS.

49. There are no fractures, the treatment of which demands more attention, or is surrounded with more difficulties, than that of the olecranon. Here art cannot, as in the thigh, and the clavicle, oppose to the ever active power of the natural muscles, a constant resistance produced by the action of a kind of artificial muscle, consisting in permanent extension. The superior fragment, being too small to give any purchase to extending forces, can be only pushed downwards, and kept in that position with a greater or less degree of stability and firmness, while the ulna, so to speak, is drawn to meet it. Whence it follows, that extension here is of little use, and that it is chiefly by position or attitude, aided by a judicious conformation, that the reduction is effected.

50. The position has varied in the hands of different practitioners. Some have proposed that, in which the fore-arm is half-bent, so as to form a right angle with the os humeri. The example mentioned by David, is not the only one where recourse has been had to this. But, by rejecting the general principle respecting the reunion of parts, which requires them to be kept in perfect contact, this mode is exposed to a double inconvenience. The reunion is extremely slow in being accomplished, and, when ultimately obtained, is accompanied by the loss of one part of the movements of the limb, in consequence of the length of the callus. This callus must necessarily fill up the whole space that intervened between the fragments during the treatment, and being thus added to the natural extent of the olecranon, lengthens this appendix to such a degree, that, in extending the fore-arm, its summit or upper end comes too soon into contact with the cavity in the os humeri destined to receive it.

51. This practice appears to have been chiefly owing to an opinion then in existence, that an anchylosis being the necessary consequence of the fracture, it was proper to place the arm in that position in which it would be most likely to be still of some service.

52. We must not, however, by throwing the fore-arm into the greatest possible degree of extension, allow it to be drawn into the opposite extreme. From this error the same inconveniencies would result. In such a case, should the fragments touch each other, and press too hard at their posterior edges, they must inevitably leave an intervening vacuity or space between their anterior edges. Hence a greater thickness of callus on the one side than on the other, and consequently an impediment more or less troublesome in the motions of the joint. If the inferior fragment do not touch the superior one, it sinks into the olecranon cavity, leaves the other behind it, and hence another source of irregularity in the consolidation.

53. Between these two extremes (50 and 51), it remains to choose a middle course, and that position will be best, in which the fore-arm shall be, so to speak, in a state between semi-flexion and extension. By this the fragments, being brought into perfect contact, will experience no obstacle to a reunion, which will be therefore both speedy and uniform.

54. But it would be useless to place the limb in a proper position, if no means were made use of to retain it there. Being immediately submitted to the action and influence of a multitude of causes, it will lose its position, and the work of nature being interrupted, the consolidation will be retarded.

Hence appears, both the necessity of placing a solid body, as Desault did, before the whole of the limb, to prevent its flexion, and the insufficiency of the apparatus proposed by Duverney and others, who directed to lay a thick compress on the fracture, to surround the elbow then by a circular one, to secure the whole by a kind of figure of 8 bandage, similar to that used in blood-letting, and, finally, to place the limb on a pillow, without further precaution.

55. Position alone evidently acts only on the lower fragment, which it directs towards the upper one. But it is also necessary to draw the upper fragment towards the lower one, and fix it there, and this is certainly the most difficult point; because, the triceps muscle having a constant tendency to contract, opposes its action to the approximation of the fragments, and indeed prevents it, if, as in the means usually proposed and adopted, the pieces of the bandage glide easily over each other.

56. These considerations determined Desault to search for some means which, being more efficacious than those already in use, might better fulfil the indications of the fracture. He accordingly invented the apparatus which we are about to describe; some ideas of this apparatus are indeed borrowed from other bandages. The success which attended the use of it at the Hotel-Dieu, will, without doubt, introduce it generally into rational practice, where the insufficiency of the old forms of apparatus is acknowledged.

1st, The fore-arm being placed in the position already directed (53), two assistants retain it in that situation, while the surgeon applies on its lower part the end of a roller five or six yards long, and about four inches wide, wet with some discutient liquid, making with it, at first, one or two circular turns to fasten it. Then ascending from below upwards, he covers the whole of the fore-arm with oblique and reverse turns moderately tight.

2dly, Having arrived at the joint, he stops, and makes an assistant draw the skin of the elbow upwards, lest, being loosened and wrinkled by means of the extension, it might get between the fragments, and create an impediment to their reunion. Then, taking hold of the olecranon, he draws it down towards the ulna, and passes behind it, as a substitute for his fingers which have hitherto kept it firmly fixed, a cast of the roller, which he brings from the anterior part of the fore-arm above the elbow. Descending again with the roller along the external side of the arm, and returning across the anterior part, he pursues again the same course, so as to make the casts of the roller lie on each other, and surround the elbow like a kind of figure of 8.

3dly, The surgeon proceeds now by oblique turns, to the upper part of the arm, where he fixes the roller, by a circular turn, and gives it into the hand of an assistant. He next applies along the arm and fore-arm, a splint very strong, but a little bent at the place which corresponds to the joint, in order to prevent too great an extension of the limb: then, resuming the roller, he employs it, in a descending direction, to secure the splint.

4thly, The apparatus being applied, the limb is placed on a pillow, so as to be equally supported throughout its length, and is protected by hoops from the weight of the bed-clothes.

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.

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