Elements of Surgery

by Robert Liston

Luxation of the Elbow-joint is an extremely common accident, particularly in young persons, before the bony processes have been fully formed. It is produced by wrenches, or by force applied to the farther end of the forearm, the bones neither breaking nor bending. Sometimes, though very rarely, it is caused by direct violence, as in a fall, and then may be combined with fracture of one or both bones of the forearm; but in other circumstances, fracture and luxation can scarcely coexist. In general, both bones of the forearm are displaced backwards, sometimes a little to the ulnar side. The coronoid process occupies the cavity for the reception of the olecranon, and the head

of the radius lodges behind the external condyle; the extremity is shortened, and looks twisted; it is slightly flexed, and in the middle state between pronation and supination. Unnatural lateral motion can be produced, but flexion is impracticable, the limb cannot be brought quite into the extended state, and rotation is difficult and painful. Swelling soon takes place, and consequently the hollows are filled up, and the processes of the bones obscured. Yet the olecranon and inner condyle can always be recognised and felt, and their relative position ascertained; the form of the end of the humerus, its hollows, and its prominences, can be distinctly discerned, both before and after the swelling, the soft parts being stretched over the bone; and by rotating the limb with one hand, whilst the other is placed over the outer and back part of the joint, the situation of the head of the radius is detected. Thus the relations of the bones to one another are discovered; and this must be done at once, whatever pain may be produced by the examination, for it is a saving of suffering in the end. Yet the nature of this injury would seem difficult of detection—a fact scarcely intelligible by any one who is careful in his manipulations, and who possesses common observation, and a sound knowledge of anatomy. Many cases of unreduced luxation are met with; I have seen it in both elbows of the same person; and I have had a dozen of cases, in as many months, of unreduced elbows shown too late for attempts at reduction. The frequent occurrence of such blunders is the more lamentable, as it is almost impossible to replace the bones after three or four weeks; indeed, I have been foiled at the end of two weeks. The parts soon accommodate themselves to their new position, the olecranon process shortens, motion rapidly increases, and the bones get more and more secure in their new relations,—osseous matter being deposited laterally, forming cavities for their lodgement, and new ligamentous matter confining them thereto. After a time, flexion can be made to a right angle; and the limb becomes tolerably useful. By unsuccessful attempts to restore the natural position, inflammation is excited; and thus the salutary processes, commenced by nature for reparation of the displacement, are interrupted and delayed; in young persons such disease of the joint may be produced as might lead to loss of the extremity.

Luxation of the Radius alone, backwards on the outer condyle, is sometimes met with; but this bone is seldom singly displaced far from its original site. A hollow is felt below the end of the humerus, on the outer and fore part, and there is a corresponding prominence behind; the head of the bone is found unnaturally moveable on rotation, and this motion is difficult and painful; the arm is extended, presenting a twisted appearance, and flexion is very limited. Extension is to be made, along with pronation.

Sometimes the radius is displaced forwards. The coronoid process of the ulna is occasionally broken off; there is no deformity during flexion of the elbow, but when the limb is extended, the olecranon is drawn upwards.

In luxation of both bones, reduction is much facilitated by position of the arm. The arm and forearm are extended, and the limb is brought well behind the trunk, so as to relax the triceps; then the surgeon performs extension and counter-extension, pulling the forearm with one hand, whilst he pushes with the other placed on the scapula. If the force thus employed prove insufficient, as it seldom will in recent cases, the patient may be placed on his face, on a couch, and on the limb being brought into the favourable position already noticed, counter-extension may be made by the heel planted against the inferior costa of the scapula, whilst the wrist is pulled with both hands. It is seldom necessary to employ pulleys, excepting in cases of old standing; if so, the only peculiarity in their application to this joint is the direction of the force, backwards. And this I consider to be a very material part of the manipulations, for, by attention to it, I have succeeded after previous failures,—after great force had been applied, causing excoriation and swelling of almost the whole limb. In luxation of the radius, backwards, flexion and pronation, combined, if necessary, with extension, will generally effect replacement.

Dislocation at the Wrist is very unfrequent. The articulation is naturally strong, admitting of little motion, the bones being accurately fitted to each other, whilst the retaining ligamentous apparatus is both copious and unyielding; on this account greater force is required to effect displacement here than at either the elbow or shoulder-joints, and violence applied to the hands usually causes fracture of one or both bones of the forearm, not luxation of their extremities. Luxation, however, sometimes occurs, either from violent twisting, or from falling on the palm of the hand; and the displacement may be either of both bones or of one. In the latter case, it is almost uniformly the radius that suffers; in the former, the luxation is forwards.

Dislocation of the distal extremity of the radius is generally produced by a sudden wrench or twist. The bone is felt loose and prominent, sometimes riding over the upper part of the carpus. The position of the hand is towards pronation, supination cannot be performed, and, on attempting it, great pain is occasioned. Reduction is readily accomplished, by pulling the palm with one hand, whilst with the other the head of the bone is pressed backwards into its situation.

Displacement of both bones is more frequently the result of a fall on the palm, with the hand bent much backwards. In this case there are two projections, so distinct as at once to mark the true nature of the accident, one anteriorly, formed by the ends of the radius and ulna, the other posteriorly by the carpus; above the posterior prominence there is a considerable depression. Here also reduction is easy; it is sufficient to perform simple extension with one hand, whilst with the other the wrist is moulded into its proper form. The after treatment, however, requires attention, for extensive laceration of tendinous and ligamentous tissue, perhaps combined with fracture of the bony processes to a greater or less extent, must have taken place to admit of displacement; in consequence violent inflammation is to be expected, and means must be taken to avert it. On account of this laceration, also, mere reduction is not sufficient, retentive apparatus must be applied; as soon as the limb has been made straight, a pasteboard splint is to be applied on each side, as in fracture of the forearm, and retained with a roller, a wooden splint being placed exteriorly until the pasteboard hardens. This precautionary measure is also necessary to avert redisplacement in dislocation of the radius singly; in both accidents the apparatus should be retained for at least a fortnight. Afterwards, passive motion, gradually increased and combined with friction, is requisite to prevent stiffness of the joint.

In mere sprain of the wrist, large swelling soon forms anteriorly, from extravasated blood, resembling somewhat projection of the bones, and so leading towards fallacy in diagnosis; indeed it is not unreasonable to suppose that dislocation here does not occur so frequently as is imagined. Fracture also near or through the distal extremity of the radius, an accident formerly mentioned as exceedingly common from falls on the hand, is very apt to be mistaken for luxation. On this account, and because in every injury of the wrist the parts are soon obscured by bloody swelling, there is a strong necessity for early and accurate examination.