23. When the reduction is finished, the articulating surfaces have
sometimes a great tendency to be displaced, by the different movements
of the fore-arm, a tendency of which we may easily form an idea, if we
observe, that in a state of pronation, the head of the ulna presses
against the back part of the strained capsule, and consequently against
its opening, when the luxation has been forward: a contrary state of
things occurs in a luxation backward. Whence it is always prudent
to avoid, for some time, the motions of pronation and supination,
according to the direction of the displacement.
24. Should the tendency to displacement be very great, it will be
necessary to adopt the simple method pointed out in a case already
published by Desault.
CASE I. The case was a luxation forward, which was easily reduced.
But the easier the reduction, the more difficult was it to retain the
replaced parts. This was at length accomplished, by fixing the fore-arm
in a state of supination, and applying one thick compress behind the
ulna, while the radius was pushed backward by another compress, placed
on its anterior part, both secured by a common roller. This apparatus
was continued for the space of a month, after which the reduced bones
remained in their natural situation. The patient began, at first, to
perform gentle motions of the wrist, avoiding those of pronation, on
which he afterwards ventured by degrees, and with great caution.
25. These gentle motions frequently repeated, when a displacement is
no longer to be apprehended, remove that unavoidable rigidity which,
for some time, occupies the parts around the joint. It is advisable,
for some time, to apply on the hand and extremity of the fore-arm,
compresses wet with some discutient liquor, to prevent the swelling
resulting perhaps from the inactivity and sprain of the parts. This was
the practice of Desault.
I will close this memoir by two cases, extracted from the Journal of
Surgery, in order to confirm, by experience, what has been already
settled in theory.
CASE I. Desault was called to visit a child five years old, supposed to
be labouring under a fracture of the arm. He learnt from the parents
of the child, that, as it was lying in a very low bed, a young man
who was playing with it, had taken hold of its fore-arm, and drawn it
towards him, twisting it forcibly at the same time in the direction of
pronation; that the effort had been accompanied by a report, and the
child had immediately experienced an acute pain throughout the whole
limb, but more particularly along the posterior part of the fore-arm.
When Desault saw the patient, no swelling had as yet supervened; the
arm was removed from the body, and carried a little forward, while
the fore-arm, half-bent, was kept in a state between pronation and
supination. There existed, at its lower and back part, a preternatural
tumour, formed by the head of the ulna carried behind the sigmoid
cavity of the radius. The hand was a little extended, and in a state
of adduction. The patient carefully preserved that position, and, as
soon as it was changed, or the part affected touched, manifested signs
of the most acute pain.
From these appearances, Desault discovered immediately a luxation of
the radius forward, which was reduced in the manner already mentioned
(16 and 17). By this process, the bones, being a little separated from
each other, were replaced with facility. The suffering of the patient
was immediately at an end; the limb resumed its natural state, and
performed its functions as freely as before; lest some congestion might
be the consequence, the injured parts were covered by compresses wet
with camphorated spirits; these were secured by a bandage moderately
tight, and no accident whatever supervened.
CASE II. On the 29th of January, 1789, Madeleine Fuser, a washer-woman,
thirty-four years of age, had the lower extremity of the radius luxated
forward.
Just as she had finished wringing a sheet, another washer-woman, who
was assisting her to wring it, giving it a forcible jerk, did violence
to her left arm, which was at the time in a state of strong pronation.
The woman experienced immediately a severe pain, accompanied by a
sensation as if something had been torn. The sheet dropt from her
hand, and she fell on the ground. Believing that she had received
only a sprain, she neglected to apply for aid, and did not enter the
Hotel-Dieu till the sixth day after the accident.
There was then a little swelling at the lower part of the fore-arm and
at the wrist: the latter was extended and in a state of adduction;
the fingers were bent. This woman suffered but little, when her hand
was supported and kept still; but the pains became severe, when she
attempted to move it. It was plainly perceived that the radius was
placed before the ulna, and that the bones overlapped each other.
Process of reduction the same as in the preceding case. It was
accompanied by a kind of report, and its completion was clearly
announced by the restoration of the natural shape of the limb, and by
the freedom of its motions. Compresses wet with vegeto-mineral water
were applied to the wrist.
This patient remained fifteen days in the hospital, at the end of
which, she performed with ease the motions of the wrist and hand.