68 



ABNORMAL CONDITION OF THE ELBOW-JOINT. 



chronic inflammations, the consequences of 

 which we cannot omit to notice, and many of 

 these have their reputed source either in struma 

 or syphilis, while others are attributed to an ar- 

 thritic or to a rheumatic diathesis. 



I. Accident. Fractures. Fractures of the 

 bones of the elbow-joint may be classed as 

 to their situation and direction : first, as they 

 affect the lower extremity of the humerus ; and, 

 secondly, as they engage the upper extremities 

 of the bones of the fore-arm. 



1. Simple fractures of the humerus near 

 the elbow-joint may be transverse or oblique. 

 When this hone is fractured transversely at its 

 lower part immediately above its condyles, or 

 in young subjects through its lower epiphysis, 

 in either case the olecranon process is pulled 

 backwards and upwards by the triceps, while 

 the part of the humerus superior to the fracture, 

 that is, almost the whole of the bone, is carried 

 forwards, and forms such a projection below as 

 much resembles a luxation forwards of the true 

 articular extremity of the bone ; the prominence 

 in front is ,tlso considerably increased by the in- 

 clination forwards of the upper extremity of the 

 lower short fragment, which is pulled in this 

 direction by the supinators and pronators taking 

 their fixed point below. The prominence for- 

 wards, fori led by the angle of contact between 

 the upper and lower fragments of the humerus, 

 is covered in front by the brachialis anticus 

 and biceps; and there is a projection behind 

 formed by the olecranon process equally well 

 marked ; so that, in comparing the posterior 

 aspects of the two articulations, we see the ole- 

 cranon process at the affected side exceed by its 

 projection backwards that of the uninjured arm 

 an inch or more : when to all this we add the 

 observation that the anterc-posterior diameter of 

 the arm is evidently augmented, we have here 

 many of the signs which might lead one to sus- 

 pect the existence of the luxation of the bones of 

 the fore-arm backwards. There is this differ- 

 ence however, namely, that in fracture acrepitus 

 can be felt, and the deformity is not accompa- 

 nied with any changes of the normal relations 

 existing between the olecranon and the con- 

 dyles. 



Oblique fractures near the elbow-joint are 

 usually prolonged into the articulation, and 

 may be either external or internal. The frac- 

 ture may traverse in an oblique line from 

 without inwards, and from above downwards; 

 and then the external condyle and capitulum 

 of the humerus will be detached from the shaft 

 of that bone, and will constitute the external 

 or inferior fragment ; or the fracture may take 

 place obliquely from above downwards, and 

 from within outwards, so as to comprehend 

 the trochlea of the humerus and internal con- 

 dyle in the inner fragment. In the first case, 

 or external fracture, the posterior muscles of 

 the fore-arm will have a tendency to pull 

 the condyle downwards and backwards ; and 

 in the second, the internal fragment with the 

 trochlea will be drawn downwards and for- 

 wards by the pronator muscles. 



Oblique fractures, extending into the elbow- 

 joint, detaching the external condyle of the os 



humeri, maybe detected by the following sym- 

 ptoms. There is considerable swelling and 

 pain upon pressure on the external condyle : 

 and the motions of the elbow-joint, both of ex- 

 tension and flexion, are performed with pain; 

 but the principal diagnostic sign is the crepitus 

 produced by communicating a rotatory motion 

 to the fore-arm. If the portion of the frac- 

 tured condyle be large, it is drawn a little 

 backwards, and it carries the radius with it ; 

 but if the portion be small, this circumstance 

 does not occur; if the fracture of the external 

 condyle take place immediately above it and 

 within the synovial sac, it is stated by Sir A. 

 Cooper that no union will take place except 

 by means of ligament.* The oblique fracture 

 of the external condyle is frequently met with 

 in children ; a fall on the hand forwards may 

 cause it, the impulse being transmitted along 

 the radius to the capitulum and outer condyle 

 of the humerus. The connexion of the radius 

 with the ulna at this period of life is so loose 

 that no resistance is afforded to the forcible 

 ascent of the radius when a sudden fall for- 

 wards on the palm of the hand occurs; and 

 hence in the young subject particularly an 

 oblique fracture of the outer condyle of the 

 humerus can readily happen : at a late period 

 of life, the connexions between the bones of 

 the fore-arm are so strong and unyielding, that 

 from a similar fall forwards on the hand, it is 

 the lower extremity of the radius which would 

 be obliquely fractured. 



There is at this moment in the Richmond 

 Hospital a young woman who met with this 

 oblique fracture of the external coudyle of the 

 humerus near the elbow, when she was only 

 five years of age. The outer condyle and 

 capitulum of the humerus were detached ob- 

 liquely from the shaft of the bone and thrown 

 backwards, carrying with them the head and 

 upper extremity of the radius ; she now has 

 very good use of her arm, but in consequence 

 of the accident much deformity exists, parti- 

 cularly when she extends the fore-arm. The 

 obtuse angle salient internally, which the fore- 

 arm forms with the arm in the natural state 

 when it is fully extended, and the hand supi- 

 nated, does not exist. On the contrary, in this 

 case the salient angle is external, and corres- 

 ponds to the outer condyle and head of the 

 radius, and the retiring angle is placed inter- 

 nally. (See Jig. -10.) 



The internal condyle of the humerus is fre- 

 quently broken obliquely from the body of the 

 bone, and the symptoms by which the accident 

 is known are the following : when the fore-arm 

 is extended on the arm, the ulna projects be- 

 hind the humerus ; the lower end of the hume- 

 rus, too, advances on the ulna, so that it can 

 be easily felt on the anterior part of the joint; 

 on flexing the fore-arm on the arm, the ulna 

 resumes its usual position ; by grasping the 

 condyles and bending and extending the fore- 

 arm, a crepitus is perceived at the internal con- 

 dyle: this accident usually occurs in youth, 



* See plate xxvi.yfj. 1, of Sir A. Cooper's work 

 on Fractures and Dislocations. 



