1514 



fore them was one of dislocation of the wrist. 

 Four hours after the admission of the patient 

 into hospital he died. 



" The forearm was semi-flexed as well as the 

 hand. The bony plane represented by the 

 metacarpus and the carpus was almost parallel 

 to that of the forearm. The hand was neither 

 adducted nor abduced, but had suffered a dis- 

 placement "de totalite" towards the internal 

 side. At the posterior and inferior part of 

 the forearm there was a saliency formed by 

 the displaced carpus. A line drawn from the 

 summit of this saliency to the phalangeal ex- 

 tremity of the metacarpal bone to the middle 

 finger, measured three inches and seven lines, 

 the same length which the uninjured carpus and 

 metacarpus of the opposite side presented. At 

 the inferior and anterior part of the forearm 

 A, there existed a transverse eminence, situ- 

 ated about eight lines nearer to the extreme 

 point of the fingers, than the posterior sali- 

 ency B, while it projected anteriorly beyond 

 the plane of the palmar surface of the hand, 

 fully seven lines. The radii on both sides 

 measured alike. The skin was abraded, and 

 a wound about an inch long existed on the 

 dorsal surface of the radius near the wrist, 

 at about the level of the superior border of 

 the pronator quadratus. 



Ligaments. The external lateral ligament 

 and the posterior ligament were lacerated ; 

 the anterior completely torn from the border 

 of the radius. Some remnants of this struc- 

 ture lay on the front of the carpus. The in- 

 ternal lateral ligament was not torn, but the 

 styloid process of the ulna, maintained by this 

 ligament, and at the same time by the attach- 

 ment of the sheath of the flexor carpi ulnaris, 

 had been detached from the body of the bone. 

 Thus all the means of union of the articu- 

 lations had been completely severed, and the 

 bones of the forearm were only held to the 

 carpus by some bundles of fibres, which passed 

 posteriorly from the triangular ligament to 

 the internal side of the carpus. 



Bones. The radius did not present any 

 trace of fracture ; the body of the ulna was 

 also unbroken, but its styloid process was 

 torn from the rest of the bone, although still 

 held by ligament and tendon, as above men- 

 tioned. In the new position which the bones 

 of the forearm had accidentally assumed, re- 

 latively to the carpus, they concealed and lay 

 in front of the whole first range of carpal 

 bones, a"nd had been arrested in their descent 

 only by the true annular ligament, and the 

 tendons of those flexor muscles which pass 

 behind this ligament."* 



Let us suppose now a transverse fracture 

 of the radius, situated near to the wrist-joint, 

 with the displacement backwards of the in- 

 ferior fragment. This kind of accident will 

 most simulate a luxation of the wrist, such as 

 the foregoing case, in consequence of the 

 size of the two eminences, the one placed 

 anteriorly, the other posteriorly ; but in frac- 



* Archives Generates de Medecine, Decemb. 1839, 

 p. 401. 



WRIST-JOINT (ABNORMAL ANATOMY). 



ture the anterior and posterior saliency, in 

 general, are not very conspicuous ; whi'le in 

 luxation the posterior formed by the carpus, 

 and the anterior by the bones of the forearm, 

 have each a thickness of more than half an inch. 



It is very true that we have seen cases 

 (see Jig. 933., for example) of fractures through 

 the junction of the lower epiphyses of the 

 radius, with fracture also of the ulna, which 

 even in this amount of saliency of the anterior 

 and posterior prominency, much resembled 

 the case of a dislocation ; but the saliency pos- 

 teriorly in the case of the dislocation is formed 

 only by the rounded summit of the carpus, and 

 the measurement from this point to the ulti- 

 mate extremity of the middle finger gives 

 only the normal length of the hand ; whereas, 

 if the deformity at the back of the forearm 

 resulted from a fracture of the radius with 

 displacement backwards of the lower frag- 

 ment surmounting the carpus, a measurement 

 taken from the summit of the dorsal pro- 

 minence to the end of the middle finger would 

 show an increase of at least half an inch over 

 the normal length of the whole hand, because 

 to the summit of the carpus in the case of 

 fracture with displacement is superadded the 

 amount of the depth of the lower fragment 

 of the radius. By this test of measurement, 

 therefore, we might settle our diagnosis be- 

 tween these two accidents which so much 

 resemble each other. 



The styloid process, too, of the radius can 

 be felt still holding its normal relation to 

 the carpus in cases of fracture, and to move 

 with the hand when any motion is communi- 

 cated to it ; whereas, in the rare dislocation 

 of the wrist-joint, which we are here consi- 

 dering, the^ lower extremity of the radius and 

 ulna will be found placed in front of the 

 carpus, and here, too, form an abrupt swell- 

 ing, just above the superior margin of the 

 annular ligament of the wrist. 



Dislocation of the bones of the forearm back- 

 wards with displacement forwards of the carpus. 



It is said that this dislocation, which is the 

 reverse of the foregoing case of Voillemier, 

 may occur as the result of accident.* Upon 

 this head all we have to say is, that this dis- 

 location of the bones of the forearm back- 

 wards at the wrist-joint, as the result of acci- 

 dent, must be exceedingly rare ; but that, on the 

 other hand, this is the very displacement of 

 the bones which so usually exists in almost 

 all cases of congenital dislocation of the wrist- 

 joint (figs. 924. and 925.). 



Luxations of the lower extremity of the ulna. 



There are two species of this luxation of 

 the lower extremity of the ulna. In one, the 

 ulna escapes from the sigmoid cavity of the 

 radius in passing backwards ; in the other, it 

 is by the anterior part of the articulation that 

 the displacement occurs. Luxation of the 

 inferior extremity of the ulna backwards is the 

 more frequent of the two ; that for wards must 

 be rare, says Boyer, for I have seen but one 



* See Nelaton, Ele'mens de Pathologic, vol. ii. 

 p. 408. 



