WRIST-JOINT (ABNORMAL ANATOMY). 



complained of intense pain in the limb ; the 

 hand became cold and discoloured ; the roller 

 was not removed nor relaxed. On Tuesday, 

 dark coloured vesicles formed ; constitutional 

 symptoms of the gangrene showed themselves; 

 the pulse 159, feeble; countenance anxious. 

 The gangrene increased for two days more, 

 and reached within two inches of the elbow- 

 joint. On the sixth day a line of separation 

 showed itself; and on the twenty-fourth day 

 the bones were sawn through, and the wound 

 soon healed. 



Dissection of amputated Forearm. The 

 radius was found to have been completely 

 broken through in the line of junction with its 

 lower epiphysis. The ulna was entire. The 

 preparation of the disjoined epiphysis and 

 gangrened hand is preserved in the Museum 

 of the Richmond Hospital. 



The causes which have been known to pro- 

 duce a disjunction of the epiphysis are said to 

 be similar to those which produce a transverse 

 fracture of the bone close to the wrist-joint: 

 but why in one case we should have a fracture, 

 and in another a disjunction of the epiphysis, 

 we cannot say. All my own observation has, 

 as yet, taught me relative to this subject from 

 the cases I have seen and inquired into, has 

 been that the cause producing the disjunction 

 in question has always been a violent one. 



When a patient has suffered a disjunction 

 of the lower epiphysis of the radius, there is, 

 in general, much deformity observable in the 

 region of the wrist. The hand, carpus, and 

 lower fragment are carried backwards, and 

 form together a plane which is from half an 

 inch to three quarters of an inch behind the 

 plane of the back part of the rest of the fore- 

 arm ; the transverse line of elevation of the 

 lower fragment above the level of the dorsum 

 of the upper fragment of the radius is very 

 abrupt and obvious : and the first impression 

 on the mind is, that a dislocation backwards 

 of the carpus and hand is the accident which 

 has occurred. This abrupt transverse ridge 

 and depression are crossed vertically by the 

 extensor tendons of the carpus; and pressure 

 with the fingers discovers these longitudinal 

 tendinous bands to be on the stretch, having 

 been forcibly elevated from the back part of 

 the radius as they pass to their grooves formed 

 in the lower fragment. 



The palmar surface of the forearm is un- 

 usually convex from above downwards, and 

 does not present a salient angle in front, such 

 as we might expect from the abrupt depression 

 we noticed on the dorsum of the wrist and 

 forearm. This convexity of the forearm in 

 front, however, abruptly terminates in a trans- 

 verse narrow sulcus which marks the situation 

 of the upper margin of the anterior annular 

 ligament. The radial margin of the forearm is 

 concave, and the ulnar margin presents a cor- 

 responding convexity. The patient complains 

 much of pain, and has the same inability to 

 move the forearm and hand as in cases of 

 fracture. 



By the above-mentioned signs we become 

 informed that a solution of continuity in or 



1489 



near to the transverse line of junction of the 

 lower epiphysis of the radius exists : but 

 without having had any opportunity of insti- 

 tuting an anatomical examination, we believe 

 it would be difficult for any one to affirm 

 whether the case were one of fracture, or 

 disjunction of the epiphysis. Some writers 

 seem to think that the case of disjunction 

 of the epiphysis may be recognised by the 

 circumstance, that, although there is an evi- 

 dent solution of continuity in the line of the 

 radius, the crepitus of an ordinary fracture 

 cannot be produced. To which we reply, 

 that the absence of crepitation is not by any 

 means unusual in cases of fracture of the ra- 

 dius in the region of the wrist; and, therefore, 

 from this observation no useful inference can 

 be deduced to aid our diagnosis. 



In the examples of disjunction we have 

 seen, we have always noticed a fixed condi- 

 tion, as it were, from the interlocking with 

 each other of the portions of the disjoined 

 radius ; so that it seemed quite vain to seek 

 for crepitus; indeed we found it invariably 

 demanded a considerable force in these cases 

 to restore the limb to its original form. 



We believe it is impossible to make a dif- 

 ferential diagnosis entirely to be relied on in 

 these cases ; but we may, we think, conjec- 

 ture that the disjunction in question exists 

 rather than a fracture, when the age of the 

 patient is under eighteen or nineteen years, 

 and the situation of the solution of con- 

 tinuity is in the exact transverse line of the 

 junction of the epiphysis to the shaft of the 

 bone. If, however, the diagnosis be difficult, 

 we have practically little to regret this cir- 

 cumstance, because the prognosis and thtr 

 treatment will be the same in both cases. 



SECTION 111. DISEASE. In describing 

 the alterations, the result of disease as it af- 

 fects the other articulations, the abnormal 

 anatomy of which we have already adverted 

 to in this work, we have classed these morbid 

 changes into those which are the consequence, 



1st. Of Acute Arthritis. 



2nd. Of Strumous Arthritis ; that is to say, 

 "a scrofulous disease of the joints, having 

 its origin in the cancellous structure of the 

 bones." 



3rd. Of Chronic Rheumatic Arthritis. 



Here we may adopt a similar arrangement, 

 but shall find it necessary to add, 



4thly. A few observations on Synovial Tu- 

 mours of the Region of the Wrist. 



Acute Arthritis of the radio-carpal, and of 

 the inter-carpal articulations, may be the con- 

 sequence of a contusion or a wound, or it 

 may originate in some internal cause, such as 

 an acute rheumatic, or a diffuse inflammation. 



Acute arthritis of any or all the joints which 

 enter into the composition of the region of the 

 wrist may be the consequence of a sprain or 

 wound, or the inflammatory action may have 

 been communicated to these joints by having 

 extended along an injured tendon of the fin- 

 ger, or the inflammation, suddenly showing it- 

 self in the joints, may have originated in some 

 unknown internal causes, such as those which 

 5 E 2 



