Disease of Elbow-joint 267 



separation of the lower humeral epiphysis, but this is excluded by 

 the fact that when the lesion has recurred the top of the olecranon 

 process is far above the horizontal line of the humeral condyles. 



Other dislocations may take place, a not very uncommon variety 

 being that in which the head of radius tears through the front of its 

 orbicular ligament and the thin anterior ligament of the joint, and, 

 slipping up above the capitellum, rests against the front of the lower 

 end of the humerus. The characteristic features of the lesion are the 

 absence of the head of the radius from the pit below the external con- 

 dyle, and a mechanical impediment to full flexion of the joint, on 

 account of the radial head impinging against the front of the humerus. 



In children the head of the radius is apt to be dragged out of the 

 orbicular ligament by a sudden pull upon the hand or fore-arm, the 

 elbow at once becoming swollen and tender. To replace the bone, 

 the elbow should be bent to a right angle, so that the head of the 

 radius may be brought close to the empty collar, and then, by firmly 

 and fully pronating, the bone is ' screwed' again into its place. 



In synovitis there is a general fulness about the joint, with a bulging 

 on either side of the olecranon and of the insertion of the biceps, and in 

 the fossa below the external condyle, in which region the joint is com- 

 paratively superficial. The intra-articular effusion fixes the joint in a 

 position midway between flexion and extension, the greatest use as 

 well as the greatest comfort, moreover, being secured in this way ; later 

 on, the weight of the hand may carry the radius round to extreme 

 pronation a most undesirable condition. At the commencement of 

 treatment, therefore, the elbow should be fixed at a right angle, and 

 only halfway pronated. 



Abscess in the joint. If suppuration occur the pus will be likely 

 to escape between one of the condylar ridges and the triceps, where the 

 capsule is thin and comparatively near the surface of the limb. 



Excision of the joint is performed by an incision of three or four 

 inches through the triceps in the middle line, down to the bone, divid- 

 ing the skin, superficial and deep fasciae, the triceps, and the peri- 

 osteum over the olecranon process and down the prominent posterior 

 border of the ulna. By the aid of a raspatory the periosteum and the 

 triceps are peeled from the humerus, and the insertion of the muscle is 

 detached by a scalpel. In doing this the edge must be kept close to 

 the bone, all those fibres which run to their insertion in the deep 

 fascia being carefully preserved, so that trie muscle may retain as 

 much of its power of extension as possible. Chiefly by the raspatory, 

 and slightly by the knife, the origins of the muscles from the condyles 

 of the humerus are detached, but no transverse cuts are to be made, 

 lest, by chance, the ulnar nerve be wounded and useful bundles of 

 fibrous tissue be sacrificed. The ulnar nerve is raised from its bed 

 between the condyle and the olecranon and turned inwards, but the 

 operator ought not to expose it. If he do see it he has evidently 



