Vol, XVIIENo. 3 AN OPERATION FOR UNREDUCED Pos- ‘TERIOR DISLOCATION OF THE ELBOW? By J. 8. Sree ‘Memp! MD, FACS, Tenn, Unreduced posterior dislocation of the elbow ig a condition which, in our present state of en- lightment, should never be encountered, Cline faaly, the appearance of the joint is almost di- agnostic and roentgenogram clears up all pos- sible doubt, “However, then the case is seen iate, after marked swelling has taken place, it {5 not dificult clinically to confuse with a supra- condylar fracture of the humerus. Many phy- ticlans practicing in the rural communities, do not have the help of the x-ray to check up their tbservations, and without reduction of the dis- locaton, put the arm up in the routine acutely flexed position, ‘The error is not discovered unl the arm is taken down some weeks later. What was at first a very simple condition to carrect has been changed by. this time into 4 most difficult task.” Closed reduction of an'elbow which has been dislocated for i] HN eh bY jin 2 tt of several weeks or longer cannot be accom. Plished at all in mast eases, and never without Such serious damage to the articular surfaces that ankylosis is almost a certain consequence. fo Section on one and Jlat Sure wedi Atestaon, Fghhanoat Hel ‘et ay Nowe Sn a SOUTHERN MEDICAL JOURNAL 193 AA brief description of the anatomy of the elbow joint will help to make the cause for this dif culty more evident. ‘The elbow is a hinged j firmly held together by strong ligaments qn prac- tically all sides, To add to its security, the trochlea humeri rests in the deep “U" shaped articular surface of the ulna, formed by the olecranon process behind and the coronoid proc css in front. In posterior dislocations, the trochilea and capiteltum are pushed forward over the coronoid and the head of the radius, re- spectively, the coronoid being drawn upward be- hhind the humerus in the region of the olecranon fossa by the pull of the triceps tendon and the head of the radius is wedged up behind the capi- tellum by the strong pull of the biceps tendon attached to the radial tuberosity. Immediately following the injury sulficient muscular relax tion can be obtained to slide the trochlea easily14 Umar tore Aecranen ste baans back over the coronoid process and replace the bones in their normal relation, but as each day goes by with the joint unreduced and the elbow immobilized, there is a further contracture of the various’ tendon: tudate around the joint becomes organized, fi ing the olecranon fossa with fibrous tissue and allus, and forming adhesions between the. ar- lar surfaces of the bones and the surround- ing soft tissues. By the end of three or four weeks this contracture has progressed enough effectually to prevent any mobilization of the joint sufficient to obtain reduction, To add to ly, a condition of osteoporosis from ie develops in the bone, particularly the humerus, which makes the bone extremely frag- ie and subject to injury, so much so that it often tears and crushes. more easily than the soft tissues attached to it. TL is extremely im- Portant to remember this point, even in open reductions. Serious and irreparable damage will be done by ill advised attempts at a forcibie closed reduction, Granting then that the open reduction is the SOUTHERN MEDICAL JOURNAL March 1925 necessary procedure, there are certain. fundae rental principles which must be considered. On account of its complicated architecture, the elbow joint is notoriously prone to develop) an- kylosis following injury to its bony components of to the surrounding soft parts. An operat Drocedure, to be successful, must first allow suf- ficient separation of the contracted soft tissues from the bone to permit free mobilization of the bones and replacement of the joint without force or levering. If this is not observed, the articular surfaces of the osteoparotic bone will be crushed, ankylosis results and the operation will prove a failure. Second, it must allow con plete exposure of the joint so that adhesions to the articular surfaces may be divided and scar tissue may be removed from the olecranon fossa ind the incisura semilunaris. ‘Third, in obtain- ing this exposure duc regard must be ie about the joint and an approach \t so injure the muscular at- ced wh Fig, 4eTlgve ton trned down: Inon thre mot i ee Sen ohameree Biphiv o ead of eaeVo, XVILENo.3 zy a Cera cass tachments, vessels oF nerves as to prevent a re- turn of function, ‘The operation to be described is one that has been worked out in a large part by my col- Teague, Dr. Wills C, Campbell, and many of its details have been reported by connection with his work on arthroplasty of the elbow. ‘That the operation is practical and fulfils the requirements necessary to obtain a satisfactory functional joint has been demonstrated by its use in a considerable mumber of cases. OPERATIVE TECHNIC An incision is made over the posterior sur- face of the elbow, beginning in the midcline about four inches above the Up of the olecranon ‘and extending down to just above the tip of the ‘olecranon, where it turns slightly outward over the center of the external condyle of the hu- rmerus and the head of the radius for about two SOUTHERN MEDICAL JOURNAL 195 inches on the forearm. Skin flaps are dis- seeted back, completely exposing the tendinots Insertion of the triceps muscle and the poste surface of the elbow joint. ‘The ulnar nerve is id, dissected up from its bed along condyle and retracted Beginning at its upper end, the tendon of the triceps muscle is dissected out ‘and turned down, leaving it attached to the ole- ‘eranon. An incision is next made directly in the midline, through the fibres of the triceps muscles down to the humerus, extending from three inches upon the shaft down to the reflexion, of the joint capsule around the articular sur- faces. Subperiosteally, all of the muscular at- tachments over the Tower end of the humerus, both anteriorly and posteriorly, are stripped free with a periosteal elevator, When the attach: ‘ment of the joint capsule around the condyles ‘of the humerus is reached it is necessary to di vide this with the knife or scissors. Some diffi. ceulty may be encountered in freeing the tissues around the internal condyle andl along the an- terior surface of the humerus just above the shame extreme Fig. 6-—Latera sew after motion, Tine xcsanally196 ch ane TT eu Wi NH Fg. Mave back tn pot, joint, but it is essential that they all be loosened And the lower end of the be completely mobilized. ‘This difficulty will be greatly les- sened ifthe incision has previously been ex- tended dawn over the radius, exposing the head anda small portion of the shaft. ‘There is often considerable callus formed over the posterior surface of the humerus around the olecranon fossa, due to stripping up of the periosteum at the original injury. ‘This callus with the scar tissue in the olecranon fossa and incisura semi- Tunaris is next thoroughly removed. Having completely mobilized the lower end of the humerus and exposed the capitellum and Tnead of the radius, the first step in the reduc- tion is now made. "By simply twisting the fore- arm with gentle pressure over the capitellum, the head of the radius is made to glide forward ‘over the eapitellum into the normal position. Tf this is not easily accomplished it is a great temp- {ation forcibly to skid the capitellum backward with a periosteal elevator. Enough force should not be used to injure the capitellum, as a Tittle more dissection will render force unnecessary. ‘After the radius is reduced itis an easy matter to stip the coronoid process forward over, the {rochlea and complete the reduction. ‘The joint 4s then carried through the full range of motion to ascertain that thete fs no obstruction. The periosteum and muscles are next close! along the posterior surface of the humerus, the fascia closed over the head of the radius and the ten- SOUTHERN MEDICAL JOURNAL March 1925 don of the triceps muscle sutured back into its normal position, ‘The arm is placed in a terior splint with the elbow flexed at right sles. POST OPERATIVE TREATMENT 1e arm is kept iv a right angle posterior splint for from seven to ten days, depending ‘upon the amount of operative reaction. Light massage and baking are then started and the splint removed several times a day for a gentle active and passive motion. By the end of the third week, the splint is discarded and func- tional use of the am encouraged. At this time the use of dumb bells and exercisers is of ma- terial benefit. When the dislocation has ex- ed for a long period of time, there is consid- erable muscular atrophy, and the articular car- tilages are roughened and atrophic, hence a long period after treatment is necessary to ob- tain the best possible function. Children, of course, respond more quickly than adults. Fig, A—Cheures be te eg bared Bat ito pononVol.NVIIINo.3 SOUTHERN INDICATIONS. ‘The operation fs suitable in all uncomplicated posterior dislocations of the elbow, which have femained out a sulficient length of time to pre- vent closed reduction without undue trauma to the joint, After the second or third week, closed reductions are generally not satisfactory. Jin the doubtful cases, much less damage will be done and a much better functional result ob- tained by an open reduction. Of course,, in casts complicated by extensive fractures “and bony ankylosis, an arthroplasty of the elbow offers the only hope of a movable joi RESULTS We have employed the operation in a num: ‘The st gratifying results, depends upon two rst, the Tength of time the dislocation te, and second, whether the case is an adult or child, Four of the cases were in children, three of whom had been tically normal motion and a perfect functional result, One that had been dislocated ¢j months had about 60 per cent normal motion after six months. | Hovtever, sullicent function had been re-established to induce normal growth, and development, and prevent the atrophy and shortening which follows disuse of a limb in a growing child, One adult of ten weeks? duration, with the bow in full extension and no motion in any irection, regained a complete range of supina- tion and’ pronation, and about 40 per cent flex fon, A second adult, with a dislocation of only six weeks? duration,’ we have been unable to trace, but on discharge she was making excel- Tent progress, and we believe obtained an excel- lent result. 869 Madison Avene DISCUSSION (Abstract) br, Fred G. Hodgion, Allama, Ga—tn the eater days, when T'did not make Tong enough incsons, 1 twas troubled with parabjis of the ulnar nerve. Unest Jou fee it and put tout of the way you wil hoy Trouble T have had great deat of trouble in thise cases. have tsed the Usshaped Incision, the Lateral faci, find biter facslons, In the fature L shall adopt this ‘method, which appears to be most rational Dr, Barney Brooks, St. Loui, Mo—Dr. Speci bas scribed what. would séem to! be ‘an deal surgieal ‘operation for unreduced dslacation of the elbow. MEDICAL JOURNAL, 197 3s ptr fovorbhy tmp th the meta Ot oncoming the contain of he Weg me Ike tose a pit whch Dr Speed me rol enphatie, the eatin of the ne Sas esd for any oem oid a tine thse 124 sry mated atopy tthe nea any ae 2rd of te dt by toe ded etd isin tamoge othe font sata, ey epto, ited he opt meted ston Me ppd tha prema atop free the sation ie ace need Dr ire Cob, Re Oran, Lats De, Drgks ss ths modo spray andthe mod ot iene he tape en ena aie Ry tamed ln cote pet et ‘ir ony et on cho SE a Be Spee nthe mtd of sprnche tare he {2 eshte tt este the tke don Su Go's neye by tah apes te sees idan beg stre tc pl whe thy all tte ental! theta tgs, hay we Fou'hie todo 900 tan striata {Se eta tp te pers and ake no Isto vil Be. ont ote nea ot Tr not cw ee Jos immed, eee 1 sel, om tenn af thet sce tat cerca nou of tno ad Wi ate ‘he fant cape ode Oe pet pla" We teat the acrig "the Wie pa of ave oO ‘land lee aml opening fr dri De, W. 8. Carl, Dat, Teasi—The ne a: pean ts rom mtn sft a at bari perros you're omnes wa ony. som if by ding 9 He more dicen you cept ie aon oat Sec he ads ion De BD. Fee, Ney Oran, Lh inpesion sci to hve ben caneye ye Speer 28d some Sf thow dct he pe tat weed dele tan af thea te nach move ees ate wih tapes thm fo be Amore Connon tat To "le mtake sapacndd oe other iatres Ofte humeas or dneton rier thy ate: thn for rac" 1 have tat fad the lege a Crployng ths fal apron, at mpreion wats nc prow waul ty no te ve the openness Ueto or ia, it mii be very dle to die ow soft thos Sones and bore ah er won wht fee tote ee may ty be ade We ona Oak (iii he ce he fo te crete, kek {beyond ret ta eh eyo ie ta ney imprint pat ofthe posed and She hat coh Uo ered fo. Dr. Wills C. Campbell, Memphis, Tenn —There ate A few points Which might be emphasized. Tn the fest Of the series of 15 ancient dlocalfons of the elbow the toveried U-incision was employed, but great dil- fictty was experienced in freing the bones Irom the dee’ set tse and as the postion was aly ce the pesteior soft structures could not be cased tere the it was Boxed, thos imparing Tatu fe tion.” By the method which Dr. Speed has describedsourH 198 the soft stctures are eaglly: separated, giving ample ew 0 the isocation. This cam then be easily re- Uoced without danger of jnjury to the ulnar nerve oF ital structures, "After reduction, passive motion is Ttee, ‘In the lateral approach the alnar nerve Es une protected ad might be inpiaged fn the process fe Uteton A great de Joint upon Adepemls jn disacation on the type of te operate. In a Tare fat oman, ‘with a Tange Gt ara, or'a. man of loose muscle de ‘elopment the joints axe mow oF less of the loose te, and reintion is much eater ih stall incon than in the sal miscuse ilielduas, oF the tspe In Irie there he boon considerable fibrosis. That pot thas to. be taken ito consideration In operative ro cre on any fla De. Speed (closing).—This approach to the, elbow joint hae previously een described by Dr. W pel his wotk on arthroplasty of the elbow. Dr, Brooks has emphasized the danger of injuring the conde of the humerus in attempting. closed re Ahtions in these ease. Many. make the mistake of Saying! “This ditocation ha existed oly about thee tveeke and Re ought to slip. in without ang rouble, We will give am anesthetic an tempt to reduce forcibly, "Mit dove not reduce we wil then operate ‘This fe a very dangerous allude to assume in-any Aislocaton that a existed Tong as thece weeks. By Terparable damage may ie done to the atrophic condyles of the humerus, re- sting in anklosts even though the reduction i done ty operative means Iter. “The posterior approach is far sap fist brcause Hi necesary (0 obtain a f of the internal condyle of the humerus which is very ‘hitch am external lateral Hndsion. Second, it lloee 2 miueh beter exposure” of the inciura semi Tunis sid the oleranon fess. Third it logical from an aratomeal standpoint a8 1 does not injure any" of the oft pats. ‘As to freeing the rds, we do not hesitate to disect down from #2 10 incon the shaft when necessary Dislocations of the elbow sue rare, but in a large sof Titres and san they our In an ap Dreciable number. When they cannot be reduced yy fhe closed method they” offer afar more dificalt preblem, sind we feel that the above procedore 1s the Fest method availabe of ring the. fo the lateral ACUTE NON-TUBERCULOUS ILIO-PSOAS ABSCESS* By LeRoy Loxe, M.D. F. Oklahoma City, Okt ACS, T wish to call attention to a syndrome made up of fesion deformity ofthe thigh, tender mass of recent formation on the inner side of outer Poupar’s ligament, moderate pain about sicueh, Roneal Hecn. New Or RN MEDICAL JOURNAL March 1925 the inguino-crural region, remittent fever, marked leukocytosis, emaciation and weakness, which is associated with and caused by an acute abscess behind the iliac fasci T have operated upon six patients presenting this syndrome during the last few years, which would seem to indicate that the condition is not an extremely infrequent one. Probably sur- eons have encountered the condition many times, but apparently there is very little in the literature about tically all the standard textbooks ignore it most direct reference to it that [ have found is in the last edition ‘of Ashhurst’s “Surgery” under the heading, “Traumatic Hine Abscess.” He covers the sub: ject in the following paragraph: ‘Traumatie Hae abscess deserves recognition asa linea entity, An estrapertoneal abscess, cht of forme ar the result of trina or sprain. Prob. wees @ hematora, which becomes Ine ‘lood stream, In some ates the hadenlis of the Hodes, ‘There Is no evideace that it ie The agnosis the esternal Mae artery tesule from er peons absces, Treatment conte In opening and drain. Ing the abcess by an Incson else to. Poupan’s laa- ill be observed that there is scarcely a a8 to symptomatology and clinical course. Tn this series there were five white boys, rang- ing in age from five years to seventeen years, fone white married woman, twenty-nine years of age “There was definite and permanent recover in five of the patients in from three to six weeks, In one of them, the seventeen year old boy, there was an illness of longer than a year, and there is some doubt as to whether it is ap- propriate to include this case in the series. The infecting organism was Staphylococcus aureus in three cases, Slaphylococeus albus and strepto- coccus in one case and streptococcus in one case. Tn one case there is no record of the organism, ‘The last patient in the series was operated upon July 2, 1924. A brief recital of the his- tory, physical findings and clinical course in this ‘case, both before and after operation, will cover the characteristic features as presented by the average patient ‘A white boy elght years of age whose previows heath had been ‘ood, was Drought to the ‘osptal fn account of a marked flexion deformity of the night iMigh acocated ‘with -moderate pain about the BE nd roi fever, You of weight and weakness "The child had been fl fora file Longer than four weeks, "The fist notkeable symptom, according, to