FRACTURE 
OF THE 
HUMERAL EPIPHYSIS 
IN 
OLD DISLOCATIONS OF THE ELBOW 
BY 
THEODORE A. McGRAW, M.D., 
PROFESSOR OF SURGERY IN THE DETROIT MEDICAL COLLEGE 
Reprinted from The Medical Record, 
January 17, 1880. 
NEW YORK: 
TROW'S PRINTING & BOOKBINDING CO., 
201-213 East Twelfth Street. 
1880. FRACTURE OF THE HUMERAL EPIPHY- 
SIS IN OLD DISLOCATIONS OF THE 
ELBOW. 
The few cases of unreduced dislocation which I have 
seen have resulted in great and permanent disability. 
The inability which almost invariably accompa- 
nies this injury-to flex the forearm within an angle 
of 120°-is in itself a great inconvenience. 
Patients with backward luxation of the elbow-joint 
can neither feed nor dress themselves, nor comb their 
own hair, nor even write, except in a most constrained 
posture. I cannot understand, therefore, the timidity 
with which Hamilton, in his famous work, approaches 
this subject, for while he quotes some cases of old 
dislocations in which he attempted, with varying suc- 
cess, the replacement of the bones, he records many 
others in which the disability was very serious, and 
in which he advised non-interference. 
It has seemed to me that so grave a disability 
should warrant almost any procedure which would 
offer hope of improvement, and it was with that feeling 
that I proceeded to operate in the case I am about to 
relate : A little girl of nine years fell and dislocated 
her right elbow. The irregular practitioner who 
was called upon to attend her failed to recognize the 
trouble, and treated the case as one of fracture with 
the arm in extension. 4 
The accident occurred on October 2, 1877. Nine 
weeks afterward, Drs. Taylor, of Mt. Clemens, and 
Brownell, of Utica, saw the child, recognized the 
nature of the injury, and made a vain attempt at re- 
duction. Six weeks later, and fifteen weeks after the 
reception of the injury, the child was brought to me 
for treatment. On examination I found the arm 
nearly extended. There was limited motion at the 
elbow, but flexion caused pain and had to be dis- 
continued when it had reached an angle of 120°. 
On the 26th of January, assisted by Drs. Brownell, 
Gowan, Reynolds, and others, and in the presence of 
my medical class, I had the child anaesthetized and 
attempted the reduction of the dislocation. 
I first broke up the adhesions and tried the ordi- 
nary methods of reduction by manipulation. These 
failing, the pulleys were applied and extension made 
to the utmost justifiable extent in every position of 
the arm. I then divided the tendon of the triceps 
subcutaneously and applied the extending force 
until motion in every direction seemed absolutely 
unrestricted, and yet, though every obstacle had ap- 
parently been ruptured, the luxation could not be 
reduced. During the manipulation something sud- 
denly gave way and the deformity disappeared, and 
I thought for the moment that I had achieved suc- 
cess ; careful examination showed, however, that the 
old abnormal relations of the olecranon and the con- 
dyles still persisted, and further investigation re- 
vealed a fracture of the humeral epiphysis and a dis- 
placement of the epiphysis forward upon the shaft in 
such a way as to permit of easy flexion of the elbow 
and an apparent disappearance of deformity. 
Comparison of the two arms showed that the de- 
formity had only changed in character and not dis- 5 
appeared, for the humerus of the injured side 
seemed now abnormally short in comparison with 
that of the other. I availed myself of the new con- 
ditions to secure better motion to the elbow-joint, 
and to so apply lateral angular splints as to permit 
the epiphysis to remain in its new position on the 
shaft. 
No inflammation or bad symptoms of any kind in- 
terfered with the healing process. At the beginning 
of the second week in February, 1878, the patient 
left the hospital convalescent. Last month, nearly 
two years after the operation, I had occasion to ex- 
amine the arm again, and found it in a most gratify- 
ing condition. The humerus was a little shorter than 
that of the opposite side. Flexion was nearly perfect, 
but extension could be made only to an angle of about 
145°. 
As the free flexion permitted almost every use to 
which the hand could be put, and as the limited ex- 
tension prevented only such uses as would require 
the arm absolutely straight, it can be readily seen 
that so far as usefulness was concerned, the patient 
had been vastly benefited by the operation. 
As regards beauty, the present deformity would not 
attract the notice of any casual observer, while the 
awkward position entailed by an elbow dislocation 
forces itself on the observation of all. 
This case confirmed the truth of Erichsen's asser- 
tion that muscular contraction has nothing to do with 
the difficulty of reducing an old dislocation of the 
elbow. 
Division of the triceps, although it made possible 
the utmost freedom of flexion, did not facilitate at 
all the reduction of the luxation. 
This experience has made me doubt whether frac- 6 
ture of the olecranon after Crosby's method, actually 
permits reduction. Fracture of the olecranon would 
undoubtedly make possible the same free flexion as 
tricipital tenotomy. It would cause the disappear- 
ance of the principal deformity, viz.: the undue pro- 
jection of the olecranon; but how it could in any 
way relieve any obstacles to reduction which tenoto- 
my of the triceps had failed to overcome, I cannot 
understand. 
Now, when we consider that the only positive test 
of the reduction or non-reduction of a posterior dis- 
location of the elbow consists in a careful comparison 
of the relations of the olecranon process to the con- 
dyles, it becomes evident that fracture of the olecra- 
non destroys the only test by which we can establish 
the true position of the bones in relation to each 
other. 
As fracture of the olecranon has given to such pa- 
tients more useful extremities, as it has enabled them 
to flex the forearm upon the arm, it has, of right, a 
claim to be considered a proper procedure. 
It may not, however, be regarded as a mode of re- 
ducing the dislocation, and of bringing the joint sur- 
faces into their old normal relations until exact post- 
mortem observations shall have shown such to have 
been actually the case. 
It is unfortunate that we do not, as yet, understand 
the actual pathology of an ancient elbow dislocation. 
It is evident to me that muscular contraction plays 
little or no part in opposing the reduction. It is in- 
conceivable that the mere interlocking of the bones 
should make so strong an obstacle. I can believe 
only that the ligamentous structures which are rup- 
tured at the time of injury become glued so firmly to 
the bones as to prevent their disentanglement. 7 
When we consider the extreme loss of function 
caused by such a condition, it does not seem to me 
good surgery to dismiss such cases unrelieved. 
Our surgical resources for the relief of a chronic 
dislocation of the elbow are first, attempts at reduc- 
tion by manipulation and extension. These rarely 
succeed after the lapse of three or four weeks. Sec- 
ond, fracture of the olecranon. This procedure re- 
lieves the deformity, and by permitting free flexion 
adds immensely to the usefulness of the extremity. 
T have already stated the reasons for doubting whether 
it ever facilitates the actual reduction of the luxation. 
I feel especially justified in adopting this view when 
on reading Hamilton's record of cases, I find two of 
said cases in which he expressly states that, though 
certain of having reduced the ulna by fracture of the 
olecranon process, he had been unable to bring the 
radius into place. It may be a fair question to ask. 
how he could be certain that the ulna was in place 
after its relations with the condyles had been de- 
stroyed by fracture ? * 
The third method of treating an ancient disloca- 
tion of the ulna is that which accident demonstrated 
to be of service in the case I have just related. This 
could occur, of course, only in young persons, before 
the union of the epiphysis with the shaft. It oc- 
curred in my case as I was flexing, and at the same 
time pulling with considerable force on the forearm. 
Had the tricipital tendon not been previously divided, 
it is probable that the olecranon process would have 
broken instead, and that I should to-day have labored 
under the delusion that I had thus actually reduced 
the luxation. 
Extreme flexion of the forearm, in children suffer- 
ing from an ancient dislocation of the elbow, will be 8 
liable to produce either a fracture of the olecranon 
or one of the humeral epiphysis. Either occurrence 
would vastly improve the condition of the joint. Sub- 
cutaneous incision of the ligamentous structures 
around the joint has not been followed, so far as I 
know, by any benefit. The lack of positive knowl- 
edge as regards the nature of the obstacles to re- 
duction make the procedure too blind to be of 
service. 
There still remains two possible means of improv- 
ing an old dislocation of the elbow. Excision of the 
joint has all the dangers and all the possibilities of 
that operation when undertaken for other maladies. 
I do not care, in this connection, to dwell upon it. 
The other remaining operation is one that suggests 
itself to me as feasible and as offering hopes of bet- 
ter results than nature could ever possibly accom- 
plish in a neglected dislocation. I hold in reserve 
as a procedure, which I shall not hesitate to resort to 
if I ever get the opportunity in a suitable case, the 
incision of the joints under the antiseptic spray ; the 
division of all ligamentous and muscular obstacles 
which prevent reduction;, the replacement of the 
joint surfaces, and subsequent strict attention to all 
the details of the antiseptic treatment. The elbow 
should, of course, in such cases be put in rectangular 
splints. Healing, if it occurred without suppuration, 
might reasonably be expected to result in a good 
joint, with tolerably free motion. If suppuration 
should take place, the anchylosed arm would be in- 
finitely more useful in a flexed position than when 
nearly extended.