CASES 
OF 
LUXATION OF THE ELBOW, 
BY LEWIS A. SAYER/M. IY, 
Professor of Orthopedic and Clinical Surgery, Bellevue Hospital Medical College. 
REPRINTED FROM THE TRANSACTIONS OF THE MEDICAL SOCIETY 
OF THE STATE OF NEW YORK FOR THE YEAR 1871. 
ALBANY; 
THE ARGUS COMPANY, PRINTERS. 
1871. LUXATION OF THE ELBOW. 
Case 1. 
Ricardo Gibbs, aged five years, a native of Cuba, came to me on the 
9tb of August, 1867, with a luxation of the forearm backwards, the 
result of a fall received fourteen weeks previously. 
The limb was very nearly straight and fixed at the joint, no motion 
being manifest. Several attempts had been made in Cuba to reduce 
it, but they were all unsuccessful. 
Col. Lewis Lay, of Havanna, then sent him to me, and after a care- 
ful examination of the case, I decided that it was worth a trial, 
although the fibrous adhesions were so firm as to give it the appear- 
ance of bony anchylosis. 
Dr. Frank Hamilton and Prof. James M. Bush, of Kentucky, were 
called in consultation, who both agreed with me as to the propriety 
of attempting the reduction. 
The boy was perfectly anesthetized with chloroform by Dr. Paine, 
and I made vigorous efforts at reduction by flexion and extension for 
nearly half an hour, without any manifest change in the position of 
the bones, although I succeeded in breaking, considerably, the fibrous 
adhesion. Dr. Hamilton then tried the reduction, but without any 
better result than my first effort. I made another attempt, and find- 
ing that I could not succeed unless I fractured the olecranon, I 
requested Dr. Hamilton to divide the triceps tendon subcutaneously, 
which he did, while I made it tense by very strong flexion, and in a 
few minutes I succeeded in making the reduction perfect and 
complete. The elbow was secured at a right angle with “Aid’s Felt 
Splint,” and kept wet with an evaporating lotion. The advantage of 
these splints over all others that I have seen, in cases where we wish 
accuracy of adjustment, with permanency of retention, and at the 
same time wish to keep the parts wet with lotions, either hot or cold, 
without any danger of their change of form or position, can only be 
appreciated by those who have had practical experience in their appli- 
cation. In this case it was retained on the arm for several days with- 4 
out the slightest change in position, although saturated with the lotion 
all the time, and gave the greatest possible comfort to the patient. 
Two days after the operation the arm was much swelled, and greatly 
discolored from the extravasated blood, but it gradually subsided, and 
on the tenth day the swelling had almost entirely disappeared, but the 
discoloration lasted for some weeks. 
After the tenth day the splint was removed daily and jjassive 
motions given to the joint with friction to the arm and forearm, and 
on the twentieth day from the operation, the flexion and extension of 
the elbow could be made complete, and without any pain whatever. 
There was very little voluntary power over the brachialis anticus 
muscle, and electricity was applied to it and the biceps flexor. This 
was continued every other day for two months, with friction and 
passive motion to the joint, by which time he could flex his arm to a 
right angle, could tie and untie his cravat and extend his arm nearly 
straight. 
He then left for his home, and I have not seen him since, but 
learned from his father, a few months since, that the motions of his 
elbow were as good as that of the other. 
Case 2. 
On the 7th of December, 1870, Dr. E, S. Dunster sent to my clinic 
at the Charity Hospital a lad aged thirteen years, who had a luxation 
of his elbow backwards, of thirteen weeks’ standing, and had been 
treated by a druggist in the country, by a straight splint, and of course 
his arm was quite firmly anchylosed in a perfectly straight position. 
Dr. Dunster had tried, a few days before, to reduce the luxation, 
but without success, and sent him to me for another effort, if I deemed 
it advisable. The joint was so inflamed at the time from the result 
of this effort, that I was afraid to attempt it, and advised the applica- 
tion of ice-bags until the inflammation should subside. 
He wras presented again on the following week, and while examin- 
ing his arm, and before any attempt made to reduce the 
luxation, he swmoned, and was revived with great difficulty. 
The boy was anaemic from starvation, and the bruit in his neck was 
like that of a chlorotic girl. 
As any anesthetic in his present condition wras dangerous, and as 
it was impossible to perform the operation without it, he was advised 
to wait until his general health wras improved, and for that purpose 
he was put upon a nutritious diet, with a full allowance of iron and 
quinine. 5 
Some doubts having been expressed as to the propriety of attempt- 
ing the reduction, I called a consultation on the 22d of Decem- 
ber, 1870. Dr. Hewitt, formerly surgeon U. S. A., advised exsection; 
some of the other gentlemen also advised this course. Dr. Mason 
detected the fracture of the coronoid process, which had become 
attached to the anterior portion of the condyle of the humerus. 
The arm was perfectly straight, and admitted of only the slightest 
possible motion. 
After carefully weighing all the points in the case, I decided not 
to resect it, as it might be followed by tedious suppuration, and his 
condition was too feeble to take that risk. 
Resection of a joint that has been a long time inflamed, and where 
the periosteum has become thickened, and will readily peel from the 
bones so that you can make the resection sub-periosteally, is a very 
easy matter; but when the boiies are in their noimal condition, it is 
impossible to detach the periosteum except in shreds. And I there- 
fore decided to attempt the reduction, and should this prove impossi- 
ble, I would then fracture the olecranon, and take my chances 
for motion ; but at all events have recovery with the arm anchylosed 
at a right angle, which would make it much more useful than in its 
present position. 
He was fully anaesthetized by ether, and with some considerable 
force I succeeded in breaking up the adhesions, and flexing the arm 
to an angle of about 135 degrees, when I was checked by the tension 
of the triceps; and fearing that the olecranon wTould fracture if any 
more force was used, I requested Dr. Mason to divide the triceps, 
which he did subcutaneously, and almost instantly the forearm was 
brought to a right angle with the arm, when it was checked from any 
further flexion by the coronoid process, which was attached to the 
anterior portion of the condyle of the humerus. 
By using the forearm as a lever, and with some considerable force, 
I fractured otf this attachment and succeeded in flexing the arm to 
an angle of forty-five degrees. 
The arm was secured in this position, and treated the same as in 
the first case. Yery little inflammation followed, and at the end of a 
fortnight passive movements -were commenced, and I was informed 
yesterday, by Dr. Dunster, that he has every prospect of a recovery, 
with very good, if not perfect motion. 
The dislocation had existed sixteen wrecks, lacking two days. 
Gross, vol. 2, page 144, says: “The reduction of this dislocation is 6 
extremely easy, if attended to immediately after its occurrence, but 
very difficult if it be neglected even for a very short time. 
Upon this subject there is no difference of sentiment among prac- 
titioners, writers and teachers. 
My experience in regard to it is ample, and in perfect accordance 
with that of the profession generally. 
I have no recollection of ever being foiled in my efforts, in a soli- 
tary instance of recent dislocation of the elbow joint. 
While I can call to mind a large number of cases where everything 
that could be done proved unavailing, after the third week, and some- 
times even by the end of the second. I am not prepared to assign 
any reason for this, to say why a displacement that is always so easily 
rectified, if properly managed in its early stages, should so soon 
become utterly resisting, and defying all the best directed efforts of 
the surgeon.” 
These two cases show that we may sometimes be successful, even 
after a longer period than three weeks, and therefore justify the effort. 
That there was a fracture of the coronoid process, in this ease, there 
can be no possibility of doubt, its crescentic edge could be distinctly 
felt on the anterior surface of the condyles of the humerus, and to 
which it had become quite firmly attached, and when the forearm was 
strongly flexed, it was fractured off with a very distinct snap, that 
was clearly audible to the entire class. 
The olecranon was not fractured, nor any other bone, and there- 
fore, this distinct noise of a fracture must have been made by the 
fracture of the coronoid from its new attachment. 
Hamilton, in his work on Fractures, edition 1863, page 267, et seq., 
says; “ Dissections have established the possibility of this fracture as 
a simple accident in the living subject, but I have not, myself, seen 
any example of which I can speak positively. 
He relates two cases, in which the existence of such a fracture was 
at first suspected, but in regard to which he afterward had very little 
doubt that his diagnosis was incorrect. 
After analyzing the reported cases, he concludes : “ The fact, there- 
fore, that so few cases have been reported, and that most of these are 
far from being clearly made out, remains presumptive evidence that 
the actual cases are extremely rare; but, if to this we add such nega- 
tive evidence as is furnished by actual dissection and examinations of 
the pathological cabinets of the world, we think the testimony almost 
conclusive.” 7 
“ Only four specimens have been mentioned by any of the surgical 
writers known to me.” And these four be shows to be not altogether 
satisfactor}r, and concludes : “We are therefore, left as before, with 
no evidence that the coronoid process was ever broken by the action 
of the muscle, and with only one example in which it is probable that 
a fracture occurred, as a consequence of a dislocation of the radius 
and ulna backwards.” 
The last one of my two cases I feel quite confident can be added 
to this list. 
And Dr. Mosely, Demonstrator of Anatomy in Bellevue Hospital 
Medical College, showed me a specimen a few days since, which he 
had obtained in the dissecting room, in which there was distinct 
fracture of the coronoid process, and union by ligamentous junction. 
Dr. Darling, Professor of Anatomy in the Medical University of 
Hew York, has another specimen which was presented to him by Dr. 
Bradley, of this city, which is almost the exact counterpart of my 
second case, luxation of both bones backward, and fracture of the 
coronoid process, which had become anchylosed to the anterior portion 
of the condyle of the humerus. 
The variety of this accident, according to Hamilton, and the diffi- 
culty of its treatment, according to Gross, and which, in this instance 
was so perfectly successful, has appeared to mo a sufficient reason for 
placing the facts before the Society for permanent record. 
285 Fifth Avenue, Jan. 2(BA, 1871.