ON 
SUBLUXATION 
OF THE HEAD OF THE RADIUS 
ITT CHILEBETT; 
WITH A RESUME OF 
OEE HUNDRED CONSECUTIVE CASES. 
By W. W. VAN ARSDALE, M.D., 
New York, 
INSTRUCTOR IN SURGERY IN THE NEW YORK POLYCLINIC; 
ATTENDING SURGEON AT THE EASTERN DISPENSARY. 
Reprint from Annals of Surgery, June, 1889. ON SUBLUXATION OF THE HEAD OF THE 
RADIUS IN CHILDREN-WITH A RESUME 
OF ONE HUNDRED CONSECUTIVE CASES.1 
By WILLIAM WALDO VAN ARSDALE, M.D., 
OF NEW YORK. 
INSTRUCTOR IN SURGERY IN THE NEW YORK POLYCLINIC; ATTENDING SURGEON 
AT THE EASTERN DISPENSARY. 
THE lesion to which I beg to call attention is generally 
observed under the following conditions : 
A child is brought to the physician by its mother complain- 
ing of pain at the wrist, and inability to use the arm. The 
child lets its arm hang motionless at its. side, slightly flexed 
at the elbow, the hand being half-way between pronation and 
supination. 
Upon further questioning the mother tells how she was lead- 
ing the child by the hand when it stumbled or slipped, and in 
an effort to save it from a fall, she forcibly jerked the hand up- 
ward. At this moment she- felt a click at the wrist, and the 
child cried out as if in pain. Although the child did not fall, 
yet since that time it has not used its arm or hand, and any in- 
terference with either has again called forth complaints. 
On examination everything about the hand is found to be 
normal. The movements at the wrist are free and not painful, 
adduction and abduction, flexion and extension can be made 
passively without resistance. 
Examination of the elbow-joint reveals no deformity what- 
ever ; the olecranon, the condyles of the humerus, are all in 
place, and so is the head of the radius. At this point of the 
examination, however, the first abnormal symptom is discov- 
ered ; pressure, even if slight, upon the head of the radius is 
painful. Flexion of the fore-arm upon the upper arm is now 
1Read before the Surgical Section of the New York Academy of Medicine. 2 
W. W. VAN ARSDALE. 
attempted, and is freely permitted to an angle of about 6o° 
when the movement causes pain and is actively resisted by the 
child. Complete extension to the straight line is also painful; 
but any flexion ranging between 1300 and 6o° may be given 
the arm without resistance, and is generally retained by the 
child. The child never supports the hand with the other un- 
jured one, however, as in cases of injury to the shoulder. 
If pronation and supination be now attempted while the 
arm is held flexed at right angles (apparently the easiest posi- 
tion for the child) the child immediately evinces symptoms of 
pains. Complete pronation is possible, but is somewhat re- 
sisted by the child. Supination, however, at once calls forth 
energetic protestations ; the child cries out and actively resists 
the motion as much as it can, interferes with the other hand, 
and endeavors to escape. There also appears to be some 
mechanical resistance to supination which asserts itself as soon 
as the intermediate position between pronation and supination 
is reached. But On forcing supination still further, a distinct 
click is to be felt at the elbow, or more correctly at the head 
of the radius, after which all the movements of the arm at 
once become free, and apparently cause no more pain. One 
symptom, however, still remains; direct pressure on the head 
of the radius is painful as at first. 
If, now, the arm is left to itself, the child lets it hang as be- 
fore, and uses it little or not at all. And in two or three days 
the child may be brought back to the surgeon with considera- 
ble swelling, both of the elbow-joint and at the wrist, and 
with all the symptoms just described present, only in a much 
aggravated degree. 
If, however, the arm is put up, the elbow flexed at right an- 
gles, the hand midway between pronation and supination, in 
some simple splint or bandage, the child is brought back by 
the mother at the end of three or four days, who says the 
hand must be well now, as the child uses it and complains no 
more. 
On removing the bandage the arm generally appears normal, 
and passive and active movements are entirely free. 
This is the clinical picture for which I have used the term 
subluxation of the head of the radius in the title of this pa- SUBLUXATION OF THE HEAD OF THE RADIUS. 
3 
per, but which has been described by various writers under 
different designations, such as partial dislocation of the head 
of the radius, dislocation of the radius downward by elonga- 
tion, Goyrand's injury, and others. 
These are very formidable titles for an injury which can be 
so easily rectified, and cured in so brief a time. And it should 
be here stated that the injury in question is not a dislocation, 
as that term is usually accepted ; there is no extensive ruptur- 
ing of ligaments, nor have the articulating surfaces of the 
bones been laterally forced out of their normal position to any 
great extent. 
The injury is comparatively slight. But, notwithstanding, it 
always occurs in the same typical manner, which should en- 
title it to acknowledgment as a separate and distinct injury. 
And in point of fact the lesion has been so recognized by a 
long line of observers-a fact which never would have oc- 
curred if the injury did not possess sufficient individuality to 
enable it to be recognized by others from simple description. 
Now it is a curious fact, that although this injury has been 
often observed and frequently made the subject of careful in- 
quiries, its nature is not perfectly understood, nor is the injury 
itself sufficiently widely known to prevent its often escaping 
detection. At any rate all authorities are certainly not agreed 
as to its nature ; and it is this air of mystery which envelops 
the lesion, that lends to it a special interest. All of these rea- 
sons have prompted me to bring the subject before you to- 
night for discussion. 
A cursory glance at the literature informs us that there have 
been about seventy articles written on our subject, mostly in 
periodical literature. The text-books, if we except the more 
recent ones, contain little or nothing about it. Histories of 
the subject are given by Malgaigue and Streubel, and others 
since then. Hippocrates and Celsus referred to the matter. 
The first who described it accurately, however, was Fournier 
in 1671. But after his publication it was again forgotten, till, 
in 1751, Duverney again described it. Subsequently it became 
a favorite subject among French authors. 
In Germany Streubel was the first to give the subject spe- 
cial attention, writing his first article in 1850. 4 
W. W. VAN ARSDALE. 
By that time it had already been described in Italy by Mon- 
teggia (1814), and in England by Collier (1836) and Gardner 
(1837). 
In our own country it was first brought forward by Batchel- 
der in 1856, and Hodges in 1862, and subsequently treated of 
by Cushing, Moore, Van Santvoord and others; while the spe- 
cial attention given to it by Hamilton and Stimson in their 
textbooks has rendered the subject a familiar one to most sur- 
geons. 
I propose, before introducing my own cases, to give a brief 
epitome of what we learn from the literature. 
Reference is made to some 400 cases in all (at a generous 
estimate). Yet many consider the injury a rare one. Goyrand 
who alone saw half this number (200 in 30 years), says it is 
very frequent. The general opinion is, that while the injury 
is rare among surgical cases in children, it is comparatively 
frequent among injuries to the elbow. According to Hoff- 
mann the proportion is about I in 230 patients (children). 
This is probably the usual frequency for dispensaries. 
As a predisposing cause we find a "lymphatic" or "stru- 
mous" constitution frequently mentioned by those writers who 
give it attention. An atonic or relaxed state of the ligaments 
is a favorite theory with most writers on the subject (Sylves- 
ter, Martin, LeLyon, Denuce). Bourgnet, however, states that 
the children are exceptionally healthy and sound, and show 
no traces of constitutional tendencies. 
As to the exciting cause of the injury, there is an over- 
whelming testimony in evidence of traction on the hand or 
forearm-so much so that this point has always been consid- 
ered of the first importance in diagnosis. Whether the trac- 
tion is exercised by the nurse when walking hand in hand with 
the child, by lifting it over an obstacle or over the gutter, or 
by trying to sustain it when it is about to fall, or by swinging 
it around by both arms in play, is comparatively of less im- 
portance. In every case the weight of the child, or part of the 
weight, is sustained by the arm. In some cases the distension 
of the arm in thrusting it through the sleeve of a jacket is 
cited as a cause. 
The question of forced pronation of the hand simultaneously SUBLUXATION OF THE HEAD OF THE RADIUS. 
5 
with extension has been much discussed. Bottentnit, Bourg- 
net, Malgaigue, Goyrand, von - Pitha, Streubel, Hoffmann, 
Hoffa, all insist that pronation during extension causes the in- 
jury. Allowance should, however, be made for the fact that 
most of the authors wrote at a time when dislocations of the 
radius were believed to be possible from forced pronation 
alone. Later writers attribute the injury more to extension 
with forced adduction in the elbow. Supination is also repre- 
sented as causing the injury by Banyan, Rendu and Hutchin- 
son, while a fall is given as a cause by Bardenheuer, Duver- 
ney, Lindemann and Peterson. 
The greatest harmony prevails in the symptomatology of 
the injury. With few exceptions, the authors describe the 
hand as being more or less pronated, the arm hanging motion- 
less by the side with the elbow slightly bent. A few cases 
where supination obtained, instead of pronation, are mentioned 
as exceptional. Some writers lay especial stress on the oppo- 
sition to supination encountered in active as well as in passive 
rotary movements. 
The click heard on attempting supination for the first time 
after the injury is denied by none. Most all writers have no- 
ticed it and do not fail to attribute great significance to it. 
Only Streubel, in his second essay (1861), and Bardenheuer, in 
his latest works, attach no importance to it, saying crepitation 
in joints is something so common that it hardly deserves men- 
tion. 
It is impossible to escape the impression that this click or 
snap so distinctly heard on supinating the fore-arm soon after 
the injury has been the main cause of all the mystery con- 
nected with the lesion. For to it alone is due the diagnosis 
of luxation or subluxation, so frequently made in these cases. 
The analogy with the snap heard in other joints during reduc- 
tion of a dislocation appears unquestionable, and the freer mo- 
tion after the snap has been heard renders the similarity still 
greater. 
There is one point, however, which fails to complete the 
Un a case reported by Perrin, as soon as the snap was felt on reduction, the child 
cried out: "Mother, I am cured." 6 
W. W. VAN ARSDALE. 
analogy between the injury under discussion and other dislo- 
cations. The head of the radius can be distinctly felt in its 
proper place, or, at least, very near its proper place. And as. 
no unchallenged cases happen to have died with the disloca- 
tion (if such it be) unreplaced, the anatomy of the lesion could 
never be entirely made out. In consequence room was left 
for the widest speculation ; and the theories advanced to sub- 
stantiate the diagnosis of the various authors form the princi- 
pal attraction in the publications. Almost all the tissues com- 
ing into contact with the radius have, one after another, been 
made the subject of special theories, not excluding the muscles, 
and the nerves. 
I. Many writers, among them Duges, James, Lindemann,. 
Monteggia, Snedden, Holmes, Hodges and Hamilton, believe 
that the lesion consists in a slight anterior displacement of the 
head of the radius in front of the radial eminence of the hu- 
merus, an incomplete luxation of the capitulum radii. The 
edge of the radial cup is imagined resting against the eminence 
which should receive the cup. Notwithstanding, the radial 
head is not imagined as entirely leaving the ulnar notch, for 
if it had done so the displacement could not escape notice on 
palpation. Nor are the ligaments said to be torn, but only 
stretched sufficiently to allow of subluxation within the cap- 
sule. If, now, supination is made, the radial cap again slips 
over the eminence and a corresponding click is heard. The 
question as to what holds the head of the radius in its abnor- 
mal position during the persistance of subluxation is answered 
by some writers by saying that the elastic contraction or tonus 
of the muscles uniting the fore-arm with the upper arm main- 
tain the position. 
The difficulty encountered here is to reproduce the subluxa- 
tion in a post-mortem specimen, which should show as little de- 
formity as we find in the actual lesion. If the radial cup is. 
brought forward sufficiently for its edge to rest against the 
eminence, the head of the radius must be displaced out of the 
ulnar notch; and if this is done the deformity is so apparent that 
it is easy of detection, and could not possibly have remained 
unappreciated for nearly two centuries. 
The same objection holds good against the theories of par- SUBLUXATION OF THE HEAD OF THE RADIUS. 
7 
tial dislocation of the head backward. Martin and Boyer 
were advocates of this theory, and Malgaigne, Poinsot and 
others admitted both the anterior and posterior types of the 
displacement. 
Goyrand who at the time of writing his first paper (1837) 
believed in an anterior partial displacement of the head of the 
radius, imputed it to the action of the biceps as did also Linde- 
mann. It is true that the biceps attaches to a point (the radial 
tuberosity) which might easily so displace the capitulum radii, 
provided the elbow were a little flexed; and we may also 
imagine that at the moment a child were lifted by the hand, it 
would forcibly contract its biceps. But I have convinced my- 
self by experiment upon the cadaver of a child that the biceps 
alone is not strong enough to displace the head of the radius. 
Even when the lacertus fibrosus has been removed the muscle 
tears, before the least injury is done to the joint, or any sub- 
luxation is achieved. 
3. A curious theory was put forward by Gardner (1837) and 
Rendu (1841). In extreme pronation the tuberosity of the 
radius was thought to slip below the internal edge of the ulna, 
and by becoming locked there, to make supination impossible. 
4. Bourgnet, later on, varied this theory by supposing that 
the locking was brought about more completely by the inter- 
position of soft parts (innoc. supinator brevis, etc.), between the 
radius and ulna at a point, which prevented the return of the 
tuberosity. 
Goyrand and Streubel carefully refuted these theories by 
showing that there was too large a space between the bones of 
the forearm in children for them to become interlocked. 
Moreover it is impossible for tissues to get wedged in between 
the two bones, unless there is extensive laceration-which, 
from the nature of injury under consideration, must be 
excluded. 
5. Goyrand's latest theory was the partial dislocation of the 
triangular cartilage backwards at the wrist, in order to explain 
what he formerly supposed to be subluxation of the head of 
the radius. The wrist-symptoms play so important a part in 
the clinical aspect of the cases that it is not surprising that the 
lesion should be looked for at this point. 8 
IV. W. I AN ARSDALE. 
Goyrand succeeded in getting a partial dislocation of the 
triangular cartilage on the cadaver by forced pronation, but 
the cartilage did not retain its abnormal position when the 
force was relaxed. 
In spite of Goyrand's close study of the subject and the fact 
that he has observed the greatest number of cases on record,- 
which lends the greatest authority to his opinion, his theory 
has not been accepted by subsequent writers; principally from 
the reason, I believe, that a luxation, partial or otherwise, 
could not be made out clinically, at the wrist. 
6. Hofmokl of Vienna has viewed the subject in a some- 
what different manner. He thus describes his cases: 
" The lesion occurs generally by suddenly pulling the child 
upwards by the hand, when it was about to fall, the hand itself 
being frequently not rotated at all. (In other cases a fall may 
account for the injury). The child lets the arm hang down as 
if paralyzed, complains of pain in the wrist and experiences 
pain on attempting to lift, or bend, or extend the forearm. 
The posture assumed is pronation, and slight flexion. There 
is very slight or no swelling at all over the radio-brachial joint; 
but immediately after injury (but only fora limited time) crepi- 
tation can be felt on supinating the forearm. This crepitation 
can be reproduced by repeated supination, after first again 
making forced pronation, and the head of the radius appears 
not to take part in the motion. After supination no pain is 
felt. But if no supination is practiced, pain at the wrist asserts 
itself." 
This description tallies exactly with the one given by ex- 
perienced observers of the injury under discussion. In these 
cases Hofmokl diagnosticates fracture of the capitulum radii 
inside the capsule; and he has observed on the cadaver that 
such a fracture can be easily produced by attaching a weight 
of two pounds to the radial tuberosity and letting it fall a few 
feet. As the biceps-muscle in a child of 2 years will well bear 
a strain of ten pounds without rupturing (according to my own 
experiments), this theory appears to me worthy of con- 
sideration. 
7. Chassaignac has described a number of very similar cases 
under the title of painful paralysis in young children, whose SUBLUXATION OF THE HEAD OF THE RADIUS. 
9 
age is given as from 2 to 4 years. The cause is some traction, 
more or less forcible, made on the hand or forearm, and its 
appearance is always sudden. No surgical lesion is found on 
examination, but frequently soft crepitation in the joints. There 
is a paresis of the muscles accompanied with pain, which pre- 
vents free motion. The arm hangs in pronation, with slight 
flexion at the elbow. Recovery takes place spontaneously 
after four or five days, more frequently in forty-eight hours. 
The author accounts for the lesion by assuming an injury to the 
nerves. 
The similarity of the description to that given above is so 
striking that we are justified in including the cases in this 
paper. Especially as Hamilton too hinted that a nervous lesion 
might account for the symptoms of the injury. 
I have left till the last a theory which has been steadily gain- 
ing in favor since it was first substantiated by Streubel. Its 
originator was Fournier; and Duverney more accurately de- 
scribed it. According to this author, on extension being made 
by the hand, the head of the radius moves downward in the 
orbicular ligament, so that a diastasis occurs between the cup 
of the capitulum and the eminence of the humerus. There is 
no lateral displacement of the radial head, nor is there any 
laceration of ligaments. This is what has been called displace- 
ment by "elongation." 
The obvious objection to this theory is that there is no 
apparent reason why the injury should persist. On relaxation 
of the extending force the head could be expected to slip back 
again into its normal place. 
This difficulty was overcome by Perrin who believed the 
head of the radius to be pulled out so far that its margin 
caught against the lower border of the ulnar notch. This 
theory is hardly tenable in view of the anatomical facts. 
I believe Streubel (1850) was the first to advance his most 
successful theory, that the return of the head of the radius so 
well within the orbicular ligament was prevented by the fold- 
ing in of the sides of the capsule between the radial head and 
the eminentia cepitata. 
He based his views on cadaver experiments of which he per- 
formed a number. Dissecting off the skin and the muscles 10 
W W. VAN ARSDALE. 
from the capsule of the humero-radial articulation, he could 
easily demonstrate that when the head of the radius was pulled 
partly out of the capsule and extreme pronation was added at 
the same time, the anterior part of the capsule was forced into 
the articular cavity by atmospheric pressure and could be held 
thus folded in, by quickly returning the radial head. If, now, 
supination were performed, the fold would disengage itself with 
a click. A similar mechanism occurred with the posterior 
portion of the capsule on extreme supination. 
These experiments have been repeated in this country by 
Moore and by Van Santvoord, the latter of whom published 
the results of cadaver experiments on seventeen infants. 
Nothing can be more simple than to produce the dipping-in 
of the capsule into the joint cavity above the radial head, when 
the skin and the muscles (supinator longus and extensor carpi 
radialis longior) have been removed over the joint. But when 
these are left intact, it is a much more difficult matter. 
Van Santvoord did succeed in producing the folding of the 
capsule into the joint five times without removing the skin,- 
but it should be remembered that this was in the cadaver, and 
where the muscles have not the tonus they have during life. 
When children forcibly pull on their fingers one can fre- 
quently see how the atmospheric pressure forces in the integu- 
ment into the carpo-phalangeal articulation. But it is not easy 
to comprehend how such a deformity should persist even if 
we make allowance for the fact that the edge of the radial 
head presents a more defined margin than does a phalanx of 
the hand-especially when we observe on dissection that the 
capsule is adherent to the tissues overlying it. 
The snap, too, heard in these cadaver-experiments is of a 
different character from that felt during examination of the 
injured children. It is of a softer quality, and the resistance 
to supination is not so well marked. 
If the degree of the interposition of the capsule between the 
radial head and the eminence be still further exaggerated, we 
encounter another theory: that of the partial slipping-up of 
the lower margin of the orbicular ligament over the rim of the 
radial head. In this case the radial head is at the point of 
emerging from the annular ligament altogether. This is only SUBLUXATION OF THE HEAD OF THE RADIUS. 
11 
possible when the capsule has been partly torn. This theory 
was advanced as an explanation for the lesion under considera- 
tion by Duverney, Pingaud and Hutchinson. Stimson also 
accepts this theory as the most probable from a clinical point 
of view and the best in keeping with the literature of the 
subject. 
Finally there are a number of writers who treat the whole 
matter with skepticism. Streubel himself, who had originated 
the theory of capsular interposition, abandoned it in his later 
essay (1861) and believed that all the so-called subluxations of 
the head of the radius in children were simply an ill-assorted 
and badly diagnosticated lot of bruises, sprains and stretchings 
of the ligaments, and Koenig, Bardenheuer and other recent 
writers follow in his footsteps. 
Any one, I believe, who has seen a fair number of the cases 
in question will admit that they represent a perfectly unique 
and characteristic injury, always occurring in the same typical 
manner, and easily to be differentiated, on the one hand from 
atypical sprains and bruises, and on the other, from true, pal- 
pable dislocations. 
As to the treatment nearly all the writers are agreed as to 
the manner of reduction. Extension of the forearm while in 
a semi-flexed position, combined with supination, with or with- 
out direct local pressure on the head of the radius, are the 
directions generally given. To this some add sudden flexion 
of the elbow. 
In regard to the after-treatment, opinion is divided • some 
maintaining that none is necessary, others advising the use of 
a sling or a splint for several days, Malgaigne for two weeks, 
and Hofmokl for four weeks. The treatment by splints is. 
generally advised in order to avoid recurrence of the displace- 
ment, which is admitted by many to be frequent. 
The prognosis is generally given as excellent-the injury 
rectifying itself in a short time, if left unreduced. The more 
careful observers allow that tumefaction may follow. Cushing 
says it may give rise to serious trouble and to chronic arthritis ; 
Lindemann to permanent enlargement of the elbow; and par- 
tial anchylosis is mentioned by Spear. 
As may be expected of so slight a lesion, there are scarcely 12 
W. W. VAN ARSDALE. 
any records of post-mortem examinations in these cases. 
Fifield mentions two in chldren : in one the head of the 
radius was found dislocated and resting on the outer condyle, 
in another a portion of the capitulum of the radius was found 
broken. This latter appears to me to be of some interest; 
while the former may be ruled out, I think, as representing a 
true dislocation. 
Duges had one autopsy, but the result is not given. Mal- 
gaigne gives one, but this was in the adult and was also a case 
of complete dislocation, for the head of the radius was in front 
of the ulnar notch. 
Loebker of Vienna operated upon five cases for trouble en- 
suing after injuries to the elbow in childhood, and found longi- 
tudinal fractures in two cases (through the radial head), 
complete luxations in the others. 
Sprengel gives a case where the head of the radius was 
found outside the capsule in a boy six years of age after a fall. 
But we have no evidence that these cases were analogous to 
the ones under consideration. 
We have, therefore, to fall back upon cadaver-experiments. 
And here those by Schuller appear deserving of mention, for 
the reason that he experimented most conscientiously upon 
some hundred cadavers. German surgeons ascribe to him the 
discovery that simple forced pronation cannot produce dislo- 
cation forwards of the radial head, and the most recent writers 
on our subject have not insisted that the injury under discus- 
sion was caused by pronation. He did show, however, that 
forced adduction at the elbow, where there is normally no ad- 
duction, frequently caused displacement of the radial head; 
and could even be the cause of the head slipping out of the 
orbicular ligament. But this was only in a few cases; in the 
greater number of cases forced adduction produced some epi- 
physeal injury to the lower end of the humerus. Moreover in 
order to draw the end of the radius out of the orbicular liga- 
ment, he had to support the upper end of the ulna, at the elbow 
joint with one hand. 
Stimson was the first to advance the explanation that simple 
forced extension by overcoming the normal inclination of the SUBLUXATION OF THE HEAD OF THE RADIUS. 
13 
fore-arm outward from the elbow in children, would act as 
adduction. 
I now turn to the cases that have come under my personal 
observation, of which there are one hundred. These were all 
treated at the Eastern Dispensary of New York City. There 
are nearly one hundred and thirty cases on my books. Some 
of these were seen during my absence by my colleagues, and 
have been excluded. Three cases occurred in adults, and have 
also been excluded. Then some cases were not well marked, 
so that the diagnosis rested between contusions and other 
injuries of the elbow joint in children, and the one under con- 
sideration. These have been likewise excluded. 
The remaining number one hundred. 
I believe it is essential to exclude all doubtful cases, as well 
as all cases occurring in adults, in order to obtain as clear a 
clinical picture as possible. 
As to the frequency of the injury: these cases belong to a 
material of over ten thousand purely surgical cases seen by me 
in less than two years. But as many cases were sent to me for 
treatment from the childrens' class by the courtesy of my friend 
Dr. Koplik, I may say that the cases represented a material of 
over .33,©oo patients. 
The frequency, then, of our injury is one per cent, for purely 
surgical cases of all ages, and about one-half per cent, for 
children (with all ailments, but under ten years of age.) 
These figures correspond with those of Hoffmann quoted 
above. 
The average age of the children was two years and a quar- 
ter, the oldest one being nine years and the youngest only two 
months of age. Most authorities give the age as under six. 
As regards the habit and constitution of the little patients, 
many were badly nourished pale and sickly children, while a 
great number were of robust and healthy appearance. 
In some of the cases undoubted signs of rhachitis were 
present, to which my attention was first called by Dr. Koplik; 
and I regret not having commenced to notice this symptom at 
an earlier date, so as to enable me to make a more concise 
statement on this point. A tubercular constitution was not a 
general concomitant of the injury, as many authors have stated. 14 
W. W. VAN ARSDALE. 
The exciting cause was generally some violent traction on 
the hand or fore-arm; but I could not ascertain that the hand 
was in pronation at the time in any one case. In about one- 
third of all the cases a fall was said to be the cause of the 
injury. But on closer inquiry I generally found that the 
mothers retracted this statement, when confronted with the 
statement that they must have lifted the child, or else they 
stated they had left the child under the care of others for a 
time, and that these had reported a fall on their return. In 
two cases the child sustained a fall and was picked up by one 
hand, the injury being attributed to the fall, instead of to the 
lifting. I therefor hesitate to place much reliance in the state- 
ments that a fall generally produces the injury. Quite fre- 
quently something was felt to snap or give way at the time of 
lifting; but this snap was generally localized at the wrist. 
The symptoms were invariably the same: pronation, more or 
less complete, and but slight flexion at the elbow. No case 
was observed in supination. There was certainly no displace- 
ment to be made out at the point of the radial head. The fore- 
finger and thumb could be placed on either side of the head 
with facility in most cases, and no lateral displacement existed. 
Nor could any displacement downwards be detected. When 
reduction was made, however, with one thumb over the radial 
head, at the moment when the hand entered the position of 
supination, and the characteristic snap was felt, the jar com- 
municated to the head of the radius was distinctly to be appre- 
ciated as a lateral one,-not as one in the longitudinal axis of 
the bone. 
The other symptoms were those that have been described 
above. 
In but few of the cases the click could not be felt,- in a 
number of others, however, the click could be repeated twice 
or even three times (in one case), by again executing forced 
pronation. In some cases the click could be more accurately 
described as a crunching crepitus. 
The after-treatment usually consisted in the application of a 
simple paste-board box splint; sometimes a rectangular splint 
or a well-sized dextrine bandage was used; and the patients 
directed to keep the hand in a sling. The splint was left on SUBLUXATION OF THE HEAD OF THE RADIUS. 
15 
for three days, at the end of which the child was generally 
found cured. In the first cases where no splints were used, 
relapses were frequent. In about five cases, the splint had to 
be kept on for six days, swelling having ensued at the elbow 
or at the wrist, or, more generally, both. But whether or not 
these cases were the same in which no click was felt on 
attempted reduction, my notes do not say. 
No case of serious trouble resulted from any of these in- 
juries; although if left unreduced, I am not prepared to say 
what results might possibly ensue. 
The diagnosis rests mainly upon the 'click' and the free 
motion after reduction, together with the pain on pressure over 
the radial head. Differential diagnosis lies between contusion 
and other sprains of the elbow and the wrist. 
To what anatomical conditions shall we ascribe the injury? 
Of the thirteen theories mentioned above, three appear 
especially deserving of notice. 
First. The partial anterior displacement of the head of the 
radius, which cannot be wholly excluded, although exact 
palpitation should reveal the displacement, and although we 
can find no satisfactory cause for its persistence. This theory 
would be better supported if it could be shown, that the injury 
occurred mainly in children affected with rhachitis. For we 
know that in this' disease the ligaments are relaxed and are 
easily stretched. We should however be cautious in admitting 
the ligaments to be relaxed in one joint, unless there was evi- 
dence of the existence of flail-joints in other parts of the body. 
Second. The theory of interposition of the orbicular liga- 
ment between the radial head and the humerus. It does not 
appear to me to be so easy to produce the simple folding-in of 
the membranes above the radial head in the living subject, 
where they are united with the muscles, and are distended by 
the muscular tonus, and where the synovial lining is very slip- 
pery, as it is in the cadaver. The partial emerging of the head 
of the radius below the orbicular ligament could be possible 
only if the capsular ligament were torn. 
In this case we should expect some ecchymosis and haemor- 
rhage, which, however, has never once been observed. 
The third theory deserving consideration is that of some 16 
W. W. VAN ARSDALE. 
local injury done to the head of the radius within the capsule 
of the joint. This theory is best substantiated by post-mortem 
evidence and by operations. It is vague in so far as no typical 
lesion of this sort has been experimentally established, except 
the fracture of the head. We might, however, expect partial 
solutions of the epiphysis at the head of the radius, when we 
consider that most of the children affected are under four years 
of age. This latter theory was advanced as early as 1839 in 
an editorial in the Medico- Chirurgical Review. And all obser- 
vations on record can be easily made to harmonize with it. 
The lateral jerk of the biceps when the child catches at the 
nurses hand to save itself from falling, exerts a sudden traction 
on the radius, so that the epiphysis may be partly torn off and 
pushed to one side. After replacement the head of the radius 
is held in position by the muscular tonus, which causes the 
capitellum of the humerus to press down upon it; there is no 
tendency to displacement, unless the accident is repeated, 
which accounts for the rapid recovery after a few days on the 
one hand, and the frequency of recurrence during the first few 
days on the other hand. The absence of any appreciable dis- 
placement of the head of the radius out of the ulnar notch 
harmonizes (by means of this theory) with the assertions of 
Malgaigne and other surgeons; who state they have felt slight 
displacements of the radius from its normal position. The 
theory further accounts for the uselessness of the arm, while 
the displacement remains unreduced : the pain produces reflex 
inhibition of motions; but a greater pain, as a pinch, induces 
the child to move the arm. The swelling which obtains at the 
elbow when the injury remains unreduced is accounted for, 
while absence of haemorrhage or ecchymosis is explained by 
the capsules remaining intact. The mechanical resistance to 
supination may be explained by the excentric configuration of 
the head of the radius: the epiphysis pushed partly to one 
side, impinges upon the ulna, until forced supination overcomes 
the resistance, and reduction is accomplished at the same time. 
The facts that simple pressure upon the head of the radius, 
without extension or supination will not reduce the disloca- 
tion,-that simple traction will not reduce it, and that it fre- 
quently becomes reduced spontaneously are accounted for. 
Finally the objections made to the theory of capsular inter- SUBLUXATION OF THE HEAD OF THE RADIUS. 
17 
position above the head of the radius by Bourgnet and Perrin, 
that there is no lowering of the radial cup below the level of 
the capitellum of the humerus, and the statements of Marjolin 
that he found slight deformity at the elbow, and of Barden- 
heuer, that supination and rotation do sometimes not rectify 
the injury, are all in accordance with this theory. And so are 
also those statements that sometimes the hand is retained in 
supination. 
However well this theory may accord with the descriptions, 
on paper-I have not satisfied myself clinically or anatomically 
of its truth. I could not produce any typical injury to the 
head of the radius as Hofmokl describes, by attaching a weight 
of two pounds to the neck of the radius and letting it fall. 
And I cannot conceive how a partial rupture of the radial 
epiphysis should be prevented from becoming complete, in 
which case there should in my opinion be more deformity 
present. 
I am therefore not prepared, before further study of the sub- 
ject, to decide in favor of any one of the numerous theories 
advanced to explain the lesion under consideration. 
Conclusions. 
I. The injury frequently occurring in children and called 
subluxation of the head, or displacement by elongation, of 
the radius is a well-defined, typical injury with well-marked, 
constant symptoms, and due to the same anatomical lesion in 
each case. 
2. The frequency is over one per cent, of surgical injuries 
in children. 
3. It occurs in children under nine years of age. 
4. The most frequent exciting cause is sudden traction by 
the hand or fore-arm; more rarely a fall. 
5. The principal symptoms of the injury are : absence of 
appreciable deformity ; loss of function of the arm ; localized 
pain over the head of the radius on pressure; pronation of the 
hand; slight flexion of the elbow. Crepitation or snapping 
upon forced supination with restoration of function. 
6. Treatment with a splint is advisable in order to prevent 
recurrence. 
7. The anatomical lesion causing the injury is not yet 
satisfactorily established. 18 
W. VAN ARSDALE. 
TABLE OF CASES. 
Number. 
Date. 
1887. 
Age. 
Sex. 
Nationality of 
Parents * 
Years. 
Months. 
I 
June 22. 
4 
M. 
A. 
2 
July 12. 
4 
F. 
A. 
3 
August 18. 
I 
M. 
G. 
4 
August 27. 
2 
6 
F. 
R. 
5 
September to. 
1 
6 
F. 
G. 
6 
September 10. 
2 
M. 
G. 
7 
September 23. 
2 
3 
F. 
U. S. 
8 
September 28. 
I 
IO 
M. 
G. 
9 
October 8. 
I 
IC 
M. 
R. 
10 
October 15. 
I 
5 
F. 
R. 
II 
October 17. 
2 
M. 
G. 
12 
October 22. 
I 
F. 
R. 
'3 
November 1. 
I 
6 
M. 
R. 
'4 
November 5. 
9 
M. 
A. 
15 
November 9. 
4 
M. 
U. S. 
16 
November it. 
II 
F. ' 
R. 
17 
November 14. 
2 
F. 
R. 
18 
November 28. 
10 
F. 
R. 
*9 
December 7. 
10 
F. 
R. 
20 
December 10. 
3 
F. 
U. S. 
21 
December 13. 
2 
F. 
R. 
22 
December 14. 
3 
M. 
U. S. 
23 
December 15. 
6 
M. 
R. 
24 
December 15. 
2 
9 
F. 
G. 
25 
December 27. 
3 
F. 
R. 
* The children were most all born in this country, but of German, Austrian or Russian parents, 
t o which the capitals G, A, R respectively refer. SUBLUXATION OF THE HEAD OF THE RADIUS. 
19 
Number. 
Date, 
1888. 
Years. 
Age. 
Months. 
Sex. 
Nationality of 
Parents. 
26 
January 1. 
3 
M. 
R. 
27 
January 10. 
2 
F. 
R. 
28 
January 13. 
4 
M. 
R. 
29 
January 30. 
3 
M. 
G. 
3° 
February n. 
.... 
3 
F. 
R. 
31 
March 7. 
2 
F. 
u. s. 
32 
March 13. 
3 
F. 
A. 
33 
March 23. 
7 
F. 
A. 
34 
March 24. 
I 
6 
F. 
R. 
35 
April 10. 
3 
M. 
R. 
36 
April 12. 
4 
6 
M. 
R. 
37 
April 18. 
I 
F. 
R. 
38 
April 19. 
I 
2 
F. 
R. 
39 
April 24. 
7 
F. 
R. 
40 
April 30. 
3 
F. 
R. 
41 
May 2. 
I 
I 
F. 
R. 
42 
May 22. 
2 
F. 
A. 
43 
May 28. 
1 
5 
M. 
A. 
44 
May 31. 
3 
F. 
G 
' 
45 
May 31. 
3 
F. 
A. 
46 
June 4. 
I 
F.. 
R. 
47 
June 5. 
2 
F. 
A. 
48 
June 5. 
2 
6 
F. 
A. 
49 
June 12. 
I 
6 
M. 
R. 
5° 
June 14. 
2 
F. 
R. 
TABLE OF CASES.-Continued. 20 
W. W. VAN ARSDALE. 
Number. 
Date, 
1888. 
Age. 
Sex. 
Nationality of 
Parents. 
Y ears. 
Months. 
5i 
June 16. 
2 
F. 
R 
52 
June 18. 
6 
M. 
U. S. 
53 
June 18. 
9 
F. 
R. 
54 
June 23. 
6 
F- 
R. 
55 
June 25, 
3 
F. 
R. 
56 
June 27. 
7 
F 
R. 
57 
July 5- 
8 
6 
M. 
R. 
58 
July 7- 
I 
9 
M. 
R. 
59 
July 7. 
5 
F. 
R. 
60 
August 25. 
1 
' 6 
F. 
A. 
61 
August 28. 
I 
4 
F. 
G 
62 
August 31. 
I 
I 
F. 
R. 
63 
September 1. 
I 
I 
F. 
R. 
64 
September 3. 
9 
F. 
R. 
65 
September 7. 
I 
6 
F. 
R. 
66 
September 8. 
2 
6 
F. 
A. 
67 
September 21. 
4 
M. 
R. 
68 
September 22. 
3 
M. 
R. 
69 
October 2. 
5 
F. 
R. 
70 
October 2. 
3 
r 
X1 . 
R 
71 
October 5. 
I 
6 
F. 
R. 
72 
October 7. 
2 
F. 
A. 
73 
October 13. 
3 
M. 
R. 
74 
October 16. 
3 
M. 
U. S. 
75 
October 19. 
I 
I 
F. 
R. 
TABLE OF CASES.-Continued. SUBLUXATION OF THE HEAD OF THE RADIUS. 
21 
TABLE OF CASES.-Concluded. 
Number. 
Date, 
1888. 
Years. 
Age. 
Months. 
Sear. 
Nationality of 
Parents. 
7$ 
October 23. 
I 
4 
F. 
A. 
77 
October 23. 
4 
M. 
R. 
78 
October 30. 
X 
6 
F. 
A. 
79 
November 14. 
4 
F. 
R. 
80 
November 16. 
3 
F. 
A. 
81 
November 28. 
2 
F. 
R. 
82 
December 10. 
4 
M. 
R. 
83 
December 12. 
3 
F. 
G. 
84 
December 14. 
2 
M. 
R. 
85 
December 26. 
1889. 
2 
F. 
R. 
86 
January 3. 
2 
F. 
R. 
87 
January 8. 
2 
M. 
Egypt. 
88 
January 14. 
3 
F. 
R. 
89 
January 14. 
8 
M. 
R. 
9° 
.January 15. 
7 
F. 
U. S. 
91 
January 21. 
I 
F. 
R. 
92 
January 28. 
... 
9 
F. 
R. 
93 
February 3. 
3 
M. 
U. S. 
94 
February 9. 
1 
IO 
F. 
G. 
95 
February 10. 
I 
3 
M. 
R 
96 
February 10. 
I 
2 
M. 
R 
97 
February 19. 
3 
F. 
R. 
98 
February 20. 
2 
F. 
R. 
99 
February 23, 
2 
F. 
R. 
100 
March 7. 
4 
F. 
R. 22 
W. IV. VAN ARSDALE. 
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