On the Treatment of some 
Old Unreduced" Disloca- 
tions of the Elbow. 
BY {/ 
LEWIS A. STIMSON, M. D., 
Professor of Surgery in the University of the City of 
New York, Surgeon to'the New York Hospital. 
RBPBIN'TBD FBOM 
Neto ¥orfe J&eUtcal journal 
far October 2^ 1891. Reprinted from the New York Medical Journal 
for October 2^ 1891. 
ON THE TREATMENT OF SOME OLD 
UNREDUCED DISLOCATIONS OF THE ELBOW.* 
By LEWIS A. STIMSON, Mil)., 
PROFESSOR OF SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK ; 
SURGEON TO THE NEW YORK HOSPITAL. 
The possibility of the formation of irregular and ab- 
normal masses of bone about the ends of bones that have 
long been dislocated has been known for many years, and 
examples of such formations at the elbow are to be found 
figured or described in the various atlases and text-books 
that have come down to us from the earlier writers. The 
interest that attached to them was rather languid, for they 
were looked upon as late changes, as epiphenomena of a 
condition which lay outside of and was not amenable to 
remedial measures. But the great extension that has been 
given of late years to operative procedures has led to the 
reopening of the question of the advisability of interference 
in such cases, and I desire briefly to call your attention to 
some results thus obtained, and more particularly to a 
source of error in the recognition of the exact condition in 
* Read before the American Surgical Association at ij^ twelfth 
annual meeting. 
Copyright, 1891, by D. Appleton and Company. 2 
OLD DISLOCATIONS OF THE ELBOW. 
old dislocations of the elbow, an error that is likely to lead 
to a refusal to interfere when, if the condition was correctly 
apprehended, it would be evident that interference would be 
beneficial. This error consists in mistaking certain out- 
growths of bone which appear promptly after dislocation 
for displaced fragments or exuberant callus after fracture. 
The surgeon, supposing the lower end of the humerus to be 
irremediably deformed, very properly refrains from an at- 
tempt to make what he deems an impossible reduction, 
whereas, in fact, the articular surfaces have undergone no 
change in shape, and, so far as they are concerned, a restora- 
tion of the normal relations is possible. Another and 
equally important deduction is that reduction of the dislo- 
cation and restoration of function are absolutely impossible, 
except by an open arthrotomy with removal of the bony 
outgrowths. Upon these two points-the character of the 
bony outgrowths and the results of reduction by open ar- 
throtomy-I desire to report my personal experience of eight 
cases, six of which underwent operation. 
The cases are in brief as follows, the details of symp- 
toms and treatment being reserved for a subsequent gen- 
eral description : 
Case I.-Maggie F., aged eleven years, admitted to Bellevue 
Hospital in April, 1886, with a backward dislocation of the right 
elbow that had existed for five months. The joint was fixed at 
an angle of 150°. Operation by an external incision, followed 
by division of the olecranon. Primary union. Dislocation re- 
curred unobserved under the plaster-of-Paris dressing, and in 
June the end of the humerus was excised. This case was re- 
ported in detail in a paper read before the New York Surgical 
Society in March, 1887, and published in the New York Medical 
Journal for April 2, 1887. 
Case II.-John G., aged twelve years, a patient of Dr. W. H. 
Sherman, Yonkers, N. Y. On February 28, 1888, he received OLD DISLOCATIONS OF THE ELBOW. 
3 
a backward dislocation of the right elbow which remained with- 
out treatment until he came under Dr. Sherman's care, April 2, 
1888. The elbow was almost completely extended and fixed. 
I saw him April 5th, and advised operation by two lateral incis- 
ions, which was immediately done. Primary union. The pa- 
tient eloped April 30th, having then flexion and extension 
through an arc of 45°; a year later he was reported as having a 
movable and useful arm. (Note.-He now [in October, 18911 
has complete flexion and rotation, with extension to 140°.) 
Case III.-Annie W., aged eleven years, admitted to the 
Hew York Hospital, August 11, 1888, with a dislocation of the 
right elbow backward and outward, received three weeks pre- 
viously. The joint was nearly immovable at 145° ; the internal 
epicondyle could not be felt. After failure to reduce under 
ether, operation by two lateral incisions ; epicondyle found be- 
neath and behind the trochlea; the mass capping the bead of 
the radius was only partly ossified. Primary union, except for 
a sinus leading down to side of external condyle in track of 
drainage-tube. On November 5th flexion was almost normal; 
extension to 165° ; rotation complete. 
Case IV.-John T., aged thirty-four, was brought to me by 
Dr. Jennings, August 17, 1890; two months previously he had 
received an injury of the right elbow in a fall from a wagon, 
which was supposed to be a fracture, and was treated by immo- 
bilization in full extension for four weeks, after which a forcible 
attempt was made to flex the joint, but without success. Ex- 
amination showed a backward dislocation; elbow fixed in full 
extension; marked lateral mobility. I sent him to the New 
York Hospital, and operated, August 19th, by .two lateral incis- 
ions. Primary union, except at a point over the outer condyle. 
Discharged October 30tb, with flexion within a right angle and 
almost complete extension, as shown in these photographs. 
Case V.-John G., aged twelve years, admitted to the New 
York Hospital, October 9, 1890, with a backward dislocation 
that had existed for two months. Joint fixed at about 135°. 
Operation, October 13th, by two lateral incisions; primary 
union. Patient eloped November 4th, the range of motion be- 
ing then 45°. 4 
OLD DISLOCATIONS OF THE ELBOW. 
Case VI.-Samuel D., aged twenty-five years, was sent to me 
by Dr. E. L. Keyes, November, 1890. Early in July, 1890, he had 
injured his left elbow in a fall; the injury was supposed to be a 
fracture and was treated in a hinged splint, passive motioh being 
made daily; six weeks later the range of motion was forcibly 
increased under ether, but the joint promptly stiffened again. 
The accompanying photographs show the condition at the time 
he consulted me ; dislocation backward; the joint almost abso- 
lutely fixed at about 100°; rotation of the forearm perfect. I 
sent him to the New York Hospital and operated December 2, 
1890, by two lateral incisions. The cicatricial tissue at the back 
of the joint was exceptionally abundant (undoubtedly in conse- 
quence of the passive motion and the forcible breaking up under 
ether in the seventh week), and the necessary dissection was ex- 
tensive; indeed, before the bones could be restored to place the 
flexor and extensor rpuscles of the wrist and hand had to be almost 
completely separated from the humerus. In addition to the usual 
mass on the back of the external condyle, there was a smaller 
one on the posterior inner edge of the trochlea. The healing of 
the wound was delayed by a small superficial area of suppuration 
on the outer side, but it was complete at the end of a month. 
Complete motor paralysis of the fingers, due probably to the 
pressure of the elastic tourniquet during the operation, was ob- 
served on the second day; slight return of power was noticed 
December 26th, and restoration was complete soon afterward. 
He passed from under observation February 15th; his condition 
at that time is shown in the accompanying photographs; Hex- 
ion and extension through an arc of 45°, more than half of 
which is within a right angle; rotation complete. The range 
was increasing. 
Case VII.-A man, twenty-two years old, was brought to 
me by Dr. David D. Jennings, March 20, 1891, with a backward 
dislocation of the left elbow that had existed ten weeks. The 
joint was fixed at an angle of 110°; an overgrowth of bone 
above the head of the radius, such as was found in the preced- 
ing cases and will be subsequently described, could be distinctly 
felt, and there was marked thickening of the internal epicon- 
dyle. The outlines of the trochlea and capitellum could be OLD DISLOCATIONS OF THE ELBOW. 
5 
clearly made out in the flexure and on the inner side of the 
elbow. Operation was refused'. 
Case VIII.-John N., nine years old, was sent to my clinic 
at the University Medical College by Dr. F. N. Burke, of Brook- 
lyn, in January, 1891, for advice concerning an injury of the 
elbow received about three months previously. Examination 
showed the injury to have been a fracture of the internal con- 
dyle with dislocation backward and upward of the fragment 
and both bones of the forearm ; the capitellum could be dis- 
tinctly recognized below and in front of the head of the radius. 
I advised against an operation. I include the case in this list 
because of the formation of a large nodule of bone at the back 
of the external condyle, capping the dislocated radius as in the 
other cases. 
Five of the patients were between nine and twelve years 
old ; the others were twenty-two, twenty-five, and thirty - 
four years old. In all but one case (excluding Case VII1) 
the dislocation was backward; in one (Case III) it was 
backward and outward, the coronoid process lying close 
under and behind the capitellum. The dislocation had 
lasted in one case only three weeks; in another, five weeks 
and a half; in three, two months; in two, five months ; in 
one, about three months. Tn all, flexion and extension were 
entirely or almost entirely lost; and in most of them the 
limb was fixed at an angle of about 145°. Rotation of the* 
forearm was preserved in all but one. 
The feature of special interest is the prominent mass of 
bone seen and felt above the displaced head of the radius 
and continuous with the back of the external condyle. In 
all the cases this mass was broadly attached to the back of 
the condyle, and its free end extended down so far as com- 
pletely, or almost completely, to cover the upper surface of 
the radius and form a new. articulation with it. In Case 
III, in which only three weeks had elapsed since the injury, 
this mass was only partly ossified; in all the others it was 6 
OLD DISLOCATIONS OF THE ELBOW. 
of solid bone. The external lateral ligament was attached 
to its outer border. It is this mass that is responsible for 
the frequent failure to recognize the exact nature of the con- 
dition, for its shape and relations to the head of the radius 
suggest that it is the fractured and displaced capitellum. 
That it is a new growth is fully proved by the fact, demon- 
strated in all the operations, that the lower articular end of 
the humerus was complete in all its parts and unchanged in 
form or in cartilaginous covering, and also by the observa- 
tion in Case III, just alluded to, that at the time of the 
operation the mass was still in process of ossification. The 
error in diagnosis is further favored by the difficulty of 
recognizing the capitellum under the overlying mass of the 
extensor muscles of the hand, and by the massive projection 
of the internal condyle in front and on the inner side, the 
bulk of which seems far too great for that of the normal 
trochlea, and the recognition of which as such is hindered 
by the frequent absence or masking of its epicondyle (which 
is often broken off), and the difficulty of tracing its out- 
ines and surfaces through the overlying muscles. Further- 
more, the forearm is often adducted upon the arm, and, as 
its adduction is masked by outward rotation of the hu- 
merus, the projecting condyle seems to occupy an abnormal 
position with reference to the humerus, and thus creates 
.another difficulty in diagnosis. 
The explanation of the mode of formation of this mass 
on the back of the external condyle which I suggested in 
1887 in the paper above quoted and repeated in 1888 in my 
Treatise on Dislocations-namely, that it was produced by 
the stripped-up periosteum.-has been confirmed, I think, by 
the subsequent observations and by experiment. Case III 
is of especial interest in respect to this point, for in it the 
mass was examined at an early period in its growth and was 
but partly ossified, resembling in structure that portion of OLD DISLOCATIONS OF THE ELBOW. 
7 
callus which is formed by the detached periosteum after 
fracture. Experiment upon the cadaver has shown that in 
some cases of backward dislocation the external.lateral liga- 
ment is not ruptured, but is detached from the humerus and 
remains continuous with the periosteum, which is stripped 
from the back of the condyle and caps the head of the ra- 
dius exactly as this bony mass does. 1 am convinced that 
in various specimens of old dislocation described and pict- 
ured by some of the older writers similar new growths have 
been found and erroneously supposed to be the original 
capitellum. One. of Sir Astley Cooper's cases [Fractures 
and Dislocations, Am. ed., 1844, p. 390), which seems clear- 
ly to be of this kind, was offered by him as a specimen of 
isolated dislocation of the ulna backward, and has done 
duty for many years as the first recorded example of that 
rare injury, of which only two other alleged specimens have 
been reported.* 
It may be mentioned that masses of new bone have been 
observed at other points about the joint in cases in which 
the dislocation had lasted for many years-for example, a 
broad high plate of bone on the anterior aspect continuous 
with the coronoid process and apparently produced by ossi- 
fication of the anterior portion of the capsule. These are 
probably of much late]' production and are certainly due to 
otheiy agencies ; .they do not enter into the questions that 
now occupy us. 
The symptoms of the condition under consideration are 
as follows: The history of an injury; almost complete fixa- 
* Through the courtesy of Dr. Shattoek, the pathologist of St. 
Thomas's Hospital, London, I was permitted to examine this specimen 
last July. It bears the black label 700, and white label 260.; the new 
growth of bone capping the head of the radius is easily to be recognized 
as such. In the Musee Dupuytren in Paris, specimen 734 A shows a 
similar nodule above the head of the radius. 8 
OLD DISLOCATIONS OF THE ELBOW. 
tion of the joint, usually at an angle of about 140° ; preserva- 
tion of rotation of the forearm. On the outer side the head 
of the radius can be readily recognized lying against and 
rotating upon a mass of bone that is continuous with the 
shaft of the humerus and more or less closely resembles the 
normally palpable portion of the external condyle. The re- 
lations of the olecranon to this mass and to the head of the 
radius are essentially those which it normally bears to the 
latter and to the external condyle ; but if all swelling has 
subsided, and especially if the joint is flexed nearly to a 
right angle, the olecranon will be clearly seen to stand too 
far behind the humerus, as shown in the photograph of 
Case VI. On the inner side the conditions are evidently 
abnormal ; the internal epicondyle is often unrecognizable, 
either because it has been broken off and displaced or be- 
caused it is masked by new connective tissue. The finger 
recognizes on the inner side and in front, well below the apex 
of the olecranon, a large mass of bone with a broad, flat sur- 
face directed inward and forward, and a well-defined curved 
anterior and inferior border. This surface is the inner sur- 
face of the internal condyle, with or without its epicondyle, 
and the curved border is the inner edge of the trochlea. If 
the patient is not too fat or too muscular the finger can rec- 
ognize in front the notch of the trochlea, and possibly the 
capitellum farther to the outer side and below and in front 
of the head of the radius. 
The only injury from which it should be difficult to dis- 
tinguish this would be, 1 imagine, fracture of the external 
condyle with dislocation of the fragment and both bones 
backward and upward ; the difficulty might arise through 
inability to determine the presence of the capitellum in its 
normal position or its absence therefrom. 
The method of operation in all the cases but the first 
was to expose the region by two lateral incisions. The first OLD DISLOCATIONS OF THE ELBOW. 
9 
incision was made on the outer side, beginning well up on 
the supinator ridge and passing downward across the head 
of the radius and then for. an inch or two along the interval 
between the radius and ulna; the new growth of bone is 
exposed at the upper part of the incision, denuded, and cut 
away with a chisel; the outer aspect of the external condyle 
is freed by division of its fibrous attachments to the radius 
and ulna, the periosteum not being detached until the ar- 
ticular surface of the capitellum is exposed. Drawing apart 
the sides of the upper portion of the wound, the olecranon 
is exposed, and the fibrous mass, which more or less com- 
pletely fills its sigmoid .cavity and binds it to the back of 
the humerus, is cut away. The second incision is made on 
the inner side; it is about four inches long, curved (the 
concavity forward), and passes close behind the epicondyle 
(or its site if it has been broken off); after division of the 
fascia and recognition of the ulnar nerve, the latter is drawn 
aside in the outer flap of the wound and the fibrous bands 
connecting the condyle and olecranon are divided. If the 
epicondyle has been broken off, displaced upward, and re- 
united with the humerus at a higher level, it should be cut 
tree and turned back with the attached internal lateral liga- 
ment, instead of dividing the latter. This division of the 
attachments is carried downward until the articular surface 
of the trochlea is exposed. The dislocation can then be 
easily reduced. It is important that the dissection should 
not be subperiosteal, for otherwise the subsequent nutrition 
of the cartilage of incrustation may be impaired. If the in- 
terval since the injury has been long, the flexor muscles 
arising from the internal condyle may have become per- 
manently shortened, and it will then be necessary to 
separate them more or less extensively from the humerus 
before reduction can be made. The wound is then closed 
(with oi' without drainage, according to the preferences of 10 
OLD DISLOCATIONS OF THE ELBOW. 
the operator and the exactness of his aseptic technique), 
and the dressing applied with the elbow flexed nearly to a 
right angle. 
After the removal of the dressing 1 have supported the 
arm in a sling, and have encouraged the patient to use the 
hand, and ultimately the elbow, in acts that required the ex- 
ercise of but little force. Passive motion has not been em- 
ployed. 
In the first case I employed transverse division of the 
olecranon instead of the second incision on the inner side, 
according to the method known as " osteoplastic excision 
of the elbow " ; 1 now consider it very inferior to the meth- 
od by two lateral incisions, for reasons that I have given 
elsewhere. 
A U-shaped incision, the central portion of which crosses 
and divides the triceps close above the olecranon, has been 
successfully employed in one or two cases that have been 
recently reported. The two arms of the U are essentially 
the same as the two lateral incisions I have employed, and 
the central portion appears to me to be an unnecessary ad- 
dition, with no advantage that adequately compensates for 
the division of the triceps. 
With the exception of the first case, in which the oper- 
ative method was faulty and the dislocation recurred un- 
recognized under the dressing, the results have been satis- 
factory to this extent : the bones have been permanently re- 
stored to their places and the deformity corrected, and more 
or less freedom of motion has been regained ; in all, rota- 
tion of the forearm was preserved; in three the range of 
flexion and extension was from well within a right angle to 
nearly complete extension ; in one it was about 45° at the 
end of two months and a half and was increasing; in one 
it was about the same at the end of three or four weeks, 
when the patient was lost sight of. Such results are not OLD DISLOCATIONS OF THE ELBOW. 
11 
only an improvement upon the condition that existed prior to 
the operation, but they are also better than those obtained 
by such alternative measures as fracture of the olecranon 
or excision of the joint. Reduction without a cutting oper- 
ation does not enter into the comparison, for it is evident, 
from consideration of the existing conditions, that it is im- 
practicable. . Mk /A reasons why 
IMom Piysicians shouia Sutariie 
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