CASE 3. — In December 15th, 1838, the writer laid a case before the Pathological Society of Dublin, which was a true speci men of a disjunction of the lower epiphysis of the radius.
The patient, having been above eighteen years of age, had attained to a more mature time of life than any other example of this special injury affecting the wrist hitherto recorded ; a representation of the external appearance which the lower part of the fore arm and carpus presented in this case have been preserved by a plaster cast ; and after the death of the patient, the actual condition of the parts having been ascertained anato mically, these circumstances, in the writer's opinion, make this case valuable.
A. B., wt. eighteen, a mason, fell from a scaf fold which was attached to the front of a lofty house at its third story. By the fall he re ceived a severe injury of the head, which rendered him immediately insensible, and in this condition was admitted into the Richmond Hospital. Besides the injury of the head, we noticed in this case a remarkable lesion ; the right wrist had suffered a derangement, accom panied with a deformity that at first sight we might suppose would be produced by a dislo cation of the carpus and hand backwards on the dorsum of the forearm (fig. 931.). The plane of the hand and carpus were placed fully three quarters of an inch behind the plane of the rest of the forearm ; and from the external appearances there seemed no doubt but that there was an abrupt transverse solution of continuity of the forearm, close to the wrist joint, which equally affected both radius and ulna.
On viewing the limb laterally, the peculiar curve which Velpeau compared to the hack of a silver dinner fork, was exaggerated beyond what we noticed in the ordinary fracture of the radius in this situation; and the tendons of the extensors, particularly those of the extensor carpi, were thrown remarkably into relief. The anterior, or palmar surface of the fore arm presented a longer and more uniform curve than the posterior ; the depth of the antero-posterior diameter of the wrist in the seat of injury was much increased : so that this and the bilateral measurement seemed equal.
Thus the accident presented many of the appearances of the dislocation, backwards, of the hand and carpus ; but the longitudinal measurement, taken from the highest part of inch over that of the opposite hand. This
excess of length was manifestly caused by the presence of the disjoined epiphysis, which the dorsal prominence to the root of the dex finger (from A to B fig. 931.), on the jured side, gave an excess of length of half an had been superadded to the summit of the carpus, and was carried back with it, the wrist-joint itself remaining perfect.
This simple test of the comparative measure ment proved the case was not one of mere dislocation of the hand ; but we may also add, that, although there was considerable swelling and projection forwards of the palmar surface of the region of the wrist, there were not those hard protuberances to be felt in front of the carpus which the extremity of the radius and ulna, with their styloid processes, should have presented had the dislocation above alluded to occurred.
The man died, in a few hours after admis sion, from the injuries he received, particularly of the head.
It had not been deemed advisable to reduce the fracture, as the man seemed to be in a dying state.
Dissection.—With the assistance of my friend, Dr. Power (now Professor of Anatomy of the Royal College of Surgeons, Dublin), I removed the greater part of the forearm, that we might the more carefully examine the true nature of the lesion, the external ap pearances of which we have above described.
On making, then, the anatomical examina tion of the parts composing the region of the wrist in this case the radius was found to have suffered a transverse interruption of con tinuity in the line of junction of its inferior epiphysis, and the lower fragment was dis placed directly backwards, so far as nearly to have passed the extremity of the upper frag ment (fig. 935.). The lower extremity of the ulna was broken a short distance above the line of junction with its epiphysis. This fracture was oblique. The extremities of the two frag ments of the ulna formed with each other an angle salient in front. The ligaments and the radio-carpal articulation also remained unin jured, and the carpus (of course) accompanied the lower fragment of the radius in its dis placement backwards.