Quite frequently however view one shifts of the particulars, the wrist bone parts form too each other, are brought out by heavy inflammation changes of the bones and the joint structure.
With the outcome, to the so-called pathological luxation to handtogether finds united with the other writers cases mentioned herein, where forward Subluxation of the hand was observed , without being found to be preceded by inflammation , and without ,demonstrably, a trauma having occured to the limb.
Such mis-positioning of the hand can occur spontaneously.
The description of similar observations is desired.
But more still put, than the intention of remedying this needs causes me to the available before healing the desire to try an assertion of apparent mystery coming off of this suffering the desire, essential ^[^ signifies END of ORIGINAL PAGE] analogous, between these and more frequently observed and more recognised structural disturbances of other desecration existance, clearly lay down.
-------------------------------------------
* after 1 of 4 session days of the VII Congresses of the German society fur surgery lecture held at Berlin,13 April,1878.
p 396
The forearm apparent probably is.
Under the normal, rather stretched skin the distal end of the Ulna juts out clearly.
styloid process, like joint surface are recognizable and by feel becomes apparent .
The hand, for itself alone regarded, is normal.
But it down-sank after the palm-side too.
The widest diameter of the wrist is increased almost by double.
The extensor tendon to stroke over the radius after the back of the hand bridges and covers the deep gap, which was so remarkable before the Ulna joint surface.
In addition, doubles of that almost.
One feels down over the radius distally, if the hand is in dorsal flexion, which free large parts of the joint surface of the radius can be felt.
For someone, with only unilateral occurrence of the disease, one can compare with the radius of the healthy limb, comparing that the whole lower epiphysis of the radius of the deformed side is too downward curved after something the Vola.
In the case of investigation of the palm-side "pseudo-break" stepping out the deflection is noticeable.
Among them draw particularly clearly starting from the Flexor carpi radialis and ulnar nerve, the Palmaris longus
p397
So for a long time I with hands-on investigation of such cases was limited, had I to accept that the first could touch number of the carpal bones with its joint surface only the lowest edge of the joint surface of the radius, likewise that the same am by means of from its connection with the Ulna, as the same by the Cartilago triangularis, completely yielded sci.
But this acceptance was substantially modified, when I got an opportunity to examine ,anatomically a spontaneously subluxed hand.
On the cadaver , I found the left hand of an ,approximately 20 year-old, well built girl,arrived soon after the girl had died in childbirth, she had been brought in from the outside to the surgical operation scar subluxed in a so substantial way that the distortion of the form of those equaled, which on Table V shown hand shows.
The shifting out of position was "typical".
Each character of chronic bone inflammation misdirection, both on the left arm, and at the whole remaining skeleton.
I knew, even without details about the patient history of her case to know,unerringly,in the diagnosis "spontaneous Luxation" .
Placed arm and hand in a freezing solution, sawed then in 3 Sagittal were confirmed - disks.
A saw cut was made so that it half finished the heading of the capitate bone and its socket in the lunate bone (Fig 7).
A second saw-slice part the lower part of the Ulna in two equal parts (Fig 8).
The position of the bone parts of the wrist in the still frozen disks fixed with would help of on one side ground-glass plates.
I give the two resulting sectioned drawings on the Table V which are a true likeness.
To the light demonstration of the modification, which with storage of the bones and steering welfare taken place, I attach the sectioned drawing of the sagittal slices of a normal wrist, how she to Henke * name (Table V, Fig 6).
------------------------------
p398
I notice only that with surface arranged in Fig 7 illustrated through cut the radius completely near ^ its ulnarwards that part already do not hit the Incisura semilunaris with the saw are,so that the strong inclination stepping out when far investigation after the radius epiphysis the Vola in these pictures to be detected have can.
Only by a very small amount it is possible to turn the wrist upward.
Here however the wrist only the Ulna is brought closer.
Between radius and Carpus no larger relocatability is, than with a normal wrist.
A view of the anatomical sagittal slice (Fig 7) shows, why this like that is.
The peak,in that the upper edge of the radius joint surface is changed, must each upwards push of the wrist prevent.
Leave the course at the hand in the direction of the wide diameter and the pressure on the palm-side of the carpal bones, exerted at the same time, by which the part-wise Reposition was apparent performed, after, then re-establishes itself the old form disturbance.
[ Note this is probably what i have styled the N test in the main file ]
And even in degrees of reducibility these are still somewhat different the individual cases.
If pain existed in the wrist (as we will see later, in the fresher forms, during the development of the suffering), then I saw the reducible smaller, than in such cases, where each movement had become painless.
Always, and this is certainly important enough, is possible it to make between the first and second number of the carpal bones,im to Interwrist, movements those far the boundary of the normal, actually only springy mobility between both exceeds.
Both the active, and the passive dorsal flexion of the hand are handicapped, according by the degree of the Subluxation.
In the worst cases the hand was only around a minimum from the stretched central position by would help the Dorsal flexure to remove.
In addition, with easier degrees of the have seen the dorsal flexion was far smaller, than the same is possible for flexion in normal hands.
The capability to the volar flexion was, so far pain limitation did not impose, normally, often rather increased, as mine there.
p399
In these attestations prevails,so much I see, no regularity.
Determined, on pressing painful points are only rarely, usually the top margin of the joint surface accordingly, discoverable.
But substantial painfully each movement is, particularly the dorsal flexion.
The pain would be here both on the palm-side, and on the dorsal side of the joint felt.
The symptoms were the described.
This individual explained to be almost completely incapable of work.
Only in the year 1871 I with a 16 year-old girl, the daughter of well-to-do parents in Cologne, the observed same suffering, this mark only at the right hand.
Since then the cases arrived relatively more frequently, for the most part than patient of the Bonn ones surgical health center my observation,so the fact that I up to now with a dozen of different persons Subluxation of one or both hands had forward observed, which equaled soon as typical start described case at weight two times it decided surpass to the same-remain rarely in order some behind.
A mark do not find I in my notes the body side indicated.
Two times were both hands affected.
The age of onset was about 13 years.
Nearly 23 years of age the onset of suffering (apparent causes by special circumstances) only with 2 persons was observed.
With exception of the case mentioned above, belonged all patients mentioned an above of the all, belonged all patients the working classes on.
In none of the observed cases the deformation was present at birth; in none the onset was dependent on a trauma or heavy type zurückzuföhren.
p400.
Never existed characters of acuter or chronic inflammation at possibly parts of the joint apparatus.
In most cases indicated the patients that heavy, continuous work had been the cause.
But it is to be emphasized that in no case a manual work preceeded, which would have been of completely particularly more arduously and that, people of working class are used to which too thun, exceeding type.
Women believed to have to look up frequently the cause of suffering in continuous washing.
A 25-year old leather tanner, with whom the deformation at both hands was observed, gave rather determined specification.
By hard work, particularly by continuous lifting of the tanning of skins his wrists became very painfully, the bones (ulnae) out-stepped.
After some time the pain would automatically have lost itself, but he had noticed that it could of tensor both hands disregard like in former times to the rear, particularly not the left hand ".
Two other men were a farmer and a shoemaker.
Most patients indicated 1 to 2 years.
A case, however special type, permitted me at least an approximately safe regulation.
On the skin of the of tensor side of the right upper arm lay a hand-sized burn scar, this was due as a 6 yearold having suffered a burn.
The right arm should be weaker, than the left, however for operating was used, lately to hard kitchen work.
A sticking cotton wool preparation fixed for 3 weeks right wrists and healed the Tenalgia.
Female patient appears on 3 May 1877 again in the health center nowadays existed trained Subluxion position forward on the right of the hand.
Female patient told that, after they returned again work pain had begun with movement in the right wrist and had steadily increased.
In consequence of these pain the girl had become rather unable to work and of their family doctor for a cure had sent her to hospital.
p401
The more importantly were me therefore the following observations.
Completely coincidentally I discovered the forward Subluxation position of her left hand.
The same was into as high degrees existing, as I it never otherwise seen and still more considerable, than the figures show.
This woman told that as a girl with no known reason much had been suffered from pain in the left wrist, treated also with ointment applications that it would have had to give up some domestic occupation because of the pain that however for years each pain had now already disappeared and the hand concerned can be used for each work.
The dorsal flexion was this case almost completely to be.
I was surprised, as extraordinarily frequently I found small deviations from the normal position.
These by the examined individuals normally at all not considered deviations of the form of the wrist always were after the same type, as the described spontaneous Subluxation.
Apparent protruded only cutting back head of the Ulna somewhat more than normally under the skin.
p402
In reality ^ however also the radius joint surface and the position of the wrist were changed to it.
I never found this modification before for 13 years.
This observation for the assertion of the heavy, more exactly described form of hand subluxation has which Werth, I will have directly to discuss.
It existirt a type of radial-Carpal joint, which is known to the surgeons so far not sufficient, of the certain particularly with men, who with the man's impetuous, more violent, if they let the arm of the traction operate.
Under the influence of these steady efforts one sees the ligaments of the wrist slackening not rarely and stretch so that more expanded movements are possible for the bone, than is the norm.
The wrist , which is no longer firmly fastened to the forearm, angled the feature of tensor muscles after and become angled themselves forward before the lower ends of the radius and the Ulna.
All other characters of a such Luxation are available, except pain order inflammations.
The more or less considerable deformation and the weakness of the parts are the only trouble of this adjustment.
The patient is able to bring it normally to disappearing, by pulling on the hand, but her re-establishes itself as desired, or even during rest, however by the predominance at the palm-side of the forearm are situated ^Muscles.
------------------------------------
* Dupuytren, Clinique chirurgicale Tome 1 p 164 Bruxelles 1839
p403
The individuals afflicted with minor suffering would rarely seek medical help.
The small inconvenience is borne easily and is not not large enough, it to compel to interrupt or give their work up.
"
The same is, which concerns the outside picture of suffering, onset and process, unites from me observed "speaking" similarly.
The Luxation position of the hand became observed with 36 a year old man.
From the specification only mentioned that the diameter amounted to anterior-posterior the wrist on the Ulnar side of 2 inch, on simple pressing by moved together of the bones on 15 1/3 Linien was returned here that the wrist "at the stylus extension of the radius only 3 1/2 Linien up rise," "the diameter of front to back is only on 14 Linien went," the fact that "the edge of joint of the radius very spissiated and as forward was bent".
This man now, who had to by the way complain none, by its irreducible hand dislocation caused complaint, except important handicap of the bending backwards, had brought the forearm as a child of 8 or 9 years into a transmission and had broken the radius in his middle parts.
This arm break was well healed.
Three years more afterwards, he worked as a bricklayer, carrying heavy loads, began at the lower end of the Ulna, which formed gradually a projection/lead to the rear, pain.
His mother took him away from the foreman, the Dislocation continued however becoming larger without Auschwellung, without obstruction in the motion and without another pain, than indicated the already.
After process of 18 months the wrist was completely forward set right.
Nélaton knew quite had no knowledge of time of onset.
-------------------------------
* Malgaigne, setting, over the v Burger p662 Stuttgart 1856
** Elemens de pathology surgery T III p195 v Langenbeck Archive of surgery XXIII 2
404
Malgaigne constatirt that in this case, which he also seen, no measurement organization of the bones, no visible track of old tearing up available been.
The same case became before and after Weber of W. Busch ** treated and described.
Busch giebt on that both hands were subluxed to the palm-side.
In the description of the symptoms both surgeons are correct ¨agreed, likewise in the fact that decided no trauma preceding that no character of inflammation existed.
Dupuytren and O Weber believed the same "obviously by Muscle contraction effectuation".
The basis for this opinion is absent.
Busch left unexplained in the evenly mentioned case the cause, cut through however the Flexor carpi uln and to Palmaris longus subcutan and tried then the Reposition - without reached.
Some Colleagues,who I showed cases of spontaneous Hand luxation, believed to have to assume a completely chronically running bone inflammation as a cause, a Caries sicca, for instance the type, how it occurs at the shoulder joint relation-moderately so frequently.
Neither process, nor output of suffering justify such an acceptance.
Malgaigne never in his cases "a simple slackening of the ligaments without possibly an appreciable organic cause" on.
Hereby is not said any longer, as if we would look and up Scoliose in slackening of the ligaments the cause of these deformationen with Genu valgum [knock-knees].
I count this bone deformation to the "bone-growth disturbance of the joints" ***.
-----------------
* C O Weber, surgical experiences and investigations p232 Berlin 1859.
** W Busch, text book of the surgery Bd II 3 Abth p111 Belin 1864.
*** Pitha Billroth, manual of the general and specialised surgery Bd II 2 p692
p 405
Volkmann summarizes in this group those ^ deformities, "only with children and juvenile individuals occurs and is dependent from malign shapings of the articulated surfaces probably-formed before by mechanical influences, which the normal bone growth alter".
Under the so transforming, mechanical influences the most important is "the Weight", "the load of the joint by over it which were situated and by it the carried body segment ".
Pes valgus, Genu valgum [knock-knees], Scoliose are frequent representatives of these group.
In addition, at them bone-growth disturbance will be able to initiate, if they understood, either still in the growth, or by possibly which weakening circumstances in their nutrition are disturbed, to the execution by work forced, which is relation-moderately too heavy for them, which is required too continuously by them.
In other place I would like to give their description.
At the wrist perhaps the only one is, anyhow the most frequently occurring growth disturbance the so called forward spontaneous Luxation *.
--------------------
* in the session of the surgeon Congresses I,im view to this etiology interpretation for the spontaneous forward Subluxation of the hand the name Manus valga.
Theils moved me for this the example Hueter's, which for the founded on the form distortion of the hand on foetal deformation, with which ulna ubduction and of tensor position exists, which becoming lumpy hand, Manus takes up names vara, because of the analogy of this form disturbance with the clubfoot;theils looked I at all for for a new name, around which always mistaking with traumatic Luxation that the name Manus is not suitable valga, there he already of though Contracture of the hand as the Varus accordingly, in which the hand curved, the palm-side moved, as the Valgus similarly a status of the backwards bend of the wrist (operational surgery I p838) from this can certainly the re-use of the name Manus valga for still another further
p406
It noticed then far that "an attentive observer would have to succeed to make from minimum modifications of the form of individual wrist or individual joint surfaces on the occupation of the individual a conclusion those bones carried which".
Hyperaesthesie of the joints, which we observe at the foot with muscle-weak, juvenile individuals so regularly, if special efforts in going and being are zugemuthet, are also at hands male and female youth the occurring the puberty time extraordinarily frequently to observe.
Muscle-weak students in their first terms driven by disproportionate eagerness with learning to use the weapon are exposed to this suffering.
Not after a foul blow, after a Distorsion, not after a Contusion of the joint by the same an appropriate impact, fencing exercises adjusts a status of violent pain in wrists.
Even the most eager one is forced to immobilizing the wrist for months.
Instead of the previously used right hand if the left is used instead for holding the sabre, then also this is struck soon by the same pain.
407
Rest and recuperation, often terms be through experienced, bring ^ pain to disappearing, and with the strengthen to the arm musculature and the whole organism at the same time disappears each trace of it.
The same suffering strikes, after exagerated practice of completely different art, that of pianoplayers, frequently enough the pupils of the modern girl's boarding school.
Here it probably often undeserved the name "joint neuralgie" given.
If one will find girls, who go through first training in washing,zu observe opportunity have, one that hardly from pain the same sort is completely free.
The assertion for is given if one watches, how for instance are maltreated when wringing out a larger piece of washing the wrists of the beginners, if one view, as the older, experienced woman of the beginner drives in thereby the Hand steadily in the highest degrees of dorsal flexion.
Most younger scrubber inside commit themselves, in order to the violent pain somewhat to prevent, for the support of the wrist a broad ligament around under part of the forearm.
Only if the arm musculature helped the work according to strongly become, only if these persons learned with wringing out, by timely firmer grip, with strongly developed of tensor muscles passive overstretching to evade, only then stops the pain.
The Effect will be usually certainly only still an extension bending and of the stretching ability being situated in the boundaries of the normal one.
It leads the exaggerated effort to the deformation, to the Subluxation in the same way, as at the foot, at the knee when going and being to the Pes valgus, to the Genu valgum [knock-knees] leads forward.
For the range of motion of the wrists as for other joints are given movement inhibition devices by three type: The bone, the ligament and muscle inhibition
p408
But showed like Hueter *, is for the hand of completely special importance by the arrangement polyarthrodialen muscles of the given inhibition.
The work of the daily life, which is dextrous with the hands, is performed completely predominantly by of tensor muscles.
Humans with complete muscle palsy work rough for performing remain usually still qualified.
The main factor in its causation is the more powerful action of the flexors of the forearm,due to overexertion.
Continued hyperflexion stretches the extensor tendons and the posterior ligaments over the dorsum of the radial epiphysis,exerting a forward force and producing a volar bowing.
But the fatigue overcome.
The bones - and ligament inhibition steps into effectiveness.
_ immediately will then with grow, bind and weak apparatus occur must.
Abnormal strong pressing, loads the lower edges of the radius joint surface and the wrist, brings the same to the arrest to growth, to the loss.
Of pressing against it the top margin of the radius joint surface becomes relieved.
It grows likewise, like the Condylus internus the Femur with the Genu valgum [knock-knees].
But that is not like that.
The Axen of the wrist and the upper half of the radius is approximately parallel too each other.
----------------------
* Virchow's Archive XLVI p37
p409
This brought out by the Thätigkeit of the dorsal flexion continuing nevertheless nevertheless and, ^whow I believe, also in quite considerable way by the weight of the hand in the resting position, with the vertical hangdown.
With each attempt the peak out-rampantly grown in the place of the upper sharp edge of the radius joint surface must lift itself against the back of the carpal bones.
Like for that one, the age between that is 13 and 23 year, the female sex, which particularly pre disposition to standing up.
As is the case for the Pes valgus, then the deformation with the termination of the bone growth achieves its deadlock also with the spontaneous hand subluxation.
Like there, the pain goes out also here.
although deformation and handicap of the range of motion remain existance.
But we must assume the same also for Scoliose and feet hypothetically.
If we see, how with an individual both hands change evenly, perhaps with the same individual still flatfoot formation up,so becomes us this acceptance surely easily.
As we furthermore often also with attained full growth men, if them a Fracture at the lower extremity suffered and the months-long nonusage of the member had brought Atrophie out of all bone-graft of the same, flat developing see, then person can lead an attenuation of the growth of the upper extremity and following, disproportional hard work to the Subluxation of the hand also in individual rare cases with an adult.
p410
Repeated one tried to receive the spontaneously subluxed hand equal a traumatically set right to reduce and in reduced position.
A view of what I mitgetheilten over the internal structural proportions of the wrist with spontaneous Subluxation, is sufficient to show,um that a sudden, straightening by force of the hand is just as impossible, like the cure of the make flat by sudden Reposition one or several tarsal -bones.
None of the surgeons, to which the resetting, their opinion succeeded after, was in the status to receive the hand in the reponirten position.
Bégin mentions that in its case a simple course at the hand was sufficient,um the Dislocation to create that the same was again brought out however by free pieces by the exclusive Thätigkeit of the flexor muscle.
Busch tried Reposition under anaesthesia and fixede then the hand in the of bent position, without achieving improvement.
C O Weber fell into the same trap, after it also the uselessness from plaster of Paris to the preservation of the Reposition tests, to a machine, which by means of feather force the effect of the hands replace should, its refuge (on Taf 5, Fig 3 and 4 of his working is shown the same).
It writes that the retention thereby absolutely well one managed.
But after Weber to Heidelberg again to the hospital return.
Busch cut through on that subcutan the Flexor carpi ulnar nerve and the Palmaris longus ^ and tried now the Reposition.
But the Subluxation "took constantly too".
Just as little can help anti-inflammatory means.
Frequently I saw the same applied in form elegantly with tincture of iodine applied to bracelets.
With pressure the rampantly grown bone parts would bring to the loss its,es would have other joint segment for longer time of pressure to be relieved.
Plaster of Paris, which receive the hand for longer time in dorsal flectured position, would correspond to this purpose.
but larger difficulty opposes the execution of this handling plan, than at lower the extremities at the hand.
p411
Rarely patients become cured, and to few those working class belong,, to do for months and months completely without the use of their hands.
But are the complaints, which the Subluxated position brings to the hand with itself, but too small.
Existence suffering however from both hands,so will make resistance to even the most energetic Therapy.
I have only in a case such handling somewhat consequent executed (several other patients did, after some weeks the hand had been fixed by plaster of Paris, without further handling).
The female patient, the longer time this handling left itself fallen - it was Herchenbach mentioned above - was besides substantial hysteriscal.
The right hand the same was treated during a half yearly with fixation in the plaster of Paris in different position, with hand baths and methodical exercises.
Perform lighter work again with the right hand in the end, without feeling pain.
The outside form of the deformation was not modified.
Furthermore I try to strengthen by methodical exercise the arm in all its parts.
Some patients has I a real service gethan, by recommending wearing a custom made cover of stout leather, moulded around the shape of the wrist, held in place by a loop passing between index finger and thumb however prior to this sliding up the arm was prevented.
Such a collar permits laborious occupations and prevents ,nevertheless, all too exagerated movements in the wrist.
p412
Explanation of the figures on Table V.
Fig 3 spontaneous subluxation of the hand seen from the Ulnar-side.
Fig 4 the same hand, seen from the radial side.
Fig 5 the same hand, seen from the back-of-hand side.
Fig 6 sagittal- slice by the normal wrist with mean - position (after Henke).
Fig 7.8 on p261 aforementioned sagittal slice.
.
L lunate bone.
C capitate bone.
HH hamate bone.
P pisiform bone .
T triquetrum bone.
Graphics relating to Madelung Wrist Deformity from 1878 well before the availability of Xrays and before medical photography got going.
