First Description of Madelung Wrist Deformity 1878
From:
Otto Wilhelm Madelung - Die spontane Subluxation der Hand nach vorne.
Verhandlungen d. deutschen Gesellschaft fur Chirurgie 7:259-276,1878 ( The
Spontaneous Forward Subluxation of the Hand- Proceedings of the German
Association of Surgeons 1878,Vol 7 ) [There is a discrepancy with the page
numbering ]
Translation: p395 XVIII the forward spontaneous subluxation of the hand . By Dr
Madelung in Bonn * (Illustration table V Fig 3 - 8)
Traumatic luxation of the hand at the radial-wrist joint , is admittedly,
extremely rarely the subject of surgical observation. 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 descriptions of this late onset deformity of the wrist previously
written in the literature ,so far, were rather inaccurate or too brief. 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
On Table V included are the drawings giving the outline picture to the
highest standard, how the discussed deformation of the hand comes to
develop.
The sight of the hand subluxed forward is most remarkable, if we regard it
from the side of the ulna in the profile view(Fig 3). 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 hand appears not completely so clear and to a large extent forward
subluxed, if it is viwed from the radial side. 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.
With inspection of the back by hand and forearm in the middle position
between deflection and straighten an easy radial abduction becomes remarkable,
in other easy ulna ubduction of the hand in individual cases. 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
The view of the figures is already sufficient to determine,um, how
considerable the Dislocation of the hand is to the forearm in these most
striking cases. 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). ------------------------------
* Atlas of topographe anatomy Table 49 Fig 7 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.
But I return again to the description of those symptoms of the hand
subluxation, which are to be seen in the living person. 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.
The Effect of the described abnormality of the form is a not insignificant
Functional disturbance. 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
Limited the ulna ubduction was in individual cases, even if only
insignificant^,; in others,for instance that, which supplied the corpse
preparation, however the radial abduction. In these attestations prevails,so
much I see, no regularity.
In individual cases the pain of the area of the wrist is a
substantial. 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.
It was a 18 year-old, quite healthy countrygirl, with which I observed 1868
for the first time with both arms the most expressed form of the forward
Subluxation of both hands. 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.
Nine times I observed the Subluxation on one side, four times of the right
hand, five times of the left. A mark do not find I in my notes the body side
indicated. Two times were both hands affected.
The female sex was more prone than the male to this defect in the ratio
8:4. 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.
Heavily, a judgement was to be won over it, how long time was necessary, the
substantial forms of hand subluxation, as the outlined instance brings
out. Most patients indicated 1 to 2 years. A case, however special type,
permitted me at least an approximately safe regulation.
The 27 year old Marie Herchenbach from Bolhausen the Extensor of the right
forearm came on 18 October the 1876 into the surgical health center with
Tendovaginitis crepitans. 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
Since my special attention, I can say, since almost it was turned to one
decade, this suffering and I the deformation with individual individuals found,
even suffering none ^ following to more gave,so believed I able to certainly
accept that Subluxation position of also small degree was available in the
October 1876 not yet had developed, but in the course of approximately a half
year.
Little interested me in the first cases,wo this suffering me to face came,
the question :"When achieves the deformation of the form of the wrist their high
point? Does the Function disturbance, which pain, which drives the patients to
the physician, remain, continuously existance? The inconvenience by me more
later for theoretical reasons for rationally cure regulations held suggested and
it prevented the Abulia/Aboulia, with which I faced start the patient, it that
longer time the same patients remained for me in the field of view. The more
importantly were me therefore the following observations.
1875 came as a companion one at knee joint inflammation afflicted child of
35 year old Maria Spaecht from Gaulshiem into the surgical health
center. 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.
Completely similarly circumstances were with above tanner already mentioned
Anton Schreut from Abrweiler, which could certainly indicate that age 14 was the
onset , that the spontaneous Luxation ,now aged 25 , each work of her occupation
to perform knew.
These coincidental observations of the existence of heavy deformations of
the wrist without subjective complaints led me to give on the form of the wrist
with humans of the most diverse social classes and occupations exactly watch
out. 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.
Beforehand however I, for the completion want that before now, which I found
from original remarks over spontaneous Subluxation of the hand in the literature
of the disease picture which is based mitgetheilten so far on own
investigations.
Dupuytren, who is well known for his classification investigations
overturning the terms valid since Hippocrates over the frequent traumatic of the
luxation of the wrist, which rarity the same and the reasons of mistaking with
fracture of the lower radius end make clear, name the following description *:
"under the Affectioning of the wrist, which luxation could pretend, had the
following is carefully, which we had rather frequently to see opprtunity. 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. "
Bégin * theilte a case of this type, which he in the hospital of
Dupuytren with a printer saw also an academic.
Special interest had for me the case, which before-heals as the only
Malgaigne observed of it. 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 ** mentions von Boinet of a corpse found forward Luxation of the
hand , "sans aucune fracture". 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.
C O Weber * describes a case of completely little by little emergence to
painfully curved position of the right hand with 16 year old girls. 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.
So far this form and Functional disturbance of the hand is missing at more
each sufficient assertion of coming off. 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].
After the available observation material over clinical and anatomical
findings the Mitgetheilte been sufficient, as I believes, for the support
of the opinion, which I formed over the emergence of the spontaneous Luxation of
the hand. 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.
The upper extremities are with humans of the obligation to carry the body
weight released. 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.
Also at the upper arm joint and at the elbow joint are, as I believe, so
typical growth disturbance to observe. 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 *.
Hueter describes in its hospital of the joint diseases (Bd II, s 483), like
the ulnare Abductions finding with the newborn child itself - and of tensor
position of the wrist , "due to the sphere of influence of the birth canal on
the ^Foetus" by the malign formation of the stretching movements, which require
the everyday occupation of the hands, outer-forms training.
-------------------- * 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".
Up to now nobody gave itself the trouble to study and describe this minimum
deformation, but the clinical observation name us enough characters that the
forms of the joint surface of the wrist do not become finished in the first
yearold, but that up to it locked the bone growths its reorganization by the
work, which performs the individual continues.
Rapidly before itself going shaping of joint surfaces and joint ligaments by
work always prepares pain, both at the bone edges pressed one on the other, and
to over its bulk stretched ligament apparatus. 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.
Who even at present academic years the noble fencing art experienced, or
which, later in a university town living, knows which had the small suffering of
the academic youth to treat opportunity, the state of the
"verpauktseins". 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.
With these pain is, as said, always shaping of the range of motion of the
wrist connected. 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.
But becomes only too frequent, if pain remains unconsidered, if the work
with to weak hands must be ever further performed, the shaping of the joint
surface abnorm. 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.
The mechanical process with this shaping, which the even forward Subluxation
position of the hand causes, seems to be me after my anatomical investigations
the following. 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].
If the continuing position of the hand would be only conditioned by the
effect of tensor muscles, a Contractur, like in former times often assumed,
would exist then reorganization the radius joint surface a permanent of tensor
position of the hand develops instead of the repeated work practise. 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.
Why the dorsal flexion must suffer by this formation of the wrist, a view of
the given drawings shows. 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.
A review of the clinician mitgetheilten by me observations becomes,
believes I, which let so multiples analogous, which has the spontaneous hand
subluxation with the growth disturbance at the lower extremities, fall rapidly
in's eye. 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.
Probably we must, if we see that of 100 and more individuals, whom the same
hard manual work at the same age suffers thun, but only the described Hand
deformity to the Explanation on a "primary weakness status of the bones"
recurriren. 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.
No working method succeeded in up to now eliminating the trained Subluxation
position of the hand.
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.
Became more rational circular argument its, which would have a malign
shaping of the deformed wrist parts for the purpose. 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.
Since I it knows that the pain of the wrist goes out also with substantial
Subluxation automatically that the hindrance of the dorsal flexion ability to
work not limits me on the wrath to preserve the hand as special as possible with
work, which requires forced volar flexion. 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.