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The Classic: Injuries of the Wrist: A Radiological Study

Destot, Étienne

Section Editor(s): Meals, Roy A MD, Guest Editor; Harness, Neil G MD, Guest Editor

Clinical Orthopaedics and Related Research: April 2006 - Volume 445 - Issue - p 8-14
doi: 10.1097/01.blo.0000205896.83114.05
SECTION I: SYMPOSIUM: Problem Fractures of the Hand and Wrist
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(This reprinted Classic Article is reprinted with courtesy from Destot E. Injuries of the wrist: A radiological study. New York, NY: Paul B. Hoeber; 1926. This article originally was used as the Classic in the January 1986 issue of Clinical Orthopaedics and Related Research.)

Étienne Destot (1864-1918) was born in Dijon and educated in Lyon, where in February 1896, less than two months after the announcement of the discovery of the X-ray by Röntgen, he was already making radiographs of patients in l'Hôtel Dieu. He had great enthusiasm for this new method and devoted a major share of his time to developing the technique and its application to clinical medicine. His work led to the publication of three monographs, the first dealing with injuries of the wrist,2 the second with injuries of the elbow in children,3 and the third with injuries of the foot and ankle.4 Because of severe radiation damage to his hands, he was forced to give up his position as the radiologist at the l'Hôtel Dieu in 1913. In addition to his work in radiology, he was also interested in medical applications of electricity and neurology. In the course of his work he made many contributions to orthopedics. He was something of a talented eccentric, a sculptor, and the designer of an aerodynamic car with an aluminum body! He was sent to the western front as a medical officer in World War I, and died as a result of pneumonia in 1918.1

During his life, Destot continued to revise his work. An English translation of the most recent manuscript of his work on injuries of the wrist was made by F. R. B. Atkinson of Edinburgh and published in 1926.5 It is from this translation that the following extract is excerpted. I have chosen the author's preface because I believe it best conveys the spirit of the man and the methods that he used to derive his information. It is clear that Destot interpreted his radiographs only after a careful correlation of the clinical and anatomic features of the case, an approach that should be more widely used today.

Leonard F. Peltier, MD

Since the appearance of my small book on “le Poignet et les Accidents du travail,” the study of injuries of the carpus has been the subject of numerous works, and I have thought, notwithstanding the success of this small monograph, to which the Academy was kind enough to award a prize, it would be a good thing to treat in a larger way the history of lesions of this region, quoting my own personal experiences. In spite of all the criticisms and all the controversies, I have not in any way changed my first opinions, because, having begun my studies in 1896, I had no desire to produce the whole work before 1905: my book at that time represented the results of an experience of nine years: this one, like the former, being based on observed facts, will only serve to make these first data complete. Search after truth has always been my guide, and perhaps for that reason the views expressed have appeared original. It is difficult to divorce oneself from the ideas of others, but the opinions stated are my own. Precious time is lost by clearing the brain of previous formulae, acquired laboriously and so often accepted without verification. Perhaps it will be of interest to know by what way I have been led to concern myself especially with the subject of injuries of the wrist, and what originated my researches.

Each time a new and certain means of experimental analysis arises, science is always seen to progress in relation to the questions to which this method can be applied, said CI. Bernard in his Introduction to the study of experimental medicine, and this truth shines forth in all branches of medicine whenever new methods of investigation allow of the amplification of purely personal clinical data by precise physical means, and of the substitution of the sensation of sight, the delicacy and extent of which is much greater for those of touch and of hearing.

To continue, ever since Röntgen's discovery, I had been enthusiastic about this new method, and by February, 1896, I was equipped with all the necessary apparatus. As it happened, my attention was first directed to the foot, but in November of the same year it was drawn to the wrist, of which, like my coadjutors, I thought I knew everything, but I immediately discovered it was not so.

Fig. 1

Fig. 1

I had come to Paris to buy some Crookes's tubes at the establishment of Chabaud, the famous maker, who lived in the Rue de la Sorbonne. He was then the only French manufacturer, and there was a long wait for one of his ampoules. Seeing in the front of the building a superb cast of a hand, I entered and asked the author's name: it was the Marquis de V-Rentré of Lyons: I wrote and congratulated him on his skill and enquired regarding the history of the injury, which I considered was due to his slipping and falling, the feet shooting out in front, and the body falling backwards, the hands resting on the ground to lessen the shock, an opinion corroborated by the Marquis who came to me two days later.

He had fallen three years since, whilst skating at the Brenets, in the way above described, and since that time he had, on certain movements, pain and uneasiness in his wrist.

It was the first fracture of the scaphoid I had had the opportunity of seeing. From that time searching in the immense storehouse of the Hôtel Dieu at Lyons, for all the injured wrists, I noticed the different and peculiar appearances of the scaphoid in fractures of the radius. Naturally all kinds of injuries of the wrist came under my consideration, although there was an epidemic of fractures of the scaphoid which raged until February, 1897. At this time I submitted for operation to my friend and master Vallois, an anchylosed wrist, which presented a pseudo-fracture of the scaphoid. The operation showed me my mistake: it was the first dislocation of the carpus in which Vallois attempted surgical reduction.

From that time I possessed two facts which showed that the carpal condyle played a rôle in cases of injuries, since it changed its shape, and also that a small bone to which, up to now, no importance had been attached, could break. At the same time I found, although four years as assistant, my knowledge of anatomy did not enable me to read or interpret my plates. I therefore bribed the servants of the Faculty, and with the help of my old friends and pupils, Gallois, Briau and Denis, my room was transformed into a dissecting-room: every evening, Gallois, at that time prosecutor, brought all the available wrists from the University: they were broken, radiographed and dissected every time the plate showed a change in them. The next morning they were all taken back and put into their places to avoid our theft being discovered.

Briau served as a model in front of the screen for the study of the physiology of the wrist, and placed at my disposal his drawing-pen. At the same time all the injuries, it mattered not what, of the wrist which entered the Hôtel Dieu were conscripted, so that in a short time I could read and interpret the radiograms. These old memories of seventeen years show at that time the knowledge believed to exist regarding the wrist was quite rudimentary. My old master, M. Pollosson, who as chief surgeon chose the subject for the prize at the end of the year of house-surgeoncy (Bouchut's prize), was very surprised when I asked him to select as the theme in 1898, fracture of the lower extremity of the radius, which he believed was perfectly well known.

Gallois was prizeman, and his thesis showed the rôle of the carpal condyle in fractures of the radius, the method of production of the swelling on the back of the hand, and the experimental conditions necessary for isolated fracture of the scaphoid. This enormous work included experimental examination of all the pathogenic theories invoked to explain fracture of the radius.

On August, 1898, I came across my first recent dislocation of the carpus in a student of medicine, and M. Goullioud reduced it. This lesion which I had met with and failed to recognise in February, 1897, and had been able to observe in some old cases and on which Vallois had tried partial resections without a satisfactory result, had become familiar to me. I had published 3 cases in the “Province Médicale” of 1898, under the name of mid-carpal luxation. Tavernier, in his thesis in 1906, collected 24 cases in Lyons. Since then, my own observations number 90. My cases of fracture of the scaphoid have at the same time multiplied. In Reynard's thesis, I collected all my cases up to that time, and since then my number amounts to more then 150. Fractures of the semilunar are much rarer (24 cases). Lastly, the less marked and less characteristic lesions of subluxation of the scaphoid and of the semilunar, a dislocation met with in nearly half the cases of fracture of the radius, have permitted me today to collect a whole series of conditions due to injuries of the carpus, hardly mentioned in classical treatises.

Fractures of the os magnum (4 cases), of the cuneiform (6 cases) and of the trapezium (4 cases) are only of slight importance, because of their rarity, and one of my objects is to show what strong physiological connection binds fractures of the radius to these different bones and why and how the scaphoid and the semilunar bear the brunt of injuries.

Between sprain, dislocation of the scaphoid and of the semilunar, dislocation of the carpus, fractures of the scaphoid alone or associated with fractures of the radius and of the semilunar, it is only a difference of degree and of anatomical variations, which depend on the points of application of the force, according to the different position in falling.

We are forced, for purposes of description, to isolate prominent groups from any scheme of classification, but they arise from the same chain and are connected by the links which lead from one to the other.

This general conception binding all the lesions of the scaphoid and of the semilunar has resulted from my anatomical researches, which were only undertaken to explain facts which appeared discordant and are considered in Cousin's thesis (1897). In the main, when the pathological physiology of the wrist is understood, all the facts become easily connected, whereas every hypothesis, however ingenious, ends inevitably in erroneous conclusions, if clinical facts be not sufficiently considered. The best criticism which can be made regarding M. Delbet's theory of 1906, which he supported by invoking the aid of the ligaments, is the incorrectness of the conclusion in which he denies the possibility of reduction of the semilunar. The facts are that all the recent cases which have been kindly entrusted to me since 1898 have been reduced even at the end of twenty-five days, and in one case after three and a half months.

Independently of the scientific interest of this question, there is the possibility of very rapidly bringing back to the injured person the use of his hand which, if left to itself or operated upon later, often remains greatly incapacitated. This practical knowledge, unhappily, is still not generally known, since in Paris, this very year, I have been asked to assess some unrecognised cases.

When Tavernier, on my advice and that of Vallois, wrote his beautiful thesis in 1906, a study of the 24 cases from my collection enabled him to formulate strong conclusions regarding reduction, and the different surgical operations.

Jaboulay extirpated the semilunar by the anterior route in 1901, a method which naturally suggested itself. Vallas, in 1897, tried reduction by operation, and then performed a number of partial resections, the bad results of which led him to prefer complete resection in old cases. There existed, then, a whole mass of researches and experiences dating back to February, 1897.

The first case in Eigenbrodt's memoir published in 1901, dated from September, 1897. The work of Lessev (1902), that of Gross (1903) and lastly that of Lilienfeld, who succeeded in producing dislocation experimentally goes back to 1905. Gallois and I experimented on more than 100 subjects without producing anything but different types of fracture of the radius, and fracture of the scaphoid alone.

It is not absolutely true to say, as Tavernier does, this question had not been studied in France, whilst large memoirs existed in foreign countries since 1901. I presented to the Societies in Lyons sufficient facts and enough of the physiology of the wrist for Tavernier himself only to have to consider and compare them with foreign works to show that my researches borrowed nothing from them; but these first observations were not accepted without difficulties, and the indifference shown by modern surgeons for fractures benefited me.

For twenty-five years the victory of asepsis has broken down all surgical barriers, and all efforts have been concentrated on new paths. Fractures and dislocations have been neglected, and if the law of 1898, regarding occupational accidents, have given them a little lustre, they have only come into their own today because surgical boldness does not hesitate now to upset the old treatment, and to substitute for it operative methods.

Formerly, open fractures were feared; today those which are not compound are made so. Fractures have benefited by current views, which need not be discussed. I will simply note that for many years, when I had every facility for systematic observation, only a few French surgeons showed any interest. It was not till 1906 that the memoir of Delbet and the thesis of Née attracted the attention of French surgeons, whereas foreign countries already possessed the observations of von Lesser (1902), Gross (1903), Lilienfeld (1905), Eigenbrodt (1901), Kauffmann (1903), Höfliger (1901), Codman and Melville Chase (1905). But at that date I had already gathered in a large harvest of facts.

It is not without interest to cast a retrospective glance along the road travelled, and to balance up all that was known before radiography of the subject under consideration, in order to compare it with the present state of our knowledge.

From Hippocrates to Pouteau, fractues of the lower end of the radius were considered as radio-carpal dislocations, of which four varieties were described: anterior, posterior, internal and external. In the posthumous works of Pouteau, published in 1783, thirty year before the memoir of Colles (1813), fracture of the lower end of the radius is admirably described, accompanied naturally by a wrong theory on the action of muscular contraction. In spite of Pouteau's discovery, the views of Hippocrates were in the ascendant when, in 1820, Dupuytren boldly attacked the sacred ark. He showed in all articular fractures of the foot, as well as in those of the wrist, fracture preceded dislocation, and his teaching was new.

Without absolutely denying the possibility of posterior dislocation of the radio-carpal joint, although I have never met with it, at least it must be admitted it is excessively rare, perhaps never occurs as the result of a fall on the anterior part of the wrist. The cases of posterior luxation of the carpus only on the forearm, described as such by authors, were probably only fractures of the radius situated a quarter, a half, or even a thumb's-breadth from the lower end, or simultaneous fractures at the same point of the radius and of the ulna.

The discussions of Dupuytren with Pelletier at the Hôtel Dieu, and with Marjolin at Beaujon, and the great fame of his clinical lectures both in France and in foreign countries, ended in luxations disappearing from the scene, and the fanatical partisans of Dupuytren went beyond his opinion. All observations on luxation were denied. Dupuytren had said it was rare, his pupils declared it to be impossible. But a reaction set in. Letenneur showed at the Anatomical Society a case of dislocation of the wrist, Molle reported an observation with autopsy (1938). Later, cases were described by Marjolin, and by Voillemier (1839), by Taylor (1840), Scoubetten (1841), Barker (1845), Pollosson (1845), Dupuy (1850), Paul (1851), Chassaignac (1857). The cases of Kelly and of Laloy and Huguier were described in 1859. In 1861 Jarjavay showed a specimen, and Benjamin Auger (1865), Guyon (1868), Eloy (1873) and Chapplain (1874) each met with cases. In 1878, Howard Lowe reported an autopsy, in which he had noted anterior displacement of the semilunar and of the scaphoid. In 1880 Servin described incomplete dislocation of the carpus. In 1890 Curtillet, and in 1892 Gaudier, drew attention to a case.

The experimental school substituted for pure and simple observation, and for pathological anatomy, what was found to be impossible to produce on the cadaver. Bouchut, experimenting under Dupuytren's inspiration, could only produce fractures, and all surgeons thinking themselves mechanics discussed direct transmission and transmission by means of the interosseous ligament, each one explaining the swelling on the back of the hand according to his own view.

Pouteau's theory on muscular contraction had been abandoned, and Bouchut's theory of “arrachement” had gained more and more partisans.

Naturally, the carpus played no part, and since luxations could not be produced, it was only a step to consider their existence impossible, a biassed opinion, not indeed peculiar to the older observers; Tavernier in his thesis also excluded mid-carpal luxations, and posterior displacements of the semilunar.

Abadie, in his thesis, had however referred to 71 cases of radio-carpal dislocation prior to radiography, and if after a first sifting some doubtful cases can still be found, at least the facts he reported cannot be denied. Four cases of mid-carpal dislocation certainly exist: those of Maisonneuve, Richemond, Desprès and Claudot. On the other hand, incomplete luxations were known, as the case of Howard Lowe, and that of Servin, which he interpreted as a radio-carpal luxation, save for the semilunar.

On probing into the literature, some examples of lesions can be found which, since radiography, have been studied systematically, but before 1896 they were considered curiosities of no importance and of no practical value. Albertin, having come across two cases of enucleation of the semilunar through the skin of the wrist, collected with difficulty two or three others, and although Howard Lowe had seen a dislocation of the carpus in 1878, it would never have been anticipated that a single observer would one day muster 90 personal cases.

It had not occurred to Bouilly in 1894 to look for the cause of the gravity of some fractures of the radius in lesions of the carpus, for the simple reason that experimental researches had produced wrong conceptions. Experiment, because it seemed to be pseudo-scientific, was given the first place instead of being looked upon as a method of verifying clinical observation, as Amedée Bonnet did, and of producing certain results from injuries. Hence, the endless theories to which authors are proud to give their names permanently.

There were, however, added other forms to the primary type of fracture associated with the name of Pouteau.

Cracks and fissures were seen close to the epiphysis. Hutchinson had described fractures of one and of both styloid processes, Bennett fracture of the sigmoid cavity, Rhea Barton posterior and Letenneur anterior marginal fractures.

Radio-carpal dislocations were exceptional. They are so always, and I have seen only one case.

Four authentic mid-carpal luxations, some isolated fractures of the unciform and of the os magnum, four enucleations of the semilunar, and two luxations of the scaphoid: that was all.

But today the part played by the carpal condyle in fractures of the wrist is no longer doubtful, as is shown by some new varieties of fracture of the lower end of the radius. Isolated fractures or fractures associated with the scaphoid are common, dislocations of the carpus are frequent, mid-carpal dislocations more rare, but fractures of the semilunar more numerous, since I can count 24 cases. But all these isolated or associated lesions of the carpus form a complex whole that must be analysed in order to group the cases according to their nosology, and it is here verbal difficulties arise, and I ought in these preliminary remarks to explain the terminology I employ and have chosen, for a similar affection bears many names.

It is a very difficult question how to classify and label lesions so complex as those of the wrist.

If common sense in clinical matters only governed the classification, everything would be easy.

Unfortunately there are rules, tradition, academic questions and systematisation, and then the simplest things become complicated. Classification of fractures has been based on their presumed method of production, in which experiment and theory have played a part. Some practical but narrow minds have required as a certain basis pathological anatomy, a firm foundation it is true, but the fearful complexity of these cases renders this method inapplicable, for nearly every case differs from each other in small points, and if a class were made for each of them it would end in a hotch-potch.

Nowhere, perhaps, does the weakness of the system employed appear more obvious than in the wrist, and the necessity for a general guide, drawn from pathological physiology and from clinical examination, is obvious.

It is easy to give a concrete example:

A person falls down and suffers from an injury to the wrist, radiography showing the following conditions:

  1. (1) In the forearm, fractures of both styloid processes:
  2. (2) In the carpus:
    • (a) Fracture of the scaphoid, the upper fragment of which is enucleated to the palmar side, whilst the lower tilted fragment is prominent in the anatomical snuff-box.
    • (b) Displacement of the semilunar which has lost its connections: (1) with the os magnum: (2) with the glenoid cavity of the radius; (3) with the cunei-form; (4) with the fragment of the scaphoid united to the trapezium. The semilunar suspended by its anterior horn is prominent in the palm, where it causes nervous symptoms from compression.

The os magnum, on the contrary, having preserved its connections with the trapezium, trapezoid and unciform, and the latter with the cuneiform, protrudes slightly on the dorsal surface of the wrist, and is most often found in the prolongation of the axis of the forearm. These are the bare facts. What shall this complex lesion be called?

At once, say some, the fracture predominates, and consequently the fractures of the styloid processes and of the scaphoid overrule the luxation. The old luxations of Hippocrates have here become fractures of the radius, since the time of Pouteau and of Dupuytren. They are certainly dislocations, but they can only be considered such if the bones of the forearm be intact. In the same way, in the foot, the tibio-tarsal luxations have yielded the prior place to fractures of the malleoli. But is this the case here, and can it be maintained luxation of the semilunar has, as a necessary condition, fracture of the scaphoid and of the styloid processes? No, certainly not, because in cases similar, clinically, these fractures are not met with: the scaphoid can be dislocated, either anteriorly, which is rare, or posteriorly, without breaking, and fracture of the styloid processes is only a fortuitous accompaniment. These lesions are, therefore, accessory, as the study of a series of cases shows.

Hence, the fracture has not here the importance it acquires in other articular injuries, where the eternal discussion, to wit, if it be a fracture with dislocation or a dislocation with a fracture, easily settles itself, as in the ankle, for instance, where Malgaigne and Maisonneuve have shown by facts, fracture preceded luxation, which was secondary.

We admit that in this case dislocation is predominant, but which luxation?

The name, said Malgaigne, of the distal fragment is given to dislocation. Consequently, the case related should be described: dorsal luxation of the os magnum with fracture of the scaphoid and of the styloid processes. This is correct if we admit all joints are the same.

To begin with, we must note how peculiar is the luxation of the os magnum. All the bones of the carpus are connected to each other, excepting the scaphoid and the semilunar, and these two bones have lost their attachments to each other and to the glenoid cavity of the radius. We have, therefore, to do with an incomplete mid-carpal dislocation. Why give it the name of the os magnum only, seeing it is accompanied by its satellites?

Looked at, indeed, from the point of view of the semi-lunar, we see this bone has lost its connections with the radius and with the carpus and, in some cases also, it even protrudes through the skin. Shall Albertin's cases, for example, be called dorsal luxations of the os magnum, or mid-carpal dislocations? This is contrary to all common sense, and only systematisation conduces to such absurdities. No, classification cannot be based on pathological anatomy alone, or on ordinary nomenclature, the principles of which are in the above cases faulty, and we must have recourse to physiological facts.

The foot and the hand are connected with the leg and the forearm by the astragalus, and the scaphoid, and the semilunar respectively, and the same terminology cannot be applied to lesions of these parts as to luxations of the leg and forearm owing to the intermediate structures between the two articulations.

In the wrist the scapho-lunary system is an intermediate joint which doubles the amplitude of the movements of the hand, adding to the displacements of the radio-carpal and mid-carpal joints and transmitting to the second row the shocks it receives from the forearm. The scaphoid and the semilunar are wedged between the malleus of the forearm and the incus of the second row united to the metacarpus, and according to the numerous positions on falling, the amount of violence, and numbers of different conditions, will show special lesions. The best proof that can be given of the importance of the scaphoid and of the semilunar is the frequency of their lesions. Take a thousand cases of injury to the wrist, either fractures of the radius, lesions of the carpus, or mixed lesions, and it can always be said the scaphoid and the semilunar play a part. How are the lesions of the other bones to be described: the cuneiform, os magnum, trapezium or unciform? Exceptions of no importance. If, then, clinically the lesions be centred in the scaphoid and in the semilunar, it is because these two bones from their physiological action obtain especial importance, and pathology confirms their entity. The discussion on the foot between Malgaigne and Broca, regarding the rôle of the astragalus, is applicable to the hand, and I attribute so much value to the scapho-lunary system that, in spite of all criticisms, I shall continue to speak of dislocation of the carpus in order to show that the different luxation of the scaphoid and of the semilunar met with in the majority of the plates of so-called dorsal luxation of the os magnum is the dominating factor, as demonstrated by my pathological study dating back to 1898, and hence my new name for the new facts, new, because the observations prior to radiography are not of any value, because they were isolated and disconnected ones and the cases were not methodically studied.

Tavernier in his thesis has not ventured to throw in his lot with any side, and is satisfied with the vague term, displacements of the semilunar, as if the scapho-lunary system played no part. This is an error; the major bones of the first row cannot be separated, and I hope to show how close are the ties uniting the two bones in affections of the carpus.

When we speak, for example, of isolated fractures of the semilunar, we ought to add with sub-luxation of fracture of the scaphoid, or even fracture of the radius. The carpal condyle cannot be flattened or diminished in height in the region of the semilunar without bringing in its train a diminution in the height of the column of the scaphoid, and the latter must dislocate, break or become impacted in the radius to compensate for crushing of the semilunar, in the same way, as when the scaphoid is crushed, the semi-lunar must be dislocated or be broken.

Is the semilunar exposed to the injury as a result of the fracture of the scaphoid? or is it the reverse? Usually the lesion is simultaneous, sometimes the semilunar, sometimes the scaphoidal lesion has been primary: the study of these so-called isolated cases shows it. But whatever may be the method of action of the force, the lesions of both bones are inseparable. There arises from this long discussion to which I should not have committed myself, if from it practical hints did not emanate, that injuries to the carpus present a special appearance, and their study is intimately connected with the physiology of the wrist. Anatomopathological classifications only cannot be applied, because they take no account of the subordination of one of the existing lesions to the other, and, in addition, the enormous multiplicity of the classes they bring in their train does not give a proper estimation of the lesions. Every correct classification ought to rest on clinical observation, and pathological physiology ought to occupy the first place, but it is difficult to do so, but directly it is accomplished everything becomes clear, and, as a result, treatment finds its best indication.

What constitutes the enormous difficulty in classifying affections of the wrist, is the contrast between the facts obtained from clinical examination only, and the frightful complexity of the lesions as revealed by radiography, so that if clinical types be adopted, each of them is seen to hide a certain number of different lesions: if, on the contrary, we take our stand on pathological anatomy, we become overwhelmed by numerous details.

There are only three or four clinical classes, but we must still have recourse to them, well knowing the same symptoms correspond to different lesions.

The lesions ought to be classified from a purely functional point of view, and here physiology comes into its own.

We shall describe, first, sprains, then dislocation of the carpus, and, in addition, midcarpal luxation, and then fractures of the carpus. These concern the carpus.

In the second place, we shall have to study, from the radial side, complete and partial fractures of the lower end, intra- and extra-articular, without or with displacement, isolated fracture of the lower extremity of the ulna and radio-carpal dislocation.

Under the mask of sprains, according to the classical definition, not only is there hidden temporary luxation with tearing of the ligaments and of the fibrous tissues, and hernia of the synovial membranes, but also subluxation of the scaphoid and of the semilunar, a true diastasis with permanent articular displacement, and the whole series of fractures of the scaphoid and also comminuted fractures without displacement of the lower extremity of the radius. The clinical study of sprains, analysed by radiography will then show a number of lesions, formerly unsuspected.

For instance, dislocation of the carpus has the same clinical appearance as fractures of the semilunar and midcarpal luxation, but radio-carpal dislocations, which are very rare, resemble fractures of the lower extremity of the radius rather than carpal lesions.

Roughly speaking, we can separate carpal lesions from those of the forearm, as long as we bear in mind: (1) mixed cases, where lesions of the carpus and of the forearm are plainly associated, and there are found, at the same time, symptoms connected with both the carpus and with the forearm; (2) hidden lesions, radial complications with carpal lesions, or carpal complications with lesions of the radius, be they concealed from or revealed by radiography.

We will study:

  1. The anatomy and the physiology.
  2. Sprains and sub-luxation of the scaphoid and of the semilunar.
  3. Fractures of the scaphoid.
  4. Dislocation of the carpus, and, in addition, mid-carpal luxation.
  5. Fractures of the semilunar.
  6. Rare fractures of the other bones.
  7. Radio-carpal luxation.
  8. The different forms of fractures of the lower extremity of the radius.

The headings are sharply defined and differentiated, but they do not take account, from the anatomical point of view, of all the varieties; they form, however, landmarks, and heads of chapters, which allow us to follow, without too great difficulty, the very extensive field of injuries of the wrist.

I hope this study will show the extensive knowledge we owe to the systematic application of radiography to injuries of the wrist.

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REFERENCES

1. Denier, A.: Destot, pionnier de la radiologie à Lyon. Cahiers Lyonnais d'Histoire de la Medicine 4:3-11, 1959.
2. Destot, E.: La poignet et les accidents du travail: Étude radiographique et clinique. Paris, Vitot Freres, 1905.
3. Destot, E., Vignard, P., and Barlatier, R.: Les fractures du coude chez l'enfant. Paris, O. Doin, 1909.
4. Destot, E.: Traumatismes du pied et rayons x. Paris, Masson & Cie, 1911.
5. Destot, E.: Injuries of the Wrist: A Radiological Study. New York, Paul B. Hoeber, 1926. English translation by F. R. B. Atkinson.
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