DISLOCATIONS.
The main obstacles in reducing dislocations are entanglement
together of the displaced bones and contraction of the muscles; the
entanglement of the bones determines the direction in which extension
must be made, and also of the _counter extension_, or point at which
the body is fixed to resist the traction practised on the limb; this
should be exactly opposite the direction in which the limb will be
drawn. The muscles can always be relaxed by chloroform, hence it is
better when they are powerful, not to use the limb as a lever to
prize the head of the bone into its place. Steady extension instead
is better, to disengage the bone from the parts against which it is
caught, and to bring it opposite its socket, into which the hands of
the surgeon guide it with less risk of laceration of the soft parts
than attends forcible leverage.
=Lower Jaw.=—This bone is dislocated on one or both sides; when the
condyle has slipped forward from the glenoid fossa, the contracted
temporal muscle keeps the bone from regaining its proper position,
and causes the coronoid process to hitch against the malar bone.
_Treatment._—_Apparatus._—1. A towel.
2. A four-tail bandage.
[Illustration: Fig. 60.—Dislocation of the jaw.]
The patient should be seated in a high-backed chair, resting his head
against the back. The surgeon winds the towel round both thumbs, and
standing immediately in front of his patient, places a thumb on the
second molar of both sides, if the dislocation be double, or on one
side only, if that be alone displaced (see fig. 60). He then presses
steadily downwards until the condyle is released, when it slips back
to its place. The return of the bone may be aided by pushing up the
chin with the fingers _after_ the ramus of the jaw has been lowered.
When the jaw is replaced, a four-tail bandage or split handkerchief
should be tied over the nucha and vertex of the head, to keep the
jaw closed (see fig. 23, page 32). Biting or chewing should not be
attempted for ten days or a fortnight. The patient should be warned
also that when the jaw has been once dislocated it very readily slips
out of place again; he must thenceforth avoid gaping or opening the
jaw very widely.
=The Clavicle= is rarely dislocated, nevertheless both the inner and
the outer end may be displaced. The signs are obvious—the end of the
bone is felt in its new position. The treatment for all is the same.
_Apparatus._—1. Roller, 2¼ inches wide.
2. A piece of old blanket.
The blanket should be torn into strips about a foot square, and
folded thrice, thus making a long soft pad to line the axilla, one
for each armpit. The patient is next seated on a stool; an assistant
standing behind, draws back the shoulder while he presses on the
spine with his knee; the dislocation being reduced, the surgeon fixes
the bone by a figure of 8 carried round the shoulders and across
the back. The forearm is then bent and fastened to the body by a
few turns of the roller round it and the chest. This prevents the
pectorals from acting on the bone. The apparatus may be laid aside
at the end of a week, but the arm must be fixed to the trunk for a
fortnight longer.
This bone is often difficult to keep in place after dislocation, and
even the most accurately fitted apparatus sometimes fails to effect
its object, hence many varieties of collar and yoke have been devised
by different surgeons to accomplish this purpose.
=The Shoulder= is dislocated in three directions, downwards, inwards,
and backwards. These have subordinate varieties, but the signs depend
chiefly on the direction of the greatest displacement.
Signs of dislocation into the _axilla_. When the bone is displaced
below the glenoid fossa the acromion is prominent; underneath it,
the surgeon feels a hollow instead of the head of the humerus, which
the finger detects in the axilla. Movement of the shoulder is very
limited and painful If the elbow is rotated while the finger is in
the armpit, the head will be found to move with the rest of the bone.
If the head of the bone is carried more _inwards_ on to the ribs, it
can be seen and felt near the clavicle; the hollow is again readily
detected below the acromion, while the axis of the arm is altered,
being directed inside its proper position.
When the bone is carried _backwards_ the head is plainly felt on the
scapula below the spine.
For the reduction of these dislocations several plans are employed.
When recent the two first displacements can generally be restored
without chloroform, but if the patient is muscular it often saves
time and pain to produce anesthesia before attempting to replace the
bone.
[Illustration: Fig. 61.—Reducing a dislocated shoulder by the heel in
the armpit.]
_By the heel in the axilla_ (fig. 61).—The patient lies flat on a
couch; the surgeon pulling off his boot from the left foot if he
has to reduce a left dislocation, and _vice versâ_ the right boot,
seats himself on the couch facing the patient. Putting his unbooted
foot into the armpit, he grasps the forearm with both hands and
pulls steadily downwards. When the head of the bone is disengaged
the muscles draw it into the socket, and the movements of the limb
become at once easy and natural. The arm must then be fixed to the
side by a roller for a fortnight, and the shoulder is wetted with
an evaporating lotion to allay the pain and inflammation resulting
from the laceration of the soft parts. Should the surgeon’s strength
be insufficient for the requisite extension, a jack towel may be
attached in a _clove hitch_ round the wrist and held by an assistant,
who standing behind the surgeon draws steadily in the same direction.
_To make a clove hitch._—Grasp the towel in the left hand, the little
finger being downwards, then pronating the right hand till the little
finger is upmost, seize the towel below the left hand; if the wrists
are then rotated in opposite directions the towel will be drawn into
two loops, of which the ends cross above the connecting part between
the loops (see fig. 62); if one hand holds the loops and the other
pulls the ends, the loops will be found not to slip, however tight
the ends are pulled.
[Illustration: Fig. 62.—The Clove-hitch knot.]
_Reduction by simple extension._—The patient again lies flat on his
back, a jack towel is passed round his body and fastened behind
the opposite shoulder for counter-extension, while a second towel
is attached to the wrist by a clove hitch and intrusted to two or
three assistants, who are desired to pull quietly and steadily
directly away from the patient’s body. The surgeon meanwhile watches
the progress of the extension, altering its direction as he finds
the head more or less engaged against the scapula, and finally with
his hands thrusts the head into its socket. Sometimes there is much
difficulty in getting the head back to the glenoid fossa, even
when the humerus is completely disengaged from the scapula; this
difficulty is often overcome if an assistant rotates the humerus
backwards and forwards, while the extension at the wrist and the
pressure on the head of the humerus is steadily maintained. When the
limb is replaced it is fixed to the side as before directed.
[Illustration: Fig. 63.—Dislocation of the shoulder reduced by simple
extension.]
If the dislocation has existed more than a few hours, relaxation of
the muscles by chloroform and extension of the limb carried directly
away from the body are more sure of success than the heel in the
axilla, because they allow greater power to be exerted in a steadier
manner than is possible by the other mode.
=The Elbow.=—The signs of dislocation at this joint are tolerably
evident, but there is often coexistent fracture of the coronoid or
olecranon processes. Separation of the articulating surfaces of the
humerus from the shaft is sometimes mistaken for dislocation of the
forearm backwards.
In dislocation of _both bones backwards_ the olecranon is very
plainly felt behind the lower end of the humerus; the sigmoid notch
is generally to be made out, and the forearm is fixed at a right
angle. The altered relation of the olecranon to the condyles suffices
to distinguish dislocation from fracture of the humerus at its lower
end, where the olecranon also goes backwards, but _the condyles
go with it_. The immobility of the joint distinguishes it from
separation of the lower articular surfaces of the humerus from the
shaft, an accident, moreover, only met with in children.
Other subordinate distinctions between dislocation and fracture are,
the limited movement, the difficulty of restoring the bones to their
natural position, and the absence of crepitus; lastly, the peculiar
form of the articular surfaces can sometimes be made out.
In reducing the _backward dislocations_ the patient sits on a chair
on which the surgeon rests his foot, pressing his knee against the
forearm at the elbow for a fulcrum; then, grasping the wrist with
one hand, and steadying the arm with the other, he flexes the elbow
to dislodge the coronoid process from the fossa at the back of the
humerus; when this is done, the articulating surfaces slip into
place. This plan is commonly adopted when the olecranon is displaced,
but if it fails to reduce the dislocation, direct extension at the
wrist must be employed, as for the following dislocation.
When the _radius only_ is displaced, the body should be fixed by a
jack towel carried under the armpit of the injured side, and over
the shoulder of the sound side. A wetted bandage is rolled round the
forearm, and a second towel is attached by a clove-hitch (see fig.
62, page 99) to the wrist for extension, which is made in the axis of
the limb until the radius can be slipped into its place on the outer
condyle.
[Illustration: Fig. 64.—Reducing dislocation of the elbow round the
knee.]
In all dislocations of the elbow, when the bones are returned the
limb should be bent to a right angle and put on a lateral angular
splint for a week or ten days, after which time it should be worn in
a sling a fortnight longer.
[Illustration: Fig. 65.—Handle for obtaining grasp of the thumb in
dislocation.]
=The Thumb and Fingers.=—When the first phalanx is dislocated from
the head of the metacarpal bone it is sometimes very difficult of
reduction. The most effectual mode is steady extension, which is
procured by fastening the thumb to a piece of wood, which serves as a
handle to give command of the phalanx, and is contrived as follows:
the thumb is first bandaged with a narrow wetted roller over the
two phalanges, and a thick layer of cotton wool is rolled round
it; a piece of stiff wood, 1 inch wide, ½ inch thick, and 12 long,
is perforated at one end with three pairs of holes ½ inch distant
from each other and from the end; through these, three stout tapes,
½ inch wide and 2 feet long, are threaded, leaving three loops on
one side of the piece of wood (fig. 65). The wood is then applied
to the palmar aspect of the phalanges, the loops passed over the
thumb, their ends drawn tight, and tied, not in a bow as the figure
represents, but wound round the end of the stick. The stick thus
attached becomes a good handle for extending the digit, and also a
long lever for altering the direction of the phalanx if desired.
Langenbeck of Berlin employs a pair of forceps to seize the thumb,
instead of the wooden handle just described. But with the greatest
care and perseverance it is sometimes impossible to replace the bone
unless the constricting bands be divided with a tenotome.
=Hip-joint.=—There are three chief directions in which the hip is
dislocated. First _backwards_ on the dorsum ilii, or further on to
the sciatic notch. In this dislocation the limb is shortened, moved
with difficulty, drawn inwards over the other, and its great toe
touches some part of the back of the other foot. The hip itself is
altered, the great trochanter being nearer to the crista ilii, and
more prominent than on the uninjured side, and the head is often
plainly felt in its new position. Resistance to extension of the
limb, limited movement of the hip, with rotation inwards, are the
distinguishing points between this dislocation and fracture at the
neck of the femur.
_Treatment._—_Apparatus._—A complete apparatus for this purpose
is contrived and sold by instrument makers, but a sufficiently
serviceable one can be extemporised when the former is not at hand;
it consists of:—
1. A rope running in two pulley blocks.
2. Three jack towels.
3. Two stout hooks to screw into the wall, or some firm object, to
obtain fixed attachment.
4. A wetted roller 3 inches wide.
The complete apparatus is as follows:—
_Apparatus._—1. A set of multiplying pulleys.
2. A leathern padded girth, 2 inches wide and 3 feet long, having at
each end an iron ring.
3. A stout leathern belt about 6 inches broad, furnished with
buckles, straps, and rings to fasten on to the thigh above the knee;
a rope is run through the rings to connect the hook of the pulleys
with the thigh.
4. Two strong iron hooks to screw into the wall, for fixing the
apparatus.
5. Half-a-dozen yards of stout cord.
6. A hook, fitted with a buckle and strap, and hinged so that, by
turning a pin, it at once disengages itself. If this is interposed
between the pulleys and the hook fixed in the wall, the limb may be
instantaneously released if desired.
[Illustration: Fig. 66.—Dislocation of the dorsum ilii.]
_Treatment._—Step 1. The patient is laid on a flat couch, and put
under the influence of chloroform. When he is narcotised, a jack
towel, or if it be at hand the pelvic girdle, is carried across the
perinæum, arranging it to bear on the tuber ischii behind and the
pubes in front, its ends being attached to one of the hooks screwed
into the wall behind, and about six inches below the level of the
patient. This towel should be put slightly on the stretch, that the
pelvis may be kept in the position first assigned to it when the
pulleys begin to draw. A wet roller is put on the lower third of the
thigh, the jack towel slipped up the leg to the bandage, and fastened
in a clove hitch. Another jack towel is then doubled and passed up
the limb to the perinæum. The patient is next turned on to his sound
side, and the belt of the thigh connected by the disengaging hook to
the pulleys, which are drawn out from each other as far as their cord
will allow, and attached to a hook fixed a little above the level of
the patient, on a line carried from the hip across the junction of
the middle and lower thirds of the uninjured thigh (see fig. 66).
Step 2. The surgeon being ready, an assistant draws on the pulley
cord, getting gradual extension of the limb as required by the
surgeon, who, keeping his hands on the hip and great trochanter,
watches the progress of the head of the bone towards the acetabulum.
Step 3. When the bone has reached the edge of the acetabulum, a
second assistant slips the doubled jack-towel over his shoulders,
and by raising his body, lifts the femur away from the brim of the
acetabulum, while the surgeon, grasping the foot and knee, makes a
few movements of rotation backwards and forwards to ease the head
into its socket.
When a reduction is effected, the limb should be put in a long
splint or starch bandage for three weeks, and the patient not allowed
to exercise the limb freely or violently for a month afterwards.
_Reduction by Manipulation._—When the patient is not very muscular,
and the dislocation recent, the bone can often be speedily returned
by movements of flexion and rotation.
The patient is put fully under chloroform and brought to the foot
of the bed; the surgeon grasps the ankle in one hand, and the knee
in the other, bending that joint till the heel reaches the thigh;
he next flexes the thigh on the abdomen, in doing this he carries
the knee outwards away from the body, and then rotates the limb by
pushing the foot outwards, on which the head often slips into the
acetabulum. If this plan do not quickly succeed it is better to have
recourse to extension, by assistants if pulleys are not at hand, but
the irregularity of the force when assistants are employed renders
the traction of pulleys much preferable to manual strength.
=Dislocation downwards= into the ischiatic foramen. The limb is
lengthened, capable of little motion; the knee is bent; the toe
points forwards, and away from the other foot. Here the reduction
is best managed by extension; the apparatus required being the same
as that employed in dislocation backwards, but it is differently
arranged.
Step 1. The patient lies on his back, the pelvic girth, or towel, is
carried round the pelvis and fastened to the wall on a level with
his body, opposite the uninjured side. A jack towel is put round the
upper part of the dislocated thigh, and attached to the pulleys
outside, which are fastened to the wall opposite (see fig. 67).
[Illustration: Fig. 67.—Dislocation into the foramen ovale.]
Step 2. Extension is then made by an assistant, the surgeon grasps
the leg above the ankle, and rotating the limb inwards and outwards,
but without lifting it from the bed, guides the head into the
acetabulum.
Here, as after dislocation backwards, a long splint should be worn on
the limb for three weeks before the patient is allowed to move about
at all.
=Dislocation on to the Pubes.=—The limb is easily moved at the hip,
shortened, rotated outwards, and the head of the bone is felt in the
groin.
The same apparatus is used in this as in the dislocation on the
dorsum ilii. It is applied as follows:—
Step 1. The patient lies on his back (fig. 68), with his legs
separated. The pelvic band is passed over the perinæum and pubes,
and attached above the patient, in a line passing from the pelvis a
little to his sound side. A double jack towel is slipped up the limb
to the perinæum; the pulleys are fastened to the thigh above the knee
and fixed, in the manner directed on page 106, to the wall below and
external to the injured side of the body.
[Illustration: Fig. 68.—Dislocation on to the pubes.]
Step 2. Extension is then steadily made, while the surgeon watches
the head getting free from the pubes, over the edge of which a second
assistant slipping his neck through the doubled towel, raises the
bone a little outwards. The surgeon in the meantime encourages the
bone by rotation to enter the socket.
A splint is necessary here also after reduction.
=The Knee.=—These dislocations are rarely complete, and are easily
reduced; the lateral ones by flexing the thigh on the belly,
straightening the leg, and rotating it a little from side to side.
_Another Plan._—_Apparatus._—Two jack towels. This is more useful
when the tibia is carried backwards. Lay the patient on his back,
and slip a jack towel in a clove hitch up the leg to the ham, and
another round the small of the leg; the thigh is bent and retained in
a semiflexed position by an assistant holding the jack towel at the
ham, while a second pulls on the one at the ankle and so disengages
the bones from each other, when the surgeon readily slips them into
place.
After reduction is accomplished, the limb should be fixed in a
leathern back splint until the inflammation subsides.
=Dislocation of the Patella.=—The displacement of this bone on to the
outer or inner condyle is generally easily reduced if the knee is
straightened and the vasti relaxed by bending the thigh on the belly.
When the patella is turned on its own axis, the side, not the under
surface, is locked against the condyle, and reduction is sometimes
extremely difficult or impossible. The same movements must be adopted
as for simple lateral displacement, and the surgeon must endeavour to
release the bone by pressing its upper edge downwards with his thumbs.
After their reduction, all dislocations about the knee-joint must be
treated by rest, straight splints, and evaporating lotions.
=The Foot= is very rarely dislocated from the leg without fracture
of the malleoli. Its reduction requires simple extension of the foot
on the leg, with the knee bent; the surgeon grasps the heel in one
hand, the foot in the other, while an assistant fixes the thigh
in the half-bent position. The foot is first drawn downwards to
disengage it from the tibia, and then directed into its place.
After reduction the limb should be put in a McIntyre’s splint, in the
way described for fracture of the tibia near the ankle-joint.
=Scarpa’s Shoes= are instruments for restoring deformed feet to their
natural shape. The shoe (fig. 69) consists of a flat metal sole
broader and longer than the foot, furnished with a rest for the heel.
A rod, attached to the side of the sole beneath the ankle, reaches up
the limb, to which it is secured by one broad band and buckle below,
and by a second above the knee, opposite which joint the iron stem
moves on a free joint backwards and forwards. Opposite the malleoli
are set the centres of movement required for the restoration of the
deformity; they are moved by a key. The foot is fastened to the sole
by straps across the instep and ankle; the toes are restrained by a
strap passing round them and fixed to a horizontal toe-bar by the
side of the foot. In fitting one of these shoes, which of course must
always be made specially for the limb it is to control, the points to
be attended to are—1st, the centres of the joints must be so arranged
that, when traction is made, the foot shall revolve back again
round the same centres it has passed in reaching its distortion.
For example, if the heel is raised, as in talipes equinus, the fore
part of the sole of the shoe must be capable of elevation, by moving
a joint that rotates in a plane parallel to the rotation of the
astragalus on the tibia. In most cases of talipes, the bones of the
foot have been displaced round several centres; hence, the apparatus
must be furnished with power of traction along all of these, or
along the lines resulting from these different directions acting
simultaneously. 2nd. The heel must be got thoroughly into its place
at the back of the sole to ensure that the foot will follow the shoe
in all its movements.
The treatment of talipes frequently requires division of tendons
before extension is attempted, if they are too firmly contracted
to permit the bones to regain their proper position until they are
lengthened by division. Thus, in varus, the tibiales and tendo
achillis; in valgus, the peronci; in equinus, the tendo achillis; are
often divided.
The limb must not be very tightly braced into the shoe, slight
tension, if continuous, suffices to overcome the resistance; and in
children if the straps are drawn tight the skin almost invariably
inflames, and even sloughs where it is compressed. Before the
instrument is applied, the limb should be bandaged with a soft
cotton, or Domett’s flannel roller. The foot is first fixed to the
sole or shoe, and then the leg to the rod. Traction is increased
gradually with frequent small alterations, as the foot yields to the
tension and regains its natural position. The accompanying figure
(No. 69) represents an instrument made by Mr. Heather Bigg. It shows
the shoe restoring a much elevated heel to its proper position after
division of the tendo achillis.
There are three common varieties of talipes—equinus, or horse-heel,
where the heel is drawn up and the toes only touch the ground;
varus, club-foot proper, where the foot is twisted inwards; and
valgus, splay-foot, in which the foot is drawn outwards. Equinus is
often associated with varus, and sometimes also with valgus, and
consequently for such cases the instrument must provide the mechanism
proper to each direction of displacement.
In _Equinus_ the heel is raised by the extreme extension of the
ankle, and the sole of the foot is shortened by the metatarsus being
drawn backwards. In this kind of deformity the shoe must have a joint
to bring the astragalus forwards on the tibia, and the sole of the
shoe must be well padded beneath the scaphoid and metatarsal bones,
that, as the foot is released from its position of extreme extension
at the ankle-joint, the anterior parts of the foot may be thrust
upwards into their proper relation to the astragalus and os calcis.
[Illustration: Fig. 69—Shoe for reducing talipes equinus.]
In _Varus_, or rather _Equino-varus_, for varus without elevation
of the heel is rare, the displacement is compound, the ankle is
extended, the heel raised, the scaphoid and metatarsus are drawn
inwards and downwards, so that the scaphoid lies immediately
beneath, sometimes even in contact with the internal malleolus. The
astragalus and cuboid are drawn forwards so as to lie in front of
their natural position against the tibia and os calcis. To bring
down the heel the upright stem passes outside the limb, the toe of
the shoe can be raised by a circular joint on the stem opposite the
malleolus, which by its revolution raises the toes and depresses the
heel. A second joint working outwards and upwards elevates the outer
border of the foot, and restores the scaphoid to the front of the
head of the astragalus. Lastly, the metatarsus is drawn outwards by
a horizontal spring toe-bar along the outer border of the foot, to
which the toes are fastened.
In _Valgus_, the plantar arch is flattened or even rendered convex
downwards by the sinking of the scaphoid, and in extreme cases, by
rotation outwards and upwards of the tarsus. The shoe here has the
vertical rod inside the limb, and if necessary, an axis for rotation
below the inner malleolus, and an elastic arched pad under the
scaphoid to lift it into its natural position.
=Casting in Plaster of Paris.=—It is often convenient, when ordering
an apparatus for deformity, to send the instrument-maker a cast of
the deformed part. This is readily made in the following way:—
_Apparatus._—1. Two packets of freshly burned plaster of Paris.
2. Some pasteboard, an old bandbox, or several newspapers.
3. Olive oil.
4. A basin of cold water.
Step 1. The part to be modelled should be laid in an easy position,
thoroughly oiled, and a shell or trough of pasteboard roughly built
round it to contain the plaster till it sets.
Step 2. The plaster is then prepared by shaking the powder into cold
water, till a thick cream without lumps is formed; this is secured by
constantly stirring the water as the plaster is shaken in. The cream
is then poured into the trough, little by little, that it may make
its way into the inequalities and recesses under the limb, until the
limb is half immersed, leaving the projecting parts, such as joints,
half exposed, so that the halves of the mould may separate opposite
them. This first instalment is then allowed to set, and a fresh
supply of plaster is prepared.
Step 3. The surface of the hardened mould is oiled, that the fresh
cream may not stick to it, and the whole of the limb is then covered
by pouring the cream on a second time. Plenty of plaster should be
laid over the projecting parts that the mould may be strong enough
for use. It should be ¾ inch thick everywhere, and 1 inch thick
along the sides. When the second half is set, the trough or shell is
cleared away, and the two halves of the mould removed from the limb
separately.
For casting, the mould is well oiled inside and filled with cream,
which sets into the cast required. While the plaster is liquid, the
mould should be well shaken, that the air-bubbles may be all driven
from the surface of the cast.