bone are diminished in size by interstitial absorption; ligamentous or
fibro-cartilaginous tissue is formed round the wasted extremities; and
the surrounding cellular tissue being thickened and condensed, a sort
of synovial pouch is formed, in which the ends, by this time smooth and
rounded off, move freely. The limb is shortened in some degree, and its
actions are very much diminished in force, there being no sufficient
support for the muscles. The bones of the leg and of the forearm are
occasionally the seat of false joint, sometimes the femur, but most
frequently the humerus.
By the tight application of a firm and broad belt of leather, the part
is steadied, and the limb rendered more serviceable. Various measures
have been proposed and practised with the view of promoting a salutary
increase of action in the parts, by which osseous deposit in sufficient
quantity to form a firm uniting medium might be procured. The ends of
the bones have been exposed by incision, and removed either by the saw
or by cutting pliers; they have then been placed together, retained by
proper apparatus, and the case treated as one of compound fracture.
The ends have been cut down upon, rubbed over with escharotics, as
caustic potass, and afterwards treated as in the former method. Setons
have been passed between the ends of the bones, and been retained till
sufficient action has occurred; they have been then withdrawn, and the
limb steadied by splints and bandaging.
To the last method I would, from some experience, give the preference.
It is the least severe, both immediately and consecutively; it is the
most readily accomplished, and the most likely to be followed by a
successful result. The exact site of the ends of the bones must in
the first place be ascertained; the position of the bloodvessels and
nerves must be looked to, that they may be avoided; a bistoury is then
passed through the skin and down into the substance interposed between
the ends of the bones. A strong and sharp needle, fixed in a handle,
and with its eye near the point, is passed, in the track of the knife,
fairly betwixt the bones, and pushed through the soft parts on the
opposite side of the limb. A cord is then passed through the eye, and
by withdrawal of the needle the seton is properly lodged. The effects
must be attentively watched, and when sufficient action is supposed
to have been excited, perhaps at the end of the first week, the cord
is withdrawn, and the limb placed immoveable in a proper position. If
action is slow in supervening, the chord may be smeared with irritating
substances, as the unguentum oxydi hydrargyri rubri, or the unguentum
cantharidis, &c. In this manner I have treated false joint in several
situations successfully, but I have also been sometimes foiled in
effecting my purpose. The seton must not be long retained, the object
being to excite action, not to perpetuate discharge, by the profusion
of which the end will be effectually frustrated. Much will depend on
the period at which the practice is adopted.[63]
_Dislocations._—Some joints are so contrived—their composing bones
are so notched into one another, and connected by such powerful
apparatus—and they are crossed by tendons, and tied together by
ligaments in such a manner,—that dislodgement can scarcely be effected
but by the most violent means. Nothing short of immense force is
sufficient, and the displacement is uniformly attended with fracture of
portions of the bones, or of their processes. Other bones are loosely
joined, permitting free and unrestrained motion in all or in many
directions, and but little force, applied in particular directions,
suffices to separate and luxate them. In every joint the processes
are liable to be broken, and the attachments of the ligaments to be
torn off; ligamentous tissue withstands a greater degree of sudden
violence than the osseous. The synovial membrane, and the fibrous
tissue exterior to it, are almost always torn in complete luxation;
but the extent of laceration varies in different joints, according to
the direction of luxation and the degree of displacement. The rent
may be small, closely embracing the neck of the bone; or there may be
an extensive gap on the side opposite to that on which the luxation
has taken place. In an articulation surrounded by muscular substance,
there is also laceration of this to a greater or less extent. In some
individuals, dislocation is very apt to occur, perhaps from peculiar
laxity of fibre; and if in any person luxation of a joint has once been
produced, the accident is apt to occur again and again from but slight
causes.
In general, the mobility of the luxated joint is much diminished;
the limb is either shortened or lengthened; its contour is changed;
the injury is attended with violent pain; the patient is sick and
pale; the system receives a shock, from which it gradually recovers
after some time. Then swelling, from effused blood, takes place; and
this is followed, after some hours, by excited action of the vessels
and farther effusion, giving rise to greater stiffness and pain on
attempts at motion. If no means are taken to replace the bone, and
painful feelings subside along with the swelling, the limb remains
long useless, and is the seat of occasional lancinating pains, but
at last motion and utility are to a certain extent restored by the
formation of a new joint—the head of the bone, and the parts on which
it rests, mutually accommodating themselves to each other, by degrees,
and permitting a limited extent of motion. _Post mortem_ examination,
years after the occurrence of the injury, shows change in the form of
the bones—the head is flattened, and in the bone on which it lies there
is a corresponding depression, formed partly by the deposition of new
matter, partly by absorption of the old; in dislocation on the dorsum
of the ilium, for example, there is excavation by absorption opposite
to the centre of the head of the femur, and round this new osseous
matter is deposited so as to form the cavity into a cup resembling
the acetabulum. New processes are formed for the attachment of the
muscles, and the old are absorbed to a remarkable extent. There are
also new ligaments; and a sort of capsule is formed by condensation of
the surrounding cellular tissue. The new articulating surface becomes
quite smooth internally, and is covered, if not by cartilage, by a
smooth substance which answers the purpose tolerably well; the old is
gradually filled up and obliterated, the prominences being absorbed,
and the cavity occupied by new deposit. These changes do not take place
so rapidly as is generally supposed; the cartilage and synovial surface
are not much altered for months after the occurrence of luxation;
and if replacement be effected, the functions of the parts are soon
performed as before the injury.
In some articulations, on account of the formation of the opposed
surfaces, attempts at reduction prove ineffectual after the lapse of
two or three weeks; in others, of more simple construction, it may be
accomplished after some months. The simple mode of reduction is to put
the patient off his guard, so that the muscles may be in a state of
relaxation, and then to move the limb artfully in the proper direction,
without much force. Occasionally, the bone is pulled into its place
by the action of the muscles, during the patient’s efforts to place
the limb in a comfortable position. Considerable force, however, is
sometimes required in even recent luxations of large joints, and means
must also be taken to weaken the muscular power. The patient, if young
and robust, may be bled to syncope, or placed in the warm bath till
a sense of fainting supervenes; or an enema of tobacco infusion may
be administered, and smoking of tobacco may have the same effect when
the patient has not been addicted to the noxious habit; or antimonial
solution may be given in nauseating doses. Several or all of these
methods may be necessary in some cases, particularly if the dislocation
be of long standing. When thus general exhaustion has been procured,
counter extension and extension are to be had recourse to. The former
consists in having the patient, and the bone next to the trunk, fixed
immoveably by fitting lacques and belts; and the latter is made by
one or more assistants, or, if need be, with the help of pulleys.
During extension, advantage is in many cases gained by lateral force
and by rotation of the limb, the bone being thereby moved from its
position, and brought within the sphere of muscular action, by which
it is drawn suddenly into its proper place. In some cases, there is
no doubt but considerable laceration is occasioned by the efforts at
reduction, and perhaps this is in some degree necessary to a successful
issue—as when the capsule has been slightly lacerated by the accident,
and in consequence interposes an obstacle to the head of the bone
slipping into its socket. After reduction, inflammatory action in the
articulation and its neighbourhood is to be expected, to a greater or
less degree, particularly when much force has been employed, and means
must be taken to avert this; local remedies are generally sufficient,
along with perfect rest.
In luxation of the _lower jaw_, both articulating ends are most
frequently dislodged. They can escape in but one direction, forwards
into the temporal fossæ; when both are dislodged, the mouth is widely
open, and fixedly so, the chin is drawn downwards and backwards. When
one is displaced, the jaws are partially opened, the chin is twisted to
a side, and immoveable. Great pain is experienced from the pressure of
the condyles of the bone on the temporal muscles, from stretching of
the fibres of the pterygoids, and from interruption to the functions,
by pressure, of the contiguous blood-vessels and nerves. Mastication
is impossible, the speech is altered, and indeed articulation may be
said to be impracticable.
It is supposed by the vulgar that the accident is particularly apt to
happen to infants and young persons. Nurses are in consequence careful,
when a child yawns, to support the chin, and pronounce an accompanying
blessing. The articulating cavity is then shallow, yet luxation must be
rare in young subjects. In my own experience no instance of dislocated
jaw has occurred but in adults; and then, either from over-opening of
the jaws, or from powerful muscular action during depression of the
inferior maxilla.
The nature of the injury is at once known; and the displacement
is easily remedied. But I have met with instances where, through
ineffectual attempts at reduction, the unnatural position has been
allowed to continue for many hours, to the great distress of the
individual. The object in view is to depress the ramus—one or both,
as may be—and to raise the chin. This is effected by pressure with
the thumbs on or in the situation of the molar teeth, whilst with the
fingers the jaw is moved upwards and backwards. The thumbs need not be
protected by a glove, as is generally recommended; on the bone resuming
its place, they are easily slipped into the space betwixt the jaw and
the cheek. There is no necessity for bandaging, as retentive apparatus;
the patient is not likely to yawn for some time after.
Luxation of the _clavicle_, at either end, is produced by force applied
to the point of the shoulder. It is seldom that the sternal extremity
is separated from its connexions. When this accident does happen, it
is easily recognised; the end of the bone is prominent and loose, and
is distinctly felt riding over the top of the sternum. Replacement is
effected by bringing back the shoulder; but the bone is with difficulty
retained in the proper position, and is long in becoming fixed; a
certain degree of deformity is ever after present.
Displacement of the scapular extremity is by no means rare, and occurs
to a greater or less extent, according to the laceration of the
ligaments. If those only are torn which connect the end of the bone
to the acromion, there is mere rising of the end. But if—as is often
the case when the violence has been great, as in a fall either from
a height or with great velocity—the conoid and trapezoid ligaments
connecting the tuberosity of the bone with the coracoid process, have
given way, then the end of the bone projects, pushes out the deltoid,
and gives rise to considerable flattening of the shoulder. The arm
falls forwards, and cannot be moved but with pain; nor is the patient
able to raise it by its own muscular power. If the surgeon grasps the
middle of the bone, he finds the end moveable; and the evident and
deforming projection puts an end to any doubt regarding the nature of
the case. The bone is readily reduced by raising the arm, and carrying
the scapula backwards. The limb must be retained in the proper position
for many weeks, if a cure without interruption, and with as little
deformity as possible, is desired; but after the utmost care and
patience, there still remains, in almost every case, some projection
more than before the accident. The ligaments are slow in uniting, and
the union is imperfect and weak. The requisite apparatus is the same
as for fractured clavicle, but must be retained for a longer time. The
patient experiences great relief from the limb being put up in this
manner and maintained so; and inflammatory action, with much of the
swelling, is averted.
The inferior angle of the _Scapula_ occasionally escapes from under
the border of the latissimus dorsi, usually with some laceration of
the muscular fibres. The displacement is occasioned by raising the arm
above the head to an unusual extent. The angle of the bone projects
considerably, and the muscle is felt playing beneath it distinctly
during motion of the parts; the movements of the limb are limited and
painful. The parts may be brought into their original position by
pressing the angle of the scapula towards the ribs, whilst the arm
is much raised; and the bone is afterwards confined in its proper
place by a broad bandage passed pretty tightly round the chest. The
retentive apparatus must be continued for a considerable time, and in
some cases a cure may be so effected; but in general the bone soon
regains its former unnatural position, and continues to do so, however
often and however easily it may be replaced. The parts gradually become
accustomed to the change in relative position, and little inconvenience
is experienced.
Luxation of the _Shoulder-joint_ is prevented, by the arrangement
and structure of the parts, from taking place in any direction
excepting towards the axilla—downwards into the hollow of the armpit,
downwards and forwards under the lower border of the pectoral muscle.
Occasionally, though very rarely indeed, displacement occurs backwards.
On the anterior and inferior aspects, the articulation is not
supported, as at its other sides, either by muscular substance or by
processes of bone. The accident is occasioned sometimes, though rarely,
by direct violence, as by a blow on the back part of the shoulder; and
of such I have seen a few examples. But, in almost every instance, the
displacement is caused by force applied to the distal extremity of the
humerus; either immediately, as by falling on the elbow, or through the
forearm, as when a person endeavours to break a fall by stretching out
the arm, and alights with the whole weight of the body on the palm.
The accident may also result from forcible abduction of the extremity,
particularly when the power is applied near the extremity of the limb.
There is laceration, to a greater or less extent, of the capsule, and
of the muscles immediately investing the fibrous tissue round the
articulating cavity. Without disruption, complete luxation cannot
exist—the articulating surfaces cannot be separated, nor can the head
of the humerus be altered in position; subluxation, or, in other words,
a sprain, may occur in such circumstances, but true luxation cannot.
Bruises of the shoulder, with or without fracture, either of the
scapula or of the upper part of the humerus, must not be mistaken
for dislocation, for the consequences of such a blunder are fearful.
In both descriptions of accident, the appearances of the limb are
somewhat similar, and hence the examination requires to be particularly
accurate and careful. In both there is flattening of the shoulder, but
in fracture there is crepitus, motion to an unnatural extent, though
painful, and greater suffering during manipulation; in dislocation
no crepitus at all resembling that in fracture can be perceived, the
motions of the limb are very limited, and the displaced head of the
bone can almost always be felt. The direction of the force, too, as
already observed, when on the subject of fracture, is an important
assistant in diagnosis; from falls or blows upon the shoulder we
may expect fracture, from falls on the elbow or palm, luxation. In
dislocation an indistinct feeling, sometimes amounting to obscure
crepitation, is occasionally perceived during rotation of the limb;
and this arises from one or more of the tendinous attachments of the
muscles having, during their disruption, torn away a portion of their
osseous attachment.
Great pain attends on dislocated humerus, from the head of the bone
compressing and stretching the axillary plexus; and the interruption to
the flow of the blood produces tingling at the points of the fingers,
numbness of the whole limb, and after a time swelling of the hand and
forearm. Flattening of the shoulder, and depression under the acromion,
are the most prominent marks of displacement having occurred, and are
at once apparent. They are more distinctly perceived on comparing the
two shoulders; then the acromion on the affected side stands remarkably
outwards. The projection is not so apparent when the immediate swelling
from effused blood has been fully formed, but the hollow under the
acromion can be felt through any quantity of extravasated blood. The
arm admits of very little motion, is lengthened and abducted. The
elbow cannot be brought close to the side, and attempts to do so are
productive of great suffering. The patient has little or no muscular
command over the upper arm. Rotation and elevation of the limb require
considerable force, and are practicable only to a very limited extent;
during attempts at the former, as already mentioned, obscure crepitus
is sometimes perceived. The abduction is most remarkable in the
dislocation directly downwards; and in this form of the accident, the
fingers easily detect the head of the bone lying in the axilla, deep,
yet distinct, particularly during attempted rotation. When the head of
the bone lies forward by the coracoid process, and under the pectoralis
major, it can be felt, and the prominence occasioned by it can be
clearly seen in thin people, before swelling has occurred, and after
its subsidence. The bone sometimes lodges in an intermediate situation,
and then the signs peculiar to each form of displacement are mixed.
When reduction is not accomplished, the bloody swelling first occurs to
obscure the signs; this may in part subside, but then the inflammatory
supervenes; both after a time disappear, the muscles waste, and then
all the signs are very apparent. After some weeks, the motions of the
limb become more extensive, not in consequence of the head of the
humerus having changed its position, or returned into the glenoid
cavity, but from the scapula moving on the ribs more freely, and to a
greater extent than usual. At last, but not till after a long period,
considerable motion betwixt the bones can be effected; the scapula,
where the head of the humerus rests, having furnished an adventitious
cavity, to which the latter has adapted itself. But free motion can
never be regained, for the movements that are effected are chiefly
produced by the action of the muscles of the scapula.
Replacement, even in very recent cases, sometimes is accomplished with
difficulty in those whose muscles are fully developed. But in general
a successful result will follow simple measures, particularly if the
patient is taken unawares—as by rotating the arm with one hand whilst
the fingers of the other are placed in the axilla, then suddenly
lifting the head of the bone outwards, and at the same time performing
abduction—the patient being all along assured that he will not be put
to pain, and that there is no intention of attempting reduction. In
this manner reduction may often be accomplished by the surgeon and one
assistant; the trunk and scapula being fixed by the assistant, either
grasping the patient in his arms, or holding a sheet or towel passed
round the body, close to the axilla, whilst the surgeon extends and
rotates the extremity, and at the same time lifts the head of the bone
from its situation. The rotation is made by using the forearm, bent
to a right angle, as a lever; thus considerable power can be exerted
on the head of the bone, and the long head of the biceps muscle—the
stretching of which, no doubt, affords an obstacle to reduction—is
at the same time relaxed. In luxation downwards, there is no more
successful method than that by counter-extension with the heel in the
axilla, and extension by the surgeon grasping the wrist. The patient is
placed recumbent, on a couch or on the floor, and the surgeon, sitting
by his side, lodges his heel in the axilla, and with both hands
extends the arm; after a short continuance of extension, he performs
a sudden and powerful combination of both movements, and so jerks the
bone into its natural position. In some recent, and in all old cases,
it is necessary to apply considerable force, steadily, and for a long
time, so as to tire out the muscles, and dislodge the head of the
bone. An assistant effects this by means of pulleys. These are fixed
to a laque, applied above the elbow with a clove-hitch, and to a ring
fastened either in the wall or to a post; two small iron rings which
can be screwed into a beam are useful in private practice, and should
always accompany the pulleys. When all is prepared, the assistant pulls
the end of the rope steadily, and with considerable power, whilst the
surgeon rotates the limb, and endeavours to lift the head of the bone,
at the same time regulating the degree of extension. The directing of
the degree and continuance of the force is not the least difficult
part of the procedure, for, when excessive, there is a risk of the
axillary nerves and artery giving way; such accidents have happened,
and been accompanied with serious and even fatal consequences; and from
laceration of other tissues, the muscular, fibrous, or cellular, fatal
inflammation and abscess have resulted. The surgeon is therefore called
upon to exercise judgment and discretion—not to continue extension to a
pernicious extent, and not to abandon attempts at reduction too soon,
leaving his patient disabled for life. For making counter-extension to
the extension by pulleys, a broad strong belt is useful, perforated
near the middle for transmission of the injured arm; it is passed round
the body so as to fix the trunk and scapula, coming under the axilla of
the sound side, and being then fastened by means of a hook to a ring in
the wall.