the lapse of two or three months; but the difficulty increases, and
the chance of success diminishes, in proportion to the time which has
elapsed since the date of the accident. And in deciding upon making
the attempt, many circumstances are to be weighed and considered—the
patient’s period of life and his occupations, the state of the parts,
the degree of motion that has been acquired, and the treatment, if
any, which has been previously followed. Perhaps the most important
consideration is regarding the state of the parts, as indicated by the
degree of motion. If the movements be to such an extent as to favour
the supposition of the head of the bone having been furnished with a
new recipient cavity, to which it has in a great measure accommodated
itself, and that the glenoid cavity has, from disuse, become altered,
the surgeon can scarcely hope for advantage to his patient from
attempts to break up the new articulating apparatus, and reëstablish
the old. The patient will, most probably, be put to a great deal of
pain and some danger, without experiencing improvement to the limb;
indeed the motions and power may prove less than before. In old men,
too, force sufficient for reduction cannot be employed without great
risk of laceration of nerves, bloodvessels, and muscles. But if the
patient be young, the motions still limited, and the articulation
apparently not changed by solid effusion, reduction may be attempted
with a fair prospect of success, and without injury. In all such cases,
however, the surgeon must watch every step of the proceedings, and
have sufficient experience to stop short of inflicting irreparable
mischief. No standard can be fixed for the degree of force that is
necessary and safe; he may be foiled, even after the most powerful
efforts, in a dislocation of two or three weeks’ duration; whilst, by
the use of but slight force, he may succeed in one of as many months.
Much assistance is obtained by the means formerly adverted to, as
auxiliary, by weakening the muscular energy. Of these, nauseating
doses of antimony are most generally employed, and being the most
safe, may be recommended to be tried first; and if these fail to
produce the desired effect, the patient may be bled freely, if he be
young and robust, more especially since this will assist to avert
the inflammatory action likely to follow the violent reduction.
Tobacco produces the most complete prostration of muscular power, and
may consequently be resorted to in extreme cases; but it ought, if
possible, to be avoided, as its use is far from being void of danger.
The warm bath cannot always be procured; when at hand, it merits
adoption, being both safe and effectual, particularly if combined with
antimony or bleeding. The extension should not be commenced till these
means have begun to take effect, but everything should be prepared, so
that it may be applied at a moment’s warning. After all attempts at
reduction, whether successful or not, it is necessary to moderate the
inflammation that ensues, by local bleeding and fomentation, combined,
if necessary, with nauseating laxatives: general depletion is seldom
required.
[Illustration]
_Luxation of the Elbow-joint_ is an extremely common accident,
particularly in young persons, before the bony processes have been
fully formed. It is produced by wrenches, or by force applied to the
farther end of the forearm, the bones neither breaking nor bending.
Sometimes, though very rarely, it is caused by direct violence, as in
a fall, and then may be combined with fracture of one or both bones
of the forearm; but in other circumstances, fracture and luxation can
scarcely coexist. In general, both bones of the forearm are displaced
backwards, sometimes a little to the ulnar side. The coronoid process
occupies the cavity for the reception of the olecranon, and the head
of the radius lodges behind the external condyle; the extremity is
shortened, and looks twisted; it is slightly flexed, and in the middle
state between pronation and supination. Unnatural lateral motion can
be produced, but flexion is impracticable, the limb cannot be brought
quite into the extended state, and rotation is difficult and painful.
Swelling soon takes place, and consequently the hollows are filled
up, and the processes of the bones obscured. Yet the olecranon and
inner condyle can always be recognised and felt, and their relative
position ascertained; the form of the end of the humerus, its hollows,
and its prominences, can be distinctly discerned, both before and
after the swelling, the soft parts being stretched over the bone;
and by rotating the limb with one hand, whilst the other is placed
over the outer and back part of the joint, the situation of the head
of the radius is detected. Thus the relations of the bones to one
another are discovered; and this must be done at once, whatever pain
may be produced by the examination, for it is a saving of suffering
in the end. Yet the nature of this injury would seem difficult of
detection—a fact scarcely intelligible by any one who is careful in
his manipulations, and who possesses common observation, and a sound
knowledge of anatomy. Many cases of unreduced luxation are met with;
I have seen it in both elbows of the same person; and I have had a
dozen of cases, in as many months, of unreduced elbows shown too late
for attempts at reduction. The frequent occurrence of such blunders is
the more lamentable, as it is almost impossible to replace the bones
after three or four weeks; indeed, I have been foiled at the end of two
weeks. The parts soon accommodate themselves to their new position,
the olecranon process shortens, motion rapidly increases, and the
bones get more and more secure in their new relations,—osseous matter
being deposited laterally, forming cavities for their lodgement, and
new ligamentous matter confining them thereto. After a time, flexion
can be made to a right angle; and the limb becomes tolerably useful.
By unsuccessful attempts to restore the natural position, inflammation
is excited; and thus the salutary processes, commenced by nature for
reparation of the displacement, are interrupted and delayed; in young
persons such disease of the joint may be produced as might lead to loss
of the extremity.
Luxation of the _Radius_ alone, backwards on the outer condyle, is
sometimes met with; but this bone is seldom singly displaced far from
its original site. A hollow is felt below the end of the humerus,
on the outer and fore part, and there is a corresponding prominence
behind; the head of the bone is found unnaturally moveable on rotation,
and this motion is difficult and painful; the arm is extended,
presenting a twisted appearance, and flexion is very limited. Extension
is to be made, along with pronation.
Sometimes the radius is displaced forwards. The coronoid process of the
ulna is occasionally broken off; there is no deformity during flexion
of the elbow, but when the limb is extended, the olecranon is drawn
upwards.
In luxation of both bones, reduction is much facilitated by position
of the arm. The arm and forearm are extended, and the limb is brought
well behind the trunk, so as to relax the triceps; then the surgeon
performs extension and counter-extension, pulling the forearm with one
hand, whilst he pushes with the other placed on the scapula. If the
force thus employed prove insufficient, as it seldom will in recent
cases, the patient may be placed on his face, on a couch, and on the
limb being brought into the favourable position already noticed,
counter-extension may be made by the heel planted against the inferior
costa of the scapula, whilst the wrist is pulled with both hands.
It is seldom necessary to employ pulleys, excepting in cases of old
standing; if so, the only peculiarity in their application to this
joint is the direction of the force, backwards. And this I consider to
be a very material part of the manipulations, for, by attention to it,
I have succeeded after previous failures,—after great force had been
applied, causing excoriation and swelling of almost the whole limb. In
luxation of the radius, backwards, flexion and pronation, combined, if
necessary, with extension, will generally effect replacement.
Dislocation at the _Wrist_ is very unfrequent. The articulation
is naturally strong, admitting of little motion, the bones being
accurately fitted to each other, whilst the retaining ligamentous
apparatus is both copious and unyielding; on this account greater
force is required to effect displacement here than at either the elbow
or shoulder-joints, and violence applied to the hands usually causes
fracture of one or both bones of the forearm, not luxation of their
extremities. Luxation, however, sometimes occurs, either from violent
twisting, or from falling on the palm of the hand; and the displacement
may be either of both bones or of one. In the latter case, it is almost
uniformly the radius that suffers; in the former, the luxation is
forwards.
Dislocation of the distal extremity of the radius is generally produced
by a sudden wrench or twist. The bone is felt loose and prominent,
sometimes riding over the upper part of the carpus. The position of
the hand is towards pronation, supination cannot be performed, and,
on attempting it, great pain is occasioned. Reduction is readily
accomplished, by pulling the palm with one hand, whilst with the other
the head of the bone is pressed backwards into its situation.
Displacement of both bones is more frequently the result of a fall on
the palm, with the hand bent much backwards. In this case there are
two projections, so distinct as at once to mark the true nature of the
accident, one anteriorly, formed by the ends of the radius and ulna,
the other posteriorly by the carpus; above the posterior prominence
there is a considerable depression. Here also reduction is easy; it is
sufficient to perform simple extension with one hand, whilst with the
other the wrist is moulded into its proper form. The after treatment,
however, requires attention, for extensive laceration of tendinous
and ligamentous tissue, perhaps combined with fracture of the bony
processes to a greater or less extent, must have taken place to admit
of displacement; in consequence violent inflammation is to be expected,
and means must be taken to avert it. On account of this laceration,
also, mere reduction is not sufficient, retentive apparatus must be
applied; as soon as the limb has been made straight, a pasteboard
splint is to be applied on each side, as in fracture of the forearm,
and retained with a roller, a wooden splint being placed exteriorly
until the pasteboard hardens. This precautionary measure is also
necessary to avert redisplacement in dislocation of the radius singly;
in both accidents the apparatus should be retained for at least a
fortnight. Afterwards, passive motion, gradually increased and combined
with friction, is requisite to prevent stiffness of the joint.
In mere sprain of the wrist, large swelling soon forms anteriorly,
from extravasated blood, resembling somewhat projection of the
bones, and so leading towards fallacy in diagnosis; indeed it is
not unreasonable to suppose that dislocation here does not occur so
frequently as is imagined. Fracture also near or through the distal
extremity of the radius, an accident formerly mentioned as exceedingly
common from falls on the hand, is very apt to be mistaken for luxation.
On this account, and because in every injury of the wrist the parts are
soon obscured by bloody swelling, there is a strong necessity for early
and accurate examination.
Subluxation not unfrequently occurs; in other words, the attachments
of the bones of the forearm to each other are broken up, and their
extremities separated to an unnatural distance. The accident is
distinctly marked by the deformity, the absence of hard projection, and
by the unusual space between the radius and ulna occupied by a soft and
yielding swelling. Replacement is accomplished much in the same manner
as in complete luxation, the bones being compressed towards each other
with one hand, whilst extension is made with the other; afterwards
splints must be applied and retained.
Compound luxations of the wrist are occasionally met with, and, like
compound fractures in this situation, are always troublesome, and often
terminate unfavourably. The soft parts are sparing, possessed of little
vitality, and much injured by the accident; consequently reparation
proceeds very slowly, and is generally superseded by unhealthy and
profuse suppuration, perhaps accompanied with more or less sloughing
of tendons and integument. If the ends of the bones protrude bare,
shattered, and split, they should be removed by means of either the
saw or the cutting pliers, previously to attempts at reduction; the
wound should then be approximated, and the cure conducted on ordinary
principles.
Sometimes a single bone of the _Carpus_ is displaced, usually
backwards. It is quite loose and moveable, and is easily replaced,
but in almost every case redisplacement occurs, the bone at one time
occupying its proper situation, at others forming an inconvenient and
unseemly prominence on the back of the wrist, diminished by extension,
and increased by flexion of the joint. The accident, however, is rare.
I have never seen simple dislocation of any of the metacarpal bones.
Dislocation of the _Fingers_ is produced by force applied to the
extremities of the phalanges; the displacement is always backwards,
excepting at the middle joint, where the bone of the middle phalanx is
sometimes, but very rarely, luxated forwards. The remarkable projection
on the back part of the finger marks the nature of the accident, even
to the most careless observer. Reduction is accomplished by extension
combined with flexion. In the case of the distal phalanges, it may
sometimes be necessary to fasten a cord to the tip of the finger, in
order to obtain sufficient extending power. After replacement, the
application of temporary splints and bandage is prudent. Compound
luxations, however carefully treated, almost uniformly come to
amputation.
Luxation of the first joint of the _thumb_ is rather an uncommon
accident, and is not easily managed. The base of the first phalanx
is displaced backwards upon the distal extremity of the metacarpal
bone, causing a remarkable prominence on the dorsal aspect, and a
corresponding depression on the palmar. The thumb is shortened,
deformed, and almost immoveable; the swelling and pain are severe.
This displacement is generally produced by the application of force
to the point of the thumb, as in falling on it, or in coming against
a resisting body with the thumb straight. The deformity is such as
at once to apprise even the most inattentive or inexperienced of the
true nature of the injury; but the treatment is very difficult and
puzzling even in the hands of the best informed surgeons. The base
of the bone seems to slip through the lateral ligaments, and remain
firmly locked in their embrace; and these being very strong, and in
a state of complete tension, defy all usual attempts at reduction.
The end of a silk handkerchief, or thick soft cord, is to be attached
to the distal extremity of the displaced phalanx, by means of the
clove-hitch; and with this extension is made, either by the surgeon
alone, or by one or more assistants,—frequently several are required.
Counter-extension is made by the surgeon or assistant grasping the
forearm, or another handkerchief may be passed betwixt the thumb and
forefinger for an assistant to hold on by. The extending force should
be made in a direction towards the palm, and almost uniformly requires
to be great and long continued, even in recent cases. The bone may
occasionally be jerked into its place by a sudden attempt at flexion of
the joint, during steady pulling that has been continued for some time.
But cases have occurred in which all attempts have proved ineffectual,
and it has been found necessary to divide one of the lateral ligaments.
From what has been already stated, the reason why this proceeding
should facilitate reduction is sufficiently obvious. I had recourse
to it in one instance,—one in which difficulty of reduction was not
to have been expected. The accident was very recent, not an hour had
elapsed; the patient was an old man, and very drunk; no resistance to
the reductive measures could have been offered by muscular energy;
yet very powerful force was applied and persevered in without avail.
At last the external lateral ligament was divided by the point of a
very narrow and fine bistoury, and then replacement was immediate and
easy. Some inflammation followed, but was kept within bounds, and the
man regained the use of the articulation. In other cases, again, the
bone is replaced by the use of but very slight force, provided it be
applied, as already stated, in a direction towards the palm of the
hand. The last phalanx is equally liable to luxation in the thumb as in
the fingers, and has no peculiarity of treatment.
_Luxation of the Hip-joint._—The great strength of the ligaments,
the depth and fitness of the body and cartilaginous cavity for the
reception of the head of the bone, and the great power of the muscles
surrounding the articulation, render dislocation here both difficult
and rare. The accident is generally produced by great and sudden force,
applied either to the distal end of the femur, or to the farther
extremity of the limb, as by falling from a considerable height, by
the foot slipping whilst the person is supporting a heavy weight, by
falls from or with a horse, &c. The luxation, in a great majority of
cases, takes place upwards and backwards, the head of the bone lying
on the dorsum of the ilium. The limb is shortened to the extent of
from an inch and a half to two inches and a half, the toes are turned
in, the thigh is slightly bent upon the pelvis, and very firmly fixed.
Before swelling has occurred, and also after it has subsided, the head
of the bone can be felt lying under the gluteus. The trochanter is
evidently out of place, being depressed, and lying farther up and back
than usual. This is strikingly observable on comparing the injured
limb with the opposite. Attempts to move the limb and effect rotation
produce great pain. Large swelling soon follows, along with greater
stiffness and immobility. If the head of the bone is not replaced, the
pain gradually subsides, and, after some months, freedom of motion is
regained to a slight extent; the patient is able to walk, but with a
great halt.
At first, reduction is accomplished with no great difficulty. Within a
very short time after the occurrence of the injury, before the patient
had recovered from the shock, whilst he still lay sick, faint, and
powerless, I have succeeded in effecting reduction of the femur quite
unassisted,—extending with one hand, grasping the thigh behind, and,
at the same time, rotating it outwards by pressure of the forearm on
the leg, counter-extension being made by the left hand on the symphysis
pubis. When a few hours have intervened, assistance and apparatus are
requisite. The patient is secured by a broad band,—a common sheet suits
very well,—passed under the perineum. The lacque is fixed above the
knee, with a knot that will not run, a towel wrung out of cold water
being applied next to the skin, in order to increase the security
of the hold and prevent excoriation. A well-padded broad iron ring,
tightened on the limb by a screw, and provided with suitable straps
for attachment of the pulleys, is very useful,—fully more convenient
than the common woollen lacque. Extension may be made by one or more
assistants; but this may prove ineffectual, and it is better at
once to have recourse to the pulleys: these are not alarming to the
patient, and, being efficient, will in the end materially diminish his
suffering. The extension should be gradual, steady, and persevering;
the rotation of the limb during extension should be principally
outwards, effected by laying hold of the ankle, and using the leg as a
lever. This motion is peculiarly successful when the bone has yielded a
little to the extension, when it has changed its place, and come nearly
on a line with the cotyloid cavity. In some cases, even of no long
standing, auxiliary means are required,—bleeding, antimony, &c., as
formerly noticed. In old cases, no attempts at reduction should be made
until the patient has been brought into a relaxed state, approaching
to collapse, by one or more of the auxiliary means, and by such as
are best suited to the particular circumstances of the case; in such
instances also the extension, rotation, &c., must be persevered in for
some time,—they are not at once successful. Frequently, particularly
in recent cases, reduction is accompanied and indicated by an audible
and perceptible snap, occasioned by the head of the bone slipping into
the cotyloid cavity; the motions are again readily performed, and the
limb resumes its proper length and shape. The muscular and articulating
apparatus must be kept quiet for some time afterwards; a band should
be passed round the knees, and the patient strictly confined to the
recumbent posture; at the same time, fomentations are to be used about
the joint, to the perineum, and to the part where the lacque was
applied. It is rarely necessary to have recourse to abstraction of
blood from the neighbourhood of the articulation.
There is no great risk of the bone again escaping from its situation.
I have but once witnessed such an accident. A female suffered luxation
of the hip nearly a month previously to her admission into the Royal
Infirmary, and reduction was unavoidably deferred for three days more.
It was accomplished without difficulty, and the usual precautions were
afterwards adopted; but next day it was discovered that luxation had
again taken place. The patient had cunningly contrived to have ardent
spirits brought to her, and indulged freely in these, got out of bed,
and slipped down. Replacement was again effected, more easily than
before; the limbs were firmly secured to each other, confinement to bed
and no farther indulgence in liquor were strictly enjoined, and after
thirteen or fourteen days the limb fully regained its functions.
Luxation of the hip downwards and forwards, the head of the femur
lying in the thyroid foramen, is generally produced by a fall under a
heavy load, the thigh being at the same time forcibly abducted. I have
also seen it occasioned by a fall with a restive horse. The limb is
elongated considerably, and advanced a little forwards; the trochanter
major is depressed, the toes are inclined neither outwards nor inwards;
the limb is immoveably fixed, and this most unequivocally marks the
nature of the accident.