=Dislocations=
_How to Tell a Dislocation--Reducing a Dislocated Jaw--Stimson's
Method of Treating a Dislocated Shoulder--Appearance of Elbow when Out
of Joint--Hip Dislocations--Forms of Bandages._
=DISLOCATIONS; BONES OUT OF JOINT.=
=JAW.=--Rare. Mouth remains open, lower teeth advanced forward.
_First Aid Rule 1.--Protect your thumbs. Put on thick leather gloves,
or bind them with thick bandage._
_Rule 2.--Assistant steadies patient from behind, with hands both
sides of his head, operator presses downward and backward with his
thumbs on back teeth of patient, each side of patient's jaw, while the
chin is grasped between forefingers and raised upward. Idea is to
stretch the ligament at jaw joint, and swing jaw back while pulling on
this ligament. (Fig. 29.)_
_Rule 3.--Tie jaw with four-tailed bandage up against upper jaw for a
week. (Fig. 12, p. 90.)_
=SHOULDER.=--Common accident. No hurry. See p. 122.
=ELBOW.=--Rare. No hurry. See p. 125.
=HIP.=--No hurry. See p. 129.
=KNEE.=--Rare. Easily reduced. Head of lower bone (tibia) is moved to
one side; knee slightly bent.
_First Aid Rule 1.--Put patient on back._
_Rule 2.--Flex thigh on abdomen and hold it there._
_Rule 3.--Grasp leg below knee and twist it back and forth, and
straighten knee._
=DISLOCATIONS.=--A dislocation is an injury to a joint wherein the
ends of the bones forming a joint are forced out of place. A
dislocation is commonly described as a condition in which a part (as
the shoulder) is "out of joint" or "out of place." A dislocation must
be distinguished from a sprain, and from a fracture near a joint. In a
sprain, as has been stated (p. 65), the bones entering into the
formation of the joint are perhaps momentarily displaced, but return
into their proper place when the violence is removed. But, owing to
greater injury, in dislocation the head of the bone slips out of the
socket which should hold it, breaks through the ligaments surrounding
the joint, and remains permanently out of place. For this reason there
is a peculiar deformity, produced by the head of the bone's lying in
its new and unnatural situation, which is not seen in a sprain.
Also, the dislocated joint cannot be moved by the patient or by
another person, except within narrow limits, while a sprained joint
can be moved, with the production of pain it is true, but without any
mechanical obstacle. In the case of fracture near a joint there is
usually increased movement in some new direction. When a dislocated
joint is put in proper place it stays in place, whereas when a
fractured part is reduced there is nothing to keep it in place and, if
let alone, it quickly resumes its former faulty position.
Only a few of the commoner dislocations will be considered here, as
the others are of rare occurrence and require more skill than can be
imparted in a book intended for the laity. The following instructions
are not to be followed if skilled surgical attendance can be secured;
they are intended solely for those not so fortunately situated.
=DISLOCATION OF THE JAW.=--This condition is caused by a blow on the
chin, or occurs in gaping or when the mouth is kept widely open during
prolonged dental operations. The joint surface at the upper part of
the lower jaw, just in front of the entrance to the ear, is thrown out
of its socket on one side of the face, or on both sides. If the jaw is
put out of place on both sides at once, the chin will be found
projecting so that lower front teeth jut out beyond the upper front
teeth, the mouth is open and cannot be closed, and the patient is
suffering considerable pain. When the jaw is dislocated on one side
only, the chin is pushed over toward the uninjured side of the face,
which gives the face a twisted appearance; the mouth is partly open
and fixed in that position. A depression is seen on the injured side
in front of the ear, while a corresponding prominence exists on the
opposite side of the face, and the lower front teeth project beyond
the upper front teeth.
[Illustration: FIG. 29.
REDUCING DISLOCATION OF JAW (AMERICAN TEXT-BOOK).
Thumbs placed upon last molar teeth on each side; note jaw grasped
between fingers and thumbs to force it into place.]
=Treatment.=--A dislocation of one side of the jaw is treated in the
same manner as that of both sides.
The dislocation may sometimes be reduced by placing a good-sized cork
as far back as possible between the back teeth of the upper and lower
jaws (on one or both sides, according as the jaw is out of place on
one or both sides), and getting the patient to bite down on the cork.
This may pry the jaw back into place.
The common method is for the operator to protect both thumbs by
wrapping bandage about his thumbs, or wearing leather gloves, and
then, while an assistant steadies the head, the operator presses
downward and backward on the back teeth of the patient on each side of
the lower jaw with both thumbs in the patient's mouth, while the chin
is grasped beneath by the forefingers of each hand and raised upward.
When the jaw slips into place it should be maintained there by a
bandage placed around the head under the chin and retained there for a
week. During this time the patient should be fed on liquids through a
tube, so that it will not be necessary for him to open his mouth to
any extent. (See Fig. 29.)
=DISLOCATION OF THE SHOULDER.=--This is by far the most common of
dislocations in adults, constituting over one-half of all such
accidents affecting any of the joints. It is caused by a fall or blow
on the upper arm or shoulder, or by falling upon the elbow or
outstretched hand. The upper part (or head) of the bone of the arm
(humerus) slips downward out of the socket or, in some cases, inward
and forward. In either case the general appearance and treatment of
the accident are much the same. The shoulder of the injured side loses
its fullness and looks flatter in front and on the side. The arm is
held with the elbow a few inches away from the side, and the line of
the arm is seen to slope inwardly toward the shoulder, as compared
with the sound arm.
The injured arm cannot be moved much by the patient, although it can
be lifted up and away from the side by another person, but cannot be
moved so that, with the elbow against the front of the chest, the hand
of the injured arm can be laid on the opposite shoulder. Neither can
the arm, with the elbow at a right angle, be made to touch the side
with the elbow, without causing great pain.
=Treatment.=--One of the simplest methods (Stimson's) of reducing this
dislocation consists in placing the patient on his injured side on a
canvas cot, which should be raised high enough from the floor on
chairs, and allowing the injured arm to hang directly downward toward
the floor through a hole cut in the cot, the hand not touching the
floor. Then a ten-pound weight is attached to the wrist. The gradual
pull produced by this means generally brings the shoulder back into
place without pain and within six minutes. (Fig. 30.)
[Illustration: FIG. 30.
TREATING A DISLOCATED SHOULDER.
(REFERENCE HANDBOOK.)
Patient lying on injured side; note arm hanging through hole in cot
raised from floor on chairs; also weight attached to wrist.]
The more ordinary method consists in putting the patient on his back
on the floor, the operator also sitting on the floor with his
stockinged foot against the patient's side under the armpit of the
injured shoulder and grasping the injured arm at the elbow, he pulls
the arm directly outward (i. e., with the arm at right angles with the
body) and away from the trunk. An assistant may at the same time aid
by lifting the head of the arm bone upward with his fingers in the
patient's armpit and his thumbs over the injured shoulder.
If the arm does not go into place easily by one of these methods it is
unwise to continue making further attempts. Also if the shoulder has
been dislocated several days, or if the patient is very muscular, it
will generally be necessary that a surgeon give ether in order to
reduce the dislocation. It is entirely possible for a skillful surgeon
to secure reduction of a dislocation of the shoulder several weeks
after its occurrence. After the dislocation has been relieved the arm,
above the elbow, should be bandaged to the side of the chest and the
hand of the injured side carried in a sling for ten days.
=DISLOCATION OF THE ELBOW.=--This is more frequent in children, and is
usually produced by a fall on the outstretched hand. The elbow is
thrown out of joint, so that the forearm is displaced backward on the
arm, in the more usual form of dislocation. The elbow joint is swollen
and generally held slightly bent, but cannot be moved to any extent
without great pain. The tip of the elbow projects at the back of the
joint more than usual, while at the front of the arm the distance
between the wrist and the bend of the elbow is less than that of the
sound arm. (See cut, p. 126.)
[Illustration: FIG. 31.
Above cut shows characteristic appearance of a dislocated shoulder;
note loss of fullness; also elbow held away from side and inward
sloping of arm.
FIG. 32.
DISLOCATED ELBOW AND SHOULDER.
(AMERICAN TEXT-BOOK.)
Fig. 32 shows dislocation of elbow backward; note swollen condition of
left elbow held slightly bent; also the projection of back of joint.]
For further proof that the elbow is out of joint we must compare the
relations of three points in each elbow. These are the two bony
prominences on each side of the joint (belonging to the bone of the
arm above the elbow) and the bony prominence that forms the tip of the
elbow which belongs to the bone of the forearm.
[Illustration: FIG. 33.
TREATMENT OF DISLOCATED ELBOW (SCUDDER).
Note padded right-angled tin splint; also three strips of surgeon's
plaster on arm and forearm.]
In dislocation backward of the forearm, the tip of the elbow is
observed to be farther back, in relation to the two bony prominences
at the side of the joint, than is the case in the sound elbow. This is
best ascertained by touching the three points on the patient's elbow
of each arm in turn with the thumb and middle finger on each of the
prominences on the side of the joint, while the forefinger is placed
on the tip of the elbow. The lower end of the bone of the upper arm
is often seen and felt very easily just above the bend of the elbow in
front, as it is thrown forward (see Fig. 32, p. 126).
Fracture of the lower part of the bone of the arm above the elbow
joint may present much the same appearance as the dislocation we are
describing, but then the whole elbow is displaced backward, and the
relation of the three points described above is the same in the
injured as in the uninjured arm. Moreover in fracture the deformity,
when relieved, will immediately recur when the arm is released, as
there is nothing to hold the bones in place; but in dislocation, after
the bones are replaced in their normal position, the deformity will
not reappear.
=Treatment.=--The treatment for dislocation consists in bending the
forearm backward to a straight line, or even a little more, and then
while an assistant holds firmly the arm above the elbow, the forearm
should be grasped below the elbow and pulled with great force away
from the assistant and, while exerting this traction, the elbow is
suddenly bent forward to a right angle, when the bones should slip
into place.
The after treatment is much the same as for most fractures of the
elbow. The arm is retained in a well-padded right-angled tin splint
which is applied with three strips of surgeon's plaster and bandage to
the front of the arm and forearm (see Fig. 33) for two or three weeks.
The splint should be removed every few days, and the elbow joint
should be moved to and fro gently to prevent stiffness, and the
splint then reapplied.
=DISLOCATION OF THE HIP.=--This occurs more commonly in males from
fifteen to forty-five years of age, and is due to external violence.
In the more ordinary form of hip dislocation the patient stands on the
sound leg with the body bent forward, the injured leg being greatly
shortened, with the toes turned inward so much that the foot of the
injured limb crosses over the instep of the sound foot. The injured
limb cannot be moved outward and but slightly inward, yet may be bent
forward. Walking is impossible. Pain and deformity of the hip joint
are evident.
The only condition with which this would be likely to be confused is a
fracture of bone in the region of the hip. Fracture of the hip is
common in old people, but not in youth or middle adult life. In
fracture there is usually not enough shortening to be perceived with
the eye; the toes are more often turned out, and the patient can often
bear some weight on the limb and even walk.
=Treatment.=--The simplest treatment is that recommended by Stimson,
as follows: the patient is to be slung up in the air in a vertical
position by means of a sheet or belt of some sort placed around the
body under the armpits, so that the feet dangle a foot or so from the
floor, and then a weight of about ten or fifteen pounds, according to
the strength of the patient's muscles, is attached to the foot of the
injured leg (bricks, flatirons, or stones may be used), and this
weight will usually draw the bone down into its socket within ten or
fifteen minutes.
[Illustration: FIG. 34.
REDUCING DISLOCATION OF HIP (REFERENCE HANDBOOK).
Patient lying on table; uninjured leg held by assistant; leg of
dislocated side at right angles; note weight at bend of knee.]
Or the patient may assume the position shown in the accompanying cut,
lying prone upon a table with the uninjured leg held horizontally by
one person, while another, with the injured thigh held vertically and
leg at right angles, grasps the patient's ankle and moves it gently
from side to side after placing a five-to ten-pound sand bag, or
similar weight of other substance, at the flexure of the knee. When
the dislocation has been overcome the patient should stay in bed for a
week or two and then go about gradually on crutches for two weeks
longer.
=SURGICAL DRESSINGS.=--Sterilized gauze is the chief surgical dressing
of the present day. This material is simply cheese cloth, from which
grease and dirt have been removed by boiling in some alkaline
preparation, usually washing soda, and rinsing in pure water. The
gauze is sterilized by subjecting it to moist or dry heat. Sterilized
gauze may be bought at shops dealing in surgeons' supplies and
instruments, and at most drug stores. Gauze or cheese cloth may be
sterilized (to destroy germs) by baking in a slow oven, in tin boxes,
or wrapped in cotton cloth, until it begins to turn brown. It is well
to have a small piece of the gauze in a separate package, which may be
inspected from time to time in order to see how the baking is
progressing, as the material to be employed for surgical purposes
should not be opened until just before it is to be used, any remainder
being immediately covered again. Cut the gauze into pieces as large as
the hand, before it is sterilized, to avoid cutting and handling
afterwards. Gauze may also be sterilized by steaming in an Arnold
sterilizer, such as is used for milk, or by boiling, if it is to be
applied wet. Carbolized, borated, and corrosive-sublimate gauze have
little special value.
[Illustration: PLATE I.
Fig. I.
Fig. II.
Fig. III.
Fig. IV.
APPLYING A ROLLER BANDAGE (REFERENCE HANDBOOK).
Fig. I shows method of starting a spiral bandage; Fig. II, ready to
reverse; Fig. III, the reverse completed; Fig. IV shows spica bandage
applied to groin.]
Absorbent cotton is also employed as a surgical dressing, and should
also be sterilized if it is to be used on raw surfaces. It is not so
useful for dressing wounds as gauze, since it mats down closely, does
not absorb secretions and discharges so well, and sticks to the parts.
When torn into balls as large as an egg and boiled for fifteen minutes
in water, it is useful as sponges for cleaning wounds. Sheet wadding,
or cotton, is serviceable in covering splints before they are applied
to the skin. Wet antiseptic surgical dressings are valuable in
treating wounds which are inflamed and not healing well. They are made
by soaking gauze in solutions of carbolic acid (half a teaspoonful of
the acid to one pint of hot water), and, after application, covering
the gauze with oil silk, rubber dam, or paraffin paper. Heavy brown
wrapping paper, well oiled or greased, will answer the purpose when
better material is not at hand.
=BANDAGES.=--Bandaging is an art that can only be acquired in any
degree of perfection by practical instruction and experience. Some
useful hints, however, may be given to the inexperienced. Cotton
cloth, bleached or unbleached, is commonly employed for bandages; also
gauze, which does not make so effective a dressing, but is much
easier of application, is softer and more comfortable, and is best
adapted to the use of the novice. A bandage cannot be put on properly
unless it is first rolled. A bandage for the limbs should be about two
and a half inches wide and eight yards long; for the fingers,
three-quarters of an inch wide and three yards long. The bandage may
be rolled on itself till it is as large as the finger, and then rolled
down the front of the thigh, with the palm of the right hand, while
the loose end is held taut in the left hand.
[Illustration: PLATE II.
Fig. I.
Fig. II.
Fig. III.
Fig. IV.
DIFFERENT FORMS OF BANDAGES.
(AMERICAN TEXT-BOOK AND REFERENCE HANDBOOK.)
Fig. I shows application of figure-of-eight bandage; Fig. II, a spica
bandage of thumb; Fig. III, a spica bandage of foot; Fig. IV, a
T-bandage.]
Two forms of bandages are adapted to the limbs, the figure-of-eight,
and the spiral reversed bandage. In applying a bandage always begin at
the lower extremity of the limb and approach the body. Make a few
circular turns about the limb (see Fig. I, p. 132), then as the limb
enlarges, draw the bandage up spirally, reversing it each time it
encircles the limb, as shown in Fig. I, p. 134. In reversing, hold the
bandage with the left thumb so that it will not slip, and then
allowing the free end to fall slack, turn down as in Fig. II, p. 132.
The T-bandage is used to bandage the crotch between the thighs, or
around the forehead and over the top of the skull. (See Fig. IV, p.
134.) In the former case, the ends 1-1 are put about the body as a
belt, and the end 2 is brought from behind, in the narrow part of the
back, down forward between the thighs, over the crotch, and up to the
belt in the lower part of the belly. The figure-of-eight bandage is
used on various parts, and is illustrated in the bandage called spica
of the groin, Fig. IV, p. 132. Beginning with a few circular turns
about the body in the direction of 1, the bandage is brought down in
front of the body and groin, as in 2, and then about the back of the
thigh up around the front of the thigh, as in 3, across the back and
once around the body and down again as in 2. Other bandages
appropriate to various parts of the body are also illustrated that by
their help the proper method of their application may be understood.
See pages 132, 134, 136, 137. The triangular bandage (see p. 88) made
from a large handkerchief or piece of muslin a yard square, cut or
folded diagonally from corner to corner, will be found invaluable in
emergency cases. It is easily and quickly adjusted to almost any part
of the body, and may be used for dressing wounds, or as a bandage for
fractures, etc.
[Illustration: PLATE III.
Fig. I.
Fig. II.
BANDAGES FOR EXTREMITIES (AMERICAN TEXT-BOOK).
Fig. I shows a spiral reversed bandage of arm and hand, requiring
roller 2-1/2 inches wide and 7 yards long; Fig. II shows a spiral
reversed bandage of leg and foot, requiring roller 2-1/2 inches wide
and 14 yards long.]
[Illustration: PLATE IV.
Fig. I.
Fig. II.
Fig. III.
Fig. IV.
BANDAGES FOR HEAD AND HAND.
(AMERICAN TEXT-BOOK.)
Fig. I shows a gauntlet bandage; Fig. II, a circular bandage for the
jaw; Fig. III, a circular bandage for the head; Fig. IV, a
figure-of-eight bandage for both eyes.]