Part 78

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.

Luxations of the shoulder-joint may be, and have been, reduced after 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.

_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.