CHAPTER XIV INJURIES TO JOINTS. (Part 1)

CHAPTER XIV INJURIES TO JOINTS. Dislocations; Compound Dislocations; Open Wounds; Contusions; Sprains. DISLOCATIONS. Shoulder-joini.—OF all the joints, the shoulder is by far the most frequently dislocated. Of these dislocations, there are several forms, and yet only one variety is likely to be met with by the general practi- tioner—the sub-coracoid. A clear conception of the conditions and of the manceurres necessary to a reduction presupposes a very definite notion of the anatomy of the joint. Recall the relation of the acromion and coracoid processes to the glenoid fossa, to the head of the humerus and to the capsular liga- ment; the relation of the long head of the biceps to the joint and the attachments and actions of the various muscles surrounding the joint, particularly the sub-scapularis, the spinati, the pectoralis major; and the relations of the axillary vessels and nerves. However simple a case may appear, do not begin any mancuyre until a complete diagnosis has been made, Diagnosis.—Begin by inspection. The patient is in evident pain; his head i Inclined to the injured side and he supports the injured member with the other hand; the shoulder is fattened, the rounded prominence of the deltoid has disappeared and the actomion projects; the elbow is abducted and the patient is unable to bring it down to the side, Palpation reveals the axis of the humerus pointing to the middle of the clavicle; the examining finger can be pusbed under the acromion where the humeral bead should be. The humeral head itself may be felt below or to the inside of the coracoid, and rotates with alight rotation of the arm, 252 _ | REDUCTION OF THE SHOULDER-JOINT. 253 ‘The fingers in the axillary space feel the rounded head of the hu- merus projecting inward more noticeably when the arm is slightly abdacted, ‘This question arises: ‘Is it a case of simple dislocation, or is it complicated by a fracture of the upper end of the humerus, of the great tuberosity, or the rim of the glenoid fossa?” “Have the arteries or nerves been injured?” You must test particularly for laceration of the circumflex nerve. Do this by pin pricks over the deltoid; if the skin is Insensitive, forecast paralysis and atrophy of the deltoid, and thus anticipate and disarm censure. Reduction.—(Lejars.) The method of Kocher seldom fails, if properly applied, and if the various movements are modified to suit the individual case. Its purpose is to put the head of the humerus in the position at which it left the capsule. Through the relaxed tear the head is then to be levered into the socket, Seat the patient in a chair facing a little to one side. Let a strong and able assistant, standing behind, seize the patient's shoulder firmly and make pressure downward and backward, Place yourself before the dislocation, and seizing (in the case of the left arm) the forearm at the elbow with the left hand, and the wrist with the right hand, direct the patient to hold the head up and look straight ahead. Pirst Stage: Plexion, Adduction—The elbow is flexed and then gradually adducted until it touches the body, the wrist held firmly meanwhile. The elbow is now pushed backward beyond the axillary line—the first stage is not complete without this. Neglecting this part of the first manceuvre is a frequent cause of failure. “Do not get in too great a hurry, Remember that the larger part of the resistance is due to the muscles and that they yield only gradually, Too sudden and too violent traction on them augments the pain and their resistance. ‘To pause a little now, gives them time to relax (Fig. 180). Second Stage: External Rotation —Hold the elbow fast and flexed at a right angle, and now with your right hand, swing the forearm outward and backward until it lies in the transverse vertical plane of the body (Fig. 181). Its axis lies directly in front of you. Perform the mancuvre cautiously and smoothly. Again pauscuntil the muscles are relaxed. Do not be alarmed by the snapping distinctly heard a INJURIES TO JOINTS. in the movement. One may follow the movement of the bulging head of the humerus with the eye, Occasionally reposition occurs at the tnd of this movement, if it has been carried out methodically, or at ‘east at the beginning of the third stage. Tri" to—Revouctiom of saber. Virvt rings Vienation : eddevsion ; ooo (tle pomteror U> toe sscllary bw Third Stage: Elevation.—Maintaining Oexion and external rotation, ext lift the elbow upward and forward—upward and forward exactly —de not permit the elbow to move outward, Abduction will spoil the REDUCTION OF THY SHOULDER-JOINT. a5 manceuvre (Fig. 182), Lift upward and forward till the arm reaches the horizontal—a sudden snap indicates that the head has slipped into the socket. Prd. et-Reduction of shoulder. Second stage: External rotation until fore ‘arm stands at right argle to body: Fourth Stage: Internal Rotation —Proceed now rapidly to swing the forearm inward and across the chest until the hand rests on the oppo site shoulder (Fig. 183). ‘The movement is made rapidly but with no great force. This latter holds good with respect to all the movements, 256 INJURIES TO JOINTS. It must be observed that the surgeon's hands do not change their hold it any stage of the reduction, Tf these manceuvres fail, repeat them in the same order, using a little Fra 8e—Redhection od shoulder, Thinl stage: Hlevation hile esltntalaing extemal rotation. more force in the second and third stages and pausing a little longer at the end of a stage. In the swb-claviculer form also this manceuvre will succeed, but should be modifed to this extent: prolong the second stage two ar REDUCTION OF THE SHOULDER JOINT. 257 three minutes, using more force to obtain external rotation and the backward position of the elbow. In this wise, the muscles are re- laxed more completely. Without changing the external outward ro- tation, the elbow is lifted upward and forward as before Pio, 1ij —Redloction of dhoulder. Fourth stage. Internal rotation, ‘Not less efficient in certain cases of sub-coracoid dislocation is the method of Mothe, or traction in extreme abduction, It is also applicable in all other forms of inward and downward dislocation. In this procedure, counterextension is indispensable. A long towel : ti s8 INJURIES TO JOINTS. serve. It encircles the injured shoulder, passing under the arm- it, and the two ends cross the back toward the sound side. While the ii makes forcible counter-extension, the operator manipulates No. 184 —Rectuetion f srwier.. Traction with high at! hocli“hrin line eth the eyune of crapmta. mk (he arm, It is best that be stand on a stool or chair if not tall enough ‘o make good traction upward, Now seize the arm above the dbow ind the forearm near the wrist (Pig. 1&4). Flex the elbow, Next flevate the arm by extreme abduction until it is in line with the spine REDUCTION OF WIE SHOULDER-JOINT. 250 of the scapula. The arm, you must observe, does not reach the horizontal merely, it is elevated beyond that level. This is of the Greatest importance. With the arm thus in extreme abduction, next make strong traction in that direction (Fig. 185). Assistance in trac- tion may be necessary; or one may confide the traction to an assistant, Fre. 18§.—-Reduction by high abduction and traction. Note mannor in which the ausietant ‘stendien the shoulder. (Lefurs.) while with the thumbs, one pushes against the humeral head in the axillary space. Tf this does not succeed, begin the second stage: Depress the arm rapidly and smoothly, letting the point of the elbow pass in front of the chest, all the while maintaining traction This method occasionally fails for these reasons ’ INJURIES TO JOINTS. (1) Traction with high abdaction is not long enough ral te arm js depressed before the head has been sufficiently elevated ction. {2) The arm is lowered too slowly. Ves s85.—CRipmans mucin of mpucine dhiceatel shoulder. Pins sage. Fatereational Journal of Swrger: = cemeral anesthesia m very muscula In neglected cases or in th eater care, and it must be borne in mind, too, a here is as dangerous as it is useless, ‘The p omplete anc KEDUCTION OF THE SHOULDER-JOINT. abr ticular danger of this method is laceration of the axillary structures, If general anesthesia is strongly contraindicated, local anesthesia may be employed, injecting the joint and the tendons near their lines of inser tion. How long after the injury reduction may be attempted cannot Vis. shy —Caipman’s methon of reducine di Grterwarional Jowench be determined by any rule, but by the conditions in the individual case Chipman, of New London, Connecticut, suggests a method which must prove of value, especially to the doctor compelled to act without assistance, ‘ 262 INJURIES TO JOINTS, He describes his method thus (Int. Journal of Surgery, November, 1906): Stand facing your patient. Gradually raise the disocated arm to a horizontal position and place it on your shoulder with forearm flexed on your back. Direct the patient to pass the well arm under your arm and grasp the wrist of the injured arm with the well hand. Thus the patient’s arms encircle your body, the injured one passing over one shoulder, the sound passing under the other (Fig. 185). Second Stage —Now direct the patient to sag downward, and the weight of the body drags the head of the humerus outward and up- Sed corcenid Sal pleas Pie. (8° —Dalooatios of shoakter, (Watuhaw) ward, when you ean easily return it to the glenoid cavity with your hands (Fig. 187). ‘The dislocation is so easily and expeditiously re- duced that even the surgeon himself is surprised. There is the least possible additional injury, the least possible pain; there is no need of an assistant or an ancsthetic. SUB-GLENOID DISLOCATION. ‘This variety is always the result of forcible abduction of the humerus, the tear in the capsule falling below the glenoid cavity, and the bead of the humerus remaining fixed there (Fig. 183). ‘The diagnosis is to be made from the symptoms already described for the sub-coracold form, the only difference being that the elbow REDUCTION OF SUD-GLENOID DISLOCATION. 263 is further from the chest, the flattening of the shoulder more pro- nounced, the head of the humerus more readily felt in the axilla (Fig. 189). Pio. 1839—Reduction of a sub-wlenoid diclocation. Second stage. Gradual ‘elevation with constant traction. reduction may be affected by Kocher's method, but perhaps method is that of extreme abduction with traction, which has been described, ‘I'he patient may be seated, but often must for the weight of the pendent limb may be very painful. The 6s INJURIES TO JOINTS. ijured member is grasped above the elbow with one hand, below the ‘rist with the other, flexed, slowly raised to form ah obtuse angle with te chest. In this position strong traction and countertraction are to Pru, ye. —Bedection af sath ghenntt diatncation Thin! stage Tenetion with tieh abstaction aml yeesauire on Ube haumera) bend, made, Usually this succceds, though it may help to press the bead oto place (Fig. 190). If traction and pressure are not sufficient 10 ficct reduction after the muscles have been thoroughly relaxed, the rm is to be depressed as before described. AFTER-IREATMENT OF SHOULDER DISLOCATION. 265 Sub-spinous Dislocation.—In this case the shoulder is flattened in front and the examining finger finds 4 marked depression between the tip of the acromion process and the coracold, ‘The elbow is carried slightly forward and the arm rotated inward. The head of the hu- merus can be felt below the spine of the scapula. Reduction.—General anesthesia is usually necessary. Grasp the ‘arm above the elbow; slightly abduct the arm; slightly increase the inward rotation (never rotate outward); make traction in a direction downward and forward. Pressure forward on the head is helpful. AYTER-TREATMENT OF SIOULDIR DISLOCATIONS. ‘The task in any form of dislocation does not end with reduction. ‘There it still the duty to restore usefulness as completely as possible, and to that end the subsequent care must be minutely regulated. The inclination is to immobilize the Joint too completely and too long, fearing a recurrence of the dislocation. ‘This enforced rest combined with injury is Hable to produce atrophy of the muscles, stiffness of the joint, and protracted loss of function. ‘The indications for after- treatment are various, depending upon clinical conditions. (A) An uncomplicated, easily reduced dislocation in a healthy strong : Begin by immobilizing the shoulder, but take care that after three ‘or four days of complete rest massage und passive motion shall be begun. The joint is cautiously-put through all its motions, the deltoid, and pectoralis major, and the scapular muscles carefully massaged; a daily seance gradually prolonged. Tn the interval the arm is bandaged, hut gradually the dressing is relaxed and, after a week, movement left quite free. In two weeks of such treatment the function may be entirely restored. (B) The case was complicated with injury to the soft parts, was with difficulty reduced, and only after a number of attempts; it is likely that the capsular ligament was extremely lacerated: Under such circumstances not only passive displacement, but actual dislocation is to be feared. Immobilize the joint with 2 Mayor sling or Velpeau bandage and Ict it so remainea week, But this will not prevent massage over the shoulder after four or five days. Do ' 266 INJURIES TO JOINTS, ‘not prolong the fixation, remembering that a dislocation accompanied hy great violence furnishes the condition most farorable to adhesions and weakness, and against these evils we have no remedies but mas- sage and gymnastics, which must be early begun and long continued. DISLOCATION OF THE LOWER JAW. ‘This accident, which may happen at most unexpected times, when yawning or Laughing, for instance, might be confused with certain fractures of the inferior maxilla. ‘The opened mouth, the loss of power to close it, are characteristic (Fig. 191). The reduction is usually easy. Both sides may be reduced simultancously, Wrap the thumbs; you have to deal with the powerful muscles of mastica- tion, which, when the dislocation is reduced, are likely to close the jaws with much force. ‘The thumbs, passed into the Sj mouth, press downward and back- ward on the molar teeth; at the same time, the fingers hooked under Fro. cpr —Dinkeeation of few (Mette) the chin pull upward, Im the mus- cular, considerable force is required. ‘The jaws should be moved only slightly for several days, DISLOCATION OF THE ELBOW. Dislocation of the elbow, which occurs with considerable frequency, especially in chikiren, nearly always assumes the form of backward displacement. Diagnosis.—The elbow is increased In thickness antero-posterionly. ‘The flexure af the joint is depressed. Where the head of the radius should be there isa depression. ‘The olecranon is abnormally promi REDUCTION OF THE ELBOW-JOINT, 267 nent. Compare the relation of the olecranon # the inner condylar lines on the two sides, Flexion is quite painful and practically impossible. ‘Bro. 192.—Reduction of the olbow-jolnt Traction slew, Sevteat Mexion combined ‘with pressure forward on the olecranot If the diagnosis is doubtful, as it often must be when swelling is great, one thinks of supracondylar fracture, But in the case of frac- tore, the relation of the olecranon to the intercondytar line is unaltered; the humerus is shortened; the deformity disappears with traction. 268 INJURIES TO JOINTS. Reduction.—(A) Standing on the injured side, seize the arm above the elbow with both hands, and as an assistant makes traction on the forearm, steady the arm and press with both thumbs on the olecranon, ‘The traction is made at first in the direction of the long axis, but as the limb yields, the forearm is rapidly Hexed—continuing the traction and pressure. BPG Seren pa eae? (Fig. 192.) (i) M Method af forced extension: ‘Traction and countertraction as before, except that the traction which began in the direction of the long axis of the forearm and pro- duced flexion, now produces hyper-extension, In the meantime, press on the olecranon and the bead of the radius. In this way, ope will sometimes succeed, but do not forget this method is available only for those who have supple joints (C) Method of Astley Cooper: ‘The paticot is seated on a chair—you place yourself on the side opposite the injured efbow. [1 is the right, for example, stand upon the left side and place a foot upon the chair. Get the bend of the el- bow over the knee. Steadying the humerus with one hand, draw on the flexed forearm with the other, at the same time flexing the elbow ‘over the knee. Generally speaking, however, if the first method fails, it is better to give a general ancsthetic, with which the chief difficulties di Lateral dislocstions are usually replaced without much trouble by pressure combined with extension. After-treatment.—This must be begun even carlier than for the shoulder—massage and passive mothon—else a stiff joint is very likely to follow DISLOCATION OF THE THUMB. This accident, apparently simple, presents some peculiarities, which must be bora in mind. ‘These displacements at the metacarpo-phalangeal joint, are classi- fied ax incomplete, complete, and complicated, depending upon the relation which the articular surfaces assume and upon the disposition of the sesamoid bone (Fig. 193). Incomplete dislocations Ieaverthe REDUCTION OF DISLOCATIONS OF THE THUMD. 269 articular surfaces in alight contact; complete dislocations find the artic- ular surfaces at right angles, the phalanx standing upon the dorsum of the meta- carpal (Fig, 194); and, if in addition to this, the torn anterior ligament and sesamoid bone, in attempt at flexion, are wedged be- {ween the articular suriaces, the dislocation is said to be complicated, a condition difficult to manage (Fig. 195). Since this condition is produced by maladroit attempts at reduction of the complete dislocation, it is especially desirable to understand the manceuvres. Whether the dislocation be complete or incomplete, mewr attempt reduction by flexion, ‘That is