CHAPTER XIV INJURIES TO JOINTS. (Part 2)

the thing to be avoided. Seize the thumb and slightly bend it still further backward, at the same time pushing the base of the phalanx obliquely down- Ft. 197 Complete dislocation ward and forward, Directly the phalanx will be felt to slide over the head of the metacarpal into its place, Complicated Distocation.—(Lejars.) Employ general anesthesia, tion, Pig. 195.-—Comulicaved disto- Yio.'sp4.~ Complete disbors ed thumb, Afowsite) ‘bf churn choi) Only the most carefully regulated manccuvres will succeed. Do not attempt the reduction unless the various steps are clearly in mind. | 270 INJURIES TO JOINTS. (1) Make traction on the digit in the direction of its axis antil ft is as long as normal. @) Scizing the thumb between forefinger and thumb in such manner that your thumb presses on the dorsal surface of the dislocated joint, bend it backward until it stands perpendicular to the metacarpal, or even further, The object is to put the thumb in the position of seacompli. cated distocation, and thas disengage the sesamoid bone. (3) Still holding it at that angle, push the base of the phalanx forward, (4) Having pushed the phalanx as far forward as possible in this man- ner, begin suddenly to flex it, in the meantime keeping the last phalanx extended and do not cease to push forward while flexing. If failure attends two or three at- tempts, do mot persist; proceed to operate. Dislocations of the fingers should be treated in the same manner—never begin by flexing. Reduce by first bending the finger backward and then pushing the base of the phalans forward. Trevery case Fin, 19% — Backward dintecatien demem the purpose is to reproduce in reduc MH: Rorvening. lerwenion. (Monii") tion the movements of dislocation. DISLOCATION OF THE HIP. These accidents are always serious, and yet are comparatively rare, Of the different forms of luxation of the femoral head, the backward on the dorsum ilii is by far the mast frequent (Figs. 196, 197, 198). Diagnosis.—The thigh is adducted, rotated inward, and immovable. The leg is apparently shortened, the knee slightly flexed, ——\ REDUCTION OF THU IIP-JOINT. 271 The trochanter rests above the line drawn from the spine of the ilium to the ischial tuberosity. The femoral head may be felt under the gluteal muscles on the dorsum ilii. Pie. 497.—Dislegation of the femur he arrow points rd and backwared in child. e acetabulum. Reduction.—General anesthesia is often necessary, Lay the patient on a pallet on the floor. A strong assistant, pressing on the iliac spines, immobilizes the pelvis First Movement: Flexion of Th gh.—Grasp the thigh above the knee 272 INJURIES TO JOINTS. with oac hand and with the other, the leg, and gradually flex the hip ani knee. Flex the hip to a right angle, Second Movement: Traction on the Flexed Femwr—When the hip is flexed at a right angle, begin traction, maintaining that angle. Do J femur Aroow pointe 10 the seatatvalbom not be afraid to use force. This is the most important mascuyre. Properly applied, that is to say, with powerfal traction on the hip bent ata right angle, the effort will often be rewarded by a sudden snap, Which indicates that the femoral bead has returned to its socket (Fig. 199) a * REDUCTION OF THE IP-JOINT, 273 Third Movement; External Rotation with Abduction.—Persisting in the traction, the resisting muscles are felt to yield. Now carry out the final manctuvre, which should guide the head over the rim of the ace- Po. it fiom oof the bes Gredu pain o ( ECNET a aateeeal tabulum into place. Continue traction to some extent, but rotate the thigh outward and at the same time abduct. All the other methods proposed are but modifications of this (Fig. 209). 8 274 INJURIES TO JOINTS. ISCHIATIC DISLOCATION. Diagnostic points: Adduction, inward rotation, marked flexion of both knee and hip (Fig. 221). Raxtermal retation, Reduction —By the same method as the dorvum iii, Do not begin the final movement of abduction and external rotation too soon, SUN-PURIC DISLOCATION, 275 SUB-PUBIC DISLOCATION, Diagnostic points: Compared with the ischiatic an opposite con- dition of affairs exists—abduction, external rotation and extension. ‘The great trochanter cannot be located (Fig. 202). Fy. 208: tion of hier v0. 202 —Forwand dislocation: buatborard Vaio toe selsis noes sub-pubie; extention, everson, dor ievectol (Monin) Reduetion.—Flexion is here illusory, and equally so, blind traction. Slightly lifting the extended limb, abduct it as far as possible; while abducting continue to lift. The head rolls down toward the obturator foramen, and finally the thigh stands vertically. Now adduct and rotate inward. 276 INJURIES TO JOINTS OBTURATOR DISLOCATION, Diagnostic points; The hip is flexed, abducted, and rotated out- ward (Fig. 203). ? Reduction.—Flexion of hip, traction on flexed thigh, adduction, inward rotation. DISLOCATION OF THE KNEE. ‘This accident is infrequent, easy of diagnosis, and comparatively easy to reduce, . General anesthesia is frequently necessary. Two assistants are ceded, one for traction on the Jeg and one for countertraction on the thigh, while pres- sure is applied at the joint. Onc must be concerned here with the con- dition of the blood vessels. Suppose there is no pulse at the ankle, the popliteal space is evidently filled with blood. Under these circumstances apply a toursiquet, and, under rigid antisepsis, open up the space by longitudinal incision, turn out the clots, ligate the torn vessels. Remove the tour- niquet, complete the hemostasis, and sew up the wound. ‘The limb ix bandaged in cotton, elevated, and kept warm, Time alone ean tell whether or not the circulation will be restored and gangrene averted. DISLOCATION OF THE SEMILUNAR CARTILAGES. ‘This is an injury likely to be forgotten in making a diagnosis of disabilities of the knee. The internal semilanar cartilage & much more likely to be ine volved, the accident usually occurring ia this manner: the individual atiempts.to turn suddenly while the knee is @exed. ‘The cartilage, cither as a whole or, more offen, a part, projects to the outside Or in Fu. #0 —Dowarwarg ‘tion. tor. ‘Dhrtaras es) me 4 DISLOCATION OF TH ANKLE-JOINT. 27 side of the joint circumference. There is a sudden painful locking of the joint. ‘The patient himself is often able to relieve the condition by a little manipulation of the joint, combined with lateral pressure. The injury is a serious one, functionally, and demands prolonged rest, in the hope that union may occur, An clastic silk stocking for the knee gives support and tends to prevent recurrence of the trouble, but violent movements are almost sure to bring a return. If asepsis is assured, the joint may be opened and the cartilage sutured to the tibla—an operation to be advised by the general practitioner and yet scarcely ever necessary to be undertaken by bim. DISLOCATION OF THE PATELLA. The difficulties in correcting the displacement of the patella are various, depending not only on the character of the dislocation, but also on the condition of the ligaments and muscles, In general, there is one method of treatment, viz.: Extend the leg completely and, holding it in extension, flex the thigh to a right angle. By this means the quadriceps extensor, in whose tendon of insertion the patella is lodged, is relaxed, permitting the bone to be manipulated into place. DISLOCATION OF THE ANKLE AND TARSUS. The diagnosis and correction of these injuries are more especially matters of anatomy. Whoever bas clearly in mind the relations of the components of the foot, can determine the character of the disar- rangement with the minimum difficulty. If the diagnosis is wrongly made, correct reposition is lacking, and in consequence there persists a degree of deformity and loss of function, One must begin his task of dingnosing a serious injury to the foot by recalling the relations of the malleoli and astragalus, the os calcis, and the other tarsal bones, to cach other. Inspect the foot; the heel, the sole, the borders, the malleoli, the 278 INJURIES TO JOINTS. tendo achillis—and compare each of these, point for point, with the sound side, Remember that the line of the tibial crest, prolonged, falls on the second toc. A dislocation of the ankle-joint assumes various forms, The other bones may be dislocated from the astragalus, which retains its normal relation to the malleoli. There may be solely a dislocation of the astragalus, which may take almost any position imaginable. Less often one finds displacement of the meta~ tarsals and phalanges, It is searcely possible to indicate an ex- act method of reducing such luxations. ‘The surgeon's ingenuity must saggest the proper variations of éraction combined with pressure. A type may be found in backward dislocations of the ankle (Fig, 204). ‘The malleoli are carried forward, the heel is elongated, the foot shortened, There is a transverse fold in front of the ankle, ridged vertically by the stretched extensor tendons. Matiaae late? — Reduction.—The patient’s foot projects over the end of the couch, an assistant steadying the flexed knee, Grasp the heel with one band and the mikidle of the foot with the other (Fig. 205). Make traction at first to reflex the oppasing muscles and then shove the foot forward and at the same time flex it, After-treatment.—The injured joint, carefully padded, must be fixed by a plaster splint. After eight to ten days, passive motion and massage must be begun. COMPOUND DISLOCATIONS. These are accidents always to be dreaded, and yet they yield ex- cellent results under antiseptic methods, Before you is a joint wide open, the articular earfaces bare, perhaps protruding, and immediately you think of resection or ampatation, a =i COMPOUND DISLOCATIONS. 279 and yet you will do neither. You will proceed to do a most careful disinfection and to secure a complete reposition and immobilization. ‘The one chief concern is disinfection, ‘The same indications for treatment are present as in compound fracture into joints (see page 249) and depend upon the degree of injury to the soft parts and whether the infection is or is not obvious. ‘The skin about the wound is prepared as for a surgical operation, the wound is thoroughly flushed out with sterile water, foreign bodies are removed, and replacement is effected. The next step will vary, depending upon the degree of confidence in having completely steril- io, se¢—Reduction of dislocated ankle. Tho antistant stoadics the flexed knew. (Meuth.) ized the joint cavity. If the effort has been exacting in that regard, tightly suture the deep layers over the joint, close the superficial layers with interrupted sutures and apply drainage. Tf the articular structures were impregnated with dirt, one will still fear suppuration despite the greatest care in cleansing, and will close the wound less firmly and provide for free drainage, Remov- ing as many bacteria as posible, starving those that remain by re- moving their food supply—devitalized tissue and blood serum—are the principles of treatment; cleansing and draining, the means; healing without inflammation or suppuration, the end. Dressing and Afler-care.—Having provided for drainage, cover the wound with sterile gauze, envelop the limb in absorbent cotton and immobilize the joint with a plaster splint. 280 INJURIES TO JOINTS. . As soon ‘us the soft parts are healed and the danger of infection has passed, begin massage of the muscles and slight movement of the parts daily. But in spite of careful cleansing, infection may develop. On the third day, perhaps, a chill occurs, the fever mounts rapidly and there are all the local signs of inflammation and sepsis. Do not temporize, but immediately open the wound, douche thoroughly with peroxide or jodine water and leave the wound open. Immobilize. If the temperature does not fall and the local conditions do not improve in a few hours, proceed at once to do an arthrotomy (see page 376). ‘The thorough drainage by this means obtained will usually control the situation. The drainage is gradually withdrawn and will not be after about the tenth day. If, even then, the swelling and . fever do not subside, there is nothing left to prevent a general in- fection but immediate amputation, and even that may be too late, "The shoulder-joint rarely suffers a compound dislocation. Such an injury is especially serious for the reason that there are so many com= plications; the shoulder muscles are torn, the axillary vessels and the nerves af the brachial plexus laccrated. Tt must be treated on the general principles enumerated amd the reault is often surprisingly good, If traumatic ancurysm exists, the pectoralis muscles must be divided, the space exposed and the vessels ligated. __ The hip-jeint is occasionally the site of a compound dislocation and nearly always the shock is fatal. Elbow. —This is a comparatively frequent accident and is treated ‘on the general principles outlined. If the injuries are severe, a partial excision may be required to perfect drainage and insure a better joint. Amputation will be indicated only in oki age, morbid constitutional disability, or extreme local destruction. "The wrist should be treated conservatively. A loose carpal bone may require removal or partial resection. Amputation will be ree quired if healing is obviously out of the question. Compound dislocations of the knee-joind are very rare. Uf com servatism fails, amputation is the only alternative. Ankle and Tarsus.—Thcse dislocations are frequent and require a a WOUNDS OF THE KNET-JOINT. asi much attention, Antiseptic foot baths serve an excellent purpose though the primary cleansing must be especially vigorous. The tarsal bones may need to be sutured to be retained in place. Especial care must be taken not to interfere with the circulation (see page 250, compound fractures). CONTUSIONS OF THE KNEE-JOINT. ‘These are so frequent as to call for a special word. ‘The aim is to ayoid an acute synovitis, which may become suppurative. In milder cases, rest in bed with some mild liniment and light massage will be sufficient, and the pain and stiffness will rapidly subside. In the severer cases, indicated by pain and swelling, more active measures must be instituted. Wrap the joint in absorbent cotton and apply a plaster bandage for two or three days. The uniform pressure will limit the effusion and hasten ite absorption. After that you may begin hot sponging and very gentle passive motion with massage, applied at first only to the muscles moving the joint, and afterward, as the tenderness subsides, to the joint itself. PUNCTURE AND STAB WOUNDS OF THE KNEE-JOINT. ‘The treatment will depend largely on the instrument which in- flicted the wound and the appearance of the wound. If the wound is clean-cut, and the instrument presumably non-septic, content your- self with sterilizing the ficld of the wound, enveloping the knee in an antiseptic compress and putting the joint at rest, preferably in a plaster splint. You will anxiously watch the temperature. If it does not rise within three or four days, one may cease to fear infection, and such swelling as appears is not significant. It is quite different when the temperature begins to rise and the local symptoms gradually increase, or if the wound is seen after some days of neglect and the symptoms of infection are fully developed. Under these circumstances, there must be no delay. Immediate Operation is imperative; it is indicated to do an arthrotomy, disinfect and drain (see page 376). 282 INJURIES TO JOINTS. “This treatment, carly and properly applied, As infection subsides, the drainage is gradually witl ‘There are cases, however, in which, unfortun strenuous measures fail, In spite of immediate urgency, and immediate action, laying open the joint freedorn, followed by repeated irrigations—in spite of endeavor, the symptoms of grave general infection p necessary to amputate. This may save the patient's it will not. EXTENSIVE INCISED OR LACERATED WOU THE KNEE-JOINT, In these cases, it is never sufficient merely to cleanse the sl the wound with antiseptic dressings. The wound must be thoroughly cleansed, and the joint cavity irrigated with ster or normal salt solution and wiped dry with sterile gauze. After the complete disinfection, the wound in the capsule is and, perhaps, also the skin. More frequently, however, feel safer to leave drainage in the skin wound. ‘The joint is ik ized, and if everything goes well, the drainage-tube is removed forty-eight hours. SPRAINS. In general, these conditions are to be treated by firm band the effusion; and then massage and slight passive motion are It is better to give the joint functional rest until at Jeast the part of the pain has subsided, ‘on account of its construction and partly on account of its fu The weight of the body falls an the insecurely poised foot and ankle gives way under the load. The ankle usually bends out and the external lateral ligaments are subjected to great strain. are undoubtedly often lacerated or the capsular ligament may. torn, The pain in the severe cases is immediate and intense; a an MASSAGE OF A SPRAINED ANKLE. 284 patient may faint. If the joint is continued in use, the swelling is aggravated, but in any event swelling rapidly ensues. ‘Morphia may be necessary to relieve the pain. If seen at once, the ankle is immobilized in plaster of Paris for a few days, or bandaged tighdly with a dannel or rubber bandage, or strapped with adhesive plaster, after which massage and passive motion are employed. The patient should walk with crutches at first. The joint will be stronger than if it was used before the pain and swelling had subsided, although excellent authorities advise walking from the first. Tf adhesive strips are used, in order to avoid circular constriction, apply them in this manner: cut the adhesive strips one-half inch wide and in two lengths, twelve and cightecn inches. (x) Begin with one of the long strips in front of the big toc, carry the strip back around the heel, keeping just above the contour of the sole, and bring the strip back across the dorsum of the foot to the starting-point. Overlap this with a similar strip. Both should be tightly drawn. (2) Begin