Treatment. — In uncomplicated cases reduction is usually easy by Kocher's method, as follows:— The elbow is flexed to a right angle and pressed closely to the side; then the forearm is turned as far as possible away from the trunk,—external rotation of the arm (Fig. 7). Maintaining the external rotation, the elbow is carried well for ward and upward,—flexion of the arm (Fig. 8); and finally the hand swept After a long, steady pull, manual or elas tic, the deltoid may yield and allow the head of the bone to be pushed back into place. Or, after a few moments of trac tion, the arm is violently adducted over the closed fist in the axilla (this is safer than the heel). If amesthetics a.re used all of these violent measures should be executed very cautiously.
Dr. Cole suggests a method which he claims is successful in a large number of over until it touches the chest,—inward rotation (Fig. 9),—the elbow being si multaneously lowered. Ansthetics may or may not be necessary. If, after the "first movement," the head does roll out in front of and below the acromion, the attempt will fail. Direct manipulation of the head may be of assistance.
If Kocher's method fail, traction downward and outward (never upward and outward, on account of the danger of lacerating the vessels) should be tried.
cases. The surgeon, standing by the patient's side, holds the arm abducted and the elbow flexed, and, while distract ing the patient's attention, gently oscil lates the arm. As the deltoid is seen to relax, a sharp blow is delivered into the fold of the elbow and the arm rotated sharply ontward, thus rolling the bone into place.
If judicious attempts at reduction by these methods fail, even under anms thesia, an open arthrotomy should be done for the purpose of discovering and removing the obstacle to reduction.
In intracoracoid dislocations the head an unusual amount of laceration of the capsule and subscapularis, which allows the head of the bone to slip higher into the axilla. Reduction by outward trac tion is easy unless the subscapularis or a torn portion of the capsule intervene. In such cases operation is the only re course.
In subelavicular dislocations the same forces acting more energetically force the head of the bone up under the clavicle.
Downward dislocations include all cases in which the head of the bone lies is displaced farther inward and the symp toms are those of the subcoracoid, except that the head of the humerus is felt farther displaced and the shoulder is more flattened. The arm may be fixed in horizontal abduction. The cause of this particular dislocation is, as a rule, below the glenoid fossa. In subtricipital dislocation, of which one case is recorded, the head of the humerus was displaced secondarily backward and upward be hind the long head of the triceps.
Subglenoid Dislocations.— The symp toms are those of subcoracoid disloca tion; but abduction and flattening of the shoulder more marked. The head of the bone is palpable below its socket. The upper part of the greater tuberosity is habitually torn away. The usual cause is forcible abduction followed by rota tion or impulsion.
Treatment—Traction in moderate ab duction with direct pressure.
Luxatio Eucta.—Very rarely, by forc ible elevation of the arm the head of the bone is displaced so far downward that the extremity maintains its erect posi tion, It is reduced by upward traction until the head falls into place.
Posterior Dislocations. — The two va
rieties differ only in the extent of dis placement.
Symptoms.—The arm is adducted and rotated in, the elbow being directed slightly forward. The shoulder is flat in front and full behind (when the head of the bone may be felt). Passive motion is restricted, voluntary motion absent.
The cause is direct pressure outward and backward, or the pressure exerted in the same direction along the adducted and inward-rotated humerus.
The outer side of the capsule is torn and the external and internal scapular muscles more or less lacerated or avulsed with fragments of the tuberosities. The head of the bone lies on the outer edge of the glenoid fossa, or farther back be neath the spine of the scapula, or on the infraspinatus.
Treatment.— R eduction is accom plished by traction and direct pressure forward. Avulsion of the subscapularis makes recurrence probable. TJnreduced dislocations backward are accompanied by an unusual amount of disability.
Upu;ard Dislocatioils.—These are ex tremely rare. The head of the bone is forced npward between the coracoid and acromion, usually to above the clavicle. The arm is almost immobilized in adduc tion and slight extension. Reduction may be effected by downward traction.
Complications of Dislocations of the Shoulder.— Compound dislocations are very rare, and are commonly caused by direct violence. The skin-wound is usu ally in the axilla. Aside from complica tions which may exist not dependent on the dislocation, the great dangers are from laceration of the main arteries (fre quent) or nerves (unusual) and from sup puration. The treatment consists of en larging the wound until the extent of damage can be fully appreciated and, as far as possible, repaired. Meanwhile the wound should be thoroughly irrigated. with "normal" salt solution. The dislo cation may now be easily reduced. In most cases thorough drainage should be provided for, and in some cases it may be advisable to excise the head of the humerus to this end to oppose ankylosis.
Fractures of the various bony promi nences of the scapula and humerus have commonly a purely pathological impor tance. Fractures of the anatomical or surgical neck of the humerus are impor tant, but often difficult to diagnose. The diag,nostic points of fracture of the ana tomical neck are the recognition of the head in the axilla and its failure to move with the shaft, the maintenance of near-by normal range of motion and the normal position of the greater tuberosity. Crepitus may sometimes be elicited. In fracture of the surgical neck the signs are quite the same, except that the tuber osity is displaced with the head, and, with it, fails to move with the shaft, and crepitus is more easily elicited. In either case the upper fragment may be reduc ible by direct manipulation. This fail ing, if the fragments can be approxi mated, the arm may be immobilized for three or four weeks in an appropriate position with the hope of obtaining union and effecting reduction at the end of that time by manipulation. But the better plan is probably to do an open arthrotomy and reserve the upper frag ment except in such fractures of the surgical neck as can be reduced, and to this end the use of a strong right-angled hook inserted into a hole drilled at the lower end of the upper fragment, may be of great service (McBurney). Or a fairly useful false joint may sometimes be ob tained at the point of fracture.