DISLOCATIONS.
The obvious procedure is to effect reduction at the earliest moment before reflex contracture sets in. If this be attempted immediately, the end of the displaced bone can usually be so manipulated as to replace it in its normal position through the rent in the capsule of the joint by which it has just escaped.
Rarely, except on the hunting-field perhaps, will the surgeon he fortunate enough to meet the injury in this early stage, more or less muscular rigidity being always present when the case presents itself for relief.
Force was formerly the remedy always used for overcoming this, but the use of the general aniesthetic—Chloroform and Ether—has almost relegated the pulley, cord, and weights to the museums of surgical an tiquities. Nevertheless, judiciously applied force will always continue to be a valuable aid in some cases. The aim of the surgeon should be to replace the hone by manipulation when possible; as a rule this is easy when the patient has been thoroughly anxsthetised.
By movements of flexion, extension, adduction, abduction, or circum duction, the bone is replaced noiselessly in its capsule, the exact nature and degree of movement being determined by various factors, such as the formation of the joint, the extent of the rent in its capsule, the displace ment of tendons, &c. Sometimes when complete narcosis has taken place the bone may be, as in shoulder dislocation, easily replaced in its socket by the direct pressure of the fingers upon its articular extremity.
Should an be not available or contra-indicated, steady traction is to be made in the direction of the new axis of the limb till the resistance of the muscles is almost completely overcome, when the bone may be felt to slip into its place with a snap, being replaced by the action of its own muscles, as is witnessed in the reduction of dislocations of the humerus by placing the heel in the axilla,"and making steady, forcible traction upon the limb. Often, patient and gentle manipulation will achieve this by tiring the muscles without any appreciable degree of force being employed, and the writer, when resident surgeon in a large hospital for two years, nearly always reduced shoulder dislocations without chloroform in this way by raising the arm upwards, the bone being manipulated into its socket at a moment when the muscles were taken unawares, or during a brief period of relaxation, exhaustion or faintness, the heel in the axilla being very rarely resorted to. Dislocation of the lower jaw is readily reduced without anaesthesia by inserting the thumbs into the mouth and steadily pressing downwards behind and outside the last molar, whilst the chin is elevated to permit the condyle to slip into its socket. Dislocations of the hip in all recent cases can be reduced by manipulation under chloroform. The surgeon uses the femur as a lever to replace the head through the torn capsule by executing the movements of flexion, rotation, abduction, or adduction, according to the position of the displaced bone.
In old-standing dislocations considerable force must be used, hut even then pulleys are seldom required. It becomes a serious question to determine the limit of time since dislocation, which should prohibit some attempt being made to replace the bone. Valuable, indeed indispens able, information will he gained by X-ray examination of old dislocations. The humerus has been replaced after six months, and even after the lapse of a year. The hip has been reduced in several cases after six months, but many instances are on record where death from rupture of arteries has supervened upon attempts at reduction in long-standing dislocations. It will therefore be necessary in many old-standing dislocations (and exceptionally in recent ones also) to cut down upon the end of the dis placed bone, and if this cannot be then replaced it will be found necessary to excise a portion of it. When the normal socket is found to be obliter ated with new fibrous growth and a fairly useful new joint has been formed around the end of the displaced bone, matters should be allowed to remain as they are. It is not necessary to enter into a detail of the various manipulative manoeuvres required for the reduction of luxations of the several joints of the body; these will in each instance be dictated by a knowledge of the anatomical peculiarities in the formation of the affected joint.
After the bone has been replaced an ice-bag or evaporating lotion should be applied to the joint. Some apparatus or bandage will be necessary for a time to prevent the bone slipping out again through the rent in the capsule, especially when the laceration has been extensive, but the mistake most generally made is to keep the joint too long at rest. Gentle movements should be commenced early, not later than one week, and the absorption of effused products promoted by massage. This is especially necessary in the elbows of children, and excessive care has been responsible for numberless ankylosed elbows. Most surgeons now commence with massage immediately after the reduction of all dislocations and carry out passive movements daily, avoiding the movement likely to bring the end of the bone opposite to the rent in the capsule.
Dislocations complicated with fracture, especially common about the shoulder-joint, should be always reduced if possible by manipulation, after which the fracture is to be treated. When manipulation fails the opera tion of arthrotomy should be at once resorted to, and the head of the bone fixed to the shaft by screws or wire sutures; sometimes resection may be necessary.
Recurring dislocation of the shoulder may be prevented by the habitual use of a leather splint apparatus, but the only satisfactory treatment in chronic cases is the performance of capsulorrhaphv, and in some cases the relaxed and widened capsule may be diminished in capacity by " reefing " without opening the joint; the glenoid cavity has sometimes been deep ened by the surgeon.