Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

On no account should the lower fragment be employed as a lever in attempting reduction. When reduction by manipulation fails, recourse should be had to an open operation. The upper fragment should be exposed by an incision over its lateral aspect, and made to return to the socket by using Arbuthnot Lane's levers or M'Burney's hook, or a long steel pin may be inserted into the fragment to give the necessary leverage.

Reduction having been accomplished, the fracture is adjusted in the usual way, advantage being taken of the open wound, if necessary, to fix the fragments together by plates. The best position in which to fix the limb is that of abduction at a right angle. Massage and movement should be commenced early to prevent stiffness of the joint.

When it is found impossible to reduce the dislocation, it is usually advisable to remove the upper fragment.

The method of allowing the fracture to unite without reducing the dislocation, and then attempting reduction, usually results in re-breaking the bone, or else in failure to replace the head in the socket, and has nothing to recommend it.

Old-standing Dislocation of the Shoulder.—It is impossible to lay down definite rules as to the date after which it is inadvisable to attempt reduction by manipulation of an old-standing dislocation of the shoulder. Experience of a hundred cases in Bruns' clinic led Finckh to conclude that, provided there are no complications, reduction can generally be effected within four weeks of the accident; that within nine weeks the prospect of success is fairly good; but that beyond that time reduction is exceptional.

The patient is anæsthetised, and all adhesions broken down by free yet gentle movement of the limb. The appropriate manipulations for the particular dislocation are then carried out, care being taken that no undue force is employed, as the humerus is liable to be broken. If these are not successful, they should be repeated at intervals of two or three days, as it is frequently found that reduction is successfully effected on a second or third attempt.

Should manipulative measures fail, it may be advisable to have recourse to operation if the age of the patient and his general health warrant it, and if the condition of the limb is interfering with his occupation or involves serious disability. If operation is deemed advisable, a few days should be allowed to elapse to permit of the parts recovering from the effects of the manipulations. The joint is freely exposed, the capsule divided, the head of the bone freed and returned to the glenoid cavity. It is sometimes so difficult to replace the head of the bone that it is necessary to resect it and aim at the formation of a new joint, an operation which usually yields satisfactory results.

Habitual or Recurrent Dislocation.—Cases are occasionally met with in which the shoulder-joint shows a marked tendency to be dislocated from causes altogether insufficient to produce displacement under ordinary circumstances. This condition is usually met with in young women, and, in some cases at least, appears to be due to too early and too free movement of the joint after an ordinary dislocation, so that the capsule is stretched and remains lax. In some cases it would appear that the liability to dislocation is due to some structural defect in the joint, and under these conditions both sides are sometimes affected, and the accident is not attended with the usual pain and disability either at the time or after reduction. The facility and frequency with which dislocation recurs render the limb comparatively useless, and may seriously incapacitate the patient. We have had cases under observation in which dislocation resulted from the hyper-abduction of the arm in swimming, from throwing the arms above the head in dancing and in gymnastic exercises, and even in “doing” the hair.

The treatment consists in preventing the patient making the particular movements which tend to produce the dislocation. These are chiefly movements of hyper-abduction and overhead movements; we have found an apparatus consisting of a belt applied around the thorax, and fixed to another around the upper arm by a band which passes above the axillary fold of the dress, useful in restraining these movements. If these measures fail, it may be advisable to have recourse to operation; this may consist in tightening up the capsule, the results of which are said to be uncertain, or in detaching a portion of the deltoid or subscapularis muscle and stitching it beneath the joint to cover and strengthen the weakened portion of the capsule. It is suggestive that in performing this operation no rent in the capsule is discovered.

The condition is also met with in epileptics; and it is generally found that the head of the bone is deficient, as a result either of fracture or disease; that the muscles which naturally support the joint are atrophied or torn; and that the capsule is unduly lax.