A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

62. But, if the extensions render the muscles straight, and restore to them their primitive direction, then, obeying their natural irritability, which is still further increased, by means of the extension, they will draw the head to the rupture in the capsule, and force it to re-enter it, with much more certainty than this can be done by the efforts of the surgeon, who is always ignorant of the precise situation of this rupture. On the other hand, if the extension be not judiciously made how can it restore to the muscles their natural direction? In such a case, the head of the bone will be drawn towards some other part of the capsule than that where the rupture exists, and hence, the difficulties that so frequently occur, in reducing luxations of the humerus.

63. From these circumstances it follows; 1st, that the whole art in the treatment of luxations, consists in giving to the extending powers a proper direction; 2dly, that, in general, the process of conformation is unnecessary and useless; 3dly, that to reduce a luxation is not to replace the head of the bone in its cavity, by force, but to restore the muscles to such a state, as to enable them to replace it. Here, therefore, as in every other case, art is only the minister and handmaid of nature.

There are instances, however, where the muscles cannot act properly in consequence of the long standing or age of the luxation, and in consequence of adhesions, more or less strong, having taken place between the surrounding parts. In such cases it is necessary to employ proper measures to force the head of the bone into its cavity, as it cannot be carried thither by the muscles.

64. Reason concurs with experience, which is on all subjects the best authority, in establishing the truth of this doctrine, respecting the reduction of luxations of the humerus. In this operation, Desault employed, in general, nothing but extensions, varied according to circumstances, until the muscles thrown into a favourable state, were themselves enabled to accomplish the reduction. The most immediate success constantly crowned his practice on this point. This success was, no doubt, owing to his judiciously remaining inactive himself, and suffering the muscles to do the work, after the necessary extensions had been made.

65. When the reduction is accomplished, if the arm, in consequence of being very moveable, appears likely to be displaced again, it is necessary, for a few days, to fix it in such a manner as to prevent all motion; an object which may be effectually attained by Desault’s bandage for fractures of the clavicle.

All writers recommend, for this purpose, the use of the Spica bandage.[17] But what service can this render? It does not restrain the motions of the humerus, which, hanging down the side, may move forward, backward, &c. and produce a new displacement; an accident that may be always prevented by the bandage proposed.

§ VIII.

OF CIRCUMSTANCES RENDERING REDUCTION DIFFICULT.

66. I will close this memoir by an examination into some circumstances, which may either prevent reduction or render it difficult, and into certain accidents that sometimes accompany it.

I have said that, on some occasions, the rupture of the capsule, being too narrow to admit the head of the humerus to repass it, and return to its cavity, constitutes one of the principal obstacles to a reduction (24). To enlarge this passage, by further lacerating its edges, is evidently the indication that here presents itself. This is fulfilled by communicating to the bone great motion, either by circumduction, or rotation on its own axis, forcing it suddenly in different directions, particularly in that direction in which the luxation has been produced. Its superior extremity must be, at the same time, pushed forcibly against the ruptured capsule, which, by being thus pressed between two resisting bodies, will suffer a more extensive rupture. Reduction, oftentimes impracticable previously to these violent and varied motions, takes place of itself as soon as they have been properly made. Of this the practice of Desault furnishes many examples.