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

by P.-J. Desault

70. Oftentimes the first efforts are fruitless, and the luxated head remains stationary, amidst the most violent efforts. Let the extensions then be discontinued: renew the forcible motions of the limb: carry the humerus upwards, downwards, forward, and backward: force the resistances to give way; make the arm describe a large arch of a circle round the place which it occupies; let the rotatory motions on its own axis be impressed on it anew; and then recommence the extensions, and let them be made in every direction. By these, the head, already disengaged by means of preceding violent motions, will be brought to a level with the glenoid cavity, and ultimately replaced.

It may not be improper to confirm by experience the truth of these precepts, which might to some appear rash, in consequence of the changes that seem likely to occur in the glenoid cavity, during the absence of the head of the humerus. I will relate, among others, a case reported by Giraud, second surgeon to the Hotel-Dieu.

Case X. Maria Gauthier, thirty-four years of age, entered the Hotel-Dieu, on the twentieth of June, 1790, to be cured of a luxation of three months standing, produced originally by a fall on the arm, which was separated, at the time, from the body and carried backward. Different surgeons had, at different times, attempted the reduction, but always without effect, and when every hope of a cure appeared to have expired, Desault, imboldened by reiterated success, tried whether or not he would be equally fortunate in this case.

The patient being placed in a horizontal position, as already directed (55), great motions were first impressed on the limb: extensions were then commenced, first in the direction of the luxation, and afterwards forward and backward. Vain efforts; the head remains immoveable; new motions are again made in every direction, and afterwards, the extensions are renewed: the same want of success. The patient being fatigued, the reduction was deferred till the day following, when the same trials were, after a short time, attended with complete success. The head being at first disengaged, and afterwards drawn slowly along the track through which it had passed in becoming displaced, at length re-entered the capsule. The arm, being supported by the usual apparatus, soon became œdematous, and, notwithstanding the remedies common in such cases, the swelling continued for two months. The motions performed by the limb in the mean time, restored to it, by degrees, its usual suppleness; and, on the sixty-eighth day after her entrance, the patient was discharged cured.

To this case, I might subjoin many others, and, in particular, that of John Putot, also reported by Giraud, and in which the means just described (69 and 70), succeeded in the reduction of a luxation at the expiration of the fourth month. But too great an accumulation of facts distract the attention, and add nothing to conviction, especially when they are already so plain as those just related.

71. But further, in cases of this kind, where a very old luxation presents great obstacles to reduction, although the attempts made to reduce it, do not actually force the head of the bone into the capsule, still they may not prove entirely useless. By bringing the head nearer to the glenoid cavity, or placing it even on that cavity, and making it form new adhesions there, after having destroyed its old ones, the motions of the limb will be facilitated. For, in cases, where the luxation is not fairly reduced, these motions will be always less impeded, in proportion as the head of the bone occupies a place less remote from its natural situation.

72. A third obstacle, common to the reduction, of every kind of luxation, is the muscular force, increased by the irritation of the displaced bone, beyond its natural degree. So great, at times, is this force, that the head of the bone cannot be moved, even by the strongest efforts. What means should then be employed? 1st, Those which diminish general irritability, such as blood-letting, bathing, a relaxing regimen, &c. 2dly, Those which act locally, in diminishing the irritability of the muscles of the shoulder. For example: the application of emollient cataplasms or fomentations to the part; or, what is still better, a powerful extension, continued for some time. In consequence of such extension, the muscles of the part become fatigued, whence their contractions are succeeded by a state of atony, of which advantage may be taken to replace the bone. Frequently this extension ought to be continued for a very long time; and we have known Desault not to complete the reduction in less than half a day, or even a whole day, the limb being suffered to remain all that time in the apparatus for fractures of the clavicle, which draws the shoulder and muscles outwards. Thus, in fractures of the thigh, where muscular contraction prevents the contact of the fragments, permanent extension previously employed, assists in producing this contact.

§ IX.