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

by P.-J. Desault

Here genius seems to have been as prodigal of resources, as nature has been of obstacles. Indeed, to accomplish the reduction, we sometimes see the surgeon placing his elbow in the fold of the affected arm, interlocking his fingers with those of the same limb, and, then, bending with his whole force, both his own fore-arm, and that of the patient, to effect at the same time extension, counter-extension, and reduction or conformation: at another time we see him fixing the fold of the injured arm against some resisting body, such as a bed-post; and while an assistant, then, pushes the displaced olecranon against this body, he himself, pressing on the shoulder with one hand, and grasping the fore-arm with the other, bends it forcibly, in order, by that means, to produce a replacement: again, a body of some size, being placed in the fold of the arm, serves as a fulcrum, on which the fore-arm, being suddenly flexed, moves and acts like a lever of the first kind, of which the power, being applied at the extremity next the hand, draws it backward and upward, and by that means pushes in a contrary direction its luxated end, where the resistance is made. On some occasions, the fore-arm of the diseased side, bent at a right angle, is placed on a horizontal table, and, while the lower extremity of the humerus is thus resting on the table, the surgeon pushes it backward with one hand, and with the other, taking hold of the extremity of the fore-arm, draws it in a contrary direction.

18. The ancients employed the three first modes. Pare has had engravings of them made: Scultel has also given figures of them as practised by Hippocrates. The Arabians knew of no other modes, nor did their descendants, who were only compilers from them. The practitioners of our own day still continue their use. But, in general, they are chargeable with the numerous inconveniences and faults of producing intense pain, of not being completely under the direction of the surgeon, of bringing the point of luxation too near to the place on which counter-extension is made, and of bruising and doing violence to the parts: nor do they disengage, by means of previous extension, the luxated ends of the bones, to facilitate their replacement in their natural situations.

This last charge is not applicable to the last of the processes proposed by Petit. But, here, the extending forces are most commonly insufficient; the surgeon, having both his hands engaged, is not able to act on the joint to assist in the replacement: and the counter-extension made is too near to the point of luxation.

19. In common cases, Desault employed a method as simple and more efficacious, which few writers have recommended, and none have described with accuracy.

The patient is, indifferently, either seated or standing. The fore-arm being half-bent, an assistant takes hold of the extremity next the hand, to make extension; another, to make counter-extension, takes hold of the humerus a little below its middle, with both hands, the fingers crossing before, and the thumbs behind. The extension is made gradually, and when it begins to move the olecranon, and draw it from the place it accidentally occupies, the surgeon, to aid in the reduction, grasps the lower end of the humerus with both hands, crosses his fingers in the fold of the arm, applies his thumbs to the olecranon, and drawing the first backward, pushes at the same time the latter forward; thus, he favours, on the one hand extension, and on the other counter-extension, and in that way finishes the reduction.

20. This method is most commonly practised with success, in recent luxations, where we have oftentimes seen the reduction effected at the Hotel-Dieu, by the simple process of pushing, as just mentioned, the olecranon forward, the humerus being held backward, without any previous extension, while the fore-arm was merely supported by the assistants.

21. But the luxation being oftentimes of long standing, presents very great difficulties. What means must then be employed? It is an established principle, that the force with which a power acts, is in direct proportion to its distance from the point of resistance. Augment this distance, and the extending forces, being doubled and even trebled, will more easily dislodge the luxated extremity. But this indication is fulfilled, by two long straps, formed each of a towel folded several times, one of which is fixed above the wrist, and the other round the humerus a little below its middle. Extension is then made at their extremities, and is almost always sufficient, when aided by skilful efforts of the surgeon (19), to accomplish the reduction. The application of a strap round the humerus is never necessary, unless when the resistance is very great; because, in counter-extension, it is requisite only to withstand or bear against the efforts of extension, but not to act in a contrary direction.

22. But in cases of this kind, the strap, placed, as we have directed, round the lower part of the humerus, has sometimes the disadvantage of compressing too much the brachialis and the biceps muscles, and thus preventing them from acting; this inconvenience is particularly felt in old luxations, where great force is employed; for, the more active then the contraction of these muscles is, the more it will aid the surgeon in his efforts to draw the bones into their natural situation, when once disengaged by extension, from that which they had accidentally occupied. If, in such a case, we impede the contraction of these muscles, how can they fulfil this office?

23. It was this which, in certain cases, induced Desault to place his counter-extension under the armpit, by means of a strap passing, as in the luxation of the humerus, over a ball previously fixed in this hollow, and crossing, not on the top of the opposite shoulder, but behind that of the diseased side. By this contrivance the humerus was drawn or rather held back, by a force acting perfectly in the line of its direction. But is not this force situated too near to the centre of motion? The strap for making extension, fastened at the wrist, answers very well, as has been already mentioned (21).