The principles and practice of modern surgery

by Roswell Park

TREATMENT OF DISLOCATIONS.

The essential requisite of every case is complete reduction or replacement of the dislocated bone end. The earlier this is attempted the better the result. Brief as such a statement is, dislocations frequently offer considerable difficulties, both in reduction and in maintenance in proper position with the necessary physiological rest of the injured part. Thus dislocations of the clavicle, which can hardly occur without considerable injury to the ligaments, may be reduced with slight effort, but are kept in place with difficulty. The simplicity of the after-treatment is proportionate to the difficulty experienced in reduction, so that while “to put the part in place and keep it there” sounds very simple, it will often perplex the ingenuity of the surgeon.

Reduction having been effected, rest is the essential feature of the after-treatment, which should be absolute for a few weeks and relative for many months. Should reaction be extreme, ice-cold applications will afford relief.

The causes which prevent reduction of dislocation are either those attributable to ignorance, carelessness, or failure in diagnosis on one hand, or, on the other, mechanical difficulties, including “button-holing” of the capsule around the expanded end of a bone or the interposition of some of the adjoining tissues. Dislocations of the class referred to above as unreduced or ancient, offer great difficulties, proportionate to their duration, which are due to the formation of adhesions that sometimes take place and become very dense. Judgment, skill, and effort are needed in their management. A dislocation which has become unreducible is only to be treated by arthrectomy and the establishment of a false joint. Nevertheless in a small proportion of cases, especially of the hip and shoulder dislocations, the adhesions which first form gradually relax, and in time there is formed a natural substitute for a joint which may be regarded as a nearthrosis, and which will sometimes prove as serviceable as any result afforded by arthrectomy. The duration of time after which reduction is impossible or impracticable varies so widely with different cases that it can scarcely be stated. It rarely is more than a few months and often but a few weeks. It is greater when it is a ball-and-socket joint which is affected.

Nearly everything that has been stated in the previous chapter concerning compound fractures applies here to compound dislocations. They are subject to the same dangers, both of infection and of injury to important adjoining structures. There is the same necessity for aseptic management if the case be seen early, and for antiseptic treatment, including drainage, if seen late. In many instances there is so much liability to subsequent ankylosis that the first treatment may well be made to include an arthrectomy, or the total removal of a small bone, e. g., the astragalus. Fortunately compound features are less frequent in dislocations than in fractures.

SPECIAL DISLOCATIONS.

DISLOCATIONS OF THE LOWER JAW.

Unless accompanied by fracture there is but one direction in which the condyle of the inferior maxilla can be dislocated, i. e., forward. One side or both may be affected, i. e., dislocation may be unilateral or bilateral, the latter being more frequent. It is rare during the extremes of age, and most common during middle life. There is considerable variation in the degree of tension of the capsule of the maxillary joint. In some it is so loose that dislocation may occur during the act of yawning or vomiting. Ordinarily it occurs only as an expression of violence from without. By a blow which shall thrust the jaw forward, whether the mouth be closed or open, the ramus may be made to carry the condyle over the articular eminence. The capsule is not necessarily torn, but is always tightly stretched, while as a reflex result the temporal muscle is thrown into a condition of tonic spasm by which the jaw is fixed and firmly held in its abnormal position. This produces the symptoms, then, of a more or less widely opened mouth, with rigidity and inability to close it, with protrusion of the chin and tense contraction of the temporal muscle, which can be easily recognized. When the dislocation is unilateral the symptoms are essentially the same, save that the protrusion is toward the side that is injured.

Treatment.

—The method of reduction is simple and consists in depressing the angle of the jaw, while, at the same time, the chin is supported and carried both upward and backward. If temporal spasm be not too pronounced the reduction is rather easy and may be effected while the patient is seated in a chair, the surgeon standing in front of him and grasping the jaw with the fingers of each hand, while the thumb is utilized within the mouth to press the angle of the jaw downward and backward. At the same time the fingers should lift the chin. The operator should protect his thumbs by wrapping them with some material in order that they may not be injured by the patient’s teeth. Should muscle spasm offer much resistance it would be well to administer nitrous oxide or one of the other anesthetics, at least to the point of primary anesthesia, with sufficient relaxation of muscle to make reduction easy. When once this has been effected the lower jaw should be bound to the upper and kept at rest for at least two weeks. When this injury has taken place it is likely to recur with much less effort until it becomes almost a habit.