Arm is being carried forward and upward toward second position.
Fig. 349
Completion of third movement in Kocher’s method.
This method of manipulation, with such modification as circumstances may require, or such addition as pressure with the hand or fingers of the assistant, has superseded all the older more crude and forceful methods, and proves sufficiently applicable for all cases. It is assumed that the operator has sufficient judgment to modify any method to fit the exigencies of a given case, else he should not proceed with it. For instance, in the axillary dislocations upward traction affords valuable assistance. In the subspinous form the arm is raised to a level while extension is made upward and forward. In other words, all these methods depend upon the combination of traction, rotation, and leverage. The old method of Astley Cooper, with the foot in the axilla, the shoe having been removed, coupled with traction upon the arm and swaying movements, combined with rotation, abduction, and adduction, may be made effective, but is not nearly as elegant as the simpler manipulation above described. On the other hand, old, unreduced dislocations, complicated with adhesions, are often exceedingly difficult.
In rare instances dislocations several months old have been reduced after adhesions have been broken up by more or less violent manipulations. When forcible efforts of this kind prove futile fair restoration of function may be obtained by maintaining regular motion, at first passive, later active, to prevent reformation of adhesions, the head of the bone gradually forming a new and false socket for itself. Finally, the method of excision can be employed should occasion demand. The experience of a number of surgeons has shown that in old cases, or those impossible of reduction by justifiable force, an open division of the joint, with severance of those tissues which prevent reduction, may be profitably, safely, and satisfactorily practised. Porter and McBurney, among the American surgeons, have devised a corkscrew instrument which may be driven into the head of the bone, by which manipulation after arthrotomy is materially facilitated.
The simultaneous occurrence of fracture and dislocation has been treated of in the previous chapter. When difficulty presents the best result will be obtained by open incision, replacement of the head of the humerus, and fixation of fragments by sutures, wire or otherwise. If seen late the upper fragment should be removed. The possibilities of aseptic surgery have led to the abandonment of the old method of first permitting the fracture to unite and then attempting to reduce dislocation.
Physiological rest is the essential feature of the after-treatment of all these cases, a sling and a retentive bandage being sufficient for the purpose. Function should be restored by an increasing degree of motion.
One of the most serious complications of shoulder dislocations is deltoid paralysis from injury to the circumflex nerve. The momentary pressure of the head of the bone upon the nerve is sufficient to more or less permanently impair its function. In its medicolegal aspect it should always be maintained that the surgeon is never to blame for the accident, and is only to some degree blamable in case he has failed to diagnose the dislocation so soon as opportunity was afforded and has thus permitted prolonged pressure to possibly intensify the effect which has already been produced by the injury.[42]