Part 10

10. A protuberance over the superior edge of the sternum, a difficulty in raising the shoulder, the pain which results from attempting such a motion, the diminution of the protuberance which it occasions, the absence of the sternal extremity from its natural cavity, the approximation of the shoulder to the thorax, and its depression and diminished projection, compared to its usual state, afford evidence of a luxation upwards.

11. A luxation inward or backward, would be characterized by a projection of the shoulder exteriorly, by a difficulty in performing motions in a backward direction, by the alarming effects, which, as Petit remarks, the compression of the trachea would doubtless produce, and by a depression or hollow at the joint, more perceptible here than in the two preceding cases.

12. These appearances will be more or less striking, accordingly as the membranes, lacerated or only distended, offer a greater or less resistance.

§ IV.

OF THE REDUCTION.

13. To reduce a luxation, is, in general, to make the bone re-enter its cavity, by retracing, or returning along, the same route which it followed in escaping from it. Now, in a forward luxation, the displacement is from behind forward, in an upward one from below upward, in an inward or backward one from before backward, but, in each of the three, it is more particularly from without inward. In the first case, therefore it is backward, in the second, forward, in the third downward, but, in each of the three, more particularly outward, that the powers for producing extension must be directed.

14. Hence the method generally employed by most practitioners, recommended by almost every author who has written on the subject, adopted by Petit, Duverney, Heister, &c. and which consists in placing the knee between the shoulders of the patient, as a point of resistance, by the aid of which the shoulders may be drawn backward, fulfils only half of the indication of cure; because at the time that the humeral extremity is drawn backward, it is not directed sufficiently outward.

Hence a difficulty of replacing the bone sometimes occurs, a difficulty always removed, when, pursuant to the method employed by Desault in fractures of the clavicle (see Desault’s method), the arm is made to serve as a lever of the first kind, to carry backward and outward, the head of the bone, which is displaced in the opposite directions, when the luxation is forward. This method possesses the advantage, not only of giving the powers of extension a proper direction, but also of increasing them to a degree even beyond what is necessary for effecting a reduction, by removing them further from the resisting force. Hence it is unnecessary to adopt any particular measures for restoring and preserving the form of the part, as the extension is alone sufficient for that purpose.

These principles, evidently applicable in effecting a reduction, are still more strikingly so in the means destined for retaining it. Let us apply what I have just said, to a case of dislocation in a forward direction. It will be easy to transfer it afterwards to the other kinds of luxation.

§ V.

OF THE MEANS OF RETAINING A REDUCTION.

15. Few luxations are so speedily reduced, but few are more easily displaced again, than that of the clavicle. This disposition is the reverse of that of most other luxations, which are reduced indeed with difficulty, but seldom afterwards suffer a displacement. The cause of this we find, 1st, in the extreme mobility of the clavicle, to which all the motions of the arm are communicated; 2dly, in this further consideration, that most of the muscles, which have their insertion towards the shoulder, tend to draw this bone inward, when the ligaments, in consequence of being either broken or distended, as happens in this accident, do not offer a sufficient resistance.

16. From this two-fold cause of displacement, arises a two-fold indication in the arrangement and application of the apparatus. These are, 1st, to render the clavicle immoveable, by restraining every kind of motion in the shoulder and arm; 2dly, to retain the extremity of the clavicle outward, a direction opposed to that in which it has a tendency to be displaced. But if to those indications we compare the forms of apparatus hitherto used, we will readily perceive that they are insufficient to fulfil them.

17. The figure of 8 bandage, so generally in use, and all the various modifications, under which it has been revived, without being improved, fix the clavicle in the very direction most favourable to a displacement, and even do it in the very manner in which that accident is sometimes brought about; as maybe seen in the history of the case of the porter (6). This bandage does not, under any of its modifications, prevent the motions of the shoulder, because it does not restrain those of the arm, which remains free and unencumbered. Far from constituting an antagonist power to, it even co-operates with, that which has produced the displacement. (For further light on this subject, see what has been already said on the fracture of the clavicle, pages 22 and 25.)

Bell, in condemning the figure of 8 bandage, not so much because of its action being insufficient, as because of its obstructing respiration, proposes, as a substitute for it, a kind of machine analogous to the iron cross of Heister, which, being fixed by straps passing under the arm-pit, and round the neck and body, is intended to retain the parts firm and immoveable. But the motions of the arm not being restrained, nor the action of the muscles of the shoulder opposed by an antagonizing power, places this piece of apparatus in the same class with those, which, from not being devised and constructed on a proper view and conception of the causes of displacement, have no affinity to rational practice.

18. The apparatus for a continued extension, invented by Desault, for fractures of the clavicle, fulfil here all those indications in which the others fail.

By this, 1st. The aim, being firmly fixed against the side, by means of the roller (c c Fig. 3), can communicate no motion either to the shoulder, or the clavicle. 2dly. The shoulder itself, being forcibly drawn outward, with the upper extremity of the humerus, by the action of the kind of lever into which this bone is converted, and to which the bolster (a b Fig. 1) serves as a fulcrum, cannot, by its movements, derange the luxated bone. 3dly. The sternal extremity, being drawn both by the muscles which tend to displace it inwardly, and by the bandage which acts on it in an opposite direction, remains fixed between those two antagonizing forces, which thus destroy each other. Hence the apparatus of Desault, when accurately applied, offers to both of these powers of displacement, a resistance perfectly calculated to combat them.

20. We must, however, admit that this apparatus partakes of one inconvenience, common indeed to all bandages, but which is perhaps more particularly applicable to this in consequence of the numerous casts of the rollers that form it, namely, the great facility with which it becomes relaxed. Hence one cause of displacement, which the most exact and scrupulous attention cannot at all times prevent.

CASE. Desault had, for a long time, the care of a patient, whose luxation, having been neglected for four days, was reduced on the fifth, by a surgeon, who, for the purpose of retaining it, employed a bandage of a particular kind. An hour afterwards, a motion of the shoulder backward, displaced the luxated extremity: a new reduction was the consequence; on the day following, another displacement, and so on in succession, for ten days, at the expiration of which, Desault being consulted, applied to the part the bandage formerly described.

On being examined the next day, the apparatus was found in a favourable state. On the day following, a slight displacement rendered necessary a new application of the bandage, which, this time, continued longer than before. But, about the expiration of the third day, the projection of the bone was again considerable. Finally, the patient recovered, with a very perceptible protuberance in front of the sternum, and a difficulty of motion, great at first, but less afterwards, and which exercise succeeded ultimately in removing.

21. The application of the apparatus differs from that intended for a fracture of the clavicle, only in this, that it is of service to place on the luxated extremity, graduated compresses, calculated to make pressure backward and outward, and which are to be secured by the turns of the roller (b Fig. 4).

Compresses laid one upon another, of which the upper one is still the smallest, not in relation to thickness, but as far as regards length and breadth. TRANS.

A second precaution, not less essential, is, to push the humeral extremity of the clavicle, a little forward, and fix it in that direction, in order that the sternal being directed backward, may be removed from the place through which it has a tendency to escape.

The rupture in the capsule that surrounds the joint. T.

22. Desault almost always obtained complete success by this process, and by the most accurate attention to prevent the relaxation of the bandage. In the mean time, a stiffness, more or less considerable, always remains in the joint for a long time after the reduction, and it is not unfrequently a month or two before the part recovers its usual facility of motion.

The following cases, collected by Brochier, confirm the doctrine for which I have been contending.

CASE II. A man luxated the clavicle by falling on the point of his shoulder, and forcing it backward. He was immediately brought to the Hotel-Dieu, where Desault demonstrated to his pupils, that the head of the bone, carried in front of the sternum, was removed nearly an inch from its natural cavity, the ligaments of which were no doubt lacerated.

Here, as in the fracture of the clavicle, the application of the bandage answered the purpose of reduction, and removed the protuberance formed by the extremity of the bone.