Chapter 17 - Surgical Diseases
Modern Surgery
Inflammation
Suppuration and Abscess
Mortification
Pyaemia
Ulceration and Ulcers
Boils
Carbuncle
Malignant Pustule
Burns and Scalds
Frost Bite
Chilblains
Mechanical,Injuries
Septic Wounds
Incised Wounds
Rules for Examining and Dressing Wounds
Antiseptic Dressings
Way Wounds Unite
Punctured Wounds
Lacerated Wounds
Granulation and Scarification
Gunshot Wounds
Poisoned Wounds
Fractures
Way Broken Bones Unite
Dislocations
Different Diseases of Bones
Pereostitis
Necrosis
Coxalgia
White Swelling
Bunions
Whitlow
Stiff Joint
Tumors
Cancer
Polypus
Piles
Wens
Aneurisms
Bronchocele
Water in the Scrotum
Blood in the Scrotum
Phlebitis
Varicose Veins
Hernia
Varicocele
Deformities and Irritations of the Spine
Wry Neck
Foreign Bodies in the Eye
Stye
Inflammation of the Edge of the Eyelids
Disorder of the Lashes
Ptosis
Chronic Inflammation of the Lachrymal Sac
Opthalmia
Inflammation of the Cornea
Inflammation of the Iris
Weakness of Sight
Imperfect Vision
Short and Long Sight
Squinting
Affections of the Ear
Inflammation of the Meatus
Wax in the Ear
Earache
Inflammation of the Tympanum, Deafness
Bleeding from the Nose
Ingrowing Toe Nail
Chafing and Excoriation
Foreign Substances
Bleeding from Wounds
Proud Flesh
Ambrine
Compression of Arteries to Stop the Flow of Blood
Anesthetics
Care of the Teeth
Rotting of the Teeth
Tooth-Ache
Filling Teeth
The First Teeth
Cleaning the Teeth
Ulcer of the Stomach
Glanders
X-Ray
Radium
Trachoma
Arterio-Sclerosis
Flatfoot
Riggs' Disease
Bandages

17.26 Dislocations

Dislocations. Luxations.

THE, surfaces where two bones meet and glide upon each other for the purposes of a joint, are called articular surfaces, and the union is said to be an articulation. These surfaces are covered by a smooth cartilage, to render their play upon each other easy.
The joints are held together by cartilaginous straps and ligaments, which serve as pulleys ; by the aid of these, the joints turn back and forth, as a door opens and shuts upon its hinges. When by some, external violence, or the weakening of these ligaments, these surfaces are suddenly separated, or forced apart, there is said to be dislocation or luxation.
Joints are divided into two kinds, the ball and socket (orbicular), which has a rotary motion, as the shoulder, hip, thumb, and the angular, or pump handle (ginglymoid), as the elbow and knee.
The ball and socket joints have a greater diversity of motion, and are more exposed to dislocation. They are likewise more easily put in their place.

In a Primary Dislocation, the bone is thrown at once into the place where the surgeon finds it.

The Secondary Dislocation is one in which the muscles pull the head of the bone still further from its natural place than it was thrown by the first shock of violence.

A Dislocation is Simple when there is no wound penetrating the synovial membrane.

It is Compound when attended by such a wound.

A Dislocation is Complete when the articular surfaces are entirely separated.

It is Incomplete when the separation is only partial.

Recent Dislocations are rectified with comparative ease.

Old Dislocations axe hard to be repaired, and sometimes cannot be reduced at all.

The Symptoms of Dislocation are, inability to use the joint; the head of the bone being felt in an unnatural place ; the limb shortened, lengthened, or distorted; a change in the shape of the joint etc.
Simple dislocations are generally trivial. Compound dislocations often render amputation necessary, and are always perilous.
Aged persons are less liable to dislocations than the young.
When a dislocation and a fracture occur at the same time, the dislocation is to receive attention first.
A dislocation is to be reduced by a gradual and continuous extending force. The reduction is known by the limb recovering its natural length, shape and direction, and by its being able to perform certain motions which are not possible while in a dislocated state. The pain is immediately reduced upon reduction taking place. In shoulder and hip dislocations, the head of the bone makes a loud noise when it slips into its place.

Dislocation of the Lower Jaw.

GAPING very wide is the usual cause of this. It has been known to result from a mere yawn. One or both sides may be disjointed.

Symptoms. If but one side is dislocated, the chin is twisted to one side, and immovable, and the jaws are partial y open; if both sides, the mouth is wide open, the chin projects, there is a hollow in front of each ear, great pain, inability to speak, and dribbling of spittle from the mouth.

Treatment. To effect a reduction, cover the thumbs with a towel or a piece of wash leather to prevent their being injured by a sudden snapping together of the jaws, and then, standing in front of the patient, introduce them into the mouth, press them upon the crown of the back lower teeth, at the same time lifting the chin with the fingers.
After the jaw is set, it should be kept bandaged for a few days, the bandage being merely passed once or twice over the top of the head, and under the chin. No solid food requiring chewing should be taken for a short time.

Dislocation of the Collar Bone.

This may take place by the end attached to the breastbone slipping over or under that bone, or by the other end slipping above or below the bone to which it is attached. When the first named end of the bone slips over the breast bone, it is said to be a forward dislocation; when it slips under the breast bone, it is backward. In this latter form of dislocation, the end of the collar bone sometimes presses upon the gullet, and prevents swallowing.

Symptoms. In the forward dislocation of the inner end of the bone, a bunch may be felt by the hand at. the top of the breast bone ; in the backward dislocation, a depression or hollow. The upward dislocation of the outer end of the collar bone may be known by the flattened and sunken condition of the shoulder.

Treatment. To put the bone in its place in the first of these accidents, draw the shoulders back, by which means the collar bone (clavicle) is drawn away from the breastbone (sternum), and easily slips into its place. To reduce the dislocation at the other end of the bone, place the knee between the patient's shoulder blades (scapula), and draw his shoulders backwards and upwards. After the reduction, support the arm in a sling.

Dislocation of the Shoulder Joint.

THE head of the long bone of the arm (humerus) may be displaced in three different directions, downward, into the arm pit (axilla) ; forward, under the muscles of the breast; and backward, upon the back of the shoulder blade.
It is recognized by the shoulder losing its roundness, and becoming flat; by the lengthening of the arm; by the head of the bone being felt in the arm pit; and by severe pain.
To effect the reduction in the first form of displacement, put the patient on a bed, or upon the floor. Put one heel in the arm pit, against the bead of the bone. Then, taking hold of the arm above the elbow, or at the wrist, pull steadily, and push with the heel. (Fig. 166.) The extension may be more steady and powerful by a double towel around the surgeon's neck.

If the reduction cannot be effected, relax the muscles by a warm bath or by etherization.
A simpler method often succeeds and is the only one required in certain forms of shoulder dislocation. Bend the elbow at right angles and place it at the side of the body. Next rotate the fore arm outward as far as possible; then carry the elbow, still flexed, inward and upward onto the chest, and then allow the elbow to fall. The head of the humerus often slips into place with the greatest of ease.
After the reduction, a sling will be required, and three weeks' or a months rest,

Dislocations of the Elbow Joint.

OF these there are six varieties. In the first, both bones of the fore arm (radius and ulna) are thrown backwards ; in the second, both are drawn backwards and inwards; in the third, both are thrown backwards and outwards; in the fourth, the ulna alone is forced backwards; in the fifth, the radius is forced forwards; and in the sixth, the radius is thrown backwards.
In general, these dislocations are all easily set. In the first four, the knee is to be placed at the bend of the elbow, and the fore arm bent upon it, the surgeon grasping the upper arm with one hand, and the, fore arm with the other. In the dislocations of the radius, the upper arm is to be put in a fixed condition, while the surgeon takes hold of the hand and pulls, at the same time throwing the bone forward. If the luxation be backwards, there must be the same extension and counter extension, while the fore arm is bent.

Treatment. The fore arm must be placed in a half bent position, and a splint should be bandaged upon the front of the whole limb, compresses being placed upon the head of the bones opposite the direction of the dislocation. This confinement must be continued three weeks.

Dislocations of the Wrist.

THESE, are caused by falls upon the hand. Both the radius and ulna may be thrown backwards or forwards upon the wrist, causing a projection either in front or behind. (Fig. 167.) The bones are to be set by pulling in opposite directions upon the hand and the forearm, and pressing laterally, if the displacement be at the side of the wrist.

Treatment. Put a straight splint on the front, and another on the back of the forearm and band, with compresses on both sides of the wrist, and a bandage over the whole. Support the forearm in a sling, and keep down inflammation by cold water, cooling lotions, etc.

Dislocations of the Bones of the Hand.

Some one of the carpal bones may be pushed up out of its place so as to form a projection on the back of the hand. To put it in its place, press upon it simply, and then put compresses on the front and back, with straight splints upon these and a bandage over all. Put the hand in a sling.
Dislocations of the finger joints may generally be replaced by bending the displaced phalanx over the head of the bone from which it has been disjoined. Sometimes a good deal of extension and counter extension are required, for which purpose a piece of cord may be wound around the finger, the skin being protected by covering it with a piece of wetted buck skin.

Dislocations of the Hip Joint.
THESE, are four in number, upwards, downwards, backwards and upwards, forwards and upwards.
To reduce these, a greater amount of power is needed than in the dislocations of any other bone, owing to the greater power of the muscles which are to be overcome.

Dislocations of this joint are often confounded with fracture of the head and neck of the thigh bone. This latter may be distinguished from the luxation by the grating sound to be heard, by the possibility of pulling the limb out to its natural length, and by its being shortened up again by the action of the muscles the moment the pulling is given up.

The Upward Dislocation of the head of this bone upon the back of the haunch bone is known by the shortening of the limb, and by the knee and foot turning inward, the foot lapping over the opposite foot, and t he great toe resting upon the other instep. (Fig. 168.)

The Dislocation Downward is known by the lengthening of the limb, the projection of the knee, the turning of the foot and knee out ward, and the bending of the body forward. (Fig. 169.)

The Dislocation Backward and Upward is distinguished by the inclining of the foot and knee inward, the drawing up of the heel, and the resting of the great toe against the ball of the great toe of the other foot. (Fig. 170.)

The Dislocation Upward and Forward is known by the shortening of the limb, and the turning of the foot and knee outward. (Fig.171.)
For replacing the bone, put the patient upon a table, on his back. Draw a sheet between his thighs, and extending it up by the side of his body, let it be fastened to a staple.

Put a padded belt, with rings attached, around the injured limb, just above the knee. To these rings, fasten one block of a pulley, and attach the other to a post, giving the pulley rope to an assistant. The surgeon now, Standing on the injured side, directs gradual extension to be made, while he, by, his hands, or by a band passing around the injured thigh and over his own shoulders, lifts the head of the bone, and guides it into its socket. Etherization is not infrequently required.

Treatment. Keep the patient in bed for two weeks or more, with his knees tied together by a strip of muslin, and a broad belt around his hips.

Dislocations of the Knee Pan or Patella.
This bone may be thrown outward, causing a great projection on the outside, and an inability to bend the knee.
It may be thrown inward, causing the same impossibility to bend the knee, and a projection on the inside.
To restore the bone to its place, put the heel of the patient upon the shoulder of an assistant; then press down the edge of the kneepan which is farthest from the centre of the joint, thus tilting up the other edge of the bone, when the muscles, aided by a lateral pressure, will draw it to its place.
Treatment. Put a straight splint upon the back of the limb, and make moderate pressure upon the knee by a bandage. Cold water, or cooling washes, should generally be applied. Keep the patient in be(I two weeks.

Dislocations of the Knee Joint.
THERE, are four of these, forward, backward, inward and outward. They are readily corrected by extension and counter extension from the ankle and thigh, and pressure upon the head of the displaced bone.
Treatment much the same as for displacement of the knee pan.



Dislocations of the Ankle.
THESE may occur in a forward, backward, outward, and inward direction. (Figs. 172 andl73.)
To rectify it, bend the limb, so as to relax the muscles on the back of the leg; then, while extension and counter extension are made upon the foot and thigh, press firmly on the dislocated bone, and thus force it to its place.

Treatment. Confine the foot and leg in splints made of thick pasteboard, soaked in hot water and molded to the shape of the limb, with a foot piece at right angles. Keep the patient in bed five or six weeks, and when he begins to walk, support the ankle with a roller bandage, or a laced gaiter.

Contusions. Bruises.

WHEN any blunt, hard substance comes in violent collision with the soft parts of the body, without breaking the skin, the injury received is called a bruise. One of these accidents generally ruptures a great number of the very smallest blood vessels, which let out blood under the skin, producing , black and blue," or livid spots (eechymosis). What fist fighters call a black eye is an example.

Treatment. Cold applications at first to prevent the blood running out of the small vessels under the skin. After the inflammation has subsided, stimulating applications, as vinegar and water, alcohol camphorated liniment, ammonia and alcohol, equal parts, and sometimes bandages.

Sprains.

A sprain is a forcible wrenching and twisting of a joint to such a degree as to stretch and more or less lacerate the ligaments of the part, and sometimes to break a tendon, but without entirely displacing a bone. Its symptoms are, violent pain, swelling, and discoloration of the parts from the blood running into the cells under the skin. In elderly persons, the effects of sprains are very tedious, disabling them for many weeks, or even months.

Treatment. Elevate the limb, keep the joint perfectly quiet, and apply cold lotions or fomentations. When the inflammation is all past, apply stimulating liniments, and bandages, or shower the part with cold water.
When first done, put the part, if possible, into as hot water as can be borne and maintain it there for half an hour, then strap the part moderately tight with plaster. An ice bag applied over a joint when the hot water cannot be obtained, or is inapplicable, is nearly as efficacious.

Ruptures of Tendons.

THESE, accidents are known by a sudden snap, followed by pain, loss of motion in the part, and swelling and discoloration.

Treatment. Place the part in such a position as to relax the broken tendon, the ends of which must be brought together, and retained in contact till they grow together. They are to be sewn aseptically and the wound treated like any closed wound.

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