The Home Medical Library Volume I Part 9

=DISLOCATIONS; BONES OUT OF JOINT.=

=JAW.=--Rare. Mouth remains open, lower teeth advanced forward.

_First Aid Rule 1.--Protect your thumbs. Put on thick leather gloves, or bind them with thick bandage._

_Rule 2.--a.s.sistant steadies patient from behind, with hands both sides of his head, operator presses downward and backward with his thumbs on back teeth of patient, each side of patient's jaw, while the chin is grasped between forefingers and raised upward. Idea is to stretch the ligament at jaw joint, and swing jaw back while pulling on this ligament. (Fig. 29.)_

_Rule 3.--Tie jaw with four-tailed bandage up against upper jaw for a week. (Fig. 12, p. 90.)_

=SHOULDER.=--Common accident. No hurry. See p. 122.

=ELBOW.=--Rare. No hurry. See p. 125.

=HIP.=--No hurry. See p. 129.

=KNEE.=--Rare. Easily reduced. Head of lower bone (tibia) is moved to one side; knee slightly bent.

_First Aid Rule 1.--Put patient on back._

_Rule 2.--Flex thigh on abdomen and hold it there._

_Rule 3.--Grasp leg below knee and twist it back and forth, and straighten knee._

=DISLOCATIONS.=--A dislocation is an injury to a joint wherein the ends of the bones forming a joint are forced out of place. A dislocation is commonly described as a condition in which a part (as the shoulder) is "out of joint" or "out of place." A dislocation must be distinguished from a sprain, and from a fracture near a joint. In a sprain, as has been stated (p. 65), the bones entering into the formation of the joint are perhaps momentarily displaced, but return into their proper place when the violence is removed. But, owing to greater injury, in dislocation the head of the bone slips out of the socket which should hold it, breaks through the ligaments surrounding the joint, and remains permanently out of place. For this reason there is a peculiar deformity, produced by the head of the bone's lying in its new and unnatural situation, which is not seen in a sprain.

Also, the dislocated joint cannot be moved by the patient or by another person, except within narrow limits, while a sprained joint can be moved, with the production of pain it is true, but without any mechanical obstacle. In the case of fracture near a joint there is usually increased movement in some new direction. When a dislocated joint is put in proper place it stays in place, whereas when a fractured part is reduced there is nothing to keep it in place and, if let alone, it quickly resumes its former faulty position.

Only a few of the commoner dislocations will be considered here, as the others are of rare occurrence and require more skill than can be imparted in a book intended for the laity. The following instructions are not to be followed if skilled surgical attendance can be secured; they are intended solely for those not so fortunately situated.

=DISLOCATION OF THE JAW.=--This condition is caused by a blow on the chin, or occurs in gaping or when the mouth is kept widely open during prolonged dental operations. The joint surface at the upper part of the lower jaw, just in front of the entrance to the ear, is thrown out of its socket on one side of the face, or on both sides. If the jaw is put out of place on both sides at once, the chin will be found projecting so that lower front teeth jut out beyond the upper front teeth, the mouth is open and cannot be closed, and the patient is suffering considerable pain. When the jaw is dislocated on one side only, the chin is pushed over toward the uninjured side of the face, which gives the face a twisted appearance; the mouth is partly open and fixed in that position. A depression is seen on the injured side in front of the ear, while a corresponding prominence exists on the opposite side of the face, and the lower front teeth project beyond the upper front teeth.

[Ill.u.s.tration: FIG. 29.

REDUCING DISLOCATION OF JAW (AMERICAN TEXT-BOOK).

Thumbs placed upon last molar teeth on each side; note jaw grasped between fingers and thumbs to force it into place.]

=Treatment.=--A dislocation of one side of the jaw is treated in the same manner as that of both sides.

The dislocation may sometimes be reduced by placing a good-sized cork as far back as possible between the back teeth of the upper and lower jaws (on one or both sides, according as the jaw is out of place on one or both sides), and getting the patient to bite down on the cork.

This may pry the jaw back into place.

The common method is for the operator to protect both thumbs by wrapping bandage about his thumbs, or wearing leather gloves, and then, while an a.s.sistant steadies the head, the operator presses downward and backward on the back teeth of the patient on each side of the lower jaw with both thumbs in the patient's mouth, while the chin is grasped beneath by the forefingers of each hand and raised upward.

When the jaw slips into place it should be maintained there by a bandage placed around the head under the chin and retained there for a week. During this time the patient should be fed on liquids through a tube, so that it will not be necessary for him to open his mouth to any extent. (See Fig. 29.)

=DISLOCATION OF THE SHOULDER.=--This is by far the most common of dislocations in adults, const.i.tuting over one-half of all such accidents affecting any of the joints. It is caused by a fall or blow on the upper arm or shoulder, or by falling upon the elbow or outstretched hand. The upper part (or head) of the bone of the arm (humerus) slips downward out of the socket or, in some cases, inward and forward. In either case the general appearance and treatment of the accident are much the same. The shoulder of the injured side loses its fullness and looks flatter in front and on the side. The arm is held with the elbow a few inches away from the side, and the line of the arm is seen to slope inwardly toward the shoulder, as compared with the sound arm.

The injured arm cannot be moved much by the patient, although it can be lifted up and away from the side by another person, but cannot be moved so that, with the elbow against the front of the chest, the hand of the injured arm can be laid on the opposite shoulder. Neither can the arm, with the elbow at a right angle, be made to touch the side with the elbow, without causing great pain.

=Treatment.=--One of the simplest methods (Stimson's) of reducing this dislocation consists in placing the patient on his injured side on a canvas cot, which should be raised high enough from the floor on chairs, and allowing the injured arm to hang directly downward toward the floor through a hole cut in the cot, the hand not touching the floor. Then a ten-pound weight is attached to the wrist. The gradual pull produced by this means generally brings the shoulder back into place without pain and within six minutes. (Fig. 30.)

[Ill.u.s.tration: FIG. 30.

TREATING A DISLOCATED SHOULDER.

(REFERENCE HANDBOOK.)

Patient lying on injured side; note arm hanging through hole in cot raised from floor on chairs; also weight attached to wrist.]

The more ordinary method consists in putting the patient on his back on the floor, the operator also sitting on the floor with his stockinged foot against the patient's side under the armpit of the injured shoulder and grasping the injured arm at the elbow, he pulls the arm directly outward (i. e., with the arm at right angles with the body) and away from the trunk. An a.s.sistant may at the same time aid by lifting the head of the arm bone upward with his fingers in the patient's armpit and his thumbs over the injured shoulder.

If the arm does not go into place easily by one of these methods it is unwise to continue making further attempts. Also if the shoulder has been dislocated several days, or if the patient is very muscular, it will generally be necessary that a surgeon give ether in order to reduce the dislocation. It is entirely possible for a skillful surgeon to secure reduction of a dislocation of the shoulder several weeks after its occurrence. After the dislocation has been relieved the arm, above the elbow, should be bandaged to the side of the chest and the hand of the injured side carried in a sling for ten days.

=DISLOCATION OF THE ELBOW.=--This is more frequent in children, and is usually produced by a fall on the outstretched hand. The elbow is thrown out of joint, so that the forearm is displaced backward on the arm, in the more usual form of dislocation. The elbow joint is swollen and generally held slightly bent, but cannot be moved to any extent without great pain. The tip of the elbow projects at the back of the joint more than usual, while at the front of the arm the distance between the wrist and the bend of the elbow is less than that of the sound arm. (See cut, p. 126.)

[Ill.u.s.tration: FIG. 31.

Above cut shows characteristic appearance of a dislocated shoulder; note loss of fullness; also elbow held away from side and inward sloping of arm.

FIG. 32.

DISLOCATED ELBOW AND SHOULDER.

(AMERICAN TEXT-BOOK.)

Fig. 32 shows dislocation of elbow backward; note swollen condition of left elbow held slightly bent; also the projection of back of joint.]

For further proof that the elbow is out of joint we must compare the relations of three points in each elbow. These are the two bony prominences on each side of the joint (belonging to the bone of the arm above the elbow) and the bony prominence that forms the tip of the elbow which belongs to the bone of the forearm.

[Ill.u.s.tration: FIG. 33.

TREATMENT OF DISLOCATED ELBOW (SCUDDER).

Note padded right-angled tin splint; also three strips of surgeon's plaster on arm and forearm.]

In dislocation backward of the forearm, the tip of the elbow is observed to be farther back, in relation to the two bony prominences at the side of the joint, than is the case in the sound elbow. This is best ascertained by touching the three points on the patient's elbow of each arm in turn with the thumb and middle finger on each of the prominences on the side of the joint, while the forefinger is placed on the tip of the elbow. The lower end of the bone of the upper arm is often seen and felt very easily just above the bend of the elbow in front, as it is thrown forward (see Fig. 32, p. 126).

Fracture of the lower part of the bone of the arm above the elbow joint may present much the same appearance as the dislocation we are describing, but then the whole elbow is displaced backward, and the relation of the three points described above is the same in the injured as in the uninjured arm. Moreover in fracture the deformity, when relieved, will immediately recur when the arm is released, as there is nothing to hold the bones in place; but in dislocation, after the bones are replaced in their normal position, the deformity will not reappear.