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place, he slowly and steadily moves the wrist outward with his left hand (external rotation of the humerus), and stops when the resistance becomes considerable. The evidence that the movement has accomplished what was expected of it is the appearance of greater fulness of the outer deltoid

FIG. 61.

Kocher's method of reduction; 3d movement, inward rotation and lowering of elbow. (CEPPI.)

region. If the resistance begins promptly, before the fulness has appeared, the pressure should be steadily maintained for a few moments. Then, still maintaining the external rotation of the arm and the flexion of the elbow, the surgeon moves the elbow forward, or forward and slightly inward, until the arm is horizontal; during this movement the fulness of the outer deltoid region becomes more marked, and at its termination the manoeuvre is completed by rotating the arm inward and bringing the hand to the opposite shoulder. The bone may slip into place during the second movement, elevation of the elbow.

The method as thus described is applicable to those cases in which the displacement is neither very far inward nor low down, in short, to the medium forms of the subcoracoid variety; and as it depends for its success upon the resistance of the untorn portion of the capsule it will also fail whenever the capsule is very extensively torn. It has sometimes been applied with success to the more marked inward dislocations by exaggerating the outward rotation and maintaining it for about a minute before beginning to elevate the elbow; during this period of waiting it is said a peculiar crackling is heard, produced by the outward movement of the head of the humerus. I have heard the same crackling during both outward rotation and elevation in cases of less displacement and have attributed it to progressive laceration of the capsule. Kocher himself modifies the manoeuvre in these inward cases by placing the elbow not simply against the side of the body in the axillary line, but as far backward and inward as possible, or he steadies the head of the humerus and draws it outward by a bandage passed under the axilla.

König modifies it for the lower anterior and subglenoid dislocations by making traction in abduction, rotating outward, and then adducting. This is practically the same as the method described as traction downward and outward and generally known as Lacour's method by manipulation. Farabeuf studied Kocher's method experimentally with a view to determine the mechanism by which its result was accomplished, and

König: Speciel. Chirurgie, 3d ed., vol. iii. p. 40.
2 Farabeuf: Bull. de la Soc. de la Chir., 1885, p. 395.

reached the conclusion that the efficient agent was the untorn posterior portion of the capsule, and that the upper portion, the coraco-humeral ligament, had little or nothing to do with it. He showed, experimentally, that when this latter had been divided and the posterior portion left intact the manœuvre would still effect reduction, but that when the posterior portion was divided and the upper portion left whole it failed, and that then the head of the humerus instead of being moved outward by the external rotation simply revolved about the longitudinal axis of the shaft. His explanation is clear and intelligible. According to it the approximation of the elbow to the side tightens the posterior portion of the capsule where it extends between the posterior lip of the glenoid fossa and the under and back part of the neck of the humerus; this prevents the posterior surface of the humerus from moving inward when the arm is rotated outward, and consequently its attachment to the humerus serves as the fixed point or centre about which the bone rolls outward, winding itself, as it were, upon the capsule. The elevation and adduction of the elbow, turning upon the same fixed point, then throws the head backward and further outward, and finally the internal rotation unwinds the capsule and leaves everything in place.

When Prof. Kocher first made his method known he thought it would be useful only in recent cases, but he has since ascertained that it can be successfully used in those that have remained unreduced for three or four months. Ceppi's paper contains the notes of twenty cases in which reduction was effected by this means after a lapse of from three weeks to four months. Twelve of them were Kocher's; in one the dislocation was three weeks old, in two five weeks, in three seven weeks, in four three months, and in two four months. He failed in only one case, a dislocation of eight weeks' standing in a woman seventy years of age; the humerus broke below its middle during the attempt. With such a record in its favor the method should certainly receive a trial before resort is had to the more dangerous methods of abduction and forcible traction.

Schinzinger's method, the introduction of which appears to have antedated Kocher's, was in like manner based upon the persistence of the posterior portion of the capsule, but differed from Kocher's in the second and third steps of the manœuvre. He rotated the arm outward until the hand was as far back as the elbow, and then either pressed the bone upward and outward into place by direct pressure, or turned it in by slow internal rotation while an assistant made pressure on the inner side of its head to prevent it from slipping back into the position from which it had been removed by the outward rotation. The method is favorably spoken of by several of the later German writers, and is thought to be especially useful in rupturing the adhesions of old dislocations without the risk of injury to the vessels or nerves.

Circumduction, sometimes known as Heine's method, in which, after fixation of the scapula as for traction, the arm is slowly abducted, raised to the side of the head, inclined slightly backward, and then brought forward and downward across the face and chest, has been recommended and used in old dislocations; it is undoubtedly efficient in breaking up

the adhesions, but it is a rough, uncertain, and dangerous plan, and should be condemned.

To recapitulate, the treatment of a recent anterior dislocation of average displacement may be thus summed up: Kocher's method may first be tried; if that fails, traction downward and outward should be tried, the elbow not being raised higher than the shoulder, combined with direct. pressure upon the head, or followed by adduction over the fist in the axilla. If these also fail, the patient should be etherized, and the attempts repeated.

In older dislocations the same plan should be followed, and resort should be had to forcible traction only after other measures have failed.

The signs of a successful reduction are the sound that is usually heard when the bone slips into place, the restoration of form and function, and the diminution or cessation of pain. The sound is not always heard, and, on the other hand, a similar sound may be caused by the rupture of adhesions or by the slipping of the bones upon each other. Complete restoration of form is the best evidence; this is to be determined by an examination similar to that employed in making the diagnosis of a dislocation and by attention to the same signs. The reduction may be incomplete because of the interposition of a portion of the capsule, or because of the presence of tissues of new formation in the glenoid cavity. The incompleteness is shown by the abnormal projection forward of the head of the humerus under the acromion.

After-treatment.-After reduction has been obtained it is highly desirable that the arm should be immobilized for two or three weeks in a position that will favor the speedy repair of the lacerations of the capsule, tendons, and muscles; otherwise the joint may remain in a condition that favors recurrence, and the patient may suffer much inconvenience or even disability in consequence. As the rent in the capsule is on the inner side, and as its edges are separated by external rotation of the limb, the head of the humerus should be directed toward the outer side (adduction of the elbow) and the arm should be kept rotated inward. These two indications are met by binding the limb to the body with the hand resting just below the opposite clavicle. Fixation may be made by a silicate-of-soda or plaster-of-Paris dressing or even by simple bandages, but the most convenient and effective dressing is a strip of adhesive plaster arranged as follows: beginning in front at the clavicle it is carried over the shoulder and down the back of the arm, then under the elbow to the back of the forearm, and along the latter and the back of the hand to and over the top of the opposite shoulder. A small pad of absorbent cotton or lint should be placed in the axilla and between surfaces of skin that are in contact. If the patient is unruly a second band may be placed circularly about the body and lower part of the arm. This dressing should be retained for two or three weeks, and the arm carried in a sling for a fortnight longer. If passive motion is made, abduction and external rotation should be avoided.

If the greater tuberosity has been broken off in whole or in part and widely separated by the retraction of the attached muscles, the indication is to favor its reunion by keeping the limb in the position of outward

rotation, an indication that is difficult of accomplishment unless the patient stays in bed. Fortunately, such separation of the fragments as would make this position desirable is rare; they are usually kept in sufficiently close approximation by the untorn periosteum and ligamentous surroundings.

For complications, accidents, prognosis, and the treatment of old dislocations, see Chapter XVIII.

CHAPTER XVII.

DISLOCATIONS OF THE SHOULDER.-(Continued.)

DOWNWARD DISLOCATIONS: SUBGLENOID, LUXATIO ERECTA, SUBTRICIPITAL DISLOCATION. POSTERIOR DISLOCATIONS: SUBACROMIAL, SUBSPINOUS. UPWARD DISLOCATIONS.

DOWNWARD DISLOCATIONS. (SUBGLENOID.)

Under this title are here included those rare cases in which the head of the humerus is displaced directly downward upon the tendon of the

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FIG. 62.

long head of the triceps, and those more frequent ones in which it is engaged under the lower and inner edge of the glenoid cavity, and rests against the flattened upper portion of the axillary border of the scapula on the inner side of the tendon of the triceps. (Fig. 62.) As explained in connection with the classification given in the preceding chapter, the name is here restricted to a portion of those cases which are termed subglenoid by most English and American authors, to those, namely, in which the head of the bone is low in the axilla. By some the term is still further restricted in use, and is applied only to the first of the two forms abovementioned, those in which the head is displaced directly downward upon the tendon of the triceps. Although it is denied by some on theoretical grounds that this form can exist, yet it must be admitted not only as possible, but as having been actually observed, on the evidence of several observers who fully understood the point in dispute. Von Pitha (quoted by Bardenheuer) says that he had seen it only in cases in which he had the opportunity to examine the patient immediately after the accident, and before any movements had been communicated to the limb or attempts made to reduce. He believes that the head can be easily displaced from its new position, and moved upward and forward, the dislocation being thus transformed into a subcoracoid, by involuntary or communicated

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Subglenoid dislocation.

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