The essentials of bandaging /

The main obstacles in reducing dislocations are entanglement together of the displaced bones and contraction of the muscles; the entanglement of the bones determines the direction in which extension must be made, and also of the counter extension, or point at which the body is fixed to resist the traction practised on the limb; this should be exactly opposite the direction in which the limb will be drawn. The muscles can always be relaxed by chloroform, hence it is better when they are powerful, not to use the limb as a lever to prize the head of the bone into its place. Steady extension instead is better, to disengage the bone from the parts against which it is caught, and to bring it opposite its socket, into which the hands of the surgeon guide it with less risk of laceration of the soft parts than attends forcible leverage.

Lower Jaw.—This bone is dislocated on one or both sides; when the condyle has slipped forward from the glenoid fossa, the contracted temporal muscle keeps the bone from regaining its proper position, and causes the coronoid process to hitch against the malar bone.

Treatment.—Apparatus.—1. A towel.

2. A four-tail bandage.

The patient should be seated in a high-backed chair, resting his head against the back. The surgeon winds the towel round both thumbs, and standing immediately in front of his patient, places a thumb on the second molar of both sides, if the dislocation be double, or on one side only, if that be alone displaced (see fig. 60). He then presses steadily downwards until the condyle is released, when it slips back to its place. The return of the bone may be aided by pushing up the chin with the fingers after the ramus of the jaw has been lowered.

When the jaw is replaced, a four-tail bandage or split handkerchief should be tied over the nucha and vertex of the head, to keep the jaw closed (see fig. 23, page 32). Biting or chewing should not be attempted for ten days or a fortnight. The patient should be warned also that when the jaw has been once dislocated it very readily slips out of place again; he must thenceforth avoid gaping or opening the jaw very widely.

The Clavicle is rarely dislocated, nevertheless both the inner and the outer end may be displaced. The signs are obvious—the end of the bone is felt in its new position. The treatment for all is the same.

Apparatus.—1. Roller, 2¼ inches wide.

2. A piece of old blanket.

The blanket should be torn into strips about a foot square, and folded thrice, thus making a long soft pad to line the axilla, one for each armpit. The patient is next seated on a stool; an assistant standing behind, draws back the shoulder while he presses on the spine with his knee; the dislocation being reduced, the surgeon fixes the bone by a figure of 8 carried round the shoulders and across the back. The forearm is then bent and fastened to the body by a few turns of the roller round it and the chest. This prevents the pectorals from acting on the bone. The apparatus may be laid aside at the end of a week, but the arm must be fixed to the trunk for a fortnight longer.

This bone is often difficult to keep in place after dislocation, and even the most accurately fitted apparatus sometimes fails to effect its object, hence many varieties of collar and yoke have been devised by different surgeons to accomplish this purpose.

The Shoulder is dislocated in three directions, downwards, inwards, and backwards. These have subordinate varieties, but the signs depend chiefly on the direction of the greatest displacement.

Signs of dislocation into the axilla. When the bone is displaced below the glenoid fossa the acromion is prominent; underneath it, the surgeon feels a hollow instead of the head of the humerus, which the finger detects in the axilla. Movement of the shoulder is very limited and painful If the elbow is rotated while the finger is in the armpit, the head will be found to move with the rest of the bone.

If the head of the bone is carried more inwards on to the ribs, it can be seen and felt near the clavicle; the hollow is again readily detected below the acromion, while the axis of the arm is altered, being directed inside its proper position.

When the bone is carried backwards the head is plainly felt on the scapula below the spine.

For the reduction of these dislocations several plans are employed. When recent the two first displacements can generally be restored without chloroform, but if the patient is muscular it often saves time and pain to produce anesthesia before attempting to replace the bone.

By the heel in the axilla (fig. 61).—The patient lies flat on a couch; the surgeon pulling off his boot from the left foot if he has to reduce a left dislocation, and vice versâ the right boot, seats himself on the couch facing the patient. Putting his unbooted foot into the armpit, he grasps the forearm with both hands and pulls steadily downwards. When the head of the bone is disengaged the muscles draw it into the socket, and the movements of the limb become at once easy and natural. The arm must then be fixed to the side by a roller for a fortnight, and the shoulder is wetted with an evaporating lotion to allay the pain and inflammation resulting from the laceration of the soft parts. Should the surgeon’s strength be insufficient for the requisite extension, a jack towel may be attached in a clove hitch round the wrist and held by an assistant, who standing behind the surgeon draws steadily in the same direction.

To make a clove hitch.—Grasp the towel in the left hand, the little finger being downwards, then pronating the right hand till the little finger is upmost, seize the towel below the left hand; if the wrists are then rotated in opposite directions the towel will be drawn into two loops, of which the ends cross above the connecting part between the loops (see fig. 62); if one hand holds the loops and the other pulls the ends, the loops will be found not to slip, however tight the ends are pulled.

Reduction by simple extension.—The patient again lies flat on his back, a jack towel is passed round his body and fastened behind the opposite shoulder for counter-extension, while a second towel is attached to the wrist by a clove hitch and intrusted to two or three assistants, who are desired to pull quietly and steadily directly away from the patient’s body. The surgeon meanwhile watches the progress of the extension, altering its direction as he finds the head more or less engaged against the scapula, and finally with his hands thrusts the head into its socket. Sometimes there is much difficulty in getting the head back to the glenoid fossa, even when the humerus is completely disengaged from the scapula; this difficulty is often overcome if an assistant rotates the humerus backwards and forwards, while the extension at the wrist and the pressure on the head of the humerus is steadily maintained. When the limb is replaced it is fixed to the side as before directed.

If the dislocation has existed more than a few hours, relaxation of the muscles by chloroform and extension of the limb carried directly away from the body are more sure of success than the heel in the axilla, because they allow greater power to be exerted in a steadier manner than is possible by the other mode.

The Elbow.—The signs of dislocation at this joint are tolerably evident, but there is often coexistent fracture of the coronoid or olecranon processes. Separation of the articulating surfaces of the humerus from the shaft is sometimes mistaken for dislocation of the forearm backwards.

In dislocation of both bones backwards the olecranon is very plainly felt behind the lower end of the humerus; the sigmoid notch is generally to be made out, and the forearm is fixed at a right angle. The altered relation of the olecranon to the condyles suffices to distinguish dislocation from fracture of the humerus at its lower end, where the olecranon also goes backwards, but the condyles go with it. The immobility of the joint distinguishes it from separation of the lower articular surfaces of the humerus from the shaft, an accident, moreover, only met with in children.

Other subordinate distinctions between dislocation and fracture are, the limited movement, the difficulty of restoring the bones to their natural position, and the absence of crepitus; lastly, the peculiar form of the articular surfaces can sometimes be made out.

In reducing the backward dislocations the patient sits on a chair on which the surgeon rests his foot, pressing his knee against the forearm at the elbow for a fulcrum; then, grasping the wrist with one hand, and steadying the arm with the other, he flexes the elbow to dislodge the coronoid process from the fossa at the back of the humerus; when this is done, the articulating surfaces slip into place. This plan is commonly adopted when the olecranon is displaced, but if it fails to reduce the dislocation, direct extension at the wrist must be employed, as for the following dislocation.

When the radius only is displaced, the body should be fixed by a jack towel carried under the armpit of the injured side, and over the shoulder of the sound side. A wetted bandage is rolled round the forearm, and a second towel is attached by a clove-hitch (see fig. 62, page 99) to the wrist for extension, which is made in the axis of the limb until the radius can be slipped into its place on the outer condyle.

In all dislocations of the elbow, when the bones are returned the limb should be bent to a right angle and put on a lateral angular splint for a week or ten days, after which time it should be worn in a sling a fortnight longer.

The Thumb and Fingers.—When the first phalanx is dislocated from the head of the metacarpal bone it is sometimes very difficult of reduction. The most effectual mode is steady extension, which is procured by fastening the thumb to a piece of wood, which serves as a handle to give command of the phalanx, and is contrived as follows: the thumb is first bandaged with a narrow wetted roller over the two phalanges, and a thick layer of cotton wool is rolled round it; a piece of stiff wood, 1 inch wide, ½ inch thick, and 12 long, is perforated at one end with three pairs of holes ½ inch distant from each other and from the end; through these, three stout tapes, ½ inch wide and 2 feet long, are threaded, leaving three loops on one side of the piece of wood (fig. 65). The wood is then applied to the palmar aspect of the phalanges, the loops passed over the thumb, their ends drawn tight, and tied, not in a bow as the figure represents, but wound round the end of the stick. The stick thus attached becomes a good handle for extending the digit, and also a long lever for altering the direction of the phalanx if desired. Langenbeck of Berlin employs a pair of forceps to seize the thumb, instead of the wooden handle just described. But with the greatest care and perseverance it is sometimes impossible to replace the bone unless the constricting bands be divided with a tenotome.

Hip-joint.—There are three chief directions in which the hip is dislocated. First backwards on the dorsum ilii, or further on to the sciatic notch. In this dislocation the limb is shortened, moved with difficulty, drawn inwards over the other, and its great toe touches some part of the back of the other foot. The hip itself is altered, the great trochanter being nearer to the crista ilii, and more prominent than on the uninjured side, and the head is often plainly felt in its new position. Resistance to extension of the limb, limited movement of the hip, with rotation inwards, are the distinguishing points between this dislocation and fracture at the neck of the femur.

Treatment.—Apparatus.—A complete apparatus for this purpose is contrived and sold by instrument makers, but a sufficiently serviceable one can be extemporised when the former is not at hand; it consists of:—

1. A rope running in two pulley blocks.

2. Three jack towels.

3. Two stout hooks to screw into the wall, or some firm object, to obtain fixed attachment.

4. A wetted roller 3 inches wide.

The complete apparatus is as follows:—

Apparatus.—1. A set of multiplying pulleys.

2. A leathern padded girth, 2 inches wide and 3 feet long, having at each end an iron ring.

3. A stout leathern belt about 6 inches broad, furnished with buckles, straps, and rings to fasten on to the thigh above the knee; a rope is run through the rings to connect the hook of the pulleys with the thigh.

4. Two strong iron hooks to screw into the wall, for fixing the apparatus.

5. Half-a-dozen yards of stout cord.

6. A hook, fitted with a buckle and strap, and hinged so that, by turning a pin, it at once disengages itself. If this is interposed between the pulleys and the hook fixed in the wall, the limb may be instantaneously released if desired.

Treatment.—Step 1. The patient is laid on a flat couch, and put under the influence of chloroform. When he is narcotised, a jack towel, or if it be at hand the pelvic girdle, is carried across the perinæum, arranging it to bear on the tuber ischii behind and the pubes in front, its ends being attached to one of the hooks screwed into the wall behind, and about six inches below the level of the patient. This towel should be put slightly on the stretch, that the pelvis may be kept in the position first assigned to it when the pulleys begin to draw. A wet roller is put on the lower third of the thigh, the jack towel slipped up the leg to the bandage, and fastened in a clove hitch. Another jack towel is then doubled and passed up the limb to the perinæum. The patient is next turned on to his sound side, and the belt of the thigh connected by the disengaging hook to the pulleys, which are drawn out from each other as far as their cord will allow, and attached to a hook fixed a little above the level of the patient, on a line carried from the hip across the junction of the middle and lower thirds of the uninjured thigh (see fig. 66).

Step 2. The surgeon being ready, an assistant draws on the pulley cord, getting gradual extension of the limb as required by the surgeon, who, keeping his hands on the hip and great trochanter, watches the progress of the head of the bone towards the acetabulum.

Step 3. When the bone has reached the edge of the acetabulum, a second assistant slips the doubled jack-towel over his shoulders, and by raising his body, lifts the femur away from the brim of the acetabulum, while the surgeon, grasping the foot and knee, makes a few movements of rotation backwards and forwards to ease the head into its socket.

When a reduction is effected, the limb should be put in a long splint or starch bandage for three weeks, and the patient not allowed to exercise the limb freely or violently for a month afterwards.

Reduction by Manipulation.—When the patient is not very muscular, and the dislocation recent, the bone can often be speedily returned by movements of flexion and rotation.

The patient is put fully under chloroform and brought to the foot of the bed; the surgeon grasps the ankle in one hand, and the knee in the other, bending that joint till the heel reaches the thigh; he next flexes the thigh on the abdomen, in doing this he carries the knee outwards away from the body, and then rotates the limb by pushing the foot outwards, on which the head often slips into the acetabulum. If this plan do not quickly succeed it is better to have recourse to extension, by assistants if pulleys are not at hand, but the irregularity of the force when assistants are employed renders the traction of pulleys much preferable to manual strength.

Dislocation downwards into the ischiatic foramen. The limb is lengthened, capable of little motion; the knee is bent; the toe points forwards, and away from the other foot. Here the reduction is best managed by extension; the apparatus required being the same as that employed in dislocation backwards, but it is differently arranged.

Step 1. The patient lies on his back, the pelvic girth, or towel, is carried round the pelvis and fastened to the wall on a level with his body, opposite the uninjured side. A jack towel is put round the upper part of the dislocated thigh, and attached to the pulleys outside, which are fastened to the wall opposite (see fig. 67).

Step 2. Extension is then made by an assistant, the surgeon grasps the leg above the ankle, and rotating the limb inwards and outwards, but without lifting it from the bed, guides the head into the acetabulum.

Here, as after dislocation backwards, a long splint should be worn on the limb for three weeks before the patient is allowed to move about at all.

Dislocation on to the Pubes.—The limb is easily moved at the hip, shortened, rotated outwards, and the head of the bone is felt in the groin.

The same apparatus is used in this as in the dislocation on the dorsum ilii. It is applied as follows:—

Step 1. The patient lies on his back (fig. 68), with his legs separated. The pelvic band is passed over the perinæum and pubes, and attached above the patient, in a line passing from the pelvis a little to his sound side. A double jack towel is slipped up the limb to the perinæum; the pulleys are fastened to the thigh above the knee and fixed, in the manner directed on page 106, to the wall below and external to the injured side of the body.

Step 2. Extension is then steadily made, while the surgeon watches the head getting free from the pubes, over the edge of which a second assistant slipping his neck through the doubled towel, raises the bone a little outwards. The surgeon in the meantime encourages the bone by rotation to enter the socket.

A splint is necessary here also after reduction.

The Knee.—These dislocations are rarely complete, and are easily reduced; the lateral ones by flexing the thigh on the belly, straightening the leg, and rotating it a little from side to side.

Another Plan.—Apparatus.—Two jack towels. This is more useful when the tibia is carried backwards. Lay the patient on his back, and slip a jack towel in a clove hitch up the leg to the ham, and another round the small of the leg; the thigh is bent and retained in a semiflexed position by an assistant holding the jack towel at the ham, while a second pulls on the one at the ankle and so disengages the bones from each other, when the surgeon readily slips them into place.

After reduction is accomplished, the limb should be fixed in a leathern back splint until the inflammation subsides.

Dislocation of the Patella.—The displacement of this bone on to the outer or inner condyle is generally easily reduced if the knee is straightened and the vasti relaxed by bending the thigh on the belly. When the patella is turned on its own axis, the side, not the under surface, is locked against the condyle, and reduction is sometimes extremely difficult or impossible. The same movements must be adopted as for simple lateral displacement, and the surgeon must endeavour to release the bone by pressing its upper edge downwards with his thumbs.

After their reduction, all dislocations about the knee-joint must be treated by rest, straight splints, and evaporating lotions.

The Foot is very rarely dislocated from the leg without fracture of the malleoli. Its reduction requires simple extension of the foot on the leg, with the knee bent; the surgeon grasps the heel in one hand, the foot in the other, while an assistant fixes the thigh in the half-bent position. The foot is first drawn downwards to disengage it from the tibia, and then directed into its place.

After reduction the limb should be put in a McIntyre’s splint, in the way described for fracture of the tibia near the ankle-joint.

Scarpa’s Shoes are instruments for restoring deformed feet to their natural shape. The shoe (fig. 69) consists of a flat metal sole broader and longer than the foot, furnished with a rest for the heel. A rod, attached to the side of the sole beneath the ankle, reaches up the limb, to which it is secured by one broad band and buckle below, and by a second above the knee, opposite which joint the iron stem moves on a free joint backwards and forwards. Opposite the malleoli are set the centres of movement required for the restoration of the deformity; they are moved by a key. The foot is fastened to the sole by straps across the instep and ankle; the toes are restrained by a strap passing round them and fixed to a horizontal toe-bar by the side of the foot. In fitting one of these shoes, which of course must always be made specially for the limb it is to control, the points to be attended to are—1st, the centres of the joints must be so arranged that, when traction is made, the foot shall revolve back again round the same centres it has passed in reaching its distortion. For example, if the heel is raised, as in talipes equinus, the fore part of the sole of the shoe must be capable of elevation, by moving a joint that rotates in a plane parallel to the rotation of the astragalus on the tibia. In most cases of talipes, the bones of the foot have been displaced round several centres; hence, the apparatus must be furnished with power of traction along all of these, or along the lines resulting from these different directions acting simultaneously. 2nd. The heel must be got thoroughly into its place at the back of the sole to ensure that the foot will follow the shoe in all its movements.

The treatment of talipes frequently requires division of tendons before extension is attempted, if they are too firmly contracted to permit the bones to regain their proper position until they are lengthened by division. Thus, in varus, the tibiales and tendo achillis; in valgus, the peronci; in equinus, the tendo achillis; are often divided.

The limb must not be very tightly braced into the shoe, slight tension, if continuous, suffices to overcome the resistance; and in children if the straps are drawn tight the skin almost invariably inflames, and even sloughs where it is compressed. Before the instrument is applied, the limb should be bandaged with a soft cotton, or Domett’s flannel roller. The foot is first fixed to the sole or shoe, and then the leg to the rod. Traction is increased gradually with frequent small alterations, as the foot yields to the tension and regains its natural position. The accompanying figure (No. 69) represents an instrument made by Mr. Heather Bigg. It shows the shoe restoring a much elevated heel to its proper position after division of the tendo achillis.

There are three common varieties of talipes—equinus, or horse-heel, where the heel is drawn up and the toes only touch the ground; varus, club-foot proper, where the foot is twisted inwards; and valgus, splay-foot, in which the foot is drawn outwards. Equinus is often associated with varus, and sometimes also with valgus, and consequently for such cases the instrument must provide the mechanism proper to each direction of displacement.

In Equinus the heel is raised by the extreme extension of the ankle, and the sole of the foot is shortened by the metatarsus being drawn backwards. In this kind of deformity the shoe must have a joint to bring the astragalus forwards on the tibia, and the sole of the shoe must be well padded beneath the scaphoid and metatarsal bones, that, as the foot is released from its position of extreme extension at the ankle-joint, the anterior parts of the foot may be thrust upwards into their proper relation to the astragalus and os calcis.

In Varus, or rather Equino-varus, for varus without elevation of the heel is rare, the displacement is compound, the ankle is extended, the heel raised, the scaphoid and metatarsus are drawn inwards and downwards, so that the scaphoid lies immediately beneath, sometimes even in contact with the internal malleolus. The astragalus and cuboid are drawn forwards so as to lie in front of their natural position against the tibia and os calcis. To bring down the heel the upright stem passes outside the limb, the toe of the shoe can be raised by a circular joint on the stem opposite the malleolus, which by its revolution raises the toes and depresses the heel. A second joint working outwards and upwards elevates the outer border of the foot, and restores the scaphoid to the front of the head of the astragalus. Lastly, the metatarsus is drawn outwards by a horizontal spring toe-bar along the outer border of the foot, to which the toes are fastened.

In Valgus, the plantar arch is flattened or even rendered convex downwards by the sinking of the scaphoid, and in extreme cases, by rotation outwards and upwards of the tarsus. The shoe here has the vertical rod inside the limb, and if necessary, an axis for rotation below the inner malleolus, and an elastic arched pad under the scaphoid to lift it into its natural position.

Casting in Plaster of Paris.—It is often convenient, when ordering an apparatus for deformity, to send the instrument-maker a cast of the deformed part. This is readily made in the following way:—

Apparatus.—1. Two packets of freshly burned plaster of Paris.

2. Some pasteboard, an old bandbox, or several newspapers.

3. Olive oil.

4. A basin of cold water.

Step 1. The part to be modelled should be laid in an easy position, thoroughly oiled, and a shell or trough of pasteboard roughly built round it to contain the plaster till it sets.

Step 2. The plaster is then prepared by shaking the powder into cold water, till a thick cream without lumps is formed; this is secured by constantly stirring the water as the plaster is shaken in. The cream is then poured into the trough, little by little, that it may make its way into the inequalities and recesses under the limb, until the limb is half immersed, leaving the projecting parts, such as joints, half exposed, so that the halves of the mould may separate opposite them. This first instalment is then allowed to set, and a fresh supply of plaster is prepared.

Step 3. The surface of the hardened mould is oiled, that the fresh cream may not stick to it, and the whole of the limb is then covered by pouring the cream on a second time. Plenty of plaster should be laid over the projecting parts that the mould may be strong enough for use. It should be ¾ inch thick everywhere, and 1 inch thick along the sides. When the second half is set, the trough or shell is cleared away, and the two halves of the mould removed from the limb separately.

For casting, the mould is well oiled inside and filled with cream, which sets into the cast required. While the plaster is liquid, the mould should be well shaken, that the air-bubbles may be all driven from the surface of the cast.