Treatment, especially of the thumb dislocations, is facilitated by first exaggerating the abnormal position, then making traction and pressure in the proper direction at the same time. Special forceps have been devised for seizing and holding the digits, or a clove-hitch can be thrown over the thumb or finger. Extension should not be first made in the axis of the metacarpal bone, but rather at an abrupt angle to it in order to relieve the expanded phalangeal end. The majority of writers concede that in some cases reduction is practically impossible. When effort has proved futile the parts should be sterilized and incised, the incision being utilized for open reduction or for excision, as deemed best.

Dislocations of the other phalanges are usually easily recognized and treated by traction and pressure.

DISLOCATIONS OF THE HIP.

Hip dislocations constitute about 5 per cent. of the total. As they are produced by violence they are much more frequent in men, and occur mostly between the ages of twenty and fifty years. Before the twentieth year epiphyseal separations often take place, while after the fiftieth year violence will usually break the neck of the femur. Nevertheless dislocations may occur at any age. The hip is a ball-and-socket joint, with a deep socket still further extended by cartilage, in which the head of the bone is not only retained by the ligamentum teres, but by atmospheric pressure, which in the natural state furnishes a factor of perhaps one hundred pounds. The strongest muscles and tendons of the body envelop the joint. When dislocation occurs the capsule is usually torn along its inferior aspect. The limb is usually in an extreme position, or it would require more violence to tear the head from the socket. The anterior dislocations occur during abduction without outward rotation; posterior dislocations occur during flexion. Thus when a person is stooping over in work and a heavy weight falls upon the back the head of the bone is more easily pushed backward, especially if the feet be close together.

While hip dislocations are classified for convenience, and because of their final form, the head of the bone may rest upon almost any segment of the margin of the acetabulum, though within a short time it will assume a position justifying a designation as anterior or posterior, meaning thereby in front of or behind Nélaton’s line. This is, moreover, a convenient distinction, as the symptoms vary between the two groups. Another classification is into the forward, the backward or backward and upward, and the downward, which are again referred to as iliac, ischiatic, dorsal, and supracotyloid among the posterior, and perineal, obdurator, suprapubic, etc., among the anterior (Fig. 355).

Allis, however, has simplified the subject by showing that all forms of dislocation escape primarily from the lower segment, shifting their position later either upward or downward. He classifies them as follows:

The relation of the so-called Y-ligaments to the successful reduction of these dislocations, as well as to their formation, is of considerable importance.

Fig. 356 illustrates the manner in which this ligament receives its name, it being simply a reduplication of fibers which strengthen the capsule and which are arranged in the shape of an inverted Y. No matter how serious the injury it is seldom entirely detached. While it prevents too great displacement it is of special service in that it may be made to serve as a fulcrum for the leverage required in certain manipulations. American surgeons are entitled to the credit for the establishment of the importance of this ligament in this consideration, and while Bigelow’s name is most prominently mentioned, the names of Gunn, of Chicago, and Reid and Moore, of Rochester, New York, deserve almost equal prominence, not only for their anatomical studies, but for working out the entire method of manipulation which has completely supplanted the old and more violent methods in which the use of pulleys and tackle was not infrequent. The Jarvis “adjuster,” a powerful mechanism, which was formerly employed for this purpose, is not now seen except in museums.

Symptoms and Signs.

—These vary decidedly in the different forms. In every case where the head of the bone rests on a higher level than the acetabulum there will be shortening. In nearly every instance a certain degree of flexion is present. In anterior displacements there is generally abduction and outward rotation. When the head of the bone is beneath the pubes or in the obturator foramen the limb may be lengthened as well as flexed, while the trochanter is shifted to a correspondingly lower position. In most instances the head of the bone can be felt in its abnormal position, and muscle spasm is always a pronounced feature, especially when there is actual elongation and muscles are really stretched. In the backward displacements adduction and inward rotation are the conspicuous features, the reverse of those of forward dislocation. When the head of the bone is actually in the ischiatic notch, and even when it is on the dorsum of the ilium, the limb is the more flexed, while the trochanter will be found above Nélaton’s line. Figs. 357 and 358 illustrate the two types of anterior and posterior displacement, with the usual and predominating postural features, while Figs. 359, 360, 361 and 362 (from Lejars) portray the anatomical features of the four principal types in graphic form. By these can be determined the class to which the dislocation belongs.

This classification into the anterior and posterior seems to the writer to simplify the general subject and to be serviceable for its particular purpose and place. Inasmuch as anesthesia is nearly always required for these injuries it may be expected to clear up difficulties in diagnosis by its aid.

Treatment.

—Through the anatomical researches of the surgeons above named, as well as those of Allis and others, the method of reduction of hip dislocations is practically always that by manipulation, and is in nearly every instance commenced with flexion. In fact a considerable number of backward dislocations can be reduced almost alone by flexion and rotation with traction, the patient being upon his back, preferably upon the floor, and the surgeon standing over him. While anesthesia is not necessary in all cases it affords sufficient assistance to justify its general employment.

In the backward dislocations, the patient and surgeon being in position as above, it is well to employ the Kocher method, which consists of (1) inward rotation, by which the capsule is relaxed and the head of the bone carried from the pelvic surface; (2) flexion to a right angle, preserving the existing adduction and inward rotation; (3) traction, by which the capsule is made tense and the head of the bone raised to the level of the socket; (4) outward rotation, by which the posterior part of the capsule and the outer band of the Y-ligament are tightened and the head turned forward into the socket.

During the practice of this or any other method the pelvis should be firmly held in place by assistants, who may seize it with the hands and hold it down. If the patient lay upon the table the pelvis may be bound to it. The surgeon may need help in making a sufficient degree of traction. This can be furnished by a strong loop passed under the patient’s knee and over the surgeon’s shoulders, the hands thus remaining free for manipulation, traction being the most important feature.

Stimson accomplishes the same purpose by placing the patient, face downward, upon a table, the dislocated limb hanging downward as represented in Fig. 363. Traction is here partly affected by the weight of the limb, while in some instances the surgeon has to wait only for the muscles to relax and the bone to resume its place without much further effort than a slight rocking or rotation. Stimson claims that this often succeeds without anesthesia, and sometimes so quietly that there is scarcely any jar or sound to indicate the effection of the reduction.

In those forms of dorsal dislocation which are accompanied by eversion instead of inversion it is necessary only to convert them into the ordinary dorsal type before proceeding as above.

In high displacement of the head of the bone traction should be made in the extended position, by which the head will be brought back of the acetabulum, and then proceed as above.

Of the anterior dislocations the obturator is perhaps the more common, while for its reduction the following directions usually suffice: The limb is flexed toward the perpendicular to disengage the head of the bone, then rotated inward and adducted while the knee is carried to the floor. As Bigelow suggested, in this maneuver we may need the aid of a towel passed around the upper part of the thigh, an assistant making upward and outward traction while the operator is bringing the limb downward. Inward rotation is likely to transform the dislocation into a posterior one. On account of this fact, Kocher would give the following advice: (1) Flex the thigh to a right angle with the pelvis, preserving abduction and outward rotation until (2) traction is made, by which the posterior part of the capsule is tightened and the head brought nearer the socket; then (3) forcible outward rotation is made, which should bring the head upward and backward into place.

A perineal dislocation is usually accompanied by laceration of the capsule. This will permit of easy reduction, which can probably be effected by traction in the axis of the limb in its abnormal position and by direct pressure, with some rotation or rocking.

The pubic and suprapubic dislocations require forcible flexion with traction in the axis of the limb, followed by inward rotation and circumduction of the knee. Some of these maneuvers are illustrated in Figs. 364 and 365.

So of the other dislocations of the hip; an application of principles similar to the above, coupled with such assistance as may be afforded by manipulation, practised by the operator, or by traction, with the help of an assistant, will usually suffice.

If a general rule could be formulated covering all cases it would be of great assistance. I have been in the habit of quoting a rule of this character, which I first saw mentioned in the American edition of Bryant’s Surgery, edited by Roberts, to the following effect: (1) Flex the leg on the thigh and the thigh on the body; (2) carry the knee as far as it will go in the direction in which it already points; (3) carry the knee to the extreme in the opposite direction and combine this movement with circumduction and traction. In the backward dislocations these manipulations should be accompanied by traction made with one of the operator’s hands in the popliteal space. In the anterior displacement backward pressure instead of traction can be made by pressing upon the knee. I have found this an admirable working direction.

The after-treatment of hip dislocations consists mainly in rest and quiet. These should be enforced, at least by a binder around the pelvis, and, if necessary, a starch or plaster-of-Paris protection. The anterior suspension splint affords a comfortable and efficient method of treating these cases after the first few days. (See Fig. 322.) Very little liberty should be allowed the patient until the expiration of the first month.

Ancient and Unreduced Dislocations.

—The longer a hip dislocation is allowed to go unreduced the more difficult is its replacement. The expiration of six weeks will usually make a hip reduction very difficult, while after a lapse of three or four months it becomes wellnigh impossible. The longer a limb is disused the more do its osseous structures atrophy. Therefore a fracture of the neck of the femur or upper end of the shaft may occur in attempting to reduce an old luxation. The most marked obstacles are offered by formation of adhesions about the femoral head in its new position, and the shrivelling or change in shape of the capsule, whose opening may be distorted or obliterated, so as to make reëntrance impossible within it of the head of the bone.

Other things being equal, then, more force and wider range of motion are necessary in reducing the older dislocations, while success may be attained only by the expenditure of wellnigh all the muscular energy of a powerfully built man. Attempts prolonged too far produce serious laceration, with hemorrhages, which tend to encourage new adhesions in case of failure. If a dislocated hip cannot be reduced by any apparently safe procedure the operator should decide whether to leave it, in the hope of securing a false joint, or to cut down the parts and make such further division of tissues as may be necessary. Should this be contemplated it implies, of course, that each case should be adjudged upon its merits.

DISLOCATIONS OF THE PATELLA.

By various contractions of the quadriceps muscles the patella may be displaced outward, it being practically slipped over the external condyle. The same result may be produced by a blow from the inward direction and in the extended position of the limb. These displacements may be complete or incomplete; in the former case the flat plane and inner edge of the bone are directed forward instead of sidewise. Inward displacements are unusual and usually produced by direct violence. Such previous disease as shall have weakened the capsule, or caused its distention, permits these dislocations to occur with a minimum of violence. In fresh cases the capsule is usually torn.

Reduction is easily effected by lifting the limb, thus relaxing the quadriceps muscle and making pressure and manipulation in the indicated direction. An anesthetic may be given if thought admissible.

When the limb is partially flexed, and a blow is received on the edge of the patella directly from the front, it is occasionally rotated on its tendinous axis, so that without being displaced from its position in front of the condyles its articular surface looks inward and it rides the knee upon its edge. This is referred to as vertical rotation. It is relieved and replaced by suitable manipulation, a feature of which may be sudden and forcible flexion with external pressure.

The patella once displaced the joint structures are left more or less permanently impaired, and recurrence of the lesion is by no means uncommon. Some individuals, the young especially, have the habit of “slipping the knee-pan,” this implying that at least partial displacement occurs easily with comparatively slight provocation. Sometimes children become so accustomed to this that they learn how to care for it themselves.

Treatment.

—After every knee dislocation protection should be afforded for a considerable period. In habitual dislocations it may be justifiable to make lateral incisions and to excise an elliptical portion of the capsule, by which its dimensions may be reduced and its undue laxity abolished.

DISLOCATIONS OF THE KNEE.

The head of the tibia is occasionally displaced as the result of accident, though frequently this is the result of joint lesions. A traumatic dislocation can scarcely occur without considerable injury and internal derangement of the joint structures proper. Anterior dislocation may occur when the femur is forced backward or the leg forward in severe accidents. Here the popliteal vessels may undergo such pressure and injury as to constitute a serious complication. The backward dislocations are less common, though likewise the result of violence. It matters not whether the thigh be fixed and the leg forced in either direction, or whether the leg be caught and fixed while the body is made to displace the femur; such injuries are not likely to be mistaken. They are likely, also, to be accompanied by displacement of the semilunar cartilages. Lateral dislocations are practically the result of force, often combined with torsion. Injury to the lateral ligaments, usually extensive laceration, should accompany them.

Dislocations of the knee are more or less easily reduced, in theory at least, by forcible traction and manipulation, and with the aid of an anesthetic. Absolute rest, preferably in a plaster-of-Paris splint, is requisite.

The semilunar cartilages are occasionally torn loose and more or less displaced, either toward the notch or toward the exterior of the joint. A cartilage so displaced will project, as a rule, at the upper margin of the tibia. These injuries may occur alone or as a complication of more serious forms described above.

Symptoms.

—These displaced cartilages produce symptoms simulating those of movable bodies in the joint—that is, disability depending upon the extent of the original injury and the direction of the displacement. The movable cartilage may be either pulled into place by flexion or manipulated until it returns there, but will frequently reappear when the leg is straightened. It sometimes becomes so entangled in the joint as to cause almost complete disability. When movable anteriorly it may be recognized along the upper border of the tibia. The same sudden disability may be produced here as when there are other loose or movable bodies in the joint. The patient may be able to indicate that there is something movable in the joint.

Treatment.

—Non-operative treatment consists in sufficient limitation in the motion of the joint with abstention from use of it. In cases not amenable to non-operative measures the joint may be opened and the cartilage fastened in place to the head of the tibia either with absorbable or non-absorbable sutures.

The Fibula.

—The upper end of the fibula, although firmly bound to the tibial head, may be dislodged by direct or indirect violence. Forcible inward rotation of the foot, in full extension, will sometimes displace it forward, while forcible traction on the biceps may dislocate it backward. Displacements at this joint may occur when the leg bones are broken, while when the tibia alone is broken and shortened upward displacement may occur in consequence. Should displacements be discovered it will not be difficult by traction upon the foot and leg, in the normal direction, and by pressure to replace them. The backward displacement is the more unstable of the two. The lower end of the fibula is by itself rarely dislocated or distorted except in connection with violent sprains, accompanied by the laceration of ligaments or fracture of one or both bones.

DISLOCATIONS OF THE FOOT.

Backward and forward displacements of the foot are possible without fracture; as, for instance, when violence is applied to the leg after the foot is caught and fixed. Even here, however, the lateral ligaments must suffer partial or complete laceration, while one or both malleoli may be broken. The most frequent displacements of the foot are those which accompany and are permitted by fractures of the lower part of the leg, notably that originally described by Pott, with its troublesome form of bone lesions. An inward dislocation of the foot is described as produced by extreme supination and adduction.

It is necessary in studying these injuries to the ankle region to make out the existence of fracture, if any be present, as the treatment hinges largely upon such complication.

The astragalus may be dislocated from its relations with the lower ends of the leg bones, as the result of wrenches or twists or of violent injuries, as falls or blows upon the feet. When displaced it is nearly always forward. A backward dislocation is exceedingly rare. The rest of the foot itself is sometimes dislocated backward beneath the astragalus, although some portion of its lower surface still remains in contact with the upper surface of the calcis. These displacements occur in consequence of combined torsion and excessive violence. The foot here will be shortened anteriorly. No matter in what direction the astragalus may be displaced it is easily recognized.

Treatment.

—Reduction of ankle-and-foot dislocations accompanied by fracture is not a difficult matter, although their retention may be; but astragalus dislocations which are complicated are usually difficult of replacement. They will require relaxation of muscle tension by anesthesia or tenotomy and forced manipulations. When accomplished good function results. Better results may be obtained by exsection.

Many of these more serious forms of dislocation are compound. In such cases removal of the astragalus, or a more or less typical resection of the ankle-joint, may be judicious. In crushing injuries, either primary or secondary amputation may be necessary.

In general it may be said of the bones of the foot that one which resists reasonable effort at reduction, when displaced, should be removed. Various displacements of the tarsal bones, as the result of direct violence, may occur, as well as of the metatarsal and phalanges. Many of them may be reduced by judicious pressure and manipulation, but the violence which inflicts the displacement will frequently make the injury so compound that excision or partial amputation may be necessary.