FRACTURE OF THE WRIST (Scudder).Above illustrations show deformities resulting from a broken wrist; Figs. 19 and 20 the crease at base of thumb; Fig. 21 hump on back of wrist; Fig. 22 twisted appearance of hand.
FRACTURE OF THE WRIST (Scudder).
Above illustrations show deformities resulting from a broken wrist; Figs. 19 and 20 the crease at base of thumb; Fig. 21 hump on back of wrist; Fig. 22 twisted appearance of hand.
FRACTURE OF BONE OF HAND, OR FINGER.
First Aid Rule.—Set fragments of bone in place by pulling with one hand on finger, while pressing fragments into position with other hand. Put on each side of bone a splint made of cigar box, padded with folded handkerchiefs, and retain in place with bandage wound about snugly. Put forearm and hand in sling.
This accident more commonly happens to the bones corresponding to the middle and ring finger, and occurs between the knuckle and the wrist, appearing as a swelling on the back of the hand. On looking at the closed fist it will be seen that the knuckle corresponding to the broken bone in the back of the hand has ceased to be prominent, and has sunken down belowthe level of its fellows. The end of the fragment nearer the wrist can generally be felt sticking up in the back of the hand.
Fig. 23.Fig. 23.A BROKEN FINGER (Scudder).Note splint extending from wrist to tip of finger; also manner of applying adhesive plaster strips and pad in palm.
A BROKEN FINGER (Scudder).
Note splint extending from wrist to tip of finger; also manner of applying adhesive plaster strips and pad in palm.
If the finger corresponding to the broken bone in the back of the hand be pulled on forcibly, and the fragments be held between the thumb and forefinger of the other hand of the operator, pain and abnormal motion may be detected, and the ends of the broken bone pressed into place. A thin wooden splint, as a piece of cigar box, about an inch wide at base and tapering to the width of the finger should be applied to the palm of the hand extending from the wrist to a little beyond the finger tip, secured by strips of adhesive plaster, as in the cut, and covered by a bandage. The splint should be well padded, and an additional pad should be placed in the palm of the hand over the point of fracture. Three weeks are required for firm union, and the hand should not be used for a month.
It is usually easy to recognize a broken bone in a finger, unless the break is near a joint, when it may be mistaken for a dislocation. Pain, abnormal motion, and grating between the fragments are observed.
If there is deformity, it may be corrected by pulling on the injured finger with one hand, while with the other the fragments are pressed into line. A narrow, padded wooden or tin splint is applied, as in the cut (p.102), reaching from the middle of the palm to the finger tip. Any existing displacement of the broken bone can be relieved by using pressure with little pads of cotton held in place by narrow strips of adhesive plaster where it is needed to keep the bone in line. The splint may be removed in two weeks and a strip of adhesive plaster wound about the finger to support it for a week or two more.
In fracture of the thumb, the splint is applied along the back instead of on the palm side.
HIP FRACTURE.
First Aid Rule.—Put patient flat on back in bed, with limb wedged between pillows till surgeon arrives.
Fig. 24.Fig. 24.TREATING A BROKEN HIP (Scudder).Note the manner of straightening leg and getting broken bone into line; also assistant carefully steadying the thigh.
TREATING A BROKEN HIP (Scudder).
Note the manner of straightening leg and getting broken bone into line; also assistant carefully steadying the thigh.
A fracture of the hip is really a break of that portion of the thigh bone which enters into the socket of the pelvic bone and forms the hip joint. It occurs most commonly in aged people as a result of so slight an accident as tripping on a rug, or in falling on the floor from the standing position, making a misstep, or while attempting to avoid a fall. When the accident has occurred the patient is unable to rise or walk, and suffers pain in the hip joint. When he has been helped to bed it will be seen that the foot of the injured side is turned out, and the leg is perhaps apparently shorter than its fellow. There is pain on movement of the limb,and the patient cannot raise his heel, on the injured side, from the bed. Shortening is an important sign.
With the patient lying flat on the back and both legs together in a straight line with the body, measurements from each hip-bone are made with a tape to the bony prominence on the inside of each ankle, in turn. One end of the tape is held at the navel and the other is swung from one ankle to the other, comparing the length of the two limbs. Shortening of less than half an inch is of no importance as a sign of fracture. The fragments of broken bone are often jammed together (impacted) so that it is impossible to get any sound of grating between them, and it is very unwise to manipulate the leg or hip joint, except in the gentlest manner, in an attempt to get this grating. If the ends of the fragments become disengaged from each other it often happens that union of the break never occurs.
Fig. 25.Fig. 25.TREATMENT FOR FRACTURED HIP (Scudder).Note method of holding splints in place with muslin strips; one above ankle, one below and one above knee, one in middle and one around upper part of thigh.
TREATMENT FOR FRACTURED HIP (Scudder).
Note method of holding splints in place with muslin strips; one above ankle, one below and one above knee, one in middle and one around upper part of thigh.
The treatment simply consists in keeping the patient quiet on a hard mattress, with a small pillow under the knee of the injured side and the limb steadied on either side by pillows or cushions until a surgeon can be obtained. (See Thigh-bone Fracture.)
THIGH-BONE FRACTURE.
First Aid Rule.—Prepare long piece of thin board which will reach from armpit to ankle, and another piece long enough to reach from crotch to knee, and pad each with folded towels or blanket.
While one assistant holds body back, and another assistant pulls on ankle of injured side, see that the fragments are separated and brought into good line, and then apply the splints, assistants still pulling steadily, and fasten the splints in place with bandage, or by tying several cloths across at three places above the knee and two places below the knee.
Finally, pass a wide band of cloth about the body, from armpit to hips, inclosing the upper part of the well-padded splint, and fasten it snugly. The hollow between splint and waist must be filled with padding before this wide cloth is applied.
In fracture of the thigh bone (between the hip and knee), there is often great swelling about the break. The limb is helpless and useless. There is intense pain and abnormal position in the injured part, besides deformity produced by the swelling. The foot of the injured limb is turned over to one side or the other,owing to a rolling over of the portion of the limb below the break. With both lower limbs in line with the body, and the patient lying on the back, measurements are made from each hip-bone to the prominence on the inside of either ankle joint. Shortening of the injured leg will be found, varying from one to over two inches, according to the overlapping and displacement of the fragments.
Treatment.—To set this fracture temporarily, a board about five inches wide and long enough to reach from the armpit to the foot should be padded well with towels, sheets, shawls, coats, blanket, or whatever is at hand, and the padding can best be kept in place by surgeon's adhesive plaster, bicycle tape, or strips of cloth.[8]Another splint should be provided as wide as the thigh and long enough to reach along the back of the leg from the middle of the calf to the buttock, and also padded in the same way. A third splint should be prepared in the same manner to go inside the leg, reaching from the crotch to the inside of the foot. Still a fourth splint made of a thin board as wide as the thigh, extending from the upper part of the thigh to just above the knee, is padded for application to the front of the thigh.
When these are made ready and at hand, the leg should be pulled on steadily but carefully straight away from the body to relax the muscles, an assistant holding the upper part of the thigh and pulling in the opposite direction. Then, when the leg has been straightened out and the thigh bone seems in fair line, the splints should be applied; the first to the outside of the thigh and body, the second under the calf, knee, and thigh; the third to the inside of the whole limb, and the fourth to the front of the thigh.
Wide pads should be placed over the ribs under the outside splint to fill the space above the hips and under the armpit. Then all four splints are drawn together and held in place by rubber-plaster straps or strips of strong muslin applied as follows: one above the ankle; one below the knee; one above the knee; one in the middle of the thigh, and one around the upper part of the thigh. A wide band of strong muslin or sheeting should then be bound around the whole body between the armpits and hips, inclosing the upper part of the outside splint. The patient can then be borne comfortably upon a stretcher made of boards and a mattress or some improvised cushion. (See Figs.24and25.)
When the patient can be put immediately to bed after the injury, and does not have to be transported, it is only necessary to apply the outer, back, and front splints, omitting the inner splint. It is necessary for the proper and permanent setting of a fractured thigh that a surgeon give an anæsthetic and apply the splints while the muscles are completely relaxed. It is also essential that the muscles be kept from contractingthereafter by the application of a fifteen- or twenty-pound weight to the leg, after the splints are applied, but it is possible to outline here only the proper first-aid treatment.
KNEEPAN FRACTURE.
First Aid Rule.—Pain is immediate and intense. Separated fragments may be felt at first. Swelling prompt and enormous. Even if not sure, follow these directions for safety.
Prepare splint: thin board, four inches wide, and long enough to reach from upper part of thigh to just above ankle. Pad with folded piece of blanket or soft towels. Place it behind leg and thigh; carefully fill space behind knee with pad; fasten splint to limb with three strips of broad adhesive plaster, one around upper end of splint, one around lower end, one just below knee.
Lay large flat, dry sponge over knee thus held, and bandage this in place. Keep sponge and bandage wet with ice water. If no sponge is available, half fill rubber hot-water bottle with cracked ice, and lay this over knee joint. Put patient to bed.
Fracture of kneepan is caused either by direct violence or muscular strain. It more frequently occurs in young adults. Immediate pain is felt in the knee and walking becomes impossible; in fact, often the patient cannot rise from the ground after the accident. Swelling at first is slight, but increases enormously within a few hours. Immediately after the injury it may be possible to feel the separate broken fragments of the kneepan and to recognize that they are separated by a considerable space if the break is horizontally across the bone.
Fig. 26.Fig. 26.A BROKEN KNEEPAN (Scudder).A padded splint, supporting knee, is shown reaching from ankle to thigh. Note number and location of adhesive plaster strips.
A BROKEN KNEEPAN (Scudder).
A padded splint, supporting knee, is shown reaching from ankle to thigh. Note number and location of adhesive plaster strips.
Nothing can be done to set the fracture until the swelling about the joint has been reduced, so that the first treatment consists in securing immediate rest for the kneejoint, and immobility of the fragments. A splint made of board, about a quarter of an inch thick and about four inches wide for an adult, reaching from the upper part of the thigh above to a little above the ankle below, is applied to the back of the limb and well padded, especially to fill the space behind the knee. The splint is attached to the limb by straps of adhesive plaster two inches and a half wide; one around the lower end of the splint, one around the upper part, and the third placed just below the knee. To prevent andarrest the swelling and pain, pressure is then made on the knee by bandaging.
One of the best methods (Scudder's) is to bind a large, flat, dry sponge over the knee and then keep it wet with cold water; or to apply an ice bag directly to the swollen knee; a splint in either case being the first requisite. The patient should of course be put to bed as soon as possible after the accident, and should lie on the back with the injured leg elevated on a pillow with a cradle to keep the clothes from pressing on the injured limb. (See cut, p.110.)
FRACTURE OF LEG BONES, BETWEEN KNEE AND ANKLE.
First Aid Rule.—Handle very carefully; great danger of making opening to surface. Special painful point, angle or new joint in bone, disability, and grating felt will decide existence of break. Let assistant pull on foot, to separate fragments, while you examine part of supposed break. If only one bone is broken, there may be no displacement.
Put patient on back. While two assistants pull, one on ankle and one on thigh at knee, thus separating fragments, slide pillow lengthwise under knee, and, bringing its edges up about leg, pin them snugly above leg.
Prepare three pieces of thin wood, four inches wide and long enough to reach from sole of foot to a point four inches above knee. While assistants pull on limbagain, as before, put one splint each side and third behind limb, and with bandage or strips of sticking plaster fasten these splints to the leg inclosed in its pillow as tight as possible.
In fracture of the leg between the knee and ankle we have pain, angular deformity or an apparent false joint in the leg, swelling and tenderness over the seat of fracture, together with inability to use the injured leg. Two bones form the framework of the leg; the inner, or shinbone, the sharp edge of which can be felt in front throughout most of its course, being much the larger and stronger bone. When both bones are broken, the displacement of the fragments, abnormal motion and consequent deformity, are commonly apparent, and a grating sound may be heard, but should not be sought for.
Fig. 27.Fig. 27.FRACTURE OF BOTH LEG BONES (Scudder).This cut shows the peculiar deformity in breaks of this kind; see position of kneepan; also prominence of broken bone above ankle.
FRACTURE OF BOTH LEG BONES (Scudder).
This cut shows the peculiar deformity in breaks of this kind; see position of kneepan; also prominence of broken bone above ankle.
An open wound often communicates with the break, making the fracture compound, a much more serious condition. To avoid making the fracture a compoundone, during examination of the leg, owing to the sharp ends of the bony fragments, the utmost gentleness should be used. Under no circumstances attempt to move the fragments from side to side, or backward and forward, in an effort to detect the grating sound often caused by the ends of broken bones. The greatest danger lies in the desire to do too much. We again refer the reader to First Aid Rule 1.
Fig. 28.Fig. 28.BANDAGE FOR BROKEN LEG (Scudder).Note the pillow brought up around leg and edges pinned together; also length and method of fastening splint with straps.
BANDAGE FOR BROKEN LEG (Scudder).
Note the pillow brought up around leg and edges pinned together; also length and method of fastening splint with straps.
When one bone is broken there may be only a point of tenderness and swelling about the vicinity of the break and no displacement or grating sound. When in doubt as to the existence of a fracture always treat the limb as if a fracture were present. "Black and blue" discoloration of the skin much more extensive than that following sprain will become evident over the whole leg within twenty-four hours.
Treatment.—When a surgeon cannot be obtained,the following temporary pillowdressing, recommended by Scudder in his book on fractures, is one of the best. With the patient on his back, the leg having been straightened and any deformity removed as far as possible by grasping the foot and pulling directly away from the body while an assistant steadies the thigh, a large, soft pillow, inclosed in a pillowcase, is placed under the leg. The sides of the pillow are brought well up about the leg and the edges of the pillowcase are pinned together along the front of the leg.
Then three strips of wood about four inches wide, three-sixteenths to a quarter of an inch thick, and long enough to reach from the sole of the foot to about four inches above the knee, are placed outside of the pillow along the inner and outer aspects of the leg and beneath it. The splints are held in place, with the pillow as padding beneath, by four straps of webbing (or if these cannot be obtained, by strips of stout cloth, adhesive plaster, or even rope); but four pads made of folded towels should be put under the straps where they cross the front of the leg where little but the pillowcase overlaps. These straps are applied thus: one above the knee, one above the ankle, and the other two between these two points, holding all firmly together. This dressing may be left undisturbed for a week or even ten days if necessary. (See Figs.27and28.)
The leg should be kept elevated after the splints are applied, and steadied by pillows placed either sideof it. From one to two months are required to secure union in a broken leg in adults, and from three to five months elapse before the limb is completely serviceable. In children the time requisite for a cure is usually much shorter.
ANKLE-JOINT FRACTURE.
First Aid Rule.—One or both bones of leg may be broken just above ankle. Foot is generally pushed or bent outward. Prepare two pieces of thin wood, four inches wide and long enough to go from sole of foot to just below knee:—the splints. Pad them with folded towels or pieces of blanket.
While assistants pull bones apart gently, one pulling on knee, other pulling on foot and turning it straight, apply the splints, one each side of the leg.
A fracture of the ankle joint is really a fracture of the lower extremities of the bones of the leg. There are present pain and great swelling, particularly on the inner side of the ankle at first, and the whole foot is pushed and bent outward. The bony prominence on the inner side of the ankle is unduly marked. The foot besides being bent outward is also displaced backward on the leg. This fracture might be taken for a dislocation or sprain of the ankle. Dislocation of the ankle without fracture is very rare, and when the foot is returned to its proper position it will stay there, while in fracture the foot drops back to its former displacedstate. In sprained ankle there are pain and swelling, but not the deformity caused by the displacement of the foot.
This fracture may be treated temporarily by returning the foot to its usual position and putting on side splints and a back splint, as described for the treatment of fracture of the leg.
COMPOUND OR OPEN FRACTURE OF THE LEG.—This condition may be produced either by the violence which caused the fracture also leading to destruction of the skin and soft parts beneath, or by the end of a bony fragment piercing the muscles and skin from within. In either event the result is much more serious than that of an ordinary simple fracture, for germs can gain entrance through the wound in the skin and cause inflammation with partial destruction or death of the part.
Treatment.—Immediate treatment is here of the utmost value. It is applicable to open or compound fracture in any part of the body. The area for a considerable distance about the wound, if covered with hair, should be shaved. It should then be washed with warm water and soap by means of a clean piece of cotton cloth or absorbent cotton. Then some absorbent cotton or cotton cloth should be boiled in water in a clean vessel for a few minutes, and, after the operator has thoroughly washed his hands, the boiled water (when sufficiently cool) should be applied to the wounded area and surrounding parts with the boiledcotton, removing in the most painstaking way all visible and invisible dirt. By allowing some of the water to flow over the wound from the height of a few feet this result is favored. Finally some of the boiled cotton, which has not been previously touched, is spread over the wound wet, and covered with clean, dry cotton and bandaged.
Splints are then applied as for simple fracture in the same locality (p.113). If a fragment of bone projects through the wound it may be replaced after the cleansing just described, by grasping the lower part of the limb and pulling in a straight line of the limb away from the body, while an assistant holds firmly the upper part of the limb and pulls in the opposite direction. During the whole process neither the hands of the operator nor the boiled cotton should come in contact with anything except the vessel containing the boiled water and the patient.
FOOTNOTES:[5]The engravings illustrating the chapters on "Fractures" and "Dislocations" are from Buck's "Reference Handbook of Medical Science," published by William Wood & Co., New York; also, Scudder's "Treatment of Fractures" and "American Text-Book of Surgery," published by W. B. Saunder's Company, Philadelphia.[6]It should be distinctly understood that the information about fractures is not supplied to enable anyone to avoid calling a surgeon, but is to be followed only until expert assistance can be obtained and, like other advice in this book, is intended to furnish first-aid information or directions to those who are in places where physicians cannot be secured.[7]For treatment of compound fracture, see Compound Fracture of Leg (p.116).[8]This method follows closely that recommended by Scudder, in his book "The Treatment of Fractures."
[5]The engravings illustrating the chapters on "Fractures" and "Dislocations" are from Buck's "Reference Handbook of Medical Science," published by William Wood & Co., New York; also, Scudder's "Treatment of Fractures" and "American Text-Book of Surgery," published by W. B. Saunder's Company, Philadelphia.
[5]The engravings illustrating the chapters on "Fractures" and "Dislocations" are from Buck's "Reference Handbook of Medical Science," published by William Wood & Co., New York; also, Scudder's "Treatment of Fractures" and "American Text-Book of Surgery," published by W. B. Saunder's Company, Philadelphia.
[6]It should be distinctly understood that the information about fractures is not supplied to enable anyone to avoid calling a surgeon, but is to be followed only until expert assistance can be obtained and, like other advice in this book, is intended to furnish first-aid information or directions to those who are in places where physicians cannot be secured.
[6]It should be distinctly understood that the information about fractures is not supplied to enable anyone to avoid calling a surgeon, but is to be followed only until expert assistance can be obtained and, like other advice in this book, is intended to furnish first-aid information or directions to those who are in places where physicians cannot be secured.
[7]For treatment of compound fracture, see Compound Fracture of Leg (p.116).
[7]For treatment of compound fracture, see Compound Fracture of Leg (p.116).
[8]This method follows closely that recommended by Scudder, in his book "The Treatment of Fractures."
[8]This method follows closely that recommended by Scudder, in his book "The Treatment of Fractures."
Dislocations
How to Tell a Dislocation—Reducing a Dislocated Jaw—Stimson's Method of Treating a Dislocated Shoulder—Appearance of Elbow when Out of Joint—Hip Dislocations—Forms of Bandages.
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.—Assistant 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 theear, while a corresponding prominence exists on the opposite side of the face, and the lower front teeth project beyond the upper front teeth.
Fig. 29.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.
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 byplacing 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 assistant 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. (SeeFig. 29.)
DISLOCATION OF THE SHOULDER.—This is by far the most common of dislocations in adults, constituting 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 treatmentof 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.)
Fig. 30.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.
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 pullsthe arm directly outward (i. e., with the arm at right angles with the body) and away from the trunk. An assistant 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.)
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.
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.
Fig. 33.Fig. 33.TREATMENT OF DISLOCATED ELBOW (Scudder).Note padded right-angled tin splint; also three strips of surgeon's plaster on arm and forearm.
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 upperarm is often seen and felt very easily just above the bend of the elbow in front, as it is thrown forward (seeFig. 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.
Treatment.—The treatment for dislocation consists in bending the forearm backward to a straight line, or even a little more, and then while an assistant holds firmly the arm above the elbow, the forearm should be grasped below the elbow and pulled with great force away from the assistant and, while exerting this traction, the elbow is suddenly bent forward to a right angle, when the bones should slip into place.
The after treatment is much the same as for most fractures of the elbow. The arm is retained in a well-padded right-angled tin splint which is applied with three strips of surgeon's plaster and bandage to the front of the arm and forearm (seeFig. 33) for two or three weeks. The splint should be removed every few days, and the elbow joint should be moved to andfro gently to prevent stiffness, and the splint then reapplied.
DISLOCATION OF THE HIP.—This occurs more commonly in males from fifteen to forty-five years of age, and is due to external violence. In the more ordinary form of hip dislocation the patient stands on the sound leg with the body bent forward, the injured leg being greatly shortened, with the toes turned inward so much that the foot of the injured limb crosses over the instep of the sound foot. The injured limb cannot be moved outward and but slightly inward, yet may be bent forward. Walking is impossible. Pain and deformity of the hip joint are evident.
The only condition with which this would be likely to be confused is a fracture of bone in the region of the hip. Fracture of the hip is common in old people, but not in youth or middle adult life. In fracture there is usually not enough shortening to be perceived with the eye; the toes are more often turned out, and the patient can often bear some weight on the limb and even walk.
Treatment.—The simplest treatment is that recommended by Stimson, as follows: the patient is to be slung up in the air in a vertical position by means of a sheet or belt of some sort placed around the body under the armpits, so that the feet dangle a foot or so from the floor, and then a weight of about ten or fifteen pounds, according to the strength of the patient's muscles, is attached to the foot of the injured leg (bricks, flatirons, or stones may be used), and this weight will usually draw the bone down into its socket within ten or fifteen minutes.
Fig. 34.Fig. 34.REDUCING DISLOCATION OF HIP (Reference Handbook).Patient lying on table; uninjured leg held by assistant; leg of dislocated side at right angles; note weight at bend of knee.
REDUCING DISLOCATION OF HIP (Reference Handbook).
Patient lying on table; uninjured leg held by assistant; leg of dislocated side at right angles; note weight at bend of knee.
Or the patient may assume the position shown in the accompanying cut, lying prone upon a table with the uninjured leg held horizontally by one person, while another, with the injured thigh held vertically and leg at right angles, grasps the patient's ankle and moves it gently from side to side after placing a five-to ten-pound sand bag, or similar weight of other substance, at the flexure of the knee. When the dislocation has been overcome the patient should stay in bed for a week or two and then go about gradually on crutches for two weeks longer.
SURGICAL DRESSINGS.—Sterilized gauze is the chief surgical dressing of the present day. This material is simply cheese cloth, from which grease and dirt have been removed by boiling in some alkaline preparation, usually washing soda, and rinsing in pure water. The gauze is sterilized by subjecting it to moist or dry heat. Sterilized gauze may be bought at shops dealing in surgeons' supplies and instruments, and at most drug stores. Gauze or cheese cloth may be sterilized (to destroy germs) by baking in a slow oven, in tin boxes, or wrapped in cotton cloth, until it begins to turn brown. It is well to have a small piece of the gauze in a separate package, which may be inspected from time to time in order to see how the baking is progressing, as the material to be employed for surgical purposes should not be opened until just before it is to be used, any remainder being immediately covered again. Cut the gauze into pieces as large as the hand,before it is sterilized, to avoid cutting and handling afterwards. Gauze may also be sterilized by steaming in an Arnold sterilizer, such as is used for milk, or by boiling, if it is to be applied wet. Carbolized, borated, and corrosive-sublimate gauze have little special value.