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Dislocations of the Shoulder.The shoulder joint is arranged so as to afford a very extensive range of motion ; hence, it is impossible that the socket should be very deep. As a matter of fact, the bony socket of the shoulder joint is quite shallow, and affords but little purchase to hold the head of the arm-bone. The socket is, however, deepened by a rim of cartilage placed around the bony edge. Yet, notwithstanding this arrangement, the head of the arm-bone is easily displaced from its attachment to the shoulder-blade. This accident may result from direct as well as indirect violence. It is most frequently caused perhaps by blows or falls upon the shoulder; it often results from falls in which the weight of the body strikes upon the hand or forearm. The accident happens though more rarely as the result of violent muscular efforts, such as are made in lifting heavy weights. Signs.-The head of the arm-bone may be displaced in any one of four ways : that is, it may take any one of four positions, outside of the shoulder joint. In order to understand these, the reader must have a slight knowledge of the anatomy of the joint. Just above the shallow socket of the shoulder-blade, in which the head of the arm-bone rests, there is a bony projection, which constitutes the point of the shoulder. This is called the acr07ni0n process of the shoulder-blade. Just in front of this, at the outer end of the collar-bone, is another projection from the shoulder-blade, which is called the coracoid process. The acromion process prevents the head of the bone from being forced upward, but it sometimes escapes into the cavity just under the coracold process. This is not always a complete dislocation ; that is, the head of the bone usually rests upon the edge of its proper socket. This variety of dislocation - in which the head of the bone is located under the coracoid process of the shoulder-blade - is easily recognized by the existence of a lump just under the outer extremity of the collar-bone. By comparing the shoulder with the sound one of the opposite side, it will also be noticed that the injured shoulder is flatter and more pointed than the other. A second dislocation of the head of the arm-bone is that in which the arm is displaced into the armpit. The head of the bone lies, therefore, just under the socket where it belongs. In a third form, the head of the arm-bone is thrown forward onto the ribs, usually lying between the second and third rib. This is a very rare dislocation. In the fourth variety of dislocation, the head of the arm-bone is displaced backward onto the shoulder-blade. There are also other varieties which occasionally happen, and are recorded in the literature of surgery. Their occurrence is, however, so rare that no discussion of them is necessary. All dislocations of the arm-bone are accompanied by extreme pain in the arm and shoulder, and almost always by a numbness of the fingers and arm of the injured side. This numbness results from the pressure of the dislocated bone upon the large nerves which pass to the arm directly under the shoulder joint. The extent of these symptoms varies with the amount of damage done to the tissues during the escape of the bone from its socket. The most frequent dislocation is that in which the head of the one is displaced downward and lies in the armpit. The signs of this dislocation are : First-The position of the arm. The elbow stands out from the side, while the upper end of the bone is plainly felt in the arm pit. Second-Flattening of the shoulder. This is readily understood when we remember that the natural prominence of the shoulder is due largely to the head of the arm-bone, and to the powerful muscle which covers it. When the bone is dislocated into the armpit, there remains a cavity in the position formerly occupied by the rounded head of the bone. Moreover, the acromion process, that sharp projection from the shoulder-blade, gives to the shoulder a pointed and square appearance which strikes the eye at once, especially if it be compared with the uninjured shoulder of the opposite side. Third-The immobility of the arm. All attempts to move the arm, either by the patient himself or by another person, are ineffectual in causing any extended movement. Such efforts induce extreme pain. A characteristic feature can be brought out by the attempt to place the hand of the injured arm upon the opposite shoulder. It is often impossible to accomplish this at all; if it can be done it will be noticed that the elbow of the injured arm is widely separated from the chest when the hand rests upon the opposite shoulder; if the elbow be kept in contact with the body, it will be quite impossible to place the hand on the shoulder. Fourth-The lengthening of the arm. If a tape measure be , stretched from the point of the injured shoulder to the point of the elbow, the forearm meanwhile being bent, it will be found that this distance is perceptibly greater than the corresponding measurement on the sound side. Dislocation of the head of the arm-bone under the coracoid process of the shoulder-blade, can readily be made out by feeling the head of the bone in this unusual position. By taking hold of the elbow and rotating the arm, we can feel that the head of the bone, which constitutes the lump, moves with every movement of the arm. In this dislocation the elbow is usually turned away from the body, though not to the same extent as in the dislocation into the armpit. The dislocation of the head of the bone backward onto the shoulder-blade is readily detected by the presence of a lump in this new position as well as by the unnatural flatness of the shoulder. The loss of motion and unnatural position of the arm are evident as in the former cases. In this dislocation the elbow is usually situated near the side, instead of away from the chest. Dislocations of the head of the arm-bone are usually recognized without difficulty, provided there be no complications of any sort. There are, however, many cases in which dislocations are accompanied by fractures, and others in which the fractures alone present in many respects the symptoms usually found in dislocations. The most frequent accidents which are apt to be mistaken for dislocations are : Fracture of the acromion process of the shoulder-blade; fracture of the outer end of the shoulder-blade ; and fracture of the arm-bone just below the socket. The two first-mentioned fractures can easily be distinguished from dislocations by the fact that the deformity of the shoulder is easily remedied by simply lifting the elbow upward ; so soon as the arm is unsupported, the shoulder drops again. In case of dislocation this restoration of the form of the shoulder is impossible. Furthermore, if one of the fractures named be present, the movements of the arm are not especially impaired ; while if the injury be a dislocation, the arm remains fixed. In these fractures as well as others, a grating sensation can be felt when the fragments are rubbed against each other ; in cases of dislocation there is no grating sensation to be perceived. Fractures of the arm-bone near the socket of the shoulder joint are easily detected by the usual mobility of the arm and by the grating sensation which can be detected when the arm is moved. There are, however, cases in which the dislocation of the bone is complicated with one of the fractures already mentioned. In these cases it often puzzles even an experienced surgeon to detect the exact nature of the difficulty. For the symptoms of both fracture and dislocation are present and counteract to a certain extent one another's significance. Treatment.-There are several methods for reducing dislocations, any one of which can usually be made to succeed in skillful hands. To reduce a dislocation of the arm-bone into the armpit - commonly called a downward dislocation - it is necessary to draw the arm downward in order to enable the head of the bone to ride over the edge of the cavity in which it should rest ; at the same time the upper part of the arm must be pressed outward, so as to give the head of the bone a chance to regain its socket. It will be remembered that the chief obstacle in the reduction of dislocation is the muscular contraction whereby the bone is firmly fixed in its unnatural position. It is therefore necessary to use considerable force in restoring the bone to its place. The most common method was until recently the plan com monly known as " placing the heel in the armpit. " To perform this operation the patient, stripped to the waist, is laid upon a hard bed or upon blankets placed upon the floor. The operator removes the boot from the left foot if the patient's left shoulder be dislocated, and from the right foot in dislocation of the right shoulder. He then seats himself upon the bed, opposite the patient's hips, and places the foot in the armpit. He then grasps the arm at the elbow, preferably by means of a towel or soft cloth wound tightly around the limb. The operator then pulls firmly upon the arm, so that it shall move downward and outward, bracing himself meanwhile with the foot against the shoulder. After the pulling has been continued for half a minute, the arm should be gently carried inward toward the patient's body, so that the upper end of the bone shall be forced outward and shall reach the socket. Another method consists in placing the patient upon a chair, in a sitting posture ; the operator puts his foot upon the seat of the chair, so that the knee shall rest in the patient's armpit ; the arm is then pulled outward and downward, while the shoulder is forced against the supporting knee. After this effort has been continued for twenty or thirty seconds, the elbow is pressed inward under the operator's thigh, so that the head of the bone is brought outward to its socket. This method, it will be seen, involves just the same principles as the one in which the operator's heel is placed in the patient's armpit. These methods are usually successful, though they are not by any means scientific ; the success is attained by main force and not by skill. At the present time surgeons employ a method which secures a reduction of the dislocated bone without the exercise of force. The principle upon which this method is based consists simply in placing the arm in the position which it occupied at the moment of dislocation. The method is known as that of "manipu lation. It is practically impossible to describe in detail the manipulations by which dislocations of the shoulder can be readily reduced, but it may be said that an approximation to this method can be performed in essentially the following way : The patient is laid upon a hard bed, or upon the floor ; the operator grasps the arrn at the elbow, while an assistant holds the shoulders firmly. The arm is then drawn downward and is made to describe a semicircle, the elbow being carried from the side and brought upward above the head ; after it has reached this position, the arm is drawn upward away from the body. In most cases the bone slips back into place during this movement. In the dislocation forward onto the chest or backward onto the shoulder-blade, the bone can usually be replaced by placing the heel in the armpit, or by the method last described, in which the arm is swept around from the body to a position in which the elbow lies above the head. Some difficulty may however be experienced, difficulty which can be overcome only by a knowledge of the anatomy of the structures concerned. In almost every case the successful reduction of the bone is indicated by a " click " at the moment when the head of the arm bone falls into the socket. Even if this do not occur, the restoration of the displaced bone is indicated at once by the freedom of movement exhibited by the arm as well as by the restoration of the natural form to the shoulder. If these methods fail to secure the replacement of the bone, and if the services of a surgeon cannot be procured, ether should be administered to the patient. The object of this is to relax the muscles of the body ; after this has been accomplished, the bone can often be reduced with ease, even though it has resisted violent efforts while the patient was conscious. It is important that every dislocation be reduced within a few days at the latest ; for if it be permitted to remain, the reduction becomes a matter of great difficulty and even danger. After a bone has remained out of place for several weeks, it becomes bound in its new position by bands or ligaments, while its former socket is often filled up by similar tissue. Under these circumstances the effort to reduce the dislocation is opposed not only by the muscular contraction, but also by these new tissues. It is, indeed, often possible for an experienced surgeon to reduce a dislocation which has existed for some months, but such an attempt should never be made by an inexperienced person. After the dislocation has been reduced, the arm should be suspended in a sling and firmly bound to the side of the chest by means of a broad bandage which passes around the body. Two or three turns of a bandage should also be passed under the elbow and over the shoulder, so as to support the arm and prevent it from slipping out of place. This bandage should be worn for a week or ten days at least, after which the arm should be supported in a sling. For several months, great care should be observed not to subject the shoulder to any severe strain, since the bone can be very easily dislocated a second time. But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy! Also, please consider sharing our helpful website with your online friends.
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