Reduction (orthopedics)

“ This mode of reduction, and the one formerly described, are not natural, and yet by rotating the bone of the joint, they force it to return.
Part III Those who attempt to perform reduction with the heel, operate in a manner which is an approach to the natural. The patient must lie on the ground upon his back, while the person who is to effect the reduction is seated on the ground upon the side of the dislocation ”

“ Dislocation tends to occur from the disturbance of muscular balance, anterior dislocation being commoner than posterior in about the proportion of two to one; the nature of the dislocation is best demonstrated by means of the X-rays. Reduction is rarely possible without an open operation. Tendon and nerve-transplantation are scarcely possible, and arthrodesis is rarely to be recommended; contracture deformities, however, are often benefited by tenotomy in young children, and in older children by osteotomy through the trochanter, and putting the limb up in the abducted position. ”

“ The reduction of a fracture is the effort made by the surgeon to overcome any tendency to displacement, and thus to place the fragments in such close apposition that an accurate and firm union is possible. The best time in general for the reduction of a fracture is as soon as possible after the accident, if the patient’s general condition will permit. If there is marked displacement of fragments, so that there is danger of necrosis of the overlying skin or of damage to the adjacent vessels or nerves, an early reduction is imperative. ”

“ Changes of the nature of chronic arthritis are liable to occur in and around the joint in old and rheumatic subjects; and atrophy or paralysis of muscles may follow, if their nerves are implicated.
Old-standing Dislocation.—It is impossible to lay down any time-limit for attempting reduction in old-standing dislocations of the hip. Manipulation may succeed in cases of some months' standing, and may fail when the bone has been out only a few weeks. In certain cases, even after reduction has been effected, there is a marked tendency to re-displacement. ”

“ Every hour of delay increases the difficulty. The guiding principle is to cause the displaced bone to re-enter its socket by the same route as that by which it left it—that is, through the existing rent in the capsule. This is done by carrying out certain manipulations which depend upon the anatomical arrangement of the parts, and which vary, not only with different joints, but also with different varieties of dislocation of the same joint. In general terms it may be said that the main impediments to reduction are: the contraction of the muscles acting upon the displaced bone ”

“ A second obstacle, more difficult to be surmounted in the process of reduction, is that arising from the long continuance of the luxation. The head of the bone, having continued for a long time in the bed into which it has been accidentally thrown, forms adhesions to it; the surrounding cellular membrane becomes thickened, and makes, so to speak, a new capsule for the head, which opposes its replacement, and, when the reduction cannot be accomplished, supplies in some measure the office of the old joint, by the movements which it allows to take place. ”

“ The modes of reduction are these: by flexion at the knee, or by sudden calcitration, or having rolled a swathe into a ball, and fixed it in the ham, the patient's body is to be suddenly dropped on its bended knees. Dislocation backward, also, as in the case of the elbow, may be reduced by moderate extension, and to either side, either by flexion or calcitration, but also by moderate extension. The adjustment is the same in all cases. In dislocations backward which are not reduced, the patient cannot bend the joint, but neither can he, to any great extent, in the other varieties ”

“ In general recent dislocations are easily reduced, but when the head of a bone has been out of its place for several days the reduction becomes exceedingly difficult, and as a rule the difficulty of reduction arising from the muscles is proportioned to the length of time that has elapsed from the period of the accident. ”

“ If things be properly arranged, a slight effort is sufficient to bring the separated fragments into contact and to restore to the limb its natural form; for, as I have already observed (86) , a facility of reduction is even one of the characters of this fracture. But it is very difficult for art to maintain permanently what she easily effects at the time of reduction, and on this account, our curative processes are oftentimes insufficient. ”

“ The administration of an anaesthetic, by relaxing the muscles, greatly assists the operation of reduction. The length of time that a joint has to be kept quiet after it has been restored to its normal shape depends on its form, but, as a rule, early movement is advisable. But when by the formation of the bones a joint is weak, as at the outer end of the collar-bone, and at the elbow-end of the radius, prolonged rest for the joint is necessary or dislocation may recur. ”

“ Treatment.—To reduce the displacement, the patient is placed on a couch, and, after the knee is fully flexed, the leg is rotated laterally and abducted, to separate the medial femoral condyle from the tibia, and while the rotation and abduction are maintained the leg is quickly extended. The return of the meniscus to its place is sometimes attended with a distinct snap, but in other cases reduction is only recognised to have taken place by the fact that the joint can be completely extended without causing pain. ”

“ The surgeon, taking me by the arm, said, “You seem to have a strong back; lay hold of that rope and pull.” I laid hold of the rope. There were already two men in front of me and we all three pulled our best. I had no idea what56 we were pulling for. I was afterwards informed that the operation in progress was the reduction of a dislocated hip by compound pulleys. The hip, however, was not reduced and the man remained lame for life. At the present day a well-instructed schoolgirl could reduce a recent hip dislocation unaided. ”

“ In all dislocations reduction is to be effected, if possible, immediately, while still warm, but otherwise, as quickly as it can be done; for reduction will be a much easier and quicker process to the operator, and a much less painful one to the patient, if effected before swelling comes on. ”

“ Moreover, it is to be expected, that the articular extremities of the bones of the fingers will for this generally happens, if even the least degree of inflammation take place, so that if it were not that the physician would be exposed to censure, owing to the ignorance of the common people, no reduction should be made at all. The reduction of the bones of joints which have protruded through the skin, is attended with the dangers which have been described. ”

“ In reducing a dislocation, no amount of physical force will compensate for a want of anatomical knowledge. All tugging, twisting, or wrenching movements are to be avoided, as they are liable to cause damage to blood vessels, nerves, or other soft parts, or even—and especially in old people—to fracture one of the bones concerned.
After reduction, great benefit is gained by the systematic use of massage and movement. Before any restraining apparatus is applied the whole region should be gently stroked in a centrifugal direction for fifteen or twenty minutes ”

“ In an incomplete fracture, where there is no displacement, the necessity of reduction does not exist. With the bone kept in place by an intact periosteum, and the fragments secured by the uninjured fibrous and ligamentous structure which surrounds them, there is no dislocation to correct. Reduction is also at times rendered impossible by the seat of the fracture itself, by its dimensions, alone, or by the resistance arising from muscular contraction. ”

“ Splints are not to be used.
Part LXXXVII When the foot is dislocated, either alone or along with its epiphysis, the displacement is, for the most part, to the inside. If not reduced, in the course of time, the hip, the thigh, and the side of the leg opposite the dislocation, become atrophied. Reduction is the same as in the wrist, but the extension requires to be very powerful. Treatment, agreeably to the general rule for joints. Exacerbations do occur, but less frequently than in dislocations at the wrist, provided the parts get rest. While they remain at rest the diet should be restricted. ”

“ It belongs to the surgeon to examine and ascertain, when the natural connexions of the joint are sufficiently confirmed. Then motions, at first gentle, are to be impressed on the limb; being afterwards gradually increased, they remove by degrees that stiffness, which usually follows a dislocation, particularly an old one. But if it has existed too long, to give the limb motion, is then the only resource: the new attachments or adhesions, contracted by the articulating surfaces in their displaced state, render reduction impracticable. ”

“ The younger the patient is, the greater care should be bestowed on him; when neglected, the case gets worse; when attended to, it improves; and, although there be atrophy in all parts of the limb, it is to a less extent.
Part XXII When there is a dislocation on both sides, the affections of the bones are the same; the flesh is well developed, except within, the nates protrude, the thighs are arched, unless there be sphacelus. If there be curvature of the spine above the hip-joint, the patients enjoy good health, but the body does not grow, with the exception of the head. ”

“ An open operation is seldom necessary.
Dislocation forward is rare. It results from forced flexion of the thumb with abduction, tearing the posterior and medial collateral ligaments. The deformity is characteristic: the rounded head of the metacarpal projecting behind the level of the joint, while the base of the phalanx forms a prominence among the muscles of the thenar eminence.
Reduction is easily effected by making traction on the phalanges and carrying out movements of flexion and extension. ”

“ Operative treatment is almost never of any avail, as the cord is not merely pressed upon, but is severely crushed, or even completely torn across. Even when the cord is only partially torn, operative treatment is not likely to yield better results than are obtained by reduction and extension. ”

“ A small degree of force, judiciously directed according as the displacement is inward or outward, is sufficient to effect the reduction, which even takes place of its own accord, under this process. If the surgeon lays his hands on the place of fracture, it is rather to examine the state of the fragments, than to assist in bringing them into apposition. ”

“ Permanent extension is, say some, insufficient to overcome muscular action; it is opposing to a power equal to 1000, a resistance equal to only 100. But this force of the muscles, which is oftentimes so great at the time of reduction, diminishes gradually, by the pressure of the bandages, by the immobility of the limb, and, above all, by long continued extension; for a continued effort equal to 10, will soon perform what could not be effected by a temporary exertion of a force equal to 100. ”

“ When the luxation is of long standing, it is always attended with more or less difficulty, occasioned by the adhesions of the surrounding soft parts to the articulating surfaces, by the thickening of the capsule, which diminishes the size of its opening, by the rigidity contracted by the whole part, &c. It is, in such cases, useful to employ emollient applications for some time previously to attempting the reduction, in order to produce such a relaxation, and diminution of the congestion, as may favour the efforts of the surgeon. ”

“ There are various methods of reducing the redundant bones and cartilage; those involving submucous excision [450] are difficult to perform for the inexperienced operators, and the external means of reduction are advised to be followed. The resultant scar, if the skin has been properly incised and not damaged by retracting pressure, and, lastly, properly and neatly sutured, should be barely visible.
Monk’s Method.—This author made a small incision through the skin just posterior to the inferior edge of the lobule, as in Fig. ”

“ How much should be removed?—In the elbow-joint, more than any other joint in the body, complete excision is absolutely necessary; any portion of the articular surface being left proves a source of unfavourable result.
The surgeon is apt to err rather in removing too little than too much. For the removal of too little bone is, on the one hand, apt to result in long-standing sinuses, on the other, to induce anchylosis. ”

“ In the hip-joint especially, all the resources of the art should be tried in the expectant treatment, for amputation at the hip-joint is hardly ever admissible for disease of the joint, while excision has anything but satisfactory statistics. ”

“ Before performing arthrodesis, the surgeon must decide whether the patient will be better off with a stiff joint or with a weak and movable ankle supported by apparatus. This is often a matter of social position; in the poor, an ankylosed joint is more useful and less expensive. An arthrodesis should seldom be performed at the ankle until the child has passed his eighth year, or at the knee until he has reached his twentieth year. ”