Compound Dislocations
Compound dislocations are usually the result of extreme violence produced by machinery or railway accidents, or by a fall from a height. In the majority of cases they are complicated by fracture of one or more of the constituent bones of the joint, as well as by laceration of muscles, tendons, and blood vessels. In the region of the ankle, wrist, and joints of the thumb, however, compound dislocation is sometimes met with uncomplicated by other lesions. The great risk is infection, which may result in serious impairment of the usefulness of the joint or even in its complete destruction, results towards which the concomitant injuries materially contribute. In many instances where infection has occurred, ankylosis is the best result that can be hoped for.
Treatment of Compound Dislocation
As a rule, the first question that arises is whether amputation is necessary or not, and the considerations that determine this point are the same as in compound fractures . If an attempt is to be made to save the limb, the treatment is the same as in compound fracture .
Dislocation complicated by Fracture In certain dislocations the separation of small portions of bones or of epiphyses is of common occurrence—for example, fracture of the tip of the coronoid process in dislocation of the elbow backwards, and chipping off of a portion of the edge of the acetabulum in dislocation of the hip.
The most important example of a fracture complicating a dislocation is fracture of the surgical neck of the humerus coexisting with dislocation of the shoulder. Here the difficulty of diagnosis is greatly increased, and the treatment of both injuries requires to be modified. The dislocation must be reduced—by operation if necessary—before the fracture is treated, and in many cases it is advisable to secure the fragments of the broken bone by pegs, or plates, to admit of movement being commenced early, and so to prevent stiffness of the joint.
Old-standing Dislocations.—When, from want of recognition—and, curiously enough, a dislocation is much more liable to be overlooked than would have been thought possible—or from unsuccessful treatment, a dislocation is left unreduced, changes take place in and around the joint which render reduction increasingly difficult or impossible. The rent in the capsule closes upon the neck of the bone, and fibrous adhesions form between muscles, tendons, and other structures that have been torn. The articular cartilage of the head, being no longer in contact with an opposing cartilage, tends in time to be converted into fibrous tissue, and may become adherent to other fibrous structures in its vicinity. By pressing on adjacent structures it may form for itself a new socket of dense fibrous tissue which in time becomes lined with a secreting membrane. When the displaced head lies against a bone, the continuous pressure produces a new osseous socket, from the margins of which osteophytic outgrowths may spring, and as the surrounding fibrous tissue becomes condensed and forms a strong capsule, a new joint results. The occurrence of these changes in the direction of a new ball-and-socket joint is largely dependent on the behaviour of the patient: a vigorous man, anxious to recover the use of the limb, will employ it with a degree of determination and indifference to pain that could not be expected in a sensitive elderly female. The most perfect example of a new ball-and-socket joint, following upon an unreduced dislocation at the hip, that has come under our observation, was in a hunting dog, given one of us by an Australian pupil, who testified that the animal was as fleet with the new joint as it had been with the original one. Meanwhile the cartilage of the original socket is converted into fibrous tissue, which may come to fill up the cavity. Changes resembling those of arthritis deformans may occur. The large blood vessels and nerves in the vicinity may be pressed upon or stretched by the displaced bone, or may be implicated in fibrous adhesions. In course of time they become lengthened or shortened in accordance with the altered attitude of the limb.
In many cases the new joint is remarkably mobile and useful; but in others, pain, limited movement, and atrophy of muscles render it comparatively useless, and surgical intervention is called for.
Treatment .—It is always a difficult problem to determine the date after which it is inadvisable to attempt reduction by manipulation in an old dislocation and no rules can be laid down which will cover all cases. Rather must each case be decided on its own merits, due consideration being had to the risks that attend this line of treatment. The chief of these are: rupture of a large blood vessel or nerve that has formed adhesions with the displaced bone, or has become shortened in adaptation to the altered shape or length of the limb; tearing of muscles or tendons, or even of skin; fracture of the bone, especially in old people; and separation of epiphyses in the young.
Before carrying out the manipulations appropriate to the particular dislocation, all adhesions must first be broken down; and during the proceedings no undue force is to be employed. The first attempt at reduction may fail, and yet subsequent efforts, at intervals of a few days, may ultimately prove successful; the vigorous traction and twisting of the soft parts, matted together as they are by scar-tissue, causes reactive changes in the vessels and tissues which render them more liable to yield on subsequent attempts at reduction. In old people, and where there is an absence of suffering from pressure on nerves or vessels, it may be wiser to leave the dislocation unreduced, and strive rather by massage and movement to obtain a useful variety of false joint. If the conditions are otherwise, it may be better to improve the function of the limb by an open operation. Tight ligaments and other structures are divided, and the socket is cleared out. If reduction is still impossible, a partial excision may be performed and a flap of fascia lata introduced to prevent ankylosis (arthroplasty). In the case of the hip, the dislocation may be left alone and the femur divided below the trochanter, especially if there is pronounced flexion.
Habitual or recurrent dislocation is almost exclusively met with in the shoulder, and will be described with the injuries of that joint.
Pathological Dislocations.—Joints may become dislocated in the course of certain diseases. These pathological dislocations fall into different groups: (1) those due to gradual stretching of the capsular and other ligaments weakened by inflammatory and suppurative processes, such as sometimes follow on typhoid, scarlet fever, or diphtheria, and in pyæmia; (2) those due to destructive changes in the ligaments and bones—typically seen in tuberculous arthritis, in arthritis deformans, in Charcot’s disease, and in nerve lesions, e.g. dislocation of the hip in spastic conditions, such as Little’s disease; (3) those associated with deformed attitudes of the limb; (4) those due to changes in the articular surfaces, e.g. the phalanges in arthritis deformans. These will be considered with the conditions which give rise to them.
Congenital Dislocations.—Congenital dislocations are believed to be the result of abnormal or arrested development in utero, and are to be distinguished from dislocations occurring during birth, which are essentially traumatic in origin. They will be described along with the Deformities of the Extremities.
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