The Practice and Applied Therapeutics of Osteopathy
Charles Hazzard, D. O.
1905
  
 
CHAPTER X
 
THE LIMBS
 
 
    I. SHOULDER DISLOCATIONS.  The head of the humerus may be dislocated downward into the axilla; forward beneath the clavicle; backward upon the scapula; or forward beneath the coracoid process.
    With the patient sitting, and the trunk fixed by an assistant, the practitioner stands at the side, rests his foot upon the stool and places his knee in the patient's axilla.  Traction is now made directly downward upon the arm, overcoming the tension of the muscles and drawing the head back into the glenoid fossa.  This treatment will answer for any of the dislocations
    The same object may be accomplished by placing the patient upon his back, while the practitioner stands at the side, places his stockinged foot in the axilla, and exerts strong traction upon the arm.
    II.  ELBOW DISLOCATIONS.  The radius and ulna may be both displaced backward, externally or internally; the ulna backward; the radius forward, backward, or outward.
    The patient sits, and the practitioner stands at the side with his foot resting upon the stool and his knee in the bend of the elbow.  The upper arm is fixed and traction is made strongly upon the forearm.  This will be sufficient for the first four dislocations.  When the radius is backward, direct pressure upon it is sufficient to reduce it.  When the radius is forward the hand is supinated, it is bent upon the wrist away from the radius, thus bringing traction upon it, while pressure is made upon the head of the bone above.  The outward dislocation of the radius is often accompanied by rupture of the orbicular ligament.  It is reduced by traction and pressure.
    III.  WRIST DISLOCATIONS.  The radius and ulna may both be forward, backward, or outward.  Simple traction will reduce them.
    IV.  RADIO-ULNAR DISLOCATIONS.  The radius is regarded as the fixed bone, the ulna being displaced forward or backward.  Direct pressure upon it will force it to its place.
    V.  CARPO-METACARPAL dislocations are more frequent in case of the thumb.  Direct pressure will reduce them.
    VI.  Dislocations of CARPAL bones are easily reduced by pressure.
    VII.  METACARPO-PHALANEAL dislocations in case of the thumb are most frequent.  For the backward one, continued strong hyper-extension, followed by flexion is used.  If this treatment does not succeed, the metacarpal is rotated and pressure is made upon its head.  In the forward displacement traction and pressure are employed, or strong flexion is followed by direct pressure.
    In ease of the fingers, simple traction and pressure are sufficient, as is also the ease in PHALANGEAL dislocations.
    These remarks apply to all cases of recent dislocation as described.  It more often comes within the Osteopath's province to work upon old dislocations, so frequently given over as incurable.  As far as possible he applies the usual motions for the reduction of them, but prepares the joint for reduction by a course of treatment directed to relaxing surrounding muscles, etc.; to restoration of free circulation about the part and the upbuilding of the tissues.  Often a persistent course of treatment restores a bone to position when it had been given up as hopeless.  These remarks apply especially to old dislocations of the hipjoint.
    GENERAL TREATMENT FOR THE UPPER LIMB.   In treatment for various conditions the arm is manipulated in special ways.
    I.  The shoulder-joint may be sprung to allow of free blood-flow in the ligaments.  The clenched hand is placed in the axilla, care being taken not to press the knuckles against the axillary lymphatics, or against the nerves and vessels on the inner side of the arm.  It is best to turn the hand sidewise.  The patientís arm is now forced against his side, springing the head of the humerous outward.
    II.  The elbow may be sprung by flexing the forearm over the hand placed upon the arm just above the bend of the elbow.  Or the fore-arm may be flexed to a right angle, and the treating hands draw it away from the lower end of the humerus.  They may follow along down the fore-arm, working deeply between radius and ulna to relax the interosseus tissues.
    III.  The branches of the brachial plexus and the axillary artery may be impinged against the inner side of the humerus just below the axilla.  Transverse friction reaches all these nerves and may be used to tone them.
    IV.  Contracture of the anterior fibres of the deltoid muscle and  attendant slight forward luxation of the head of the humerous, and may be remedied by grasping the arm just above the elbow and drawing it directly back and up to the level of the shoulder.  Now the arm is carried forward at the same level, and the movement is finished with a slight upward turn.
    V.  The biceps muscle and its long head may be strongly stretched by drawing the extended fore-arm directly backward and upward.
    VI.  The tendon of the long head of the biceps may be displaced from its groove, usually inward causing serious trouble in the arm.  It is then felt upon the anterior surface of the humerous and is very sensitive.  It May be stretched as in V, after which the arm is flexed and the tendon is pressed back into its groove.
    In such cases Dr. Still flexes the fore-arm to a right angle with the arm and, with a quick motion, swings it around against the front of the body, suddenly then raising the flexed arm outward laterally from the body up to a horizontal position.  The effect of this motion is to turn the groove of the humerous in toward the displaced tendon, which lodges against the carcoid process of the scapula.  The latter thus, so to speak is used to push the tendon into the groove, where it is secured 'by the sudden tension put upon it by raising the arm to the horizontal position.
 
 
GENERAL TREATMENT FOR THE LOWER LIMB
 
    I. Strong flexion of the thigh on the thorax and the leg upon the thigh stretches the quadriceps extensor muscle, but particularly the posterior portions of the gluteal muscles and the gluteal portion of the sciatic nerve. (See also VI below.)
    II.  Hyper-extension of the thigh stretches the anterior structures, including the femoral vessels and anterior crural nerve.
    III.  Hyper-extension of the foot stretches the anterior muscles of the leg.  Strong flexion of the foot stretches the calf muscles.
    IV.  Abductor muscles of the thigh are stretched by forced abduction.  The patient lies upon his back, the practitioner presses against one leg which remains upon the table, at the same time keeping the other leg straight and abducting it to the extreme.  He may stand between the legs.  The same object is accomplished by flexion combined with external circumduction.
    V.  The muscles of external rotation of the thigh are stretched by flexion combined with internal circumduction.
    VI.  The extensor muscles of the thigh are stretched by raising the straightened limb to or beyond right angles with the trunk.  This may be accomplished with the patient on his back.  The limb, still straight, may be supported at right angles while the foot is strongly flexed on the leg.  This stretches the sciatic nerve.  This nerve is also stretched by motion I.   Motion V stretches the pyriformis, gemelli, and obturator muscles, and aids in removing irritation from the sciatic nerve. All of the motions for stretching this nerve act partly through relaxation of tissues about it.
    VII.  Pressure at the midline of Scarpa's triangle, about two inches below the middle of Poupart's ligament, impinges the femoral vessels and the anterior crural nerve.
    VIII.  The popliteal nerve and vessels, are reached at the popliteal space.  The patient lies upon his back.  The limb is drawn over the edge of the table and the foot is supported between the practitioners knees.  Manipulation is now made deeply just below the knee, behind.
    IX.  Forced flexion, extension, inversion and eversion of the foot may be made for the purpose of relaxing all the ligaments of the ankle.
    All of the treatments described for the upper and lower limbs are given in a general way.  They may be used in the treatment of specific cases in various ways.  One should not forget that they are used as aids in the reduction of special lesions, or as secondary thereto.
    X. In treatment upon the feet one notes the two natural arches, the transverse and the longitudinal.  Springing these arches by pressure upon the arch above and traction at the same time upon the ends, aids in relaxing ligaments and other tissues, reducing bony luxations, removing pressure from nerves and blood-vessels.  The treatment may be made more effective by springing the arch both ways, i. e., first applying pressure such as to increase the concavity of the arch, then to lessen it.
    XI.  In treatment for the toes the blood-vessels, which lie upon the sides, are stretched, and the tissues about them relaxed, by bending them laterally.  The lateral movements, combined with extension, flexion, and traction, free the joint and its nerves, vessels and tissues
    XII.  The saphenous opening, an inch and a half below the inner end of Poupart's ligament, is often in an occluded condition such as to seriously impede the flow from the long femoral vein.  The muscles and tissues about it may be stretched by external rotation of the flexed knee.  Following this movement by internal rotation of the extended limb relaxes the tissues still further and allows of direct manipulation upon the opening.
    XIII.  With the patient lying upon the back one notes the angle of deviation of the toes. i. e, the angle between the feet.  If one foot rotates outward too much or too little, it reveals tenseness,  or laxness of the rotators or ligaments of the thigh, and may lead one to the discovery of abnormal pelvic or hip conditions.
    Concerning DISLOCATIONS of the lower limbs, one must bear in mind that many of the cases presented to the Osteopath are old dislocations.  The success of Osteopathy in the reduction of such has been marked.  Again, many cases are met within which gross dislocation is not present, but a slight luxation, or "slip", of a joint has occurred and has been overlooked by other practitioners.  The number of cases in which such a slight displacement in the hip-joint has caused apparent disease in the knee, sciatica, lameness, etc., is remarkable.  The fact that these things are commonly, or at least frequently not discovered by others than osteopaths indicates something of the need and importance of osteopathic methods.  The practitioner must bear in mind the probability of such occurrences, and must be upon his guard to discover them.  As a rule, in all old dislocations and chronic subluxations of this nature, the really important osteopathic work is the preparation of the parts for the restoration of normal relations.  Relaxation of old contractures in muscles, softening ligaments, development of atrophied parts through the upbuilding of blood and nerve-supply are the preliminary steps taken by general osteopathic methods already described.  In case of such luxations, gross dislocations excepted, the standpoint of the Osteopath in diagnosis is a new one.  This teaching leads him to look for such causes of disease, which are meaningless to other methods of practice.
    I.  DISLOCATIONS OF THE ANKLE: The displacement may be both leg bones forward, inward or outward.  In either case, the patient lies upon his back, the knee is flexed, the leg is elevated to a right angle with the thigh and fixed by an assistant, and strong traction is made upon the foot.  The muscles draw the ankle into place.
    II.  DISLOCATIONS OF THE KNEE: The leg may be forward, backward, inward, outward, or twisted.  Strong traction restores it to place.
    In cases of slight backward luxation, short of dislocation, a good method is to have the patient lie on his back, hang the leg, bent at the knee, over the edge of the table, while the foot is supported between the practitionerís knees and his hands work in the popliteal region.  The hamstring muscles are grasped by the two hands and stretched away laterally from the condyles of the femur, while the tibia and fibula are drawn forward.
    III. DISLOCATIONS OF THE HIP:  In such cases, the head of the bone may be displaced as follows:
    (1) Up and back onto the dorsum of the ilium, shortening the limb and turning the toes inward.
    (2) Down and back onto or near the sciatic notch, somewhat shortening the limb, and turning the toes inward.
    (3) Forward and downward onto or near the obturator foramen (thyroid dislocation), in which the knee is flexed, the toe points to the ground and rotates inward and or outward.
    (4) Forward and up onto the pubic crest.  The toe invariably turns out.
    In (2), as the patient sits up from a lying posture, the limb shortens; in (3) and (4) it lengthens.
    In the treatment of such conditions, fresh dislocations are set at once, but as in our practice many old dislocations are presented, the success of the treatment lies largely in knowing how to thoroughly prepare parts for adjustment.  Much lies in our way of regarding disease, for even gross dislocations are often overlooked.  These, and the many luxations of lesser degree found in osteopathic diagnosis, could scarcely be overlooked in our method of minutely scrutinizing the mechanical relations of all parts in examination of a case.
    In (1) the knee is flexed and rotated a little inward to disengage the head of the femur, then, while pressure is made to force the head toward the acetabulum, the flexed knee is rotated well outward and extended.  It is of great importance to note that during the outward circumduction and extension of the limb in this maneuver the foot must be held with the toes pointing inward, toward the body.      This directs the head of the femur toward the acetabulum.  This draws the head into the acetabulum.  The patient is lying on his back.
    In (2) the maneuver is the same, except that during outward rotation and extension the trochanter is grasped and forced forward toward the acetabulum.  In the inward rotation the head has been disengaged from the notch.
    In (3) the flexed knee is rotated far inward, freeing the head from the obturator foramen, while the "Y" ligament acts as a fulcrum.  As the inward rotation is carried downward to extension the head is forced toward the cotyloid notch.
    In (4) the patient lies upon his sound side; the dislocated thigh is hyper-extended by being strongly drawn backward.  This stretches all the muscles about the head, which, after slight flexion of the thigh, is lifted over the crest of the pubes.
    In (1) and (2) the patient may sit upon a stool, the dislocated limb is crossed above the other knee, the pelvis is fixed by an assistant, the trochanter is pressed by one hand toward the acetabulum, while the other hand draws the limb well across its fellow and extends it to place the foot on the floor.
    In (1) and (2) the patient may stand upon one foot, supporting his hands upon the back of a chair; the thigh remains straight, and the knee is flexed to a right angle; the ankle is supported by the practitioner who stands at the side of and behind the patient.  He now places one knee upon the popliteal region, allowing the weight of his body to come down upon it.  This forces the head downward, while a swing of the ankle outward disengages it.  Now a swing inward, while the weight is still applied, brings the head into the acetabulum.
    These various motions may be applied to subluxations as well as to gross dislocations.