Indirect Method

The indirect or lever method has been best systematized by Kocher of Berne, although Henry H. Smith, a former professor of surgery in the University of Pennsylvania, taught a similar method previously (see H. H. Smith's "Surgery," 11 vols., also Packard's " Minor Surgery," p. 204, and Ashhurst's "Surgery," 2d Ed., Phila. 1878, p. 284). Kocher's method is as follows: First Step. - Flex the forearm until it forms a right angle with the arm, then, with the elbow touching the side of the body, rotate the arm outward 90 degrees until the forearm points directly outward (Fig. 251). This causes the head of the bone to rotate outward and leave the side of the chest to take a position close to the glenoid cavity. Second Step. - The arm being held in this position, the elbow is raised forward until it forms a right angle or a little more with the long axis of the body. This relaxes the coracobrachialis muscle, releases the lesser tuberosity, which may be caught against it, and allows the head to pass outward and ascend from its low position up into the glenoid cavity (Fig. 252). Third Step. - Carry the arm obliquely inward, place the hand on the opposite shoulder and bring the elbow down to the surface of the chest, the humerus pointing diagonally downward and inward as in the Velpeau position for fractured clavicle (Fig. 253).

Fig. 251.   Kocher's method of reducing dislocation of the shoulder: First step   Flex the forearm at a right angle to the arm; bring the humerus alongside the chest, the elbow nearly touching the side, and rotate outward as far as the arm will go without undue force.

Fig. 251. - Kocher's method of reducing dislocation of the shoulder: First step - Flex the forearm at a right angle to the arm; bring the humerus alongside the chest, the elbow nearly touching the side, and rotate outward as far as the arm will go without undue force.

The mechanism, as readily demonstrated on the cadaver, is as follows: The head lies to the inner side of the glenoid cavity with the tense posterior portion of the capsule passing backward. When external rotation is made the capsule is wound around the head and upper portion of the neck and the head moves out. In some instances the head will not only move out but will likewise move up and be drawn at once into place. Bringing the arm forward and upward relaxes the coracobrachialis muscle, while bringing it across the chest in the last step assists the head over the rim of the glenoid cavity and restores the member to its normal position. Prof. H. H. Smith brought the elbow forward before making the external rotation instead of after, as did Kocher. This is probably the better way because persistence in rotating outward when the lesser tuberosity is caught beneath the tense coracobrachialis muscle is one cause of the frequent fracture of the humerus in attempting to carry out Kocher's method; another cause is the fixation due to strong muscular contraction or to jamming of the head between the scapula and side of the chest.

Fig. 252.   Kocher's method of reducing dislocation of the shoulder: Second step   Keeping the arm in external rotation, raise the elbow until the humerus reaches the vertical line or a little beyond.

Fig. 252. - Kocher's method of reducing dislocation of the shoulder: Second step - Keeping the arm in external rotation, raise the elbow until the humerus reaches the vertical line or a little beyond.

This method can be used without anaesthesia, but it is at times exceedingly painful and savors of cruelty. It is particularly applicable for old and severe cases. It depends for its efficiency on the integrity of the posterior portion of the capsule, if this has been torn loose the method fails and the head simply rotates in situ. If this latter is the case, reduction can readily be effected by direct traction and manipulation.

Fig. 253.   Kocher's method of reducing dislocation of the shoulder: Third (final) step   Rotate the arm inward and place the hand on the opposite shoulder bringing the elbow down on the anterior surface of the chest.

Fig. 253. - Kocher's method of reducing dislocation of the shoulder: Third (final) step - Rotate the arm inward and place the hand on the opposite shoulder bringing the elbow down on the anterior surface of the chest.