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 Managing Turnaround, 2010–2012
Looking to the Future
Case 17: Outback Steakhouse: Going International
Outback’s Strategy
Preparing for International Expansion
Overseas Expansion by US Restaurant Chains
Case 18: Vodafone in 2012: Rethinking International Strategy
Vodafone’s International Expansion, 1984–2012
Sarin and the Quest for Integration
Vodafone’s International Strategy under Colao, 2008–2011
The Future of Vodafone
Vodafone’s Strategic Positioning in Relation to Industry Evolution
Appendix: Vodafone Performance by Country and Region, 2011 and 2012
Case 19: The Virgin Group in 2012
Development of the Virgin Group, 1968–2012
The Virgin Group of Companies in 2012
Richard Branson and the Virgin Business Development Model
The Virgin Group’s Management Structure and Style
Virgin’s Financial Performance
Looking to the Future
Appendix: The History of Virgin
Case 20: Google Inc.: What’s the Corporate Strategy?
June 2012
The History of Google, 1996–2012
Google’s Management and Capabilities
Future Challenges
Appendix 1: Google Timeline
Appendix 2: Extract from Google, 10-K Report for 2011, Item 1: The
Business
Case 21: Danone: Strategy Implementation in an International Food and Beverage
Company
Danone’s Development, 1973–2011
Danone in 2012
Organizational Structure
Management Systems and Style
Knowledge Management
 Principles and Values
Emerging Market Strategy
Future Challenges
Appendix 1: Danone’s Operating Subsidiaries (fully consolidated
companies)
Appendix 2: Selected Financial Information for Danone, 2000–2011
(values in €million)
Appendix 3: Performance Comparisons for Danone’s Main Competitors,
2011
Case 22: Jeff Immelt and the Reinventing of General Electric
A History of GE
Jeff Immelt
GE’s Business Environment, 2001–2012
GE’s Growth Strategy
Changing the GE Management Model
Appendix: General Electric Segment Performance
Case 23: Bank of America’s Acquisition of Merrill Lynch
December 2008
The Strategic Issues Arising from the Merger
Appendix 1: Bank of America Corporation: Business Activities and
Performance (extracts from 10-K report for 2007)
Appendix 2: Merrill Lynch & Co., Inc.: Business Activities and
Performance (extracts from 10-K report for 2007)
Case 24: W. L. Gore & Associates: Rethinking Management?
The Founding of Gore
Origins of the Gore Management Philosophy
Organization Structure and Management Principles
Innovation
Glossary
Index
 Copyright © 2010, 2013 Robert M. Grant
Published by John Wiley & Sons Ltd
First published by Blackwell Publishing Ltd 1991, 1995, 1998, 2005, 2008 © Robert
M. Grant
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To Sue
 PREFACE TO EIGHTH EDITION

Contemporary Strategy Analysis equips managers and students of management with

the concepts, frameworks, and techniques needed to make better strategic decisions.
My goal is a strategy text that reflects the dynamism and intellectual rigor of this
fast-developing field of management and takes account of the strategic management
practices of leading-edge companies.
Contemporary Strategy Analysis endeavors to be both rigorous and relevant.
While embodying the latest thinking in the strategy field, it aims to be accessible to
students from different backgrounds and with varying levels of experience. I achieve
this accessibility by combining clarity of exposition, concentration on the
fundamentals of value creation, and an emphasis on practicality.
This eighth edition maintains the book’s focus on the essential tasks of strategy:
identifying the sources of superior business performance and formulating and
implementing a strategy that exploits these sources of superior performance. At the
same time, the content of the book has been revised to reflect recent developments
in the business environment and in strategy research and to take account of feedback
from instructors.
Distinctive features of the eighth edition include a:

broader approach to value creation that takes account of the value that is
created for stakeholders other than the firm’s shareholders (Chapter 2);
stronger emphasis on the role of complementary products, especially in
technology-based industries (Chapters 4 and 9);
more systematic treatment of resource and capability analysis that is structured
around a practical approach to undertaking an analysis of resources and
capabilities;
more integrated treatment of strategy implementation; while the book
maintains its emphasis on integrating strategy formulation with strategy
implementation, Chapters 6 and 14 offer a systematic approach to strategy
execution;
new chapter on external growth strategies through mergers, acquisitions, and
alliances (Chapter 15), which are important to firms as they navigate a
challenging and unpredictable business world.

There is little in Contemporary Strategy Analysis that is original: I have plundered

mercilessly the ideas, theories, and evidence of fellow scholars. My greatest debts
are to my colleagues and students at the business schools where this book has been
developed and tested, notably Georgetown University and Bocconi University. I
have also benefitted from feedback and suggestions from professors and students in
the many other schools where Contemporary Strategy Analysis has been adopted. I
look forward to continuing my engagement with users.
I am grateful for the professionalism and enthusiasm of the editorial, production,
and sales and marketing teams at John Wiley & Sons, Ltd, especially to Steve
Hardman, Deb Egleton, Claire Jardine, Peter Hudson, Kelly Simmons, Juliet Booker,
and Tim Bettsworth—I couldn’t wish for better support!

Robert M. Grant
 GUIDE TO WEB RESOURCES
Visit www.contemporarystrategyanalysis.com for access to all the teaching and
learning resources available for this textbook.
Instructors will find:

Instructor’s manual
Case teaching notes
PowerPoint slides
Test bank
Case video clips *NEW TO THIS EDITION*

Students will find:

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You can also access your interactive e-book at www.wileyopenpage.com using the
scratch code included on the inside-front cover of the printed book. Video clips,
quizzes, and flashcards are embedded throughout the e-book for easy access:

Simply click on the “Play” icon located at relevant parts of the text.
Refer to the advert at the front of this book for more information.
 PART I

INTRODUCTION

Chapter 1 The Concept of Strategy

 Chapter 1

The Concept of Strategy

Strategy is the great work of the organization. In situations of life or death, it is

the Tao of survival or extinction. Its study cannot be neglected.
—SUN TZU, THE ART OF WAR
To shoot a great score you need a clever strategy.
—RORY MCILROY, GOLF MONTHLY, MAY 19, 2011
OUTLINE

Introduction and Objectives

The Role of Strategy in Success
The Basic Framework for Strategy Analysis
Strategic Fit
A Brief History of Business Strategy
Origins and Military Antecedents
From Corporate Planning to Strategic Management
Strategy Today
What Is Strategy?
Why Do Firms Need Strategy?
Where Do We Find Strategy?
Corporate and Business Strategy
Describing Strategy
How Is Strategy Made? The Strategy Process
Design versus Emergence
The Role of Analysis in Strategy Formulation
Strategic Management of Not-For-Profit Organizations
Summary
Self-Study Questions
Notes

Introduction and Objectives

Strategy is about achieving success. This chapter explains what strategy is
and why it is important to success, both for organizations and individuals.
We will distinguish strategy from planning. Strategy is not a detailed plan
 or program of instructions; it is a unifying theme that gives coherence and
direction to the actions and decisions of an individual or an organization.
The principal task of this chapter will be to introduce the basic framework
for strategy analysis that underlies this book. I will introduce the two basic
components of strategy analysis: analysis of the external environment of
the firm (mainly industry analysis) and analysis of the internal
environment (primarily analysis of the firm’s resources and capabilities).
----------
By the time you have completed this chapter, you will be able to:

appreciate the contribution that strategy can make to successful performance,

both for individuals and for organizations, and recognize the key characteristics
of an effective strategy;
comprehend the basic framework of strategy analysis that underlies this book;
become familiar with how our thinking about business strategy has evolved
over the past 60 years;
be capable of identifying and describing the strategy of a business enterprise;
understand how strategy is made within organizations;
gain familiarity with the challenges of strategy making among not-for-profit
organizations.

----------

Since the purpose of strategy is to help us to win, we start by looking at the

role of strategy in success.
 The Role of Strategy in Success
Strategy Capsules 1.1 and 1.2 describe the careers of two individuals, Queen
Elizabeth II and Lady Gaga, who have been outstandingly successful in leading their
organizations. Although these two remarkable women operate within vastly different
arenas, can their success be attributed to any common factors?

STRATEGY CAPSULE 1.1

Queen Elizabeth II and the House of Windsor
June 2012 marked the diamond jubilee of the reign of Queen Elizabeth II:
for 60 years she had been the ruling monarch of the United Kingdom of
Great Britain and Northern Ireland.
At her birth on April 21, 1926, hereditary monarchies were common
throughout the world. Apart from the British Empire, 45 countries had this
form of government. By 2012, the forces of democracy, modernity, and
reform had reduced these to 26—mostly small autocracies such as
Bahrain, Qatar, Oman, Kuwait, Bhutan, and Lesotho. Monarchies had also
survived in Denmark, Sweden, Norway, the Netherlands, and Belgium, but
these royal families had lost most of their wealth and privileges.
By contrast, the British royal family retains considerable wealth—the
Queen’s personal net worth was estimated by Forbes magazine at $450
million—in addition, she and her family have use of palaces and real
estate owned by the nation and receive annual government funding of £7.9
million ($12 million). Despite having no political power, she has formal
status as head of state, head of the Church of England, and head of the
armed forces. Despite the winding down of the British Empire, the Queen
retains her role as head of the Commonwealth and is head of state of 15
other countries, including Canada and Australia. In addition, she has
created a strong informal role. According to her website, she “has a less
formal role as Head of Nation” where she “acts as a focus for national
identity, unity and pride; gives a sense of stability and continuity;
officially recognises success and excellence; and supports the ideal of
voluntary service” (www.royal.gov.uk).
How has Queen Elizabeth been able to retain not just the formal position
of the monarchy but also its status, influence, and wealth despite the
challenges of the past 60 years? These challenges include the social and
political changes which have swept away most of the privileges conferred
by hereditary status (including the exclusion of most hereditary lords from
the House of Lords, Britain’s upper chamber of Parliament) and the
internal challenges presented by such a famously dysfunctional family—
including the failed marriages of most of her family members and the
controversy that surrounded the life and death of her daughter-in-law,
Diana, Princess of Wales.
At the heart of Elizabeth’s sustaining of the British monarchy has been her
single-minded devotion to what she regards as her duties to the monarchy
and to the nation. Throughout her 60-year reign she has cultivated the role
of leader of her nation—a role that she has not compromised by pursuit of
personal or family interests. In pursing this role she has recognized the
need for political neutrality—even when she has personally disagreed with
her prime ministers (notably with Margaret Thatcher’s “socially divisive”
policies and Tony Blair’s commitment of British troops to Iraq and
Afghanistan).
Her leadership embodies a set of values—both British and Christian—
which are directed toward sustaining British traditions and promoting
British influence, British culture, and British values within the wider
world. The Commonwealth provides a key focus for her promotion of
British influence: she has made multiple visits to each of the 54
Commonwealth nations, including 26 to Canada and 16 to Australia.
Maintaining her popularity with the British people and the status of the
royal family has required adaptation to the wrenching changes of her era.
Recognizing the growing unacceptability of hereditary privilege and the
traditional British class system, she has repositioned the royal family from
being the leader of the ruling class to an embodiment of the nation as a
whole. To make her and her family more inclusive and less socially
stereotyped she cultivated involvement with popular culture, with ordinary
people engaged in social service and charitable work, and, most recently,
endorsing the marriage of her grandson William to Kate Middleton—the
first member of the royal family to marry outside the ranks of the
aristocracy.
In broadening the popular appeal of the monarchy, she has been adept at
exploiting new media. Television has provided an especially powerful
medium for communicating both with her subjects and with a wider global
audience. The Queen’s web page appeared in 1997, in 2009 she jointed
Twitter, and in 2010 Facebook. Throughout her reign, her press and public
relations strategy has been carefully managed by a group of top
professionals who report to her private secretary.
While respecting tradition and protocol, she adapts in the face of pressing
circumstances. The death of her daughter-in-law, Diana, created difficult
tensions between her responsibilities as a grandmother and her need to
show leadership to a grieving nation. In responding to this time of crisis
 she departed from several established traditions: including bowing to the
coffin of her ex-daughter-in-law as it passed the palace.
In pursuing her role of monarch, Elizabeth has drawn upon the resources
available to her. First and foremost of these has been the underlying desire
of the British people for continuity and their inherent distrust of their
political leaders. By positioning herself above the political fray and
emphasizing her lineage—including the prominent public role of her
mother until her death in 2002—she reinforces the legitimacy of herself,
her family, and the institution they represent. She has also exploited her
powers of patronage, using her formal position to cultivate informal
relationships both with political leaders such as Nelson Mandela and with
individuals such as the Australian entertainer Rolf Harris, who obtained
the rare privilege of painting her portrait.
The success of Elizabeth’s 60-year reign is indicated by the popular
support for her personally and for the institution of the monarchy. Outside
of Northern Ireland, the UK lacks any significant republican movement;
republicanism is also weak in Canada and Australia.

STRATEGY CAPSULE 1.2

Lady Gaga and the Haus of Gaga
Stefani Joanne Angelina Germanotta, better known as Lady Gaga, is the
most successful popular entertainer to emerge in the 21st century. Since
releasing her first album, The Fame, in 2008 she has certified record sales
of 42 million,a swept leading music awards including Grammy, MTV, and
Billboards, completed a 201-concert world tour that grossed $227.4
million (the highest for any debut artist), and topped Forbes Celebrity 100
list for 2011.
Since dropping out of NYU’s Tisch School of the Arts in 2005, she has
shown total commitment to advancing her musical career and developing
her Lady Gaga persona. After initially working as a songwriter, she
developed her own musical act and image. Her debut album and its follow
up, The Fame Monster, yielded a succession of number-one hits during
2009 and 2010.
Gaga’s music is a catchy mix of pop and dance, well suited to dance clubs
and radio airplay. It features good melodies, Gaga’s capable singing voice,
and her reflections on society and life, but it is hardly exceptional or
innovative: music critic Simon Reynolds described it as: “ruthlessly
catchy, naughties pop glazed with Auto-Tune and undergirded with R&B-
ish beats.”b
However, music is only one element in the Lady Gaga phenomenon—her
achievement is not so much as a singer or songwriter as in establishing a
persona which transcends pop music. Like David Bowie and Madonna
before her, Lady Gaga is famous for being Lady Gaga. To do this requires
a multi-media, multi-faceted offering that comprises an integrated array of
components including music, visual appearance, newsworthy events, a
distinctive attitude and personality, and a set of values with which fans can
identify.
Key among these is visual impact and theatricality. Her hit records were
heavily promoted by the visually stunning music videos that accompanied
them. Paparazzi and Bad Romance each won best video awards at the 2009
and 2010 Grammies; the latter is the second-most-downloaded YouTube
video of all time. Most striking of all has been Lady Gaga’s dress and
overall appearance, which have set new standards in eccentricity,
innovation, and impact. Individual outfits—her plastic bubble dress, meat
dress, and “decapitated-corpse dress”—together with weird hair-dos,
extravagant hats, and extreme footwear (she met President Obama in 16-
inch heels)—are as well known as her hit songs. The range of visual
images she projects is so varied that her every appearance creates a buzz of
anticipation as to her latest incarnation.
More than any other star, Lady Gaga has developed a business model that
recognizes the realities of the post-digital world of entertainment. Like
Web 2.0 pioneers such as Facebook and Twitter, Gaga has followed the
model: first build market presence, and then think about monetizing that
presence. Her record releases are accompanied, sometimes preceded, by
music videos on YouTube. With 45 million Facebook fans, 15.8 million
Twitter followers, and 1.9 billion YouTube views (as of November 16,
2011), Famecount crowned her “most popular living musician online.” Her
networking with fans includes Gagaville, an interactive game developed by
Zynga, and The Backplane, a music-based social network.
Her emphasis on visual imagery reflects the ways in which her fame is
converted into revenues. While record royalties are important, concerts are
her primary revenue source. Her 2012 Born This Way Ball Tour promises
to make her one of the world’s highest-earning entertainers. Other revenue
sources—product placement in videos and concerts, merchandizing deals,
and her appointment as Polaroid’s creative director—also link closely with
her visual presence.
A distinctive feature of Gaga’s market development is the emphasis she
gives to building relations with her fans. The devotion of her fans—her
“Little Monsters”—is based less on their desire to emulate her look as
 upon empathy with her values and attitudes. They recognize Gaga’s
images more as social statements of non-conformity than as fashion
statements. In communicating her experiences of alienation and bullying
at school and her values of individuality, sexual freedom, and acceptance
of differences—reinforced through her involvement in charities and gay
rights events—she has built a global fan base that is unusual in its loyalty
and commitment. The sense of community is reinforced by tools such as
the “Monster Claw” greeting and the “Manifesto of Little Monsters.” As
“Mother Monster,” Gaga is spokesperson and guru for this community.c
Lady Gaga possesses talents as a singer, musician, and songwriter;
however, her most outstanding abilities lie in her showmanship and
theatricality. Modeled on Andy Warhol’s “Factory,” The Haus of Gaga is
her creative workshop and augments her own capabilities. It includes
manager Troy Carter, choreographer and creative director Laurieann
Gibson, fashion director Nicola Formichetti, hair stylist Frederic Aspiras,
stylist and designer Anna Trevelyan, fashion photographer Nick Night,
makeup artist Tara Savelo, marketing director Bobby Campbell, and others
involved in designing and producing songs, videos, concert sets, photo
shoots, and the whole range of Gaga’s public appearances.
Notes:
ahttp://en.wikipedia.org/wiki/List_of_best-selling_music_artists, accessed 14 Nov. 2011.
b Quoted in http://en.wikipedia.org/wiki/Lady_Gaga, accessed 14 November, 2011.
cI have drawn extensively upon Mauro Sala’s BSc thesis, The Strategy of Lady Gaga, Bocconi
University, Milan, June 2011.

For neither of these successful women can success be attributed to

overwhelmingly superior resources. For all of Queen Elizabeth’s formal status as
reigning monarch, she has very little real power and, in most respects, is a servant of
the British government led by the prime minister. Lady Gaga is clearly a creative
and capable entertainer, but few would claim that she has outstanding talents as a
vocalist, musician, or songwriter.
Nor can their success be attributed either exclusively or primarily to luck. Indeed,
Queen Elizabeth has experienced a succession of difficulties and tragedies, while
Lady Gaga has experienced setbacks (e.g., the cancelation of her first recording
contract). Their ability to respond to events with flexibility and clarity of direction
has been central to their success.
My contention is that common to both the 60-year successful reign of Queen
Elizabeth II and the short but remarkable career of Lady Gaga is the presence of a
soundly formulated and effectively implemented strategy. While these strategies did
not exist as explicit plans, for both Queen Elizabeth and Lady Gaga we can observe a
consistency of direction based on a clear understanding of desired goals and a keen
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Fig. 333 Fig. 334 Fig. 335
 Fracture of upper end of Transverse fracture, with Line of fracture at junction
tibia. anterior displacement. of lower and middle thirds
(From the Buffalo of tibia.
Museum.)

While wire sutures may be used as freely as may be indicated it

will be well, at least in the majority of cases, to leave the ends
protruding in such a way that they can later be untwisted and
removed. The presence of wire after a certain length of time rather
interferes with the process of ossification than helps it.
Fractures of the lower end of the leg nearly always involve the
joint, to some extent at least, in respect of being accompanied by
sprain if nothing else. They are accompanied by displacement of the
foot, and are produced by violence, which first involves the foot. The
term “Pott’s fracture” is meant to include the injury originally
described by Pott himself. In the typical Pott’s fracture, as shown in
Figs. 336 and 337, there are a chipping off of the internal malleolus,
of the outer portion of the articular end of the tibia, and fracture of the
fibula a little above the joint. In spite of the classical description
which Pott gave fractures of the fibula alone, those accompanied by
tearing of the internal lateral ligament, or chipping off of the
malleolus, are frequently referred to under the same term. The more
complete the injury the greater the possibility for displacement.
Eversion and outward displacement, of course, are conspicuous.
Lesser degrees of injury are accompanied by less displacement, but
all of these injuries will be followed by extreme swelling of the ankle-
joint, which may at first make diagnosis somewhat difficult, because
of the extreme tenderness which prevents the handling necessary
for careful determination. It is not always easy to so completely
replace the bones, when we have the combination of three fractures
as above, as to get an ideal result. Nevertheless with suitable
treatment usually very useful limbs are secured. When the injury has
been made compound the difficulties are increased. Such a result
will not be obtained, however, unless the tendency to backward and
lateral displacement be overcome, when the limb is placed in its
permanent plaster-of-Paris splint, as it should be after a few days.
Great care should be given to this point in the management.

Fig. 336 Fig. 337

Pott’s fracture. (Hoffa.) Exaggerated deformity in Pott’s fracture.

 —Nearly all these fractures
Treatment of Fractures of the Leg.are likely to be followed by
swelling, even to a degree which makes it impracticable to put them
up in permanent dressing until the swelling has subsided. This
means a period of two to several days, during which the limb should
be kept absolutely at rest, and the bones maintained in apposition by
side splints, while the limb is restrained within a folded pillow or other
comfortable cushion. More frequently here than in any other part of
the body there will form blebs or large blisters, which are most liable
to occur in alcoholic subjects. The leg should be scrubbed and
shaved before putting on dressings, in order that the skin may be
reasonably clean before its surface epithelium is raised. Ecchymosis,
infiltration, and sometimes general edema may become somewhat
pronounced, and the splint which would be required to fit a limb
under these circumstances would soon be too large when this
disturbance has subsided. The limb should not, therefore, be placed
in a fixed or permanent dressing until it is in every respect ready.
While these disturbances are subsiding, or perhaps being
encouraged to subside by the use of an ice-bag or of cold wet
applications, extreme care should be taken that proper position and
apposition are maintained. This will at times need considerable
ingenuity. A delirious or maniacal patient would need restraint far
beyond that required for one who is rational and docile. Moreover in
all of these fracture cases which entail confinement to bed there is a
tendency to deficiency of elimination which will require judicious use
of laxatives and other eliminatives.
The writer prefers a well-molded set of side splints, properly
padded, to any other first dressing for fractures of the leg. A limb
thus dressed may be supported on a pillow and even made
adaptable for transportation should it be necessary to remove the
patient from one place to another. The fracture box can be well
superseded by this method.
So soon as swelling has subsided, plaster of Paris should be used
for a fixed dressing. The limb should be enveloped in a layer of
cotton, by which the skin is protected, within which swelling may
occur without much strangulation. Over this and down the front of the
leg a strip of thick pasteboard should be placed, which can be
moistened and made to adapt itself, or a strip of sheet tin, an inch
wide, which can be made to fit the part, and upon which one may cut
down later in removing the splint. This refers especially to the use of
the roller bandage saturated with plaster of Paris. Molded splints can
be made, as recommended for the upper extremity, out of surgeons’
lint, canton flannel, or old blanketing, while at the lower end of these
splints may be incorporated, with the plaster, a strip of bandage or
other material, by which a loop is formed beneath the foot, which
may be utilized for the purpose of traction.
The foot should always be placed at a right angle to the leg. If
there be too much muscle spasm to permit this, or make it too
uncomfortable, the tendo Achillis may be divided. This position
should be maintained during the period of repair, in order that so
soon as one resumes the use of the limb the foot may be planted
naturally upon the ground. In addition to this precaution it must be
noted that backward displacement is completely overcome, and that
eversion is perhaps a trifle overcorrected.
In all fractures of the lower end of the leg the foot and entire leg
should be enclosed in a bandage. In fractures near or above the
middle not only the leg but the lower part of the thigh should be
immobilized if the promptest and most satisfactory results are to be
obtained.
The limb being immobilized it soon becomes a question as to how
quickly the patient can leave the bed and begin to move about on
crutches. This will depend to some extent on the patient’s
temperament. Timid women are less desirous of getting out of bed
than are active men and children. Some patients acquire facility with
crutches very slowly. Others are so tenderly built that crutches give
pain and even produce crutch paralysis. It is advisable to get
patients at least into the sitting posture so soon as the immobilization
has been secured, while those inclined may be encouraged to use
the uninjured limb and move about with crutches. A foot and leg too
long kept off the ground will swell when again lowered. The later this
dependent position is attained the greater the liability to edema.
Patients should be cautioned about this.
The so-called ambulatory method of treatment has found favor
with some surgeons. This implies something more than merely
permitting motion with crutches; it means really such dressing as to
permit use of the injured limb in locomotion. The various forms of
splints used for immobilizing the limb in hip-joint disease may be
used in this way. A useful splint is made with body and perineal
bands, or an inside steel bar with ischiatic crutch and a cross-bar
below the sole of the foot, on which the weight of the body may be
supported. This is to be combined with a plaster-of-Paris support.
The ambulatory treatment is occasionally of value, but the
advantages claimed for it have not been generally sustained.

FRACTURES OF THE FOOT.

The astragalus and the calcis suffer more often than the other
tarsal bones, partly because of their size and partly because they are
in the line of transmission of force as usually directed after accident.
When the posterior end of the calcis is broken off there remains a
fragment which is easily palpated, and which would be displaced
backward and upward by the tendo Achillis were it not for the plantar
fascial fibers which are inserted into it. The bone may also be
comminuted, in which case that part of the foot will lose much of its
shape and distinctive peculiarities. The sole will be flattened, but
swelling and hemorrhage will at first be so great that there will be
much difficulty in recognizing the exact nature of the injury.
The astragalus is usually broken by being caught between the
calcis and the lower end of the leg. It is generally broken through the
line of its so-called neck. Not infrequently one or more of the
fragments is forced out of place, usually beneath the anterior
tendons. When such extensive displacement occurs the fragments
should be removed if the fracture is compound. In both of these
bones results are generally satisfactory when displacement is not
marked, also after removal of the entire astragalus. The foot and leg
should be immobilized in the best possible position, and this can be
best accomplished within a plaster-of-Paris dressing.
In regard to the tarsal bones, diagnosis can now be made
accurately by the use of the x-rays. These bones, according to
Eisendrath, may be fractured in any one of the following ways: (1)
Compression, as when the weight of the body is violently thrown
upon the feet; (2) sudden dorsal flexion, often with fracture of the
inner malleolus; (3) forced supination or pronation, the interosseous
ligaments being stronger, the bones forcibly pulling the latter apart;
(4) violent traction upon the heel through the calf muscles, by which
the tuberosity of the calcis may be torn from the rest of the bone; (5)
extensive crushing injuries, in which several tarsal bones may be
involved; (6) gunshot fractures. Some assistance in diagnosis may
be obtained by computing the distance from the malleoli to the
bottom of the heel, which will be shortened when the bones are
compressed; or shortening of the length of the foot, or by fixed
abnormal positions.
The metatarsal bones are broken by direct violence, the first and
fifth being most exposed. As in other fractures of the foot contusion
will be a serious feature, and swelling and laceration will frequently
seriously complicate, while the fractures themselves may be
compound. The same is true, also, of fractures of the phalanges,
crushing and comminution being common. The matter of treatment
often includes an estimation of the blood supply and of the vitality of
the distal portion. The operator may sometimes temporize with an
antiseptic dressing until this matter is settled. Simple fractures
require only immobilization in good position.
 C H A P T E R X X X V.
DISLOCATIONS.
A sprain has already been described as a momentary change of
emplacement or disturbance of the normal relations between joint
surfaces, which, so far as displacement is concerned, is but a
momentary affair and is promptly overcome. The term dislocation
implies something more permanent as well as complete in both
respects. It indicates an absolute and direct separation of articular
surfaces of much more than momentary duration and requiring
skilled assistance for its reduction. It pertains to articular surfaces
which are enclosed within a capsule. The term luxation is
synonymous with dislocation. When the condition is evidently partial
or incomplete it is often referred to as subluxation. As compared with
fracture dislocations are about one-tenth as frequent.
Dislocations are described as compound when through a co-
existing wound air may enter the cavity of the joint, and as
complicated when accompanied by other lacerations or injuries.
When unaccompanied by these conditions they are described as
simple.
To dislocations which result from external violence or from sudden
muscular action is given the term traumatic. Pathological dislocations
are those which are brought about by slow morbid processes,
muscle spasm being the most prominent factor in their production. A
third variety of dislocations, the so-called congenital, do not belong
strictly in this class; by common consent the term is applied to
congenital abnormalities where, from errors in development, normal
emplacements and relations are altered.
The distal bone is the one described as that which is dislocated;
thus we speak of dislocations of the forearm upon the arm, of the leg
upon the thigh, etc.
Subluxations or incomplete dislocations are frequently
accompanied by fracture of a bony prominence, e. g., the rim of the
acetabulum, the coronoid process of the ulna, etc. The direction in
which the distal member of the joint has been displaced is indicated
by one of the common terms, as forward, inward. A consecutive or
secondary dislocation implies a shifting of position from that at first
occupied by the displaced bone end. These injuries may occur at
any age, although usually during the more active period of life, from
childhood to middle age, when mankind are more subject to injuries.
Certain conditions predispose to dislocations. Abnormalities or
previous injury or disease of joint structures figure especially in this
respect. A joint already relaxed by hydrarthrosis will exercise a
relatively small restraining influence and a subluxation, at least, may
easily occur.
The immediate cause is violence, either from without or within,
generally the former. This may be direct, as from a blow, or
transmitted, as when the shoulder is displaced by a fall upon the
open hand. It occasionally happens that the component bones of a
dislocated joint were in a position of extreme flexion or extension at
the time of injury. The factors of leverage and spiral tension or
wrenching are also important ones. Luxation from muscular activity
is occasionally met with; most frequently when the lower jaw is
dislocated by the act of yawning or violent laughter. The shoulder
has been displaced in a violent effort at throwing or pitching a ball, or
in wild gesticulation.
A few individuals have been in the habit of exhibiting themselves
whose normal ligament and joint arrangements are so lax that they
can voluntarily displace one or more of them and as easily replace
them. These may be spoken of as instances of voluntary dislocation.
A joint once displaced may never fully recover its normal degree of
tension, and will yield more readily to subsequent similar injuries. In
this way there may occur so-called recurrent or habitual dislocations.
Expressions of this kind are seen most often in the lower jaw and in
the patella.
Actual injury to tissues is to some extent unavoidable. In arthrodial
joints the capsule is nearly always lacerated, at least upon one side.
In hinge joints both lateral ligaments are likely to be ruptured. It is
probable, however, that about the maxillary joints the ligaments may
stretch without tearing to any extent. Not only are ligaments torn, but
bony prominences are frequently detached, while sometimes there is
extensive tearing away of tissue.
In connection with these injuries to joints proper other
complications may occur, such as fractures of prominences about
joints and epiphyseal separations, or such injuries as compound
fracture of the neck of the humerus with dislocation of its head.
Furthermore, bloodvessels are occasionally lacerated and nerves
are frequently injured. This latter lesion is liable to occur after
shoulder dislocations, the head of the bone injuring the circumflex
nerve, paralysis of the deltoid being the consequence. This is a
feature of the injury, and yet the result has often been unjustly
imputed to the physician in attendance. Even a momentary
contusion of the nerve may be followed by lasting effects, for which
the medical attendant should be held blameless. Other injuries, e. g.,
contusions or lacerations of nerves, may occur about any of the
joints.
Dislocations of the spine subject the cord to a special class of
injuries which will be dealt with later in this work. In very rare
instances the head of the humerus has been forced within the thorax
or the head of the femur within the pelvis, these, injuries being
practically always fatal.
Compound dislocations rarely occur about the jaw or shoulder.
They pertain usually to the joints below. In every case of such
character the question will be promptly raised whether a more or less
complete exsection of the joint will not be preferable to mere
reduction with the ensuing probability of ankylosis. Such injuries will,
under all circumstances, require aseptic measures.
So far as repair is concerned, dislocations by themselves are so
rarely fatal that there have been but few opportunities for a study of
tissue recovery under these circumstances. It is apparent that repair
is complete, for after almost any simple dislocation there is
restoration of function.
The obstacles to reduction are spasm of muscles pertaining to the
injured limb, by which the dislocated bone end is firmly held in its
abnormal position, and, in those joints provided with a capsule, the
fact that the head of the bone is frequently forced out through a
comparatively small opening, through which it is only with the
greatest difficulty reduced. It is a part of the manipulation in most
cases to enlarge this rent in the capsule, after which reduction is
comparatively easy, although impossible until it is accomplished.
Dislocations which have long gone unreduced are called old,
inveterate, or ancient. By common consent a period of six weeks has
been fixed, beyond which the dislocation is spoken of as old or
ancient; up to that time it is usually described as unreduced. In
proportion to the length of this period the difficulties of reduction are
materially enhanced. So soon as a dislocated joint has been put at
rest, i. e., fixed by muscle spasm and by the timidity of the patient,
the blood which has been poured out will begin to coagulate and
conditions are soon favorable for organization of clot and formation
of adhesions in abnormal position. In the course of a few weeks
these adhesions become strong, and in the course of months they
are frequently stronger than the bone itself, which has been disused
and has undergone a certain amount of fatty atrophy. Thus it
happens that even with well-directed effort the bone will yield before
the adhesions, and thus, in spite of every precaution, fracture
sometimes complicates the effort to reduce these ancient
dislocations.
So generally is this fact now recognized that surgeons do not
hesitate to make open incisions for the purpose of separating
adhesions and reopening what remains of the capsule in the
endeavor to replace the head of a bone. Nor do they hesitate
sometimes to cut down upon the latter and exsect rather than run the
risk of more extensive injury.
Efforts at reduction under these circumstances subject the patient
not only to risk of failure, or of fracture of bone ends, but to rupture of
vessels or laceration of nerve trunks. I recall seeing one case of
enormous traumatic aneurysm of the axillary artery which was
brought about by unsuccessful attempt in this direction.

SYMPTOMS AND DIAGNOSIS OF DISLOCATIONS.

The cardinal indications of a dislocation are deformity with
alteration in contour and position of the affected joint. It usually
happens that the dislocated bone ends cannot be felt in normal
position, but are felt somewhere else in the vicinity. About the
shoulder and hip of stout or fat individuals it may not be easy to feel
the head of the bone, but unless the case be complicated by a
fracture it can usually be detected by aid of anesthesia. The
deformity may include a lengthening or shortening of the limb,
apparent or real, as well as abnormal eversion or inversion, or other
peculiarity of position.
Whatever alterations in position appear will be accentuated by
spasm of the muscles which pertain to the movement of the affected
joint or even of the entire limb. These are usually so tightly
contracted as to form a complicating feature of such cases and to
lead to that loss of mobility which is diagnostic of every dislocation.
Limitation of motion is not entirely a matter of muscle spasm. It is not
under voluntary control and subsides only under anesthesia. To
some extent motion may be limited by escape of the head of a bone
through a small rent in the enveloping capsule, by which it is
afterward tightly clasped. This is particularly true of the shoulder and
hip. Certain dislocations of the fingers or thumbs are also made
more rigid by fixation of the tendons, which become tightly stretched
within the neighboring tendon sheaths.
A sort of crepitus, which may be easily mistaken for that of
fracture, is occasionally detected during the examination of a
dislocated joint. It lacks the peculiar grating character of true bony
crepitus.
In addition to these features there are certain subjective
symptoms, of which loss of function is the most prominent, while
pain is a more or less frequent but variable accompaniment, and
dependent on the amount of tissue injury or pressure upon nerves.
Moreover, the displacement once completely rectified (“reduced”)
does not tend to recur, as is the case with fractures.

PATHOLOGICAL AND CONGENITAL LUXATIONS.

The statements made above refer almost entirely to recent and
traumatic dislocations.
Pathological dislocations are those which are produced gradually
and through the mechanism of disease affecting the joint structures.
The head of the bone is gradually drawn out of the acetabulum, in
tonic spasm of hip-joint disease, by the continuous action of
muscles, the result being the complete displacement of the bone
from its original socket, or what is known, at the hip, as the migration
of the acetabulum, where its upper margin, being softened by
disease, is gradually extended and altered, so that the femoral head
rests an inch or more higher upon the side of the pelvis than is
normal. Pathological dislocations, then, may occur both in the course
of the infectious joint diseases as well as in the neuropathic.
Congenital luxations are those which occur from defect in the
shape or arrangement of joint structures, permitting a departure from
the normal standard. While no joint in the body is exempt from
abnormalities of this description, the congenital hip dislocations are
those which have attracted attention by their frequency and the
disability which they produce.
While the general character of these changes is easily made out
by the ordinary methods of examination, coupled with a suitable
history, a well-made skiagram will tell at a glance a story which it
may take some effort to elicit by other means; hence radiography
has here been of great value to the surgeon. Congenital dislocations
are devoid of nearly all the features which characterize traumatic
dislocations, and their consideration will be found in the chapter on
Orthopedics.
Differential diagnosis as between fractures and dislocations is not
always easy. Furthermore it is frequently the separation of a
prominence by fracture which permits of dislocation, this being
particularly true of the elbow and the ankle. The extent of a fracture
may seriously complicate the problem of treatment, as, for instance,
when the head of the humerus is not only dislocated below the
clavicle but separated from the shaft by fracture at the surgical neck.
A dislocation made possible only by fracture will not remain reduced
as will one which is simple and uncomplicated, while it will display
even a greater amount of motility and displacement. Other
complications may occur, many of which are common both to
dislocations and to fractures in the vicinity of joints, such as
lacerations of bloodvessels or nerve trunks, pressure upon the latter,
compound injuries with infections, etc.
 TREATMENT OF DISLOCATIONS.
The essential requisite of every case is complete reduction or
replacement of the dislocated bone end. The earlier this is attempted
the better the result. Brief as such a statement is, dislocations
frequently offer considerable difficulties, both in reduction and in
maintenance in proper position with the necessary physiological rest
of the injured part. Thus dislocations of the clavicle, which can hardly
occur without considerable injury to the ligaments, may be reduced
with slight effort, but are kept in place with difficulty. The simplicity of
the after-treatment is proportionate to the difficulty experienced in
reduction, so that while “to put the part in place and keep it there”
sounds very simple, it will often perplex the ingenuity of the surgeon.
Reduction having been effected, rest is the essential feature of the
after-treatment, which should be absolute for a few weeks and
relative for many months. Should reaction be extreme, ice-cold
applications will afford relief.
The causes which prevent reduction of dislocation are either those
attributable to ignorance, carelessness, or failure in diagnosis on one
hand, or, on the other, mechanical difficulties, including “button-
holing” of the capsule around the expanded end of a bone or the
interposition of some of the adjoining tissues. Dislocations of the
class referred to above as unreduced or ancient, offer great
difficulties, proportionate to their duration, which are due to the
formation of adhesions that sometimes take place and become very
dense. Judgment, skill, and effort are needed in their management.
A dislocation which has become unreducible is only to be treated by
arthrectomy and the establishment of a false joint. Nevertheless in a
small proportion of cases, especially of the hip and shoulder
dislocations, the adhesions which first form gradually relax, and in
time there is formed a natural substitute for a joint which may be
regarded as a nearthrosis, and which will sometimes prove as
serviceable as any result afforded by arthrectomy. The duration of
time after which reduction is impossible or impracticable varies so
widely with different cases that it can scarcely be stated. It rarely is
more than a few months and often but a few weeks. It is greater
when it is a ball-and-socket joint which is affected.
 Nearly everything that has been stated in the previous chapter
concerning compound fractures applies here to compound
dislocations. They are subject to the same dangers, both of infection
and of injury to important adjoining structures. There is the same
necessity for aseptic management if the case be seen early, and for
antiseptic treatment, including drainage, if seen late. In many
instances there is so much liability to subsequent ankylosis that the
first treatment may well be made to include an arthrectomy, or the
total removal of a small bone, e. g., the astragalus. Fortunately
compound features are less frequent in dislocations than in
fractures.

SPECIAL DISLOCATIONS.

DISLOCATIONS OF THE LOWER JAW.

Unless accompanied by fracture there is but one direction in which
the condyle of the inferior maxilla can be dislocated, i. e., forward.
One side or both may be affected, i. e., dislocation may be unilateral
or bilateral, the latter being more frequent. It is rare during the
extremes of age, and most common during middle life. There is
considerable variation in the degree of tension of the capsule of the
maxillary joint. In some it is so loose that dislocation may occur
during the act of yawning or vomiting. Ordinarily it occurs only as an
expression of violence from without. By a blow which shall thrust the
jaw forward, whether the mouth be closed or open, the ramus may
be made to carry the condyle over the articular eminence. The
capsule is not necessarily torn, but is always tightly stretched, while
as a reflex result the temporal muscle is thrown into a condition of
tonic spasm by which the jaw is fixed and firmly held in its abnormal
position. This produces the symptoms, then, of a more or less widely
opened mouth, with rigidity and inability to close it, with protrusion of
the chin and tense contraction of the temporal muscle, which can be
easily recognized. When the dislocation is unilateral the symptoms
are essentially the same, save that the protrusion is toward the side
that is injured.
 Treatment.—The method of reduction is simple and consists in
depressing the angle of the jaw, while, at the same
time, the chin is supported and carried both upward and backward. If
temporal spasm be not too pronounced the reduction is rather easy
and may be effected while the patient is seated in a chair, the
surgeon standing in front of him and grasping the jaw with the fingers
of each hand, while the thumb is utilized within the mouth to press
the angle of the jaw downward and backward. At the same time the
fingers should lift the chin. The operator should protect his thumbs
by wrapping them with some material in order that they may not be
injured by the patient’s teeth. Should muscle spasm offer much
resistance it would be well to administer nitrous oxide or one of the
other anesthetics, at least to the point of primary anesthesia, with
sufficient relaxation of muscle to make reduction easy. When once
this has been effected the lower jaw should be bound to the upper
and kept at rest for at least two weeks. When this injury has taken
place it is likely to recur with much less effort until it becomes almost
a habit.

Fig. 338 Fig. 339

Reduction of dislocation of lower jaw.

 There is a condition of relaxation of the capsule and elongation,
with abnormal loosening of the interarticular fibrocartilage, peculiar to
this joint, by which it has too free play, to such an extent that a
clicking sound in its movements may be frequently heard by others
than the patient. This condition is either congenital or the result of
previous injury, and is one for which little can be done, although this
explanation should be afforded to all who suffer from it.

DISLOCATIONS OF THE LARYNX.

The cartilages of the larynx are sometimes displaced as the result
of direct violence applied to the anterior region of the neck. Almost
any lesion of this character may take place between the independent
cartilages of the larynx or the attachments of the larynx to the hyoid.
The injury may simply give rise to pain and soreness, or may cause
so much interior damage as to be quickly followed by edema of the
glottis and suffocation. If the latter be impending a quick tracheotomy
should be done, after which time may be afforded for such
replacement as may be required, by manipulation, and subsidence
of swelling with relief from occlusion of the respiratory tract.

DISLOCATIONS OF THE STERNUM.

The various portions of the sternum, especially the upper and the
lower, may be displaced as the result either of direct violence by
forcible backward flexion, or by muscular action accompanied by
flexion of the trunk and neck. When the latter, it is usually forward;
when produced by violence, it is usually backward.
These displacements are sometimes so easily reduced by mere
pressure as to make it almost impossible to retain them. At other
times anesthesia with firm pressure, accompanied by flexion of the
trunk backward or forward, may be required; reduction has been
possible sometimes only through incision and by the use of
instruments applied as levers, or by the use of a screw driven into
one of the fragments, thus affording a handle by which to manage it.
Serious dislocations are frequently accompanied by fractures of the
ribs or of the sternum. The same fixation of the thorax is required as
in fractures of these parts, and should be conducted in the simplest
manner possible.

DISLOCATIONS OF THE RIBS.

To displace a rib from its sternal connections requires actual
fracture of bone or cartilage. Forward dislocation at its posterior and
spinal connection, especially of the eleventh and twelfth ribs, has
been described. Considerable effort is necessary for its production,
and the case should be treated on its individual merits.

DISLOCATIONS OF THE CLAVICLE.

Either end or both ends of the clavicle may be dislocated. Its
sternal end may be thrown in any direction but downward; its
acromial end in any direction, although usually upward. Dislocations
of the sternal end can only occur in consequence of serious damage
to the sternoclavicular ligaments, because of which, and in the
absence of a socket, it is extremely difficult to maintain the parts
when restored to position. Violent backward traction upon the
shoulder permits anterior displacement when the joint is thus
weakened. Backward displacement is usually the result of indirect
violence when the shoulder is forced forward and inward, while
upward displacement is the result of tilting which occurs when the
shoulder is violently depressed. Respiration is generally more or less
disturbed, while in backward luxations deglutition may be made
difficult and painful.
Reduction is not difficult to effect, but extremely difficult to
maintain. Pressure in the proper direction, accompanied by traction
upon the shoulder, suffices for the former. For the latter there should
be a combination of fixation of the shoulder and arm with proper
traction, and at the same time pressure upon the end of the clavicle.
For all of the clavicular dislocations the dressing and position
advised by Dr. Moore, of Rochester, and referred to in the chapter on
Fractures as his double figure-of-eight, serves admirably for
maintaining the proper position of the shoulder, while pressure can
be made by a pad, retained either by adhesive plaster or by some
further addition to the dressing itself. (See p. 494.) Acromial
dislocation is usually in the upward direction, and is produced by
violence upon the shoulder, which has expended itself in rupturing
ligaments rather than in fracturing the acromion process. The
indication here is to keep the shoulder elevated by any dressing
which will accomplish the purpose and the clavicle bound down.

Fig. 340

Position of clavicle in dislocation of sternal end upward.

Dislocation of both ends, i. e., complete loosening of the bone,

occurs occasionally, in which case the indications already given are
reinforced, while the difficulties of treatment are considerably
aggravated. Here the shoulder should be kept upward, outward, and
backward, and the clavicle retained by pressure or some other
means.
Treatment.—Clavicular dislocations yield fair results to intelligent
treatment. Ideal results are difficult to secure without
coöperation on the part of the patient. Functional results, however,
are usually satisfactory.

DISLOCATIONS OF THE SHOULDER-JOINT.

The upper end of the humerus is attached to the margin of the
glenoid cavity by a capsule which has a certain degree of elasticity,
and which resembles a short section of a sleeve or a cuff. It is
sufficiently loose to permit a wide range of motion, and were it not for
the acromial process above it there would be as much motility in the
upward direction as in any other. It is not the capsule which keeps
the articular surfaces together, but the tension of the muscles which
are wrapped around the shoulder-joint, all of which contribute to this
effect. The glenoid cavity is made a more complete socket by a
fibrocartilaginous rim. Thus a certain degree of subluxation or
displacement may be permitted without very serious damage to this
rim and capsule, but a complete dislocation is hardly possible
without more or less laceration. The prominence and exposure of the
joint and its natural freedom of motion help to account for the fact
that more than half of all dislocations occur here, and that this rarely
ever occurs in children or in the aged, in whom the violence which
may be expanded produces either epiphyseal separations or
fractures of the surgical neck. The relation of structure to function
also accounts for their far greater frequency (i. e., four to one) in men
than in women. The influence of atmospheric pressure should not be
forgotten, as in the shoulder this affords a force of some fifty pounds,
and in the hip of nearly double that amount, of pressure.