Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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tioned in the Gazette MedicalSy of a recent dislocation upon the dorsum
ilii, in a child eighteen months old.* Dr. N. Fanning, of Catskill, N.
Y., informs me, in a letter dated June 25th, 1867, that he has reduced
a dislocation upon the dorsum ilii, on the tenth day, in a little girl
eighteen months old. Mr. Kirby has reported, in the Dublin Medical
Press for October 26, 1842, a case of recent dislocation in the same
direction, in a child of three years,* and Dr. Buchanan has seen another,
at the same age, in a little girl ; the dislocation being into the ischiatic
notch.* Mr. Image communicated to the Suffolk branch of the Pro-
vincial Medical and Surgical Association the case of a boy, three and
a half years old, with a dislocation upon the dorsum ilii. It had ex-
isted twelve days when he was admitted to the SuflFolk Hospital in
May, 1847. Mr. Image, in reporting this case to the Society, remarked
that he had been induced to lay it before them "in consequence of a
charge having been urged against a neighboring surgeon, of pretend-
ing to reduce a dislocation of the femur on the dorsum ilii, in a child
only four years old, that child being a pauper, and chargeable to the
parish. It was agreed and proved by authorities that no such case
was recorded, and therefore had not occurred, and that seven years
old was the earliest period at which this accident had taken place."^

J. M. Litten, of Austin, Texas, reports a case of dislocation upon
the dorsum ilii in a girl four years old, which he reduced by manipu-
lation.' In the Jan. No. for 1847 of the American Journal of Medical
Sciences is reported a forward dislocation in a boy aged five years, and
a dislocation into the ischiatic notch in a girl of the same age.

Dr. J. C. Warren, of Boston, met with an incomplete dislocation
toward the foramen thyroideum in a child six years old, which, having
been displaced eight or ten weeks, he was unable to reduce.^ Sir
Astley Cooper mentions a case in a girl seven years old.^ I have
myself met with two dislocations upon the dorsum ilii, which occurred
at ten years, and one into the foramen thyroideum.* Norris reports a

» New York Joum. Med., Nov. 1860, p. 418.

« Amer. Joum. Med. Sci., vol. xxxi. p. 207, Jan. 1848.

> London Med.-Chir. Rev., Dec. 1828, p. 251.

* New York Journ. Med., Sept. 1848, p. 281. « Ibid., March, 1852, p. 259.

* Boston Med. and Burg. Joum., vol. xxiv. p. 220.
' A. Cooper, on Disloc, Amer. ed., p. 83, Case 27.

» Buffalo Med. Joum., vol. viii. p. 6. Trans. New York State Med. Soc, 1855.
My Report on Disloc.
41



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634 DISLOCATIONS OF THE THIGH.

case at eleven years,* and Gibson at twelve." On the other band,
Gautheir has seen a dislocation of the hip in a woman eighty -six years
of age.^ The large majority, however, occur between the fifteenth and
forty-fifth years of life. From an analysis of eighty-four cases, wc
have obtained the following results : —

Under 15 years 15 cases.

15 to 30 " 32 •*

80 to 45 " 29 "

45 to 60 " 7 "

66 to 85 " 1 case.

The youngest being eighteen months old, the oldest sixty-two years»
and the average thirty-four years.

They are much more frequent in men than in women ; owing, pro-
bably, to the greater exposure of the former to the accidents from
which these dislocations usually result, and possibly, also, in some
measure, to certain peculiarities in the form and structure of the neck
of the femur in the male. Of one hundred and fifteen cases collected
by me, one hundred and four were in males and eleven in females.
Dr. J. K. Rodgers, of New York, mentioned, however, at a meeting of
the New York Kappa Lambda Society, that he had seen and reduced
four dislocations of the femur upon the dorsum ilii in females, and
that a fifth case had recently come to his knowledge in the New York
City Hospital.*

Gibson mentions an example of dislocation of both thighs at the
same moment.^

§ 1. Dislocations Upwards and Backwards on the Dorsum Iul

8yn, — *' Upwards on the dorsum ilii;" Sir A. Coooer, Miller, Pirrie. *' Upwards
and outward ;" Boyer, Dupuytren. *^ Upwards and backwards upon the ba^ of
the hip bone ;'* Chelius. ** Iliac;" Gerdy, Yidal (de Cassis), Malgaigne.

Causes. — Generally they are occasioned by some violence which
forces the thigh into a state of extreme adduction, or of adduction
united with rotation inwards ; and especially when at the same mo-
ment the head of the femur is driven upwards and backwards. Thus,
a dislocation upon the dorsum may result from a fall from a height
when the force of the concussion is received upon the outside of the
knee : the thigh being thus converted into a lever of the first kind,
whose long arm is outside of the margin of the acetabulum ; or the
dislocation may be occasioned by a fall upon the foot or knee, while
the limb is adducted, by which the head of the femur will be at the
same moment driven upwards and outwards from its socket. The
accident is equally liable to result from the fall of a heavy weight,
such as a mass of earth, upon the back of the pelvis when the body
is much bent forwards.

The following case presents an extraordinary example of this form



» Amer. Joum. Med. Sci., Feb. 1839, p. 296. « Gibson's Surg., vol. i. p. 839.
3 Gauthier, Malgaigne, op. cit., p. 805.

* J. K. Rodgers, New York Joum. Med., July, 1889, vol. 1., first ser., p. 220.
5 Gibson's Surg., vol. i. p. 885. Sixth ed.



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UPWARDS AND BACKWARDS ON THE DORSUM ILII. 635

of dislocation, produced by a force acting upon the thigh as a lever of
the first kind : —

B., of Eochester, N. Y., aet. 10, fell, in Feb. 1841, from the top of the
high bank just below the Genesee Falls, at Rochester, a distance of
about one hundred feet. Before he reached the bottom of the preci-
pice, he struck upon an oblique plane of ice, from which he slid gradu-
ally down upon the surface of the river, which was then completely
frozen over. He did not lose his consciousness in the descent, nor
after his arrest upon the river, but began immediately to call for as-
sistance. He remembers very well that when he struck the glacier, the
concussion was received upon the right side of the right kuee, and a
mark of contusion at this point confirmed his statement. Dr. EUwood,
of Rochester, assisted by myself, reduced the dislocation within one
hour after its occurrence. We employed pulleys, but the reduction
was accomplished easily in about two minutes, and without the appli-
cation of much force; the bone resuming its place with an audible
snap. His recovery was rapid and complete.*

Pathological Anatomy, — The capsule is lacerated more or less ex-
tensively, but especially in its posterior half; the round ligament is
ruptured ; some of the small external rotator muscles are generally
stretched or torn completely asunder, the gluteus maximus, medius,
and minimus are pushed upwards and
folded upon each other, the head of the Fig. 378.

femur resting upon or within the fibres "

of the deeper muscles; the triceps ad-
ductor is put upon the stretch.

Surgeons have not been agreed as to
the cause of the great diflBculty which
has usually been experienced in the re-
duction of this and of all other forms of
ooxo-femoral dislocations. While some
have ascribed it alone to the resistance of
the muscles, others have with equal con-
fidence ascribed the opposition to an en-
tanglement of the head and neck of the i
bone in the rent capsule, or in the liga-
ment; and still others believe that the
impediment ought to be looked for some-
times in the muscles and sometimes in the
capsule, or in both at the same moment.

Sir Astley Cooper thought that the
capsular ligament was generally too mUch

torn to offer any impediment to reduction, Duiocation upon the dorsum mi.
and he refers to some dissections in con-
firmation of this opinion. Nathan Smith affirmed that the chief obstacle
to reduction by extension was to be found in the resistance offered by
the gluteii muscles, which, although at first relaxed, would soon become
tense under the stimulus of the extension, and which, in order that

» Trans. New York State Med. Soc, 1855, p. 70. My report on Dislocations.



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688 DISLOCATIONS OF THE THIGH.

the bone might resume its position, must actually be stretched con-
siderably beyond their normal length.* W. W. Eeid declares that
the sole resistance is at first in the abductors and rotators, but that
finally the psoas magnus, iliacus internus, and triceps adductor become
tense where the pulleys are employed.' Chassaignac recognizes no
other impediment to reduction than the contractions of the muscles.'

Dr. Fenner, of New Orleans, gives the particulars of a dissection of
the hip of a man admitted into the Charity Hospital, who died from
injuries received by the bursting of a steamboat boiler. His condi-
tion being considered hopeless, no attempt was made to reduce the
dislocation. The limb was shortened one inch and a half, and the toes
turned inwards. Extensive ecchymosis existed. On raising the glu-
tffius maximus and medius, the naked head of the femur was found
lying on the dorsum ilii with the ligamentum teres hanging to it, but
partially torn off. Portions of the; obturator externus pyriformis, and
gemelli, were ruptured and lacerated. The capsule was torn through
one-half of its extent.

Dr. Fenner now proceeded to cut away the muscles, and when all
the external muscles about the joint had been removed the thigh could
not be brought down ; the iliacus internus and psoas magnus were
then severed, which permitted it to descend a little, but the head could
not be replaced ; the triceps adductor was then divided without effect.
The ilio-femoral ligament was found tensely stretched. All the mus-
cles between the pelvis and the thigh were then severed, and still it
was impossible to reduce the dislocation ; the head of the femur could
not be forced back through the rent in the capsule from which it had
escaped ; and it was not until the opening was enlarged from one-half
to three-quarters of an inch, that the reduction was accomplished.

Dr. Fenner infers that the capsule possesses sufficient elasticity to
allow the small head of the femur to pass out through a lacerated
opening, which might at once contract, so as to offer considerable re-
sistance to its return, and that occasionally this is the true explanation
of the difficulty in reduction.* Dr. Gunn, of Ann Arbor, Michigan,
after repeated experiments made upon the dead body, concludes that
the muscles offer no impediment whatever to the reduction, and that
the " untorn portion of the capsular ligament, by binding down the
head of the dislocated bone, prevents its ready return over the edge of
the acetabulum to its place in the socket."' Dr. Moore, of Bochester,
who has oflen repeated the same experiments upon the cadaver, de-
clares, also, that in attempting to reduce the femur by extension alone
he has constantly observed that the untorn portion of the capsule
offered the main resistance, and that reduction could not he accom-
plished until this was more completely broken up.'

> Surgical Memoirs, by N. R. Smith, 1881.

' Buffalo Med. Joum., 1851. Trans. N. Y. State Med. Soc, 1852.
3 London Med. Times and Gazette, Dec. 1865, p. 061.

* New York Joum. Med., Sept. 1848, p. 368 ; from New Orleans Med. and Surg.
Joum., July, 1848.
8 Ibid., Nov. 1853, p. 423 et seq.
6 Ibid., Jan. 1855.



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UPWARDS AND BACKWARDS ON THE DORSUM ILII. 637

Busch, of Bonn, has arrived at similar conclusions;^ as also Profs.
Roser, Weber, and Gell^. Prof. Von Pitha declares emphatically that
upon a knowledge of the ilio-femoral ligament is based the correct
understanding of the various forms of hip-joint dislocations.*

But probably the most complete and conclusive defence of the views
entertamed by the gentlemen just referred to has been furnished by
Dr. Henry J. Bigelow, the Pro-
fessor of Surgery in the Harvard Fig. 274.
University. In some respects,
also, his opinions are wholly
original. The following is a
brief sumihary of these opinions.

The ilio-femoral ligament. ^
called by Dr. Bigelow the. Y
ligament (Bertin's ligament), the
internal obturator muscle, and
that portion of the capsule of
the joint which is immediately
subjacent, are alone required to
explain, and are chiefly respon-
sible for, the phenomena of the
four regular dislocations. The
regular dislocations are those in
which complete disruption of
the ilio-femoral ligament has
not taken place.

The irregular dislocations are
those in which the ilio-femoral
ligament has suffered complete
disruption.

In reducing either of the re-
gular dislocations the limb must
be flexed, in order to relax the

ilio-femoral ligament; but if nio-femomi ligament. (Bigeiow.)

other portions of the capsule are

not sufficiently torn to admit the return of the head within its socket, it
must be torn by circumduction of the limb. After flexion, and
perhaps circumduction, the reduction may be completed by rotation,
or by extension of the thigh at right angles with the anterior surface
of the body.

The dorsal dislocation owes its inversion to the external fasciculus
of the ilio-femoral ligament.

In the ischiatio dislocation, "dorsal below the tendon'^ (Bigelow),
the head is arrested, in extension, by the tendon of the obturator and
the subjacent capsule.

The flexion and eversion of the limb in the thyroid dislocation are
due to the ilio-femoral ligament.

" Year Book of Med. and Qvlt^. for 1864. Sydenham Soc. Publications ; from
Archiv. of Clinical Surgery, vol. iv. part i., Berlin, 1863.
« Von Pitha'B and Billroth's Surgery, vol. iv., 1865.



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638 DISLOCATIONS OF THE THIGH.

In the pubic dislocation the ascent of the limb is finally arrested
by the ilio-femoral ligament.

Fig. 275.



Dislocation npon the dorsum Uil. (Bigelow.)

The conclusion at which we ought to arrive seems to be that in
some cases, the capsule being completely or almost completely torn
away, the muscles oflfer the only resistance ; and that according to the
exact position of the limb or degree of displacement, one or another
set of muscular fibres will oppose the reduction ; and in other cases,
the muscles being paralyzed by the shock, or by anaesthetics, the par-
tially torn capsule, into which the head of the bone is received as in a
button-hole, or the Y ligament, prevents its free return into the socket.

Symptoms, — Sir Astley Cooper affirmed that the limb was sometimes
found shortened in this dislocation to the extent of three inches. Liston,
B. Cooper, Gibson, and others repeat the affirmation. Chelius places
the extreme of shortening at two and a half inches ; Miller, at two
inches; while Malgaigne declares that he has never seen the limb
shortened more than half an inch, and that in some cases it is not
shortened at all, and the very opposite opinions entertained by other
surgeons he attributes to errors in the measurement. I am certain,
however, that Malgaigne has fallen into some error, and that, while
the average shortening is about one inch or one inch and a half, it
does occasionally reach three inches.

The thigh is rotated inwards, adducted and slightly flexed upon
the pelvis. The great toe of the dislocated limb, when the patient
stands erect (and in this position the examination ought, if possible,
to be made), rests upon the instep of the foot of the sound limb, and



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UPWARDS AND BACKWARDS ON THE DORSUM ILII. 639

"tlie knee touches the opposite thigh near the upper inargin of the pa-
tella. It must not be supposed, however, that the position of the limb
is in all cases precisely such as we
Have described. Indeed the degree Fig. 276.

of rotation, adduction, flexion, &c.,
"will vary according as the head of
"tlie femur is more or less displaced,
the capsule, including the liga-
ments, more or less torn, or as it
may be torn in its upper or lower
inargins, as the muscles may be ac-
tually rent asunder, or only put upon
the stretch, and perhaps also accord-
ing to the amount of injury and con-
sequent relaxation which they may
bave sustained from the shock. The
thigh can be easily flexed ; adduc-
tion is more difficult, but abduction
is almost impossible, except to a
very limited extent : the body of the
patient is a little bent forwards, the
roundness of the hip is lost in conse-
quence of the relaxation of the glu-
teii muscles ; the trochanter major is
depressed, and approaches the ante-
rior superior spinous process of the
ilium ; and if the patient is not fat,
and swelling has not already taken
place, the head of the femur may
be felt in its new position rotating
under the hand when the limb is
turned inwards or outwards, but
especially may it be felt when, by
flexing or extending the limb, the

head is made to move downwards Di»ioc»uon upon the doraomiiu.

and upwards, upon the dorsum ilii.

As we have already said, this examination ought to be made, if
possible, in the erect posture ; after which, it will be well to place the
patient alternately upon his back, upon his sound side, and upon his
belly, until the diagnosis is rendered complete.

The differential diagnosis between dislocation upon the dorsum ilii
and a fracture of the neck of the femur may be briefly stated as follows.
In fracture, we may expect to find crepitus ; the limb is in most cases
mobile ; the toes are generally turned out ; the limb is shortened mode-
ratelyor not at all ; the patient is sometimes able to walk for a short
distance; fractures of the neck of the femur generally occur in ad-
vanced life.

In dislocation, crepitus is not often present, and only when a frac-
ture coexists ; the limb is immobile, or nearly so ; the toes are turned
in; the limb is shortened more; the patient is unable to bear the



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640 DISLOCATIONS OF THB THIGH.

weight of his body upon his foot for one moment. Skey, however, says
he has seen a patient with a recent dislocation, who walked one-qoar-
ter of a mile, to the hospital. I do not think any other similar case is
upon record. Dislocations of the femur generally occur in middle life.
I have been frequently told by persons who have called upon me
with children suffering under hip-disease, that they had been iiLformed
the hip was out, and they expected me to reduce it. In two or three
instances they have blamed their surgeons very much, because they
had not detected the accident at the time of its occurrence. Norris, of
Philadelphia, mentions an extraordinary example of this kind, as
having been presented at the Pennsylvania Hospital, and which ought
to serve as a sufficient warning to prevent similar mistakes in future.
A lad, twelve years old, was brought to the hospital from a neighbor-
ing State, who a short time previous had been suddenly attacked with
lameness in his right limb, ai\d which, by his friends, was attributed
to some injury received in play. Two physicians, who had been called
to see the boy, pronounced him to be laboring under dislocation of
the hip, and had made two strong efforts with the pulleys, to reduce it;
but, after causing great suffering, they gave up all hopes of ever re-
placing the bone, and sent him to Philadelphia. The symptoms were
plainly those of hip-joint disease in its early stage. The attitude was

that assumed by those laboring under this
^' **' affection ; the leg seemed lengthened, but

a careful measurement showed that it was
of the same length with the other; the but-
tock was flattened, and the motions of the
joint were tolerably free but painful.'

If the supposed dislocation occurs in a
child, or in a person under ten years of age,
we ought to take especial pains to ascertain
that it is not a separation of the epiphysis,
of which accident we have mentioned some
examples when speaking of fractures of the
neck of the femur.

Examples have occasionally been re-
ported of " everted dorsal dislocations," in
which most of the usual signs of a dorsal
dislocation are present, except that the limb
is everted, and sometimes slightly abducted.
Bigelow attributes this condition to a rup-
ture of the outer fibres of~tE6 ilio-femoral
ligament, and he affirms that under these
circumstances the limb may be found in-
verted, but it is also easily everted; the
foot may be slightly everted, it may He flat
. _ upon the bed, or it may even point back-

wards

Everted donal dislocition. (Bige- mi * ^ . t* .\ t ^ } A'^e

low.) The treatment of the everted dorsal dis-

* Norris, Amer. Joum. Med. Sci., vol. xxy. p. 280.



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UPWARDS AND BACKWARDS ON THE DORSUM ILII. 641



location consists in reducing it first to an ordinary dorsal dislocation
by flexion and rotation inwards, aided by adduction, if necessary.

Prognosis, — Boyer says the limb remains always weaker than the
other, the round ligament never uniting completely ; and that inflam-
mation of the cartilages and synovial glands may ensue, ending in
caries of the joint. Such results have, indeed, been occasionally met
with, nor are examples wanting in which more rapid inflammation,
resulting in the formation of acute abscesses, has followed, but these are
only rare accidents. In the large majority of cases the patients recover
speedily, and in the course of a few weeks, or months at most, the
limb seems to be as sound and as useful as before.

Examples of non-reduction, however, from an error of diagnosis, or,
what is more pertinent to our present purpose, from a failure to
accomplish the reduction where the attempt has been made, are
numerous. Fortunately, Mr. Chelius, the author of a most excellent
" System of Surgery, ^^ to which we have already had frequent occasion
to refer, has sufficient reputation, the world over, to enable him to
bear a portion of these failures, without injury to himself or to the
profession which he so eminently adorns. We shall therefore make
no apology for reporting the following unsuccessful attempt to reduce
a dislocation of the hip in which Mr. Chelius himself was the operator.

On the 11th of June, 1851, John Mauren, a German, set. 19, called
at my office and related as follows : "When ten years old, I fell from
a tree, a height of six feet, and dislocated my left hip. I was then
living twelve miles from Heidelberg, and I was immediately taken
there, but I did not see Mr. Chelius until the next morning. He took
me to the University, and, before the medical class, attempted to reduce
it, but he could not. During several weeks following, he tried six
times, using pulleys, &c., but he could never succeed."

On examination, I found the limb shortened two inches, the head of
the femur lying upon the dorsum ilii ; the knee was turned in, but
the toes were inclined a little outwards. He was able to walk rapidly,
of course with a manifest halt, yet without pain or discomfort.

Treatment. — Begarding dislocations of the femur upon the dorsum
ilii as the type of all the coxo-femoral dislocations, the remarks which
we shall make under this section may be considered applicable, with
only certain qualifications, to all the others.

We shall arrange the various methods of reduction which have
been employed by surgeons under two principal heads, namely, mani-
pulation and extension. It is not possible, however, to classify rigidly
the diffisrent procedures, so as to bring them under these two simple
divisions, without some violence ; pince neither manipulation nor ex-
tension has usually been employed alone, but almost always some
degree of extension has been recommended in connection with the
manipulation ; if not in the first instance, at least in the event of the
failure of manipulation alone; while, on the other hand, extension is
seldom if ever practised without manipulation. We intend, then, to
imply by these designations respectively, that either manipulation or
extension has constituted the prevailing feature in the treatment.

Eeduction by manipulation dates from the earliest records of our



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6i2 DISLOCATIONS OF THE THIGH.

science. Says Hippocrates : '' In some the thigh is reduced witli no
preparation, with slight extension directed by the hands, and with
slight movement ; and in some the reduction is effected bj beading
the limb at the joint and making rotation,"*

Richard Wiseman, who wrote in 1676, speaks as follows : " If the
thigh-bone be luxated inwards, and the patient young and of a tender
constitution, it may be reduced by the hand of the chirurgeon, yiz^ ha



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 74 of 100)