Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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upon his back, with the knees resting over a pillow, and tied together
lightly with a towel or a strip of cotton cloth. In order also the more
certainly to prevent a reluxation, the thigh of the dislocated limb
should be gently rotated outwards, by which the head will be pressed
forwards against the anterior portion of the capsule.

Such an accident, however, as a recurrence of the dislocation, in
the case of the femur, is exceedingly rare ; and I should have deemed
it altogether impossible, except as the result of considerable violence
again applied, had not at least two examples been reported to us
upon very excellent authority. Malgaigne says he has himself seen
an example of reluxation upon the dorsum ilii, occasioned by an un-
timely movement*/ and Yerneuil has seen, ten days after the reduc-
tion of a dislocation upon the ischiatic notch, the dislocation repro-
duced by a sudden effort of the patient to sit up f indeed, it is when
the limb is in a flexed position that the accident seems most likely to
occur.

Of course, in these remarks we mean to except those cases in which
the upper margin of the acetabulum is broken off, and the head of the
femur nas consequently lost* its natural support in this direction.

The possibility of this accident is also confirmed by the examples
of " voluntary" dislocations which I shall relate in the last section of
this chapter.

I Malgaigne, op. cit., torn. ii. p. 830. > Ibid., p. 840.



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660 DISLOCATIONS OF THE THIGH.

The method of extension recommended by Dr. Bigelow, namelj,
with the thigh at a right angle with the body, has already been referred
to ; and there is much reason to believe that, as a rule, it is preferable
to extension as practised by Sir Astley Cooper. Nearly all surgeons,
however, have recognized the necessity of flexing the thigh in certain

cases. Dr. Bigelow sug-
Fig. 285. gests that where greater

force is required than can
be obtained by the usual
methods, a tripod should
be employed, as shown in
the accompanying wood-
cut.

The following case, re-
ported to me by Dr. N.
Fanning, of Catskill, N.Y.,
illustrates the occasional
necessity of resorting to
extension, and is of special
interest on account of the
extreme youth of the pa-
tient. I have referred to
the same case once before.
A little girl, two and a
half years old, was caught
under a falling door on
the 24th of May, 1867,
but her parents suspected
no injury beyond a severe
bruise until ten days later,

Tripod for Terllcalextonrion. (Bigelow.) whcn they COUSultcd Dr.

Fanning. The left femur
was then found to be dislocated upon the dorsum ilii. Dr. Fanning
attempted first to reduce the dislocation by manipulation, but he failed.
He then directed the father to make extension by the legs, while the
mother made counter-extension by seizing the child under the arms,
and thus he soon succeeded in efifecting the reduction.

§ 2. Dislocations Upwards and Backwards into the Great Ischiatig

Notch.

JSyn. — * ' Upwards and backwards into the ischiatic notch ;" Sir A. Cooper. "Up-
wards and backwards into the great sacro-sciatic notch;'* Lizars. ** Backwards
into the sacro-sciatic foramen ;" 8. Cooper. '* Backwards into the ischiatic notch ;"
Liston, B. Cooper, Miller, Pirrie, Erichsen, Skey^ibson. ** Downwards and out-
wards on the OS ischium ;" Boyer, Dorsey. *' Backwards and downwards into
the ischiatic notch ;'* Chelius, Petit, Duvemey. **Upon the ischium ;" Bertrandi.
* * Sacro-sciatic ;' ' Gerdy . * * Ischiatic ;' ' Malgaigne. * ' Dorsal below the tendon ;"
Bigelow.

Boyer considers this dislocation as only secondary upon a disloca-
tion upon the dorsum ilii ; but it is very certain that it often occurs
as a primary accident. Not unfrequently, also, what was primarily a



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"UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 661

dislocation into the ischiatic notch, becomes subsequently a dislocation
lapon the dorsum ilii.

Causes. — A fall upon the foot or knee when the limb is very much
in advance of the body ; or the fall of a heavy weight upon the back

Fig. 286. . Fig. 287.



IMtlocatlon apwards and backwards
Into the great Uehiatie notch. (A.
Cooper.)

and pelvis when the thigh
is nearly or quite at a right
angle with the body. In-
deed, the causes are very
similar to those which pro-
duce dislocations upon the
dorsum ilii, except that it
is necessary to suppose the
limb in a position more

nearly at a right angle with j,^,,^,,,^ ^p^„,. ^^^ ^^k^„a.. mto the great iecbi-
the trunk, at the moment m atie notch,
which the force is applied.

Pathological Anatomy. — Mr. Syme, who dissected the body of a
man recently dead whose thigh had been dislocated into the ischiatic
notch, found the glutsBUs maximus nearly torn asunder, the head of
the femur being imbedded in its substance; the glutsaus minimus,
the pyriformis, and the gemellus superior lacerated; the capsular liga-
ment extensively torn close to the edge of the acetabulum, and the
round ligament completely separated from the femur. The head of
the femur was lying in tne great ischiatic notch, upon the gemelli
and the sacro-sciatic nerve, behind the acetabulum and a little above



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662 DISLOCATIONS OF THE THIGH.

it ; being situated between the upper margin of the notch and the
great sacro-sciatic ligaments.^ Figure 286 is a representation of this
specimen.

Dr. Joseph C. Hutchinson, of Brookljm, N. Y., has reported an ex-
ample of this dislocation in which death having occurred four days
after reduction, he was able to ascertain the character of the lesions.
By the courtesy of Dr. H., I was permitted to be present at this
autopsy, and the lesions were found to be much the same as in the
case related by Syme ; but the glutsaus minimus was not torn, and
there was added a laceration of the obturator extemus. Dr. Lente
has reported one other dissection made after reduction.'

Dr. Bigelow speaks of a dorsal dislocation as sometimes occupying a
position as low as the upper portion of the ischiatic notch; but the
dislocation now under consideration he describes as that in which the
head of the femur having been driven from its socket downwards and
backwards, is subseq^uently, in the attempt to straighten the limb,
carried upwards behind the socket until it is arrested by the gtrong
tendon of the obturator internus, and the subjacent capsule. In some

Kg. 288.



Internal obtnrator in it« natnntl position. (Bigelow.)

cases also the head passes behind the tendon and the subjacent cap-
sule. He prefers, therefore, to speak of this dislocation as "dorsal
below the tendon."

Symptoms. — The position of the limb is in some cases nearly the

» Amer. Jonm. Med. ScL, vol. xxxii. p. 460.
« Lente, New York Joum. Med., Jan. 1851.



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UPWARDS AND BACKWARDS INTO ISCHIATIO NOTCH. 668

same as in certain dislocations upon the dorsum. It is shortened
usually about half an inch, the thigh being flezed upon the body.

Fig. 289.



Internal obturator in its new potfition. (Bigelow.)

adducted, and rotated inwards; but the flexion is often less than in
dislocations upon the dorsum, while, on the other hand, it is sometimes
much greater. Generally it is such that, when the patient is standing,
the end of the great toe of the dislocated limb touches the ball of the
great toe of the sound limb.

Bigelow observes that the extreme Fig- 290.

flexion which is sometimes found
to exist, especially when the patient
is in the recumbent position, is
generally due to the arrest of the
head of the femur by the internal
obturator and the subjacent untorn
capsule. When the patient rises, the
weight of the limb may force the
head up behind the tendon of the
obturator; or if the limb is brought
down with force, the tendon and
capsule may give way and the head
may ascend to any point upon the
outer surface of the ilium, and in

this way an ischiatic may be con- DUlocatlon npwardi and backward! mto the
verted into an iliac dislocation. great isehlatlc notch. "Selow the tendon,"

when the patient it recnmbent. (Btgelow.)



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664 DISLOCATIONS OF THE THIGH.

The head of the femur is sometimes distinctly felt in its new position,
especially when the limb is moved upwards or downwards. The tro-
chanter major is approximated toward the anterior superior spinous
process of the ilium.

Sir Astley Cooper remarks that this dislocation is the most difficult
to detect, and Mr. Syme mentions a case in which the natare of the
accident was overlooked by himself, and the thigh was not redaced
until the thirteenth day ;^ and subsequently Mr. Syme has called at-
tention to what he considers as one of the most important diagnosdc
marks — indeed, he says it is never absent, nor is it ever met with in
any other injury of the hip-joint, "whether dislocation, fractare, or
bruise ;" this is " an arched torn\ of the lumbar part of the spine, which
cannot be straightened so long as the thigh is straight^ or on a line
with the patient's trunk. When the limb is raised or bent upwards
upon the pelvis, the back rests flat upon the bed; but so soon as the
limb is allowed to descend, the back becomes arched as before."* This
position, assumed by the back when an attempt is made to straighteu
and depress the limb, is due to the action of the psoas magnus and
iliacus internus. But, in addition to this valuable sign, the inversioa
of the toes, immobility of the limb, and the absence of crepitus; are
generally sufficient in themselves to distinguish it from a fracture of
the neck. Dr. Squires, of Elmira, N. Y^, in a note addressed to me ia
March, 1860, suggests, also, that in ancient cases the projection of the
head of the femur may be felt by passing the finger into the rectum
or vagina. In this way Dr. Sayre and myself determined a dislocatioQ
into the ischiatic notch which had existed six months, in a boy twelve

} rears old ; and Dr. Wood, with myself, diagnosticated the same dis-
ocation in a woman at Bellevue Hospital, which had existed four
weeks, in the same manner.

Prognosis. — I have seen two dislocations of this character which
were not recognized by the surgeons at the time of the receipt of the
injury, nor for some weeks afterwards. One was in a lad twelve years
old, who was brought to me from an adjacent county in August^ 1847.
The accident had happened eight weeks before. His limb was short-
ened one inch; it was also forcibly adducted and rotated inwards.
Dr. Colegrove, a very excellent surgeon, had made a thorough attempt
to reduce the dislocation with pulleys a few days before he was brought
to me, and I did not deem it advisable to subject him again to the trial.
Notwithstanding the dislocation, his limb was quite useful. The second
was in the case of the boy seen by Dr. Sayre and myself, to which I
have just referred.

Treatment — In employing manipulation, we may follow, with only
a slight modification, the directions already given in dislocations upoQ
the dorsum ilii. We find the head of the femur lower, consequently
the extent of the circuit to be described in the manoeuvre is diminished,
but in other respects the processes are identical.

» Amer. Joum. Med 8ci., vol. xviii. p. 242.

< Amer. Joum. of Med. 6ci., Oct. 1Q48, p. 461, from Lond. and Edinb. Ifontk.
Jonm., July, 1848.



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UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 665

We must not forget, however, that there is especial danger, while
attemptiDg to reduce this dislocation by manipulation, that the head
of the bone will be thrown across into the foramen thyroideum. I
have already mentioned one case occurring under the care of Dr. Post
in the New York Hospital, in which the head of the femur, originally
in the ischiatic notch, passed backwards and forwards between the
ischiatic notch and the foramen ovale many times, and which, although
the reduction was finally accomplished, was followed by morbus coxa-
rius. Parker mentions a second case in the same paper,' in which his
first attempt to reduce by manipulation carried the head of the bone
into the foramen ovale; but the second attempt was successful. In
Dr. Hutchinson's case, to which I have already referred, the first
attempt at reduction was made without an ansBsthetic, and by manipu-
lation after the method described by Reid. The first two attempts
failed, and in the third, the limb being more abducted than before, the
head of the bone was thrown into the foramen ovale. By reversing
the movements, it was replaced in the ischiatic notch ; and this change
of position was made seven or eight times. The patient was now
etherized, and the bone was lifted into its socket in the same manner
which I have described in the case of Caswell. Malgaigne refers to a
patient of Lenoir's and to another of his own, in which the head of
the hone was lodged under the margin of the acetabulum during the
attempts at reduction.'

On the 23d of March, 1855, Charles McCormick, aet. 21, a laborer on
the " State Line Railroad," was caught betweentwo cars, with his back
resting against one car, and his right knee against the other, the right
thigh being raised to a right angle with his body. As the cars came
together he felt a " cracking" at his hip-joint, and found himself im-
mediately unable to walk or stand.

Two hours after the accident, assisted by my son Theodore, and
Austin Flint, Jr., I examined the limb carefully, and made arrange-
ments for the reduction with the pulleys, in case the attempt by ma-
nipulation should fail.

The patient lying upon his back, I seized the right leg and thigh
with my hands, the leg being moderately flexed upon the thigh, and
carried the knee slowly up toward the belly, until it had approached
within twelve or fifteen inches, when, noticing a slight resistance to
farther progress in this direction, I carried the knee across the body
outwards, until I again encountered a slight resistance, and immediately
I began to allow the limb to descend. At this moment a sudden slip
or snap occurred near the joint, and I supposed reduction wfis accom-
plished ; but on bringing the limb down completely, I found it was
still in the ischiatic notch. I think the head had slipped off I'rom the
lower lip of the acetabulum, after having been gradually lifted upon it.
Without delay I commenced to repeat the manipulation, and in
precisely the same manner. Again, at the same point, when the limb
was just beginning to descend, a much more distinct sensation of slip-

1 Markoe's paper, N. Y. Joum. of Med., Jan. 1855.
s Malgaigne, op. cit., torn. ii. p. 889.
48



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666 DISLOCATIONS OF THE THIGH.

ping was felt, and on dropping the limb it was found to be in place
and in form, with all its mobility completely restored.

No anaesthetic was employed, and no person supported the body or
interfered in any way to assist in the reduction. No outcry was made
by the patient, yet he informed me that the manipulation hurt him
considerably. The amount of force employed by myself was jost
sufficient to lift the limb, and the time occupied in the whole pro-
cedure was only a few seconds.




Redaction of dislocation upwards and backwards into the great Ischiatlc notch, by «xt«uloB. (Sr
Astlej Cooper's method.)

After the reduction he remained upon his back, in bed, eleven days,
in pursuance of my instructions. At the end of this time he began to
walk about, but was unable to resume work until after eight weeks
or more. It is probable that he could have walked immediately after
the reduction, without much if any inconvenience, so trivial was the
inflamma);ion which resulted from the accident. He never complained
of pain, but only of a slight soreness back of the trochanter major,
near the head of the bone. This soreness continued several weeks»
and was especially present when he bent forwards. After the lapse
of four months, when I last saw him, he occasionally felt a pain at
this point in stooping, but the motions of the joint were free ; he walked
rapidly and without halt.

If the reduction is attempted by extension, we ought to remember
that the head of the bone lies more behind than above the socket, and
that it is not requisite to carry it downwards so much as forwards;



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UPWARDS AXD BACKWARDS INTO ISCHIATIC NOTCH. 667

and especially that it must mount over the most elevated margin of
the socket^ in order to resume its position. The extension ought,
therefore, to be made at a right angle with the body, as the following
case will illustrate : —

John Hebden, aet. 40, was sitting with his legs hanging over the
dock, when his left knee was struck by a ferry-boat, dislocating the
head of the femur into the ischiatic notch. I found him at Bellevue
Hospital on the following morning, about twenty hours after the acci-
dent, Sept. 29, 1866. In the recumbent posture the limb was pretty
strongly adducted and slightly rotated inwards. It was shortened
three-quarters of an inch. In the erect posture both adduction and
inward rotation were very slight.

Having etherized him, I made three separate attempts at reduction
by manipulation, but failed. I then made extension in the following
manner : The patient resting upon his back, I stood astride his body,
and clasping my hands under the knee, I pulled directly upwards,
while an assistant held down the pelvis. I did not feel the bone re-
sume its place, nor was I aware that reduction was accomplished, but
when I let the limb down the bone was found to be in its socket.

Two or three minutes later, and before the patient had recovered
from the effects of the ether, I raised the knee, to indicate to some
young men, who had just come in, how th^ dislocation had been re-
duced, when it slipped out again, with a sudden jerk and a grating
sensation. This sensation I had felt once or twice before while ma-
nipulating. It was scarcely as rough as the crepitus of a fracture, and
it probably indicated that the cartilaginous margin of the acetabulum
had been broken off.

The limb was now brought down to the bed, and it was found to be
in the same position as before reduction was attempted. Standing
again over the patient, and placing my hands under the knee, I pulled
upwards, and the head resumed its place ; this time with a sudden
jerk and with the same rough sensation. The limb was then placed
in the extended position and secured by a long splint, which was not
removed until the eleventh day.

The facility with which the reluxation took place in the preceding
case will sufficiently explain what happened in the following case on
the tenth day after reduction, and on account of which I was subse-
quently consulted.

Wm. Milne, aet. 19, of Orleans Co., N. Y., was thrown from a wagon.
May 13, 1858, dislocating his left femur into the ischiatic notch. Dr.
Watson, of Clarendon, Orleans Co., was consulted within three hours.
Drs. Wood and Tafft were also present. Dr. Watson laid the patient
on his back, and without anaesthetics reduced the dislocation by ma-
nipulation. The bone was felt distinctly as it slipped into its place,
and the limb immediately resumed its natural position and length, as
all the surgeons present affirm. He was soon out of the house on
crutches, and on the eleventh day went in bathing. When he came
out of the water he complained of his hip, and on the following day it
was seen to be shortened. Subsequently it was examined by several
surgeons, all of whom pronounced it dislocated. An attempt was then



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668 DISLOCATIONS OF THE THIGH.

made to reduce the dislocation by Jar vis's adjuster, but without anaes-
thesia, as the patient refused to be rendered insensible. The attempt
did not succeed, and the father brought an action against Dr. Wataon
in the Supreme Court of Orleans Co., Judge Davis presiding, for Sept
1858. The prosecutor failed to appear, and Dr. Watson, the defend-
ant, took judgment by default.

Lente relates a case in which, extension being employed, the cord
was suddenly cut while the limb was abducted and rotated outwards,
when the head of the femur left the ischiatic notch, and rose upon the
dorsum ilii, assuming a position directly above the acetabulum, and
below the anterior superior spinous process ; and from which position
it was subsequently, with great difl&culty, returned to the socket.^

§ 3. Disrx)GATioNs Downwards and Forwards into ths Foramen

Thyroideum.

8yn. — " Downwards into the foramen ovale ;" Sir A. Cooper. " Downwards
into the obturator foramen ;" Lizars. ''Downwards and forwards into the fora-
men obturatorium ;^* B. Cooper. " Inwards and downwards into the oyal hole ;'*
Chelius. " Downwards and forwards into the foramen ovale ;'* Pirrie. " Down-
wards and inwards;*' Boyer. "Bub-pubic;" Gerdy. " Ischio-pubic ;" Mal-
gaigne.

Causes, — In order to produce this dislocation the limb must be, at
the moment of the receipt of the injury, in a position of abduction.
Perhaps most often it is occasioned by the fall of a heavy weight upon
the back of the pelvis when the body is bent and the thighs spread
asunder.

Pathological Anatomy, — The capsule gives way upon the inner side
especially ; the round ligament is torn from its attachment, and the
head of the femur pressing forwards and downwards, finds a lodge-
ment upon the obturator externus muscle, over the foramen thyroi-
deum.

Symptoms. — The thigh is lengthened from one to two inches, ab-
ducted and flexed, the body being also bent forwards or flexed upon
the thigh. The dislocated limb is advanced before the other, and the
toes generally point directly forwards, but they may incline either
outwards or inwards. The hip is flattened or depressed ; the long
adductors are felt tense upon the inside of the limb ; the trochanter
major is less prominent than upon the opposite side; and the head of
the bone may sometimes be felt in its new position. The lengthening
of the limb alone is sufiicient to distinguish this accident from a
i^actura of the neck.

The flexion and abduction are due in some measure to the tension
of the psoas magnus and iliacus internus, and perhaps to a similar
condition of other rotators and flexors; but, according to Bigelow, the
ilio-femoral ligament ofiers the chief resistance, and constitutes the
chief impediment to the restoration of the bone.

Treatment, — It is pretty certain that in the following example there
was a spontaneous reduction, or rather, I ought to say, an accidental

> Lente, New York Joum. Med., Nov. 1850, p. 314.



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INTO THE FORAMEN THYROIDEUM. 669

reduction of a dislocated femur from the thyroid foramen. Perhaps
it was only an example of a partial luxation ; of which species of for-
ward luxation I shall hereafter relate another case as having come
under my own notice.

Jacob Lower, 89t. 10, fell from a tree, a height of about twelve feet
to the ground. It is not known how he struck. He became imme-

Fig. 292. Fig. 298.



Relationa of the llio-r«monii lig&ment to the thyroid
dUloc«tion. (From Bigelow.)

diately quite faint, and when he had
partly recovered, he attempted to get
up, but could not. He said his leg
was broken, and cried out lustily
whenever it was moved. The father

arrived in about an hour, and found Dislocation downwards and for wards mto the

him still lying on his back where he foramen thyroweam.
had fallen, with his right leg carried

away from the other, and turned outwards. He lifted him up to place
him in a small hand- wagon, which was long enough for his body, but
only one foot and a half in width. Finding that his right leg was so
much abducted as to prevent his being laid in so narrow a space, he
seized upon it, and with some force pressed the knee inwards across
the opposite leg, when suddenly it resumed its position with a loud
snap like a "cannon." I use the language of the father. On the
following day I examined the limb carefully, and found its motion



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670 DISLOCATIONS OF THE THIGH.

free. He was, however, vomiting tfae contents of his stomach, and
passing blood from the bladder quite freely. The vomiting soon
ceased, but the hemorrhage from the bladder continued three or four
days. On the ninth day he walked out, and on the twelfth he was
seen climbing upon the top of a house. I saw him again after the
lapse of a year, and found that he was still complaining of an occa-
sional soreness in the region of the hip-joint.

If we attempt to reduce by manipulation, it will be proper to follow



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 77 of 100)