Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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the satne rule which we have stated as applicable to dislocations back-
wards, namely, to carry the limb in the first instance only in those di-
rections in which it is found to move easily. Instead, therefore, of hold-
ing the leg in a position of adduction while the thigh is flexed upon the
abdomen, it will be necessary to carry it up abducted ; and when the
further progress of the knee toward the belly is arrested, the limb must
be moved inwards, and finally brought down adducted. When the knee
is about opposite the pubes, or a little lower, in its descent^ the femur
• should be gently rotated inwards, for the purpose of directing the head
toward the acetabulum. The reduction may also be sometimes facili-
tated by lifting the head of the bone with the aid of a band passed
under the upper portion of the thigh and over the shoulder of an
assistant ; by giving to the shaft of the femur a slight rocking motion
when it is about to enter the socket ; and also by pressing with the
hand against the head of the bone, or by lifting at the knee moderately.

In one of the examples recorded by Markoe (Case 8), the rednctioo
was accomplished in the second attempt, by rotating the thigh inwards
just as the thigh had descended below a right angle with the body,
in the manner which we have above directed ; but in a second example
(Case 9), a similar manceuvre carried the head across into the ischiatic
notch, while the reduction was finally accomplished by rotating the
thigh outwards, and at the same moment adducting the limb strongly
in a direction which carried the knee behind the other one. Markoe
concludes that the latter mode is preferable, because it will throw the
head of the bone a little upwards as well as outwards ; in which direc-
tion it will find a more gently inclined plane toward the socket. He
admits, however, that both methods may accomplish the same result
But I am quite certain that the method by rotation of the shaft of the
femur inwards is in general most likely to succeed. In this way also,
I think, both W. H. Van Buren, of New York," and R. L. Brodie, of
the U. S. Army, were successful;* it is the method preferred by
Bigelow, who also recognizes the propriety of making outward
rotation when inward rotation fails. " Flex the limb towards a per-
pendicular, and abduct it a little to disengage the head of the bone;
then rotate the thigh strongly inward, adducting, and carrying the
knee to the floor." It is especially worthy of notice that Anderson,
so long ago as 1772, in the case already quoted when we were con-
sidering the history of reduction by manipulation, practised success-

> W. H. Van Buren, New York Med, Times, Jan. 1856, p. 127.
« R. L. Brodie, Memphis Med. Recorder, Sept. 1857, p. 93 ; from Charleston
Med. Rev.

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fully almost precisely the same method. In one example mentioned
"by Markoe (Case 7), it is pretty evident that the head of the femur
iwas thrown into the ischiatic notch, by having flexed the thigh too
much, so that " the knee touched the thorax." Indeed, it is question-
Fig. 294

Bednetion of thfrold dUloeatlon hj manlpaUtlon. (From Blgelov.)

able whether it will be best ever to bring the thigh much, if at all,
above a right angle with the body, since any farther flexion can only
throw the head below the acetabulum, when in fact it is already too

July 21, 1858, Nathaniel Smith, a painter by trade, 86t.83, fell from
the second-story window of the city post-office, Bufialo, upon a stone
pavement, striking, as he believes, upon the inside of his right knee.
I saw him within an hour, and found the right tibia partially dislocated
outwards, the corresponding patella dislocated completely outwards,
and the right femur in the foramen thyroideum. His thigh was forci-
bly abducted, slightly rotated outwards, and lengthened, by measure-
ment made from the pelvis to the ankle, one inch and a half. The
distance from the anterior superior spinous process to the fold of the
groin was ten inches, but upon the sound side it was only eight and a
half. The head of the femur could be distinctly felt in front, just
under the pubes.

Having administered chloroform, I first reduced the tibia and the
patella, then seizing the thigh and leg, I flexed the thigh upon the
body, carrying the limb upwards abducted until it was nearly or quite
at a right angle with the body, then inclining the knee slightly in-

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wards, I brought it down again, and when the thigh had nearly reached
the bed, it fell into its socket with a dull flapping sensation. In every
step of the procedure I followed the inclination of the limb, lie
recovery was rapid and complete.

Sir Astley Cooper says that this dislocation is in general redaced
very easily by the aid of pulleys ; at least if the accident is recent.

Pig. 295.

Sir Astley Cooper's mode of rednelng a recent laxation into the foramen thjroideaiB.

He advises that the patient shall be placed upon his back, with his
thighs separated as far as possible. The pulleys are to be raade fast
to a band drawn through the perineum of the dislocated limb, in a
direction upwards and outwards; while a counter-band is to be passed
around the pelvis through the band attached to the pulleys, and secured
to a staple, or delivered to assistants placed upon the sound side of the
body. When everything is arranged, the pulleys should be acted upon
until the head of the femur is felt moving from the foramen ovale ; at
this moment the surgeon must pass his hand behind the sound limb,
and seizing upon the ankle of the dislocated limb, adduct it forcibly,
thus converting the limb into a lever of the first order.

If the dislocation has existed some time, he recommends that this
procedure shall be varied by placing the patient upon his sound side
instead of his back, and attaching the pulleys perpendicularly over
the body. Sir Astley especially cautions us not to flex the thigh during
these manoeuvres, lest we force the head of the bone backwards into
the iscbiatic notch, from whence he affirms that it cannot afterwards
be returned to its socket; but the experience of surgeons has since
shown that this latter statement is incorrect, and that it may, in some
cases, be afterwards reduced, although it has fallen into the iscbiatic

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notch. Mr. Listen says that this accident happened to himself while
attempting to reduce a dislocation of only a few hours' standing, in a
young and powerful man, but he had no difficulty in returning it to
its first position.^

Brainard, of Chicago, reduced a dislocation of that form of which
we are now speaking, after both the compound pulleys and Jarvis's
adjuster had failed, by placing between the thighs a piece of wood
wrapped about with several layers of a wadded quilt, and making
use of this as a fulcrum upon which the thigh operated as a lever.
The legs were simply pressed together, care ^ing taken to keep the
knees straight.*

The majority of surgeons of the present day pliice the limb in the
flexed positioa before attempting to make traction. This may be
done with the patient lying

upon his back, and by the hands Fig. 296.

alone, or with pulleys, or the
patient may be placed in a sit-
ting posture, and the extension
made at right angles with the
body. In all of these attempts
to reduce by traction, measures
must be taken to secure immo-'
bility to the pelvis.

May 23, 1868, a man. 40
years of age, was admitted to
Bellevue, having a dislocation
of the left femur into the fora-
men thyroideum, which had
been caused six hours before
by the fall of a heavy weight
upon his back while stooping.
The limb was slightly abduc-
ted, and moderately flexed

upon the pelvis, while he was Btrect of flexloaopoa the mcfemoral ligament m the
lymg upon the bed the position thyroid dl»IocaUon. (From Bigelow.)

being that represented in Fig.

293. There was a very marked depression in the situation of the
trochanter major, and a fulness upon the inside of the limb, caused
by the tension of the long adductors.

The patient being under the influence of ether, the House- Surgeon,
Dr. E. D. Hudson, first attempted, under my instruction, to reduce the
dislocation by manipulation, flexion, and rotation, with adduction;
but failing in this, a folded sheet was placed in the perineum corre-
sponding to the dislocated limb, and committed to assistants, who were
directed to pull upwards and outwards, the patient lying upon hia
right side, with his left thigh flexed to a right angle with his body.
Dr. Hudson then passed a band under the upper part of the thigh and

' Practical Surg., Amer. ed., p. 93.

« Brainard, Northwestern Med. and Surg. Journ., 1852.

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over his shoulders, lifting and pressing the knee forcibly inwards at
the same time. In a few seconds the reduction was accomplished.

After the reduction is accomplished, the patient should be laid open
his back in bed, but instead of rotating the limb outwards, as we baye
advised after a dislocation upon the dorsum ilii or into the ischiadc
notch, it should be gently rotated inwards, and the knees thus bound

§ 4. Dislocations Upwards and Forwards upon the Pubes.

Syn. — ** Upwards and forwards on the horizontal branch of the share-bone;"
Chelius. "Forwards upon the pubes ;" Pirrie. *' On the body of the pubes, below
the spine and transverse part of the bone ;** Bkey. "Bur-pubic ;" Qerdy. "Ilio-
pubic;'' Malgaigne.

Causes. — This accident is generally occasioned by a fall upon the
foot when the leg is thrown backwards behind the centre of gravity;
as in a fall from the back end of a wagon, the foot being instinctively
thrown backwards in order to save the head; or it may happen to a
person who, while walking, suddenly puts one foot into a hole, in
consequence of vhich the pelvis advances, but the leg and upper part
of the body incline forcibly backwards. Occasionally it has resulted
from a fall upon the back of the pelvis, or from a severe blow received
upon the same part. A patient was admitted under the care of Dr.
Ure, into St. Mary's hospital, London, with a dislocation upon the

Fig. 297.

Speclmea of disloeatlon npon the pabes. In St. Thomat** Hosplt&l. (From Sir A. Cooper.)

pubes, occasioned by swimming. His account of it was, that when
m the act of " striking out" he felt a catch in the right groin which
he thought was cramp, and that he was able to walk after the accident,
but with a good deal of difl5culty. The examination proved that he
had a dislocation upon the pubes, which Dr. Ure easily reduced.*

> Medical News and Library, vol. XTi. p. 1; from Lond. Lancet, Nor. 7, 1857.

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Pathological Anatomy. — Sir Astley Cooper dissected the hip of a
person whose thigh had been dislocated upon the pubes for some time,
the true nature of the accident not having been at first recognized.
The acetabulum was partly filled by bone, and partly occupied by the
trochanter major, both of which were much altered in their form. The
capsular ligament was extensively torn, and the ligamentum teres
broken off completely. The head and neck of the femur had torn up
Poupart's ligament, so as to penetrate between it and the pubes, and
lay underneath the iliacus internus and psoas muscles; the anterior
crural nerve was lying upon these muscles, over the neck of the femur.
The head and neck were flattened and otherwise much changed in
form. Upon the pubes a socket was formed for the neck of the thigh-
bone, the head being above the level of the pubes. The femoral artery
and vein were to the inner side. This specimen is still preserved in
St. Thomas's Hospital.

The head of the femur may be found lying far forward upon the
pubes, as in Physick's case mentioned below; or it may lie farther
back, along the ilio-pubic mar-
gin, and rest below and in front Fig. 298.
of the anterior superior spinous
process of the ilium. When the
head rests directly below this
process, the dislocation is con-
sidered anomalous or irregular,
and this form will be considered
hereafter as the " sub-spinous"

In the accompanying drawing
the relation of the ilio-femoral
ligament to the head and neck
of the femur is shown, when the
head ascends moderately upon
the pubes. The extreme dis-
placement shown in the pre-
ceding illustration from Sir
Astley Cooper is only possible
where that portion of the cap-
sule beneath the obturator in-
ternus is torn, and perhaps the
obturator itself. According to
Bigelow, the ilio-femoral liga-
ment and the psoas magnus and
iliacus internus are then the only
remaining causes of eversion.

Symptoms. — The thigh is ^, , .. .^ v v . v ....

,•'•*, "ljaJ n J Difiocatlon upon the pubes below the anterior la-

Snortened, abaUCted, flexed ferlor iplne of the lllnm. (From Slgelow.)

slightly, rarely extended, and

rotated outwards. The trochanter major is lost, or nearly so, while
the head of the bone may be generally felt like a round ball, lying
upon or in front of the body of the pubes to the outside of the femoral

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artery and vein. Larrey saw a patient in whom the femur was placed
nearly at a right angle with the body ; and Physick once met with t
dislocation upon the pubes "directly before the acetabulum," in which
the limb was not at all shortened, but, on the contrary, a very little
lengthened.^ Other surgeons have occasionally seen similar examples.
The diflFerential diagnosis between a fracture of the neck of the
femur and this dislocation may be thus briefly stated. In the fracture

there is crepitus, mobility, slight
Fig. 299. eversion easily overcome, mode-

rate or no shortening, no abduc-
tion, the trochanter major rotates
on a short radius, the bead of the
bone cannot be felt. In this dis-
location there is no crepitus, the
limb is immobile, the eversion is
extreme and not easily overcome,
there is generally more shortening,
the thigh is abducted, the tro-
chanter major rotates upon a
longer radius, and the head of the
bone can generally be distinctly
felt in its unnatural position.

Prognosis. — Sir Astley Ox)per
remarks that although this acci-
dent is easy of detection, he has
known three instances in which it
was overlooked, and he cannot
but regard such errors as evidence
of great carelessness on the part
of the surgeon who is employed.
The reduction has generally
been accomplished, in recent cases,
with no great difficulty ; and when
not reduced, the patients have oc-
casionally recovered with very
useful limbs.

TreatmenU — From the several
reported examples of dislocation
upon the pubes reduced by ma-
nipulation, it would be difficult to
draw any practical conclusions,
since the methods have differed
so widely from each other. I

Dl«loeatlonupward.aadrorward.uponthepube.. shall mention Only three, which

may be found m our own journals.
One of these has already been mentioned in connection with the
history of this process, as a case of compound dislocation, reduced by
Dr. Ingalls, of Chelsea, Mass., and the two remaining examples were
both reported by E. J. Fountain, of Davenport, Iowa. Dr. Ingalls

* Dorsey's Surgery, vol. i. p. 238, 1818.

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succeeded by carrying the limb into its greatest state of abduction, and
rotating the thigh inwards; the replacement of the bone being aided
also \>y pressing upon its head with his fingers thrust into the wound ;
while Dr. Fountain succeeded equally in both of his cases, by an al-
most opposite mode of procedure, namely, by adducting the limb for-
cibly, rotating the thigh outwards, and then flexing the thigh upon the
body. The first of Dr. Fountain's cases occurred in June, 1854. The
patient, an adult male, had fallen from the second story of a house to
the ground, fracturing his lower jaw, and dislocating his left hip. The
limb was a trifle shortened, and the foot strongly everted. The promi-
nence of the trochanter was lessened, and the head of the bone could
be felt upon the pubes. Assisted by Dr. Arnold, he reduced the limb
in tbe following manner : The patient was laid on the floor, and placed
completely under the influence of chloroform. The dislocated limb
was then "seized by the foot and knee and rotated outwards, the leg
flexed and carried over the opposite knee and thigh, the heel kept
well up, and the knee pressed down. This motion was continued by
carrying the thigh over the sound one as high as the upper part of
the middle third, the foot being kept firmly elevated. Then the limb
was carried directly upwards by elevating the knee, while the foot
was held firm and steady, at the same time making gentle oscillations
by the knee, when the head of the bone suddenly dropped into its
socket."' The time occupied was not more than thirty seconds, and
the force employed was very slight.

The second case occurred on the 81st of Oct. 1855, in the person
of John McCarthy, an Irish laborer; the dislocation having been
occasioned by falling with a horse, while riding. The reduction was
effected in about twenty seconds by the same process, and without the
aid of chloroform.

It is probable that no one method will succeed equally well in all
cases ; but if the head of the bone, as in the case dissected by Sir
Astley Cooper, has not only actually surmounted the pubes, but
pushed itself fairly into the pelvis, then the limb ought to be abducted
in the manner practised by Ingalls, and forcibly rotated outwards, in
order that the head may be thus lifted over the pubes; and subse-
quently it should be flexed upon the body, adducted and brought
down. But in this manoeuvre we ought to be careful not to continue
the rotation outwards after the head of the femur has risen above the
pubes, lest the head and neck should grasp, as it were, tbe psoas
magnus and iliacus internus muscles, underneath which they have
been thrust. On the contrary, it will be necessary at this point to
rotate the thigh again gently inwards, which, by compelling the head
to hug the front of the pubes, will enable it, while the flexion is being
made, to slide downwards under these muscles toward the socket. If,
however, the head of the bone has never risen upon the summit of the
pubes, and is not actually engaged under the muscles which pass over
it at this point, then the rotation outwards will not be necessary in
any part of the procedure,

* Fountain, New York Joum. Med., Jan. 1856, p. 69 et seq.

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Baron Larrey has reported a case of dislocation " before tbe hori-
zontal portion of the pubes," which he reduced " by suddenly raising
with his shoulder the lower extremity of the femur, while with both
hands he depressed the head of the bone."^ This is the same case of
which we have already spoken as being attended with the unosoal
phenomenon of the thigh placed at a right angle with the body.

If reduction is attempted by extension, the patient ought to be laid
on his back upon a table, with the dislocated limb falling oflF slightly
from its side. The extending band, made fast above the knee, should
then be secured to a staple in the line of the axis of the dislocated
thigh, and of course below the table; while the counter-extending
band, crossing under the perineum, should be made fast in the same
line, above the level of the table, and beyond the head of the patient.

When extension is commenced, and the head of the femur has
begun to move, the reduction may sometimes be facilitated by lifting

Fig. 800.

Eedaetlon of dislocation upon the pabes, by extension.

the upper part of the thigh with a jack-towel or a band passed under
the thigh and over the neck of the surgeon, as we have recommended
in both of the backward dislocations. It may be found advantageous
also to flex and rotate the limb after extension has brought the bead
near the socket.

§ 5. Anomalous Dislocations, oe Dislocations which do not propeblt
belong to either of the four principal divisions before described.'

1. Dislocations directly Upwards.
%n.— " Sus-Cotyloidiennes ;" Malgaigne. " Sixth dislocation ;" Mutter.

Malgaigne affirms that the head, in this dislocation, is situated
external to the anterior inferior spinous process, and about one inch

> Larrey, Lond. Med-Chir. Rev., Dec. 1820, p. 600 ; vol. i. first ser., from Bullet,
de la Pac. de. Med., No. 1.

« Malgaigne, Traite des Frac. et des Lux., torn. ii. p. 869 et seq. Samuel Cooper,
First Lines, vol. ii. p. 391. Pirrie's Sure., Amer. ed., 1853, p. 275, Skey's Sun?.,
Amer. ed., 1851, p. 110 et seq. Gibson^s Surg., sixth Amer. ed., vol. i. p. 386.

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TdcIow the anterior superior spinous process (" sub-spinous"). But this
position is not uniform. It may be found in front of the inferior pro-
oess, or above ("supra-spinous") as well as behind, or external to it.

The symptoms which characterize this accident are shortening of
Xhe limb, slight abduction and extension, with extreme eversion or
rotation outwards. The eversion of the toes, together with the slight
amount of shortening which has in general been observed, has led
several times to the supposition that it was a fracture of the neck of
the femur ; but the rigidity, and the position of the trochanter and
bead will usually render the diagnosis clear.

The following is probably an example of the sub-spinous disloca-
tion : —

Bennett Morris, 8Bt. 51, was thrown backward, in wrestling, in 1851.
He felt a snap in the hip-joint, and found his thigh placed in a position
of moderate abduction, so that he could not get his knees together.
He was able to walk, but not without limping. This condition con-
tinued three years, during which time he was constantly lame, and
suffered much pain when walking.

At the end of this period, when in the act of jumping from his
wagon, his horses having become frightened, he felt a snap, and at once
the complete functions of the joint were restored. He could walk
without pain or halt, and he could bring his knees together. Three
months later, while ascending a flight of steps, carrying a heavy weight,
his foot slipped, and the luxation was reproduced, and in this condi-
tion it remained up to the period at which he consulted me, Oct. 1869.
I found the thigh apparently elongated, but upon measurement it was
found shortened half an inch. It was moderately abducted and ro-
tated outwards. All the motions of the joint were restricted.

Although I felt very confident that the reduction could be again
accomplished, the patient left without permitting me to make the

Other surgeons have met with examples of the upward dislocation
(sub-spinous) in which the patients have been able to walk quite well
immediately after the accident. Bigelow supposes that in these cases
the upper portion of the capsule has been completely torn from the
mifrgin of the acetabulum, and that the head has been permitted to
ascend until it was arrested by the under surface of the ilio-femoral
ligament at the point where it rises from the anterior inferior spinous
process of the ilium.

Cummins reports a case which occurred in the practice of Gibson,
of New Lanark, where the head of the bone was believed to be situated
just below the anterior superior spinous process, and inwards towards

Guy's Hospital Reports, vol. i., 1886, pp. 79 and 97 ; vol. iii., 1888, p. 163. London
Lancet, Lond. ed., vol. i., 1848, p. 184; vol. ii., 1840, p. 281 ; vol. i., 1845, p. 413,
vol. ii. p. 159. London Med. Gaz., vol. xix. pp. 657 and 659 ; vol. x. p. 19 ; vol.
xxxiii. p. 404. Med.-Chir. Trans., vol. xx. p. 112. Lente's paper on * 'Anomalous
Dislocations of the Hip-Joint," in New York Joum. Med. for Nov. 1850, p. 314 et
seq. Philadelphia Med. Examiner, No. 51. Amer, Joum. Med. 8ci., vol. xvi. p.
14. New York Med. and Phys. Jonm., 1826, vol. v. p. 597. New York Journ.
Med., Jan. 1860, Dr. Shrady^s case. Dislocation of the Hip, by Jacob J. Biirelow,
M.D., 1869, p. 105,

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the pubes (" supraspinous"). The limb was shortened fully three inches;
the toes everted; adduction and abduction were exceedingly painful
and difficult, but flexion was more easily performed. The head of the

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 78 of 100)