Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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bone could be felt in its new position, especially when the thigh was
moved. At first it was supposed to be a fracture, but this error having
been corrected, the surgeons proceeded to attempt reduction on the
eleventh day. Extension was made by pulleys, and when the head of
the bone had descended to the margin of the cavity, Mr. Gibson lifted
the upper end of the femur by means of a towel, at the same moment
pressing the knee toward the opposite thigh, and forcibly rotating the
limb inwards ; by which means the reduction was accomplished.'

Lente has seen the head of the femur in the same position as in the
case reported by Cummins, not as a primitive dislocation, but conse-
quent upon an attempt to reduce a dislocation into the ischiatic notch.
The shortening was about two inches; the limb very much rotated
outwards ; the rotundity of the affected hip greater than that of the
other, and the trochanter major one inch farther removed from the
anterior superior spinous process. The head of the bone could be
felt distinctly in its new position.

The reduction was effected finally with pulleys, by the aid of chlo-
roform, and by rotation of the limb in various directions.*

Morgan also reports a case in which the head of the femur was
above the acetabulum, and a little to the outside of the ilio-pectineal
eminence' ("sub-spinous").

In a majority of cases these dislocations have been reducal by
manipulation alone, or by manipulation aided by pressure. The limb

Fig. 301.



Anterior oblique dislocation. (From Bigelow.)

should be seized in the usual manner, at the knee and ankle, car-
ried up toward the face, abducted, then rotated inwards, gently ad-
ducted, and finally brought down again to the bed. At the moment
when the rotation and adduction commence, the head of the bone
should be pressed toward the socket by the hands, and, if necessary,

» Cummins, Guy's Hospital Reports, vol. iii. p. 163, 1838.

« Lente, New York Journ. of Med., Nov. 1850, p. 314.

» Pirrie's Surgery, p. 276. See also Phil. Med. Exam., No. 51, Mutter's paper.



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ANOMALOUS DISLOCATIONS. 681

lifted a little over the margin of the acetabulum, by moderate exten-
sion at a right angle with the body.

Fig. 802.



Ueohaoism of anterior obllqae dislocation. (From Bifelow.)

Bigelow, who regards as irregular only those which are accom-
panied with a complete rupture of the ilio-femoral ligament, but whose
classification in that regard I

am not fully prepared to adopt. Fig. 808.

has nevertheless given us the
most intelligible and most pro-
bable explanation of the me-
chanism of these irregular up-
wards dislocations, and of seve-
ral other forms of irregular dis-
locations. According to this
writer, the "anterior oblique
dislocation," in which the limb
is found greatly adducted, and
at the same time strongly evert-
ed, is A regular dorsal disloca-
tion, the head being advanced
upon the dorsum to a point near
the anterior naargin of the ilium.
If now the limb be brought
down, the neck of the femur
will be made to bear against
the outer fibres of the ilio- ,

femoral ligament, and as these supra^pinon. di.iocation. (Bigeiow.)

gradually give way the head

will become more and more hooked over the remaining fibres of the
ligament, and above the inferior spinous process (" supra-spinqus") ;
or, continued efibrts being made to straighten the limb, the ligament
44



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682 DISLOCATIONS OF THE THIGH.

will give way entirely, atid the femur will assume the position indi-
cated by the dotted lines.

Bigelow recommends a plan of treatment essentially the same as
that hitherto recommended by myself. " The anterior oblique disloca-
tion may be reduced by inward circumduction of the extended limb
across the symphysis, with a little eversion, if necessary, to disengage
the head of the bone. Inward rotation then converts this into the
common luxation upon the dorsum." In the supraspinous disloca-
tion, he recommends also inward circumduction, with as much emer-
sion as may be necessary to disengage the head from the pelvis^ by
which the dislocation is at once converted into dorsal.

2. IHsloeations Dovmwards and Backwards upon the Posterior Part of the

Body of the Ischium^ between its Tuberosity and its Spine.

James C , set. 35, was admitted to the Pennsylvania Hospital on

the 23d of January, 1835, under the care of Dr. Hewson. The patient,
a muscular man, had been crushed under a falling roof, and, as he
thought, with his right thigh separated from his body. When received
into the hospital, one hour after the accident, the right thigh was flexed
upon the pelvis, and rested upon the left ; the right leg was also flexed
upon the thigh ; the knee was below its fellow, the toes turned in-
wards, and the whole limb shortened at least one inch. The head of
the bone could be felt distinctly resting upon that portion of the
ischium which lies between the acetabulum, the tuberosity of the
ischium, and the spine.

On the following day, the muscles of the patient having been suffi-
ciently relaxed by suitable means, the pulleys were applied ; but^ after
a second attempt, some of the bands having given way suddenly, the
pulleys were removed, when it was found that the reduction had been
accomplished, although neither the patient nor his attendants had
noticed the return of the bone to its socket. For several days there
was entire loss of sensibility and motion in the leg, owing probably to
the pressure which had been made upon the sciatic nerve; but these
symptoms gradually disappeared, and at the time when the case was
reported, about two months after the accident^ he was walking with
crutches.

Dr. Kirkbride, who has reported this unusual case of dislocation,
doubts whether the extension was necessary to the reduction, as the
head of the bone was brought very near the margin of the acetabulum
by lifting the thigh with a towel, and it probably afterwards entered
the socket so soon as the extension was relaxed.^

Malgaigne has referred to several similar examples.

3. Dislocations Downwards and Backwards into the lesser or lower Ischi-

otic Notch.

5yn.— "Behind tuber ischii ;" Gibson, 8. Cooper. *' Fifth dislocation ;" Gibson.

September 7, 1821, Charles Lowell, of Lubec, Mass., was riding a
spirited horse, when the animal, being restive, suddenly reared and fell

1 Eirkbride, Amer. Joum. of Med. Sci., vol. xri. p. 13.



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ANOMALOUS DISLOCATIONS. 68S

back on his rider, in such a manner as that the weight of the horse
-was received on the inside of the left thigh ; Mr. Lowell having fallen
on his back, a little inclined to the left side. The surgeon, who was
immediately called, recognized it as a dislocation, and thought he had
succeeded in reducing it ; but a day or two later it was seen by a
second surgeon, who declared that it was still out of place, and re-
peated the attempt at reduction, but without success, as the result
proved.

In December of the same year Mr. Lowell called upon John C.
Warren, of Boston, who was now able to determine, easily, as he
affirms, the precise character of the accident. The limb was elongated,
contracted, and the head could be felt in its unnatural position. By
advice of Dr. Warren, he was taken to the Massachusetts General
Hospital, and a persevering attempt was there made to reduce the
bone, but with no better success than had attended the efiforts pre-
viously made.^

Mr. Keate has reported a case produced in a very similar way by
a horse having fallen backwards with the rider into a deep and narrow
ditch; but the position of the limb was somewhat extraordinary, con-
sidering that it was a dislocation backwards, the whole limb being
very much abducted and the toes being turned outwards, as if the head
of the bone was in front of the tuber ischii, rather than behind it.
The thigh and leg were much flexed, and the whole limb was short-
ened from three to three and a half inches. The iiead of the femur
could be distinctly felt ''inferior to the ischiatic notch, and on a level
with the tuberosity of the ischium." In the first attempt at reduction
the head of the bone was thrown into the foramen ovale, from which
it was, however, after one or two more attempts by extension, and by
lifting with a jack-towel, restored to the socket. Mr. Keate believes
that the dislocation was originally into the foramen ovale, but that in
the struggles made by the patient to extricate himself, it was thrown
backwards into the position in which he found it.*

Mr. Wormald has reported a primitive accident of the same kind,
occasioned by jumping from a third-story window. The patient died
soon after, and at the autopsy the head of the femur was found under
the outer edge of the gluteus maximus, projecting through the torn
capsule opposite the upper part of the tuber ischii. The shaft of the
femur lay across the pubes, and the limb was considerably shortened
and turned inwards.'

4. Dislocationa Directly Downwards.
8yn. — ^ ^ Sous-cotyloidieimes ;' ' Malgaigne.

The following is one of several similar examples now upon record : —

A man, aat. 60, was admitted into the London Hospital under the

care of Mr. Luke. A dislocation of the left femur was easily diagnos-

» New York Med. and Phys. Joarn., vol. v. p. 697, 1836. Letter to the Hon.
Isaac Parker, <&c., by John C. Warren : 1826. North Amer. Med. Joum., vol. iii.
p. 169.

« Amer. Joum. Med. Sd., vol xvi. p. 226, 1835; from Lond. Med. Gaa,, ▼ol. x.
p. 19.

I Wormald, London Med. Gaz., 1886.



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684 DISLOCATIONS OF THE THIGH.

ticated, but the symptoms were peonliar, inasmach as the limb was
lengthened one inch, without either inversion or eversion; yet^the
head of the bone could be easily felt, and was thought to be in the
ischiatic notch. By roanipular movements reduction was easily effected
about an hour after the accident. The man subsequently died from
the effects of broken ribs. At the autopsy, Mr. Forbes, the house-
surgeon, before dissecting the parts, again dislocated the bone. This
was done with ease, and it was clear that the original form of disloca-
tion had been reproduced, as the bone could not be made to assume
any other position. The head of the bone proved to be displaced
neither into the ischiatic notch nor the thyroia hole, but midway be-
tween the two, immediately beneath the lower border of the acetabulum.
The gemellus inferior and the quadratus femoris had been torn, the
ligamentum teres had been wholly detached, and there was a laceration
in the lower part of the capsular ligament.^

Dr. Blackman, of Cincinnati, informs me that, in Jan. 1859, he re-
duced a sub-cotyloid, incomplete dislocation, in a man st. 70, by
manipulation, Dr. Judkins lifting the thigh upwards and outwards by
means of a towel, while Dr. Blackman first flexed and then abducted
the limb.

5. Dislocations Forwards into the Perineum.

Syn, — "P^rin^ales;" Malgalgne. ** Luxation sur la branche ascendante dc
IHschion;** D^Amblard. ** Inwards on the ramus of the os pubis;** 8key.

D^Amblard published an example of this accident in 1821, occa-
sioned by a violent muscular exertion made by the patient in aD effort
to spring into his carriage, the symptoms attending which did not
difier materially from those which were found to be present in the
three following examples, except that in the first case the toes were
turned slightly inwards, while in each of the other cases they were
turned outwards.'

Mr. E , 8Bt. 85, a calker by occupation. The injury was re-
ceived while at work under the bottom of a canal-boat, July 20,1831,
the boat being raised upon props three and a half feet long. The
patient was standing very much bent forwards, with his feet far apart,
between which lay a piece of round timber one foot in diameter, when
the props gave way, letting the whole weight of the boat upon him-
self and his companions. One of the workmen was killed outright.
On extricating Mr. E. from his situation, the left leg and thigh were
found extended at a right angle with the body, the toes turned slightly
inwards, the natural form of the nates was lost, and the head of the
femur could be felt distinctly moving, when the limb was rotated, in
the perineum, behind the scrotum, and near the bulb of the urethra.

For the purpose of reduction, the patient was laid on his back
upon a table, and the pelvis made fast by a muslin band. Extension,
accompanied with moderate rotation, was then made in a direction

» Luke, Med. News and Library, vol. xvi. p. 84, March, 1858 ; from Med. Tiines
and Qaz., Jan. 2, 1858.
' Malgaigne, op. cit., torn. ii. p. 876.



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ANOMALOUS DISLOCATIONS. 685

outwards and downwards, bringing the head of the bone over the
ascending ramus of the ischium, beyond which it was lying, into the
foramen thyroideum ; and from this position the bone was replaced in
the acetabulum, by carrying the dislocated limb forcibly across the
opposite one. The patient soon recovered the use of the joint.^

J. B., an Irishman, sat. 40, on entering the St. Louis hospital, gave
the following account of his accident, which had occurred six hours
previously. He was engaged in excavating earth, and having under-
mined a bank, it unexpectedly fell upon his back while he was stand-
ing in a bent position, with his thighs stretched widely apart. The
weight crushed him to the earth, breaking both bones of his right leg,
the radius of the same side, and dislocating the left hip into the peri-
neum. The thigh presented a peculiar appearance, being placed quite
at a right angle with the body, but somewhat inclined forwards. The
part of the hip naturally occupied by the trochanter major presented
a depression deep enough to receive the clenched fist ; while the head
of the bone could be both seen and felt projecting beneath the skin of
the raphe in the perineum. Botation of the limb, which was difficult
and excessively painful, rendered the position of the head still more
manifest. The patient had also retention of urine, occasioned proba-
bly by the pressure of the femur upon the urethra. Having dressed
the fractures, Dr. Pope placed the patient under the full influence of
chloroform, and then proceeded to reduce the dislocated thigh; for
which purpose " two loops were applied, interlocking each other in
the groin, and using the leg as a lever, extension, by means of the
pulleys, was made transversely to the axis of the body. A. steady
force was kept up for a short time, and the thigh-bone glided into its
socket with a snap that was heard by every attendant and patient in
the large ward."*

A man, set. 22, was admitted to the Toronto Hospital, under the
care of Dr. E. W. Hodder, Jan, 15, 1856, having been injured by the
fall of a bank of earth an hour before. The head of the right femur
was found under the arch of the pubes, the neck resting upon the
ascending ramus. The thigh formed nearly a right angle with the
body ; it was also strongly abducted, and the toes were slightly everted.
On the following day, the patient being placed under the influence of
chloroform, extension and counter-extension were employed in the
direction of the axis of the femur, that is, nearly at right angles with
the body, while, at the same moment, the upper portion of the femur
was lifted by a round towel. By this manoeuvre the head of the bone
was carried into the foramen thyroideum. The force was now applied
in a direction " more upwards and outwards.; the ankle held by the
assistant was drawn under the other and at the same time rotated."
In a few minutes the complete reduction was accomplished. His re-
covery has been steady, and three weeks later he was discharged, being
able to walk very well with the aid of a cane.'

> W. Parker, N«w York Med. Gaz., 1841 ; N. Y. Joum. Med., March, 1852, p.
188.

« Pope, St. Louis Med. and Surg. Joum,, July, 1850; N. Y. Joum. Med,, March,
1852, p. 198.

* Hodder, British Amer. Joum., March, 1861.



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686 DISLOCATIONS OF THE THIGH.

§ 6. Ancient Dislocations of the Femur.

Says Sir Astley Cooper: "I am of opinion that tbree moDths after
the accident for the shoulder, and eight weeks for the hip, maj be
fixed as the period at which it would be imprudent to attempt to make
the reduction, except in persons of extremely relaxed fibre or- of ad-
vanced age. At the same time, I am fully aware that dislocations
have been reduced at a more distant period than that which I have
mentioned ; but in many instances the reduction has been attended
with the evil results which I have just been deprecating." A remark
which later surgeons do not seem always to have correctly anderstood,
or which, if they have understood, they have not correctly represented;
since it has many times been affirmed of this distinguished surgeon,
that he regarded reduction of the hip as impossible after eight weels,
and they have proceeded to cite examples which would prove that he
was in error. But long before Sir Astley 's day, Oockeliua mentioned
a case of reduction of the femur after six months, and Guillaume de
Salicet declared that he had reduced a similar dislocation after one
year,^ and Sir Astley says that he is "fully aware" of the existence of
such facts; yet with a knowledge of what has so frequently followed
these attempts, he would not recommend the trial after eight weeks,
except under the circumstances by him stated ; and notwithstanding
the number of these reported successes has been considerably increased
in our day, we suspect that Sir Astley's rule will continue to govern
experienced and discreet surgeons. Certain examples which have
recently been published of successful reduction aftier six months by
manipulation, would encourage a hope that the period might be greatly
extended, were it not that manipulation also has already failed many
times in the case of ancient luxations, and that the attempt has some-
times been followed with disastrous results, even in recent cases.

The following are examples of reduction by manipulation after the
lapse of six months : —

On the 21st of March, 1856, a man presented himself at the Com-
mercial Hospital, Cincinnati, with a dislocation of the femur upon the
dorsum ilii, of six months' standing. The limb was shortened two
inches. Dr. Blackman, under whose care he was admitted, adminis-
tered chloroform, and by manipulating after the method described by
Dr. Beid, the reduction was accomplished.'

In a letter addressed to me by Dr. Blackman, and dated April 21sty
1859, he informs me that this patient presented himself again before
the class about six months since, and the restoration of the functions
of the limb was found to.be complete.

The second example occurred in the practice of Martial Dupierris,
of Havana, Cuba. A Chinese boy named A-sin, aged about sixteen
years, arrived at Havana on the fourth of June, 1856, suflfering under
a severe illness, which confined him for a month or more to his bed,

1 Malgaigne, op. cit., torn. ii. p. ISo; from Gallicinium Medico-practicom, Ulm,
1700, p. 288.
' Blackman, Ohio Med. and Surg. Joum.,yol. yiii. p. 522.



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ANCIENT DISLOCATIONS OF THE FEMUR. 687

and the existence of the dislocation was not discovered until he had
sufficiently recovered to rise upon his feet. It was then ascertained
that he had a dislocation of the left femur upon the dorsum ilii. Upon
inquiry, Dr. Dupierris learned that the accident had occurred before
leaving China, a period of more than six months. The boy was still
feeble, the limb somewhat emaciated, and instead of being rigid from
muscular contraction, all the muscles "were in a flaccid condition,
except the great gluteal, which was painful to the touch." Deeming
the use of ansBSthetics improper, on account of the boy's feeble condi-
tion, these agents were not employed. Dr. Dupierris describes the
method of reduction as follows : " The body being held by two assist-
ants by means of two bands, one of which passed beneath the peri-
neum, and the other under the axillae, traction was made upon the
limb by two strong and intelligent assistants. The movement of the
head of the bone, resulting from this manoeuvre, was very limited,
even when the force was much increased ; and the excruciating pain,
-which the patient referred to the iliac region, compelled us for the
moment to desist.

" The following day, the patient having obtained a tolerable night's
rest by means of a narcotic potion, I concluded to attempt the reduc-
tion by flexion, believing that I could thus better prevent any accident
which the necessary force might produce ; the operator, in adopting
this method, having it in his power to follow the head of the bone by
pressure upon it with the hand, aiding its movement in the proper
direction, or correcting any deviation that may occur. The emaciated
condition of the boy was eminently favorable for such a procedure.

" The patient being placed upon his back, and the trunk of the body
made steady by assistants, with the left hand I grasped the upper
part of the leg, placed the right hand upon the head of the bone in the
iliac fossa, and then proceeded to flex the leg upon the thigh, and the
thigh upon the pelvis. By this movement the great gluteal muscle
was relaxed, and the head of the bone advanced, while with the right
hand I directed the latter toward the cotyloid cavity. As soon as I
judged the head to be immediately above the centre of the socket, I
extended the leg, the thigh remaining flexed at a right angle ; and
then using the limb as a lever, I rotated it from within outwards, and
at the same time extended it by making a movement of circumduc-
tion in a similar direction. Whe iby these procedures the limb was
brought near to its opposite fallow, a snap audible to the assistants,
and of a deeper character than is ordinarily observed in the reduction
of recent dislocations, indicated the return of the head of the bone to
its natural position ; a fact which was further substantiated by the
establishment of the original length and form of the member and the
subsidence of the pain.

" The after-treatment consisted in placing a pad between the knees,
and /another between the internal malleoli, and confining the limbs
together by two bands, one above the knees, and the other around the
lower part of the legs. But in spite of these precautions to prevent
redisplacement, the next morning I found that the dislocation had
been reproduced. It was again reduced, but for three successive days



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688



DISLOCATIONS OP THB THIGH.



there was a redisplacement. After this, however, the head of the bone
kept its place ; passive motion was daily employed, and all BuSering
ceased. After twenty days of rest» and a liberal use of the lactate of
iron, the patient was allowed to get up ; and, being provided with a
pair of crutches, upon which he exercised himself daily, improved
very rapidly. The muscles graduallv recovered their bulk and vigor,
and at the end of forty -eight days lie was enabled to walk without
crutches, although with some fear of falling. About the middle of
August be was put to work in a cigar manufactory, and has continued
well ever since. '

The third is a case reported by Dr. A. W. Smyth, of New Orleans.
The dislocation was upon the dorsum ilii, of nearly nine months'
standing ; and it was reduced by manipulation, in the first attempt.
The reduction was accompanied with " a good deal of snapping and
breaking."

Dr. Brown, of Boston, has published an interesting case of redaction
of an ancient dislocation of the hip in a child 8 years old. He believes
the dislocation to have been caused by rheumatic arthritis. In the
same connection he has furnished a table of the cases of reduction of
ancient dislocations of the hip, which he has found upon record.^ I
republish the table, with a single correction.



SvBOBOir.


Tmi.


AUTHOEITT.


Gockelius.


180 days. Gallicinium Hed.-practicam, p. 288.


Salicet.


865 '' Ibid.


Dupuytren.


81 »


* Op., chap. 19.


ii


78 " Ibid.


Cl


99 "


Dupierris.


180 «' Hamilton, Frac. and Dis., p. 679.


Bre8Cliet.


72 " Repertoire G^n^rale.


Cooper.


26 " Dislocations and Fractures, p. 85.


i(


5 years. Ibid,, p. 81.


Liston.


35 days. Ibid., p. 45.




2 years. M6m. de PAcad. Roy. de Chir. de Paris, lorn.






V. p. 529.


Guillatmie de Balicet.


865 days. Mal^igne, torn. ii. p. 281.


Hayward. .




Op., p. 71.


Crosby.



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 79 of 100)