Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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68 '


» Trans. Am. Med. Assoc, vol. ill. p. 356.


Atlee.


120 '


* Ibid., p. 357.


Williams.


150 '


* Lancet, 1862, vol. i. p. 665.


Bigelow.


90 •


* Dis. and Fract. of Hip, p. 211.


4i


240 '


Ibid., p. 55.


it


28 '


' *' p. 54.

* Ohio Med. and Surg. Jour., vol. viii. p. 523.

* New Orleans Jour. Med., January 1, 1869.


Blackman.


180 '


Smyth.
Brown.
Kimball.


270 »

105 '

90 »


* Northwestern Med. and Surg. Journal, June,






1870.



In the comparison of the relative value and hazards of the different
modes of reduction, I have cited several examples of fracture of the
neck of the femur in the attempt to reduce old dislocations. In some
cases the results have been much more serious. »

A man, 29 years old, was received at LaPiti^, Paris, on the ISthof

1 Spontaneous dislocation on dorsum ilii. Reduction after several months. By
Francis Brown, M.D., Surgeon to the Childr^n^s Hospital, &c &c., Boston.



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ANCIENT DISLOCATIONS OF THE FEMUR. 689

May, 1868, with dislocation of the hip of seven months' standing. M.
Broca attempted to reduce it, using a force of 480 lbs. No reduction
was obtained, and the patient insisted upon leaving the hospital five
days afterward. A fortnight then elapsed, when he presented himself
at another hospital, with the hip enormously swollen, and died the
next day of peritonitis. The autopsy showed that the head of the
bone lay in the isohiatic notch, that it was held firmly by bundles of
the torn capsule, and that the cotyloid cavity was much shrunk. Pus
was found in the capsule, in the iliac fossa, in the articular cavities,
and had found its way into the peritoneum, through the obturator
foramen.^

The following case seems deserving of mention, for the reason that
it is the first, so far as I am aware, in which an attempt has been made
to reduce the dislocation after a subcutaneous division of the cap-
sule : —

Thomas Jordan, aet. 28, of Utica, N. Y., was sent to me by my
former pupil. Dr. Jenkins, in January, 1869, having a dislocation of
his left femur upwards and backwards upon the dorsum ilii. His
account of the case was, that seven months before he was thrown in
wrestling; a surgeon was called on the following day, and finding a
dislocation, he placed him under the influence of an anaesthetic, and,
as he supposed, reduced the dislocation by manipulation.

The case did not come under the notice of Dr. Jenkins until a few
weeks before he was sent to me, and although the character of the
accident was recognized, no attempts were made at reduction.

I found the limb rotated inward, adducted, and shortened two
inches. Before the class of medical students at Bellevue, assisted by
Drs. Sayre, Crosby, Howard, and others, I made an attempt, January
29th, to break up the adhesions and reduce the dislocatio,n, the patient
being fully under the influence of ether. We were able to move the
limb quite freely in various directions ; but after a trial of nearly an
hour, we abandoned the attempt, having failed to accomplish reduc-
tion.

A few days later I applied extension, by means of adhesive plaster
and a cord, with a weight of twenty pounds. This was continued un-
remittingly until February the 24th, when he was again placed under
the influence of ether before the class. Assisted by Drs. Stephen
Smith, Howard, Cross, and others, attempts were made to reduce the
bone by manipulation, but without success. Believing now that the
untorn portion of the capsule, and particularly the ilio-femoral liga-
ment^ constituted the chief obstacle to the reduction, I introduced a
long, firm, but narrow bistoury, which I had had made for the purpose,
just above the trochanter major, carrying its point inward until it
touched the neck at the base of the trochanter. From this point, the
edge of the knife being directed towards the head of the bone, I swept
the point of the knife slowly along until the head was distinctly felt,
the point touching the neck apparently in its whole length. This was
accomplished without enlarging the external opening. While the in-

* New York Med. Record, Dec. 16, 1868.



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690 DISLOCATIONS OP THE THIGH.

cision was being made the limb was kept rotated outwards, and ab-
dacted as much as was possible, and it was felt to yield distinctlj, so
that both rotation outwards and abduction were more complete aifier-
wards than before. I then divided also the tensor vaginsd femoris;
and now the attempts at reduction were repeated, both by manipula-
tion and extension, but without success.

The result of this attempt to reduce the dislocation by division of
the ilio-femoral ligament, although unsuccessful, encourages a hope
that it may sometimes succeed ; and I shall not hesitate to repeat the
experiment, if a favorable opportunity is presented.

§ 1. Partial Dislocations of the Femuk.

Malgaigne declares that certain experiments made upon the cadaver
led him, at one time, to the conclusion that all primitive luxations of
the femur were incomplete, and that the old complete luxations found
in autopsies had become so consecutively. Later observations have
taught him to correct this error, yet he still finds "incomplete back-
ward luxations quite common, and incomplete dislocations in all the
other directions much more common."

I have more than once found occasion to call in question the
accuracy of Malgaigne^s views in relation to partial dislocations, the
relative frequency of which he seems constantly disposed to greatly
exaggerate. We cannot see the propriety of calling those cases par-
tial dislocations, in which the head of the bone has fairly led the coty-
loid cavity, and mounted upon its margin, even if it remains in this
position without tearing the capsule ; since the articular surfaces are
now as completely separated as if the capsule had given way, and the
head of the bone had escaped through the laceration. It is in fact a
complete luxation. But I doubt very much whether the head of the
bone ever rests upon the margin of the acetabulum without tearing
the capsule, unless it has previously undergone certain pathological
changes, such as I have already described; at least I cannot hesitate
to reject all those examples in which the head of the femur is sup-
posed to rest upon the upper or outer margin of the acetabulum ; and
if I permit myself to speak of incomplete dislocations at all in this
connection, I shall reserve the term for those rare cases in which the
head of the femur becomes engaged in the cotyloid notch, after break-
ing down the fibrous band which, in the natural state, is continuous
with the rim of the acetabulum.

Of this form of dislocation, I think I have met with two examples;
one of which was in the person of the boy Lower, already mentioned,
whose thigh was reduced accidentally by his father ; and the other
occurred in a boy fifteen years of age, residing at that time in Butland,
Vermont. He was brought to me on the 28th of May, 1842. by Dr.
Haynes, of Butland, at which time the dislocation had existed five
years. His account of himself was that in walking upon a slippery
floor, his left leg slid outwards and backwards in such a manner as
that when be fell it was fairly doubled under his back. On the tenth
day following the accident he began to walk with some help, and be



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COXO-FKMORAL DISLOCATIONS WITH FRACTURE. 691

Las continued to walk ever since, but witb a manifest halt. Three
months after the injury was received, it was first seen by several
surgeons, who pronounced it a dislocation, and attempted reduction
without mechanical aid, but were unsuccessful.

When the young man was brought to me, the limb was neither
lengthened nor shortened, but the thigh was forcibly abducted and
rotated outwards. It could not be flexed nor greatly extended. The
head of the femur could be distinctly felt, as it lay anterior to the
socket, but not sufficiently far forwards to rest upon the foramen
ovale.

J. C. Warren, of Boston, has reported a similar example in a child
six years old, who was brought, April 21, 1841, to the Massachusetts
General Hospital. Dr. Hale, who saw^ the lad at the end of two weeks,
thought it a dislocation, but it had been treated by another surgeon
as a case of hip-disease. The dislocation •bad now existed eight or
ten weeks. The limb was a little lengthened, abducted, turned out-
wards, and advanced in front of the body, with very slight motion of
either flexion or extension, and almost no tenderness about the joint.
Dr. Warren, also, was able to feel indistinctly the head of the bone
''immediately external to, and in contact with, the insertion of the
triceps and gracilis muscles."

An attempt was made by manual extension and manipulation to
accomplish the reduction, but without success.^

It is probable that both the above cases, which I have described
at length, were examples of partial dislocation ; yet I cannot conceal
from others a doubt which I actually entertain whether they were
not^ after all, only examples of hip-joint disease, arrested after having
wrought certain slight pathological changes in the joint and the tis-
sues adjacent. If, however, they were not examples of incomplete
dislocations of the hip-joint, then I question whether any such cases
have ever occurred.

§ 8. COXO-FEMORAL DISLOCATIONS, OOMPLIOATED WITH FrAOTURE OF THE

Femur.

Such complications are exceedingly rare, but it will not do to deny
their possibility ; although in some of the cases reported, the testimony
is so incomplete as to leave a doubt whether the surgeons have not
erred in their diagnosis.

James Douglas has reported a case of dislocation upon the pubes,
complicated with a fracture of the neck of the femur, the actual con-
dition of which was verified by an autopsy ; the patient having died
twelve years after the injury was received. The head of the femur
still remained above the pubes, and was in no way connected with its
neck or shaft. The upper end of the femur projected in the groin,
lying upon the inside of the femoral artery and vein. Many other
curious pathological changes had also occurred.'

■ Warren, Bost. Med. and Surg. Joum., vol. xxiv. p. 220.
s Amer. Joum. Med. Sci., vol. xxziii. p. 455, from Lond. and Edin. Month. Joum.
of Med. Bci., Dec. 1848.



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692 DISLOCATIONS OP THE THIGH.

The well-authenticated examples of reduction of the dislocation,
where the femur was broken also, are still more rare; and setreral of
the recorded examples which my researches have discovered, need
additional confirmation.

John Bloxham, of Newport, in the Isle of Wight, claims to have
reduced a dislocation of the femur on the pubes, which was acoom-
panied with a fracture of the thigh a little above its middle. The
following is the account of this interesting case which we find in the
London Medico- Okirurgical Review, copied from the Medical Gazette of
Aug. 24th, 1838. We regret that we are unable to see the account
as published in the Gazette, which might supply some circumstance
important to a full appreciation of the case : —

On the seventh or eighth day after the accident, '* the patient was
laid on his back upon the bed, and kept in that position by means of
a sheet passed across the pelvis and fastened to the bedst^ead ; another
sheet was also passed over the left groin, and secured in a similar
manner. The dislocated and fractured limb was then inclosed in
splints, one of which extended up the back of the thigh as far as the
tuberosity of the ischium. Pulleys, which were secured to a staple in
the ceiling, placed at. the distance of a foot to the right of a point
vertical to the patient's navel, were then attached to a bandage fastened
round the splints as high up as possible.

" The foot was raised with the knee extended, so as to bring the
limb nearly to a right angle with the line of the tackle, when, by
drawing gradually on the cord, in the course of about ten or fifteen
minutes the head of the bone was rendered movable, and was brought
considerably more forward. I then began to press on the head of the
bone, so as to push it downwards, whilst the pulleys held it partially
disengaged from the pelvis. In a few minutes the head of the bone
passed over the ridge of the os pubis, and I then directed the foot to
be raised a little higher, which, by putting the gluteii muscles more
upon the stretch, was calculated to render them more efficient in
drawing the bone into its proper place. By this manoeuvre, the bead
of the bone was drawn backwards, and on the foot being more elevated
and the cord slackened, it continued to recede from my fingers till
the trochanter major made its appearance in the natural situation, and
the reduction was found to be perfectly complete.

''Lest the head of the bone should slip backwards on the dorsum
ilii, I directed an assistant to apply firm pressure during the latter
part of the process, above and behind the acetabulum.

" The apparatus was then removed, the thigh bound up in short
splints, and the patient laid upon a double-inclined plane. No symp-
toms of inflammation appeared afterwards about the joint. Passiv^e
motion was employed at the end of a week, and occasionally repeated
during the whole reparatory process."*

Without intending to question the accuracy of the statements in
this case, which, in the main, seem to bear the marks of credibility,
we must express our surprise that so little difficulty was experienced

' Lond. Med.-Chir. Rev., vol. xix. p. 420, Oct. 1833.



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COXO-PEMOBAL DISLOCATIONS WITH FRACTURE. 698

in the redaction if the femur was actually broken, no more, indeed,
than is usually experienced when the bone is not- broken ; and that
Mr. Bloxham was able to employ safely passive motion at the end of
a week.

Charles Thornhill relates, in the London Medical Gazette for July,
1886, a case of fracture of the femur through its upper third, in a
man »t. 40, with dislocation into the ischiatic notch ; which disloca-
tion, he assures us, was reduced at the end of six weeks. But it is
much more probable that, instead of reducing a dislocation, he re-
fractured the bone. During more tilan one hour and a half, aided
by pulleys, tractions and manipulations were made in almost every
direction.

The upper part of the thigh was lifted with all the strength of one
man by means of a jack-towel ; it was violently rotated, adducted, "
and abducted. Both the perineal and the knee band gave way, from
the excess of the force employed ; and, finally, the head of the femur
resumed its place with an audible crash. After which the "limb was
of nearly equal length with the other;" but there remained an "im-
mense deposit" around the acetabulum.^

Malgaigne says that M. Et^v^ found a poor fellow with a disloca-
tion of his left thigh backwards, a fracture near its middle, a penetra-
ting wound of the knee, and a fracture of the fibula in the same leg.
Without delay he proceeded to reduce the dislocation by directing two
assistants to support the body, three to support the leg, and two more
to make extension from a towel tied not very tightly around the
thigh above the fracture. The leg was then extended upon the thigh,
and the thigh flexed upon the pelvis until it was at a right angle with
the body ; and after a gradual extension had been made in this direc-
tion, M. Et^ve pushed with all his strength the head of the bone into
its socket Of which case Malgaigne justly remarks, that the "exten-
sion" practised by the surgeon was only imaginary.* If the reduction
was accomplished at all, it was by manipulation and pressure.

Finally, Markoe relates, in the paper to which we have already
several times made allusion, the case of a boy 8Bt. 8, who was admit-
ted into the New York City Hospital on the 29th of June, 1853, with
a compound fracture of the right thigh, a simple fracture of the left,
and a dislocation of the head of the right femur upwards and back-
wards upon the dorsum ilii.

When placed upon the bed, the right limb lay obliquely across the
abdomen of the boy, with the foot resting against the axilla of the
left side. "The house-surgeon, to whose care the case fell on admis-
sion, took the injured limb in his hands and very carefully carried it
over the abdomen to the right side, and then adducted it and brought
it down toward the straight position," during which procedure the
head of the bone is supposed to have resumed its place in the socket.'

Such is the account furnished of the symptoms and treatment of
this extraordinary case; too meagre, certainly, to entitle it to much

* Amer. Joum. Med. Sci,, vol. xxr. p. 21S.

> Malgaiffne, op. cit., torn. ii. p. 206; from Gazette MM., 1S8S, p. 757.

' New York Joum. Med., Jan. 1855, p. 80.



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694 DISLOCATIONS OF THE THIGH.

confidence, or to permit us to draw from it any practical inferences.
We are not even informed what was the name of the young man who
alone saw and treated the case, nor what was his responsibility as a
surgeon.

I have been unable to find any other examples of fracture of the
femur complicated with dislocation ; and, rejecting at least Mr. Thom-
hilPs case as altogether incredible, the proper conclusion would be,
that reduction is sometimes possible in recent cases, if the suigeon
will resort promptly, before swelling and muscular contractions have
taken place, to manipulation combined with pressure upon the head
of the bone. Indeed, it is probable that pressure alone is the means
upon which the success will finally depend. Bichet says that be has
several times dislocated the femur in the cadaver; and then, baving
' sawn off the head so as to represent a fracture, he has always been
able to push the head of the bone easily into its socket.^ By seizing
the moment then when the patient is laboring under the shock, or by
placing him completely under the influence of an anaesthetic, no re-
sistance Will be offered by the muscles any more than in the cadaver,
and the reduction may, perhaps, be easily effected.

I have no confidence that anything can be accomplished by exten-
sion ; nor do I think it will be best to wait until the femur has united,
since such delay will probably render the reduction impossible.

§ 9. Voluntary Dislocations of the Femur.

Examples in which persons, having suffered no disease of the hip-
joint, have been able voluntarily to dislocate the femur, have, from
time to time, been recorded, but I am not aware that any dissections
have ever been made in these cases. I shall, therefore, not attempt
any explanation of the facts, but simply record them as matters of
curious interest, and for the purpose of inducing others to make of
them a subject of investigation.

Sir Astley Cooper mentions the case of a. man who could throw
out the head of the thigh-bone at pleasure, and reduce it with equal
facility. A similar case is alluded to by Samuel Cooper, in his Fini
Lines, Gibson mentions a case reported by Dr. Lewis, of North Caro-
lina.* Dr. Bigelow has seen two cases, both of which were dorsal.
Dr. M6ore, of Rochester, has furnished an account of the case of John
Parker, whose leg was first partially dislocated at Drury's Blu£^ May
13, 1864, and which was at the time reduced by his companions. The
accompanying illustrations (Figs. 804, 305) were obtained from photo-
graphs, and indicate the position of his limb when a voluntary sub-
luxation upon the dorsum existed.

The following case was reported to me in 1865, by John M. For-
rest, M.D., of Portland, Maine, to whom the man presented himself as a
" substitute," while Dr. Forrest was in the service of the U. S. Army.
The application was rejected.

1 New York Joum. Med., March, 1854, p. 298; from Ballet, de Thdr.
> Gibson's Surgery, vol. i. p.867, 6th ed.



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VOLUNTARY DISLOCATIONS OP THE FEMUR. 695

'* Wm. G. Gliddon, aet. 37, farmer, says tbat he has been able to dis-
locate and replace the femur at the left hip-joint since he was a boy.
It is not the result of any injury or disease, so far as he knows. He
is in good health, and his muscular development is complete. He
accomplishes the dislocation by throwing the weight of his body upon

Fig. 804. Fig. 305.



YoInnUrj •nblazation upon the dorsam illi. (From BIgelow.)

the left leg, and then contracting certain muscles about the hip. The
reduction is generally more difficult than the dislocation, sometimes
requiring the aid of his hand. When the head of the bone is out,
there is a marked projection above and behind the trochanter major,
apparently caused by the pressure of the head in this situation ; the
limb is very slightly if at all everted; while out of place it causes
pain ; and after a few repetitions the pain becomes so great as to com-
pel him to desist. The limb was not measured while it was dislo-
cated. When the limb is in position he does not walk lame."

The following is the only case which has come under my personal
observation: Dr. Wm. G. S., aet. 24, received an injury on the out-
side of the right knee, in Feb. 1862, from the kick of a horse. There
was no apparent injury of the hip. On the fourteenth day after the
accident he rode forty miles on horseback, which was followed by some
stiffiaess in the right hip. Two weeks later, in mounting his horse, he
felt something slip in the hip-joint. From that day until this, a period
of four years, he has been able to reproduce the same slipping volun-
tarily, and which phenomenon I recognize as a dislocation upwards
and backwards. I have examined him more than once, and he has



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696 DISLOCATIONS OF THE PATELLA.

dislocated and reduced the dislocation in my presence repeatedly.
Planting his right foot firmly upon the floor a little in advance of the
. left, with his toes turned out, he throws bis weight upon the right
leg by carrying his pelvis well over to the rights and then contracts
powerfully the gluteal muscles. Instantly the head leaves the socket,
and seems to mount upon the dorsum ; the trochanter major becomes
rotated inwards, causing a slight inward rotation of the leg and foot
He can do the same when lying on his back, but not with the same
ease. Beduction is accomplished without change of position, but
by what precise manoeuvre I have not determined. The reduction is
more quiet, and less sudden, apparently, than the dislocation. Both
manoeuvres are accompanied with some pain. He is not lame, nor
does the dislocation take place without his volition. I have seen one
case, also, which, although pathological in character, was nevertheless
caused by an early injury, and as such may properly be noticed in
this connection.

Dr. O. Gillett, ast. 65 (1867), of Westernville, Oneida Co., N. T., was
injured in his left; hip-joint when 16 years old, by lifting a heavy
weight. He felt at the moment something give way in the joint, and
he has been lame ever since; at first he was quite lame, but after a time
the soreness about the joint diminished, ana up to within about three
years the lameness was chiefly due to a lack of development in the
limb. Since then the joint has again become tender, and during the
last nine months he has been able to throw the head of the bone out
of the socket, backwards and upwards. Indeed, the bone is dislocated
whenever he sits down, and resumes its place again when he standi
up. It is quite apparent that the upper and outer margin of the
acetabulum is partly absorbed ; and probably, also, the head and neck
of the femur are in some measure deformed and absorbed. The dislo-
cation is apparently incomplete ; and while it exists the thigh is ab-
ducted, and slightly rotated outwards. This abduction and outward
rotation does not properly belong to a dislocation upon the dorsum of
the ilium, but as the condition of the joint and of the adjacent muscles
is abnormal, it will not require to be explained.



CHAPTER XVII.

DISLOCATIONS OF THE PATELLA.

§ 1. Dislocations of the Patella Outwakds.

Causes, — In the majority of cases it has been occasioned by muscu-
lar action ; and especially is this liable to occur in persons who are
knock-kneed, or whose external condyles have not the usual promi-
nence anteriorly. It may be caused by suddenly twisting the thigh
inwards while the weight of the body rests upon the foot, and the leg
is thus kept turned outwards ; or by falling with the knee turned
inwards and the foot outwards. Occasionally it is the result of a blow



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Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 80 of 100)