Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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his limb.

If the reduction is promptly effected, the limb kept perfectly quiet
a safficient length of time, and in other respects properly managed,
not much inflammation need generally be anticipated, and the limb
may suffer in the end very little if any maiming.

7Ve€Ument. — It will be proper, at first, to attempt the reduction by
simple manipulation, as this is often found to succeed when the dis-
location is recent and incomplete, and especially when the system is
greatly depressed by the shock of the injury. If the dislocation is
complete, however, we can hardly anticipate success without the ap-
plication of some extending force.

In the employment of manipulation we ought to be governed at
first by the same rule which we have found so generally applicable in
dislocations of the femur, namely, to carry the limb in those directions
in which it will move easily, or without much force. If this fails, we
may at once resort to forced flexion alternating with extension, rotat-
ing or rocking the limb also occasionally from one side to the other,
while at the same moment strong pressure is made upon the project-
ing bones at the knee-joint -in opposite directions or in the direction
of the articulation.

Finally, it may be necessary to resort to extension, made by means
of a lacq, or by the hands of strong assistants, above the ankle, always
at first in the direction of the axis of the tibia ; the counter-extending
band being applied to the perineum if the leg is straight, but to the
lower and back part of the thigh if the leg is flexed.

A very convenient mode of making extension, where we wish to
apply more than usual force, is to lay the whole limb over a firm
double-inclined plane, or fracture splint, securing the thigh to the
thigh-piece with a roller, and making the extension with the screw
attached to the foot-board. This method, however, while it enables
us to use great force in the extension, prevents the surgeon from em-
ploying, at the same time, those flexions, extensions, and other ma-
nipulations, upon which success so oflen depends.

Dr. James Garmichael has reported a case in which reduction was
effected easily by flexion, when traction had failed.^

Mr. Bose has related, in the Provincial Medical Journalot June 11th,
1842, a characteristic example of this accident, except that the patella
had also suffered a lateral displacement, presenting the usual favorable

A woman was standing upon a low ladder, when a carriage driven
furiously came in contact with it, and precipitated her to the ground.
Mr. Bose, who saw her almost immediately, found the tibia completely
dislocated at the knee, the head being driven behind the condyles of
the femur into the ham, with the patella thrown to the outside of the
external condyle, and the leg in a state of flxed extension. Immedi-

> New York Med. Gazette, Aug. 22, 1868; from the Lancet.

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ately, and without difficulty, the bones were restored by applying one
hand to the patella, the other to the back of the upper portion of the
tibia, and simultaneously pulling and pushing those bones toward
their natural positions. The patient was then removed to a bed, and
by the diligent use of antiphlogistic remedies inflammation was kept
in check, and the case reached a favorable termination without one
untoward symptom. After the lapse of ocily a few weeks> she had
completely recovered the use of the knee-joint.*

Dr. Walsham communicated a case to Sir Astley CJooper, in which
the dislocation was not only complete, but the tendon of the quadri-
ceps extensor was ruptured. The leg was bent forwards. The reduc-
tion was accomplished very easily by extension made with the hands
by four men, in the line of the axis of the limb. In about one month
this man began to walk with crutches, but he was not perfectly re-
covered until after five months ; at which time the crutches were
finally laid aside."

§ 2. Dislocations of the Head of the Tibia Forwards.

The signs of this accident are the reverse of those which belong to
dislocations backwards. The patella, tibia, and fibula are promineDt
in front, while the condyles of the femur may be felt behind, pressing
strongly upon the muscles, nerves, and bloodvessels which occupy the
popliteal space. In case the dislocation is complete, a shortening may

exist to the extent of one or even three
Fig. 809. inches. Dr. O'Beirne, of Dublin, has men-

tioned a case to Mr. B. Cooper, in which
the shortening was three inches and a half,
and Mr. Mayo has seen one example in
which the dislocated limb was "fully foar
inches" shorter than the other.*

In consequence of the pressure upon
the popliteal artery, the pulsations in the
branches below are frequently interrupted,
and in one instance this pressure was suffi-
cient to produce finally a dry gangrene.

Dr. Qorde relates a case in the Bulletin

de Therapeutique, occurring in a woman

nearly sixty years old. This woman was

\ returning home at night with a heavj

burden, and in a state of intoxication,

, .. , .. .... when she stepped into a ditch as deep as

Incomplete dUlocation of the head ^ ^i • j ji r i_ ^i • i mi i i^

of the tibia forward.. "P ^o the middle of her thighs. The body

was* thrown forwards by the fall, while the
feet stuck at the bottom of the ditch ; the whole force of the impulse
being sustained by the thighs. The lower end of the femur was
found driven downwards and backwards, and lodged under the mas-

* Rose, Amer. Joum. Med. Sci., vol. xxxi. p. 216.

* Walsham, Sir A. Cooper on Disloc, &c., 2d Lond. ed., p. 188.

» B. Cooper's ed. of Sir Astley Cooper on Disloc, &c., pp. 214-315.

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des of the calf of the leg ; the limb being shortened three inches. Ee-
c3 notion was promptly effected, and without inflicting any pain of
Avhich the patient complained. In six weeks the patient was cured.^

Mr. Toogood has reported also, in the Provincial Medical Journal of
June 18th, 1842, an example of complete dislocation in this direction,
in which the appearance was so dreadful, that Mr. Toogood at first
despaired of being able to reduce it ; but by directing two men to
make counter-extension while he made extension, the reduction was
immediately effected. At the end of one month the patient was able
to leave his bed ; and sixteen years after. Dr. Toogood saw him walk-
ing "with very little lameness.'*^ Parker, of Liverpool, has reported
another example in the London and Edinburgh Monthly Journal for
December, 1842, which was occasioned by the fall of a heavy spar
upon a man's back, and the consequent violent bending of the knee
under his body. In this case the limb was slightly flexed, and the
patella was loose and floating. The reduction was effected without
much difficulty by extension and counter-extension made by two men,
while the operator, placing his knee in the ham of the patient, attempted
to bring the leg to a right angle with the thigh.^

B. Cooper, Malgaigne, Little,* and others, have recorded examples
of this accident.

March 9th, 1865, Hiram Wescott, of Sandy Cove, Nova Scotia, set.
45, was caught by his sled, drawn by horses, in such a way that a
beam pressed against the front and lower end of the femur while the
heel was caught and arrested by a stump. The foot was thrown for-
wards and the upper end of the tibia completely dislocated in the
same direction. It was at once reduced by a person who was present,
but on attempting to use the leg in walking it was reluxated immedi-
ately. Mr. J. H. Harris, medical student, found the limb soon after
completely luxated, with the leg thrown forwards in the position of
dorsal flexion about 40°. The tendons of the hamstring muscles were
not ruptured, but had slid forwards past the condyles of the femur.
There was no external wound. Beduction was easily accomplished
by simple extension. Pasteboard splints were then applied. On the
third day the knee was considerably swollen, and some ecchymosis
existed about the popliteal region. On the fifth day these symptoms
had much increased. Mr. Harris then applied extension to the foot,
with the aid of adhesive plaster, pulley and weights, and by elevating
the foot of the bed. The amount of extension employed was 9 lbs.
This gave immediate relief to the pain, and was continued until the
inflammation subsided. His recovery was steady, and in four months
he walked with crutches or a cane.

In ly64 a similar dislocation was presented at the Brooklyn City
Hospital, in which reduction having l^een practised, the patient died.
The case is reported very fully by Dr. Le Roy M. Yale.*

I Gorde, Amer. Joum. Med. Sci., vol. xvi. p. 225, May, 1885.

* Toogood, Amer. Joum. Med. Sci., vol. xxxi. p. 465. ' E. Parker, Ibid.

* Little, New York Med. Times, Aug. 17, 1861.

» Yale, N. Y. Joum. Med., vol. ii. p. 124, Nov. 1865.

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Dr. White, of Buflfalo, politely invited me to see with him a lad, »L
10, whose tibia had been partially dislocated forwards eight weeks
before, by a boy's having hit the top of his knee with his head, while
they were at play. His father, who is himself a physiciaQ, residing
near town, reduced the limb very easily, by extension made with his
own hands, and by pressing upon the projecting bones. Violent in-
flammation ensued, but at the time when I saw him, the knee was
free from soreness or swelling, and the motions of the joint were nearly

D. Charles S. Downes, of Mclndoe's Falls, Vt., has sent me the fol-
lowing account of a case which occurred in his own practice. Oct
1861, Mrs. H., a robust young married woman, aged about 20 yeara>
was driving a young horse and holding her infant in her arms^ when
the horse ran and she was thrown out. One of her legs being caught
in the wheel, she was carried over three or four times in its revolutions
before she becairie disengaged, holding meanwhile upon her infant with
such firmness that it suffered no harm.

A few hours later Dr. Downes and Dr. Burton found a complete
dislocation of the tibia and fibula forwards, and the lower end of the
femur could be felt under the muscles of the calf of the leg. The
limb was shortened four inches and a half. The patella lay loosely
in front of the femur, with its lower margin tilted forwards.

The patient was laid upon a bed, and a perineal band made fast to
one of the posts, while a lacq was placed upon the foot and attached
to a rope folded upon itself and forming a pulley or "Spanish windlass,*'
such as is described at p. 650. In this way the reduction was speedily
and easily accomplished. Hot fomentations were subsequently appliecl
for several days, the limb being kept perfectly at rest. In about three
months she was able to do her own housework, and in a short time
after all traces of her accident had disappeared.

§ 3. Dislocations of the Head op the Tibia Outwards.

Occasionally, owing to a violent wrench of the knee-joint, the lat-
eral ligaments upon one side or the other are ruptured, and conse-
quently the joint surfaces separate somewhat from each other ; or when
the limb is moved, the head of the tibia may slide a little forwards or
backwards, or to either side. These are not properly examples of
subluxation ; nor should we consider as belonging to this class the
accident originally described by Mr. Hey as an '' internal derange-
ment of the knee-joint," but which also by some writers has b^n
termed a " subluxation of the knee." Of this latter accident I will
take occasion hereafter to speak a little more particularly.

In subluxation, properly so called, if the direction of the disloca-
tion is outwards, the outer condyle of the femur rests upon the inner
articulating surface of the tibia, and if the direction of the dislocation
is inwards, the inner condyle of the femur rests upon the outer articu-
lating surface of the tibia.

The signs which characterize this accident are such as cannot easily
be mistaken. The limb is not shortened, nor is there anything espe-

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cially diagnostic in its position, since it has been found to be some-
times flexed, and at other times straight; but the strong lateral
projections made by the inner condyle of the femur on the one hand,
and by the heads of the tibia and fibula on the other, cannot fail to
inform us as to the true nature of the accident.

The treatment will not diflFer essentially from that which has
already been recommended in dislocation of the tibia backwards or
forwards. . If any other expedients Can prove use-
ful, they must be left to the judgment of the sur- pig. 310.
geon whenever the exigencies of the case shall
demand them.

I have already mentioned the case of N. Smith,
-who, in consequence of a fall from a window, had
a dislocation of the right femur, tibia, and patella.
The tibia was subluxated outwards, and the leg
was partially flexed upon the thigh, with the toes
everted. By moderate extension, made with my
own hands, united with alternate flexion and ex-
tension, the bone was easily and promptly restored
to its place. Having reduced the femur also, the
limb was laid over a gently inclined plane made
of pillows ; and cloths moistened with cool water
were kept constantly applied to the knee for many
days. Very little swelling followed the accident,
and his recovery was rapid and complete.

A man was received into the North London subiuxatiouorthohoad
Hospital, with a partial dislocation of the tibia «' '^e tiwa outwardi.
outwards, and although the knee was much swol-
len, the nature of the injury was easily determined. The knee was
immovable, and the toes turned outwards. Mr. Hallam, the house
surgeon, reduced it by extension and counter-extension made by his
own hands.^

Mr. Pitt records a similar case in a young lady, produced by a fall
down a flight of stairs. It was reduced easily by extension and
counter-extension. Inflammation followed, but it was finally con-
trolled, and she regained the use of her limbs.*

In one case of subluxation, mentioned by Sir Astley Cooper, and
in a second recorded by Bransby Cooper, the recovery of the func-
tions of the joint did not seem to have been so rapid ; the joint
remaining unstable and tender for a long time afterwards.^

§ 4. Dislocations of the Head of the Tibia Inwards.

There is nothing peculiar in either the signs, condition, or treatment
of this accident, as distinguished from a dislocation outwards, to de-
mand of us a special consideration.

Sir Astley Cooper has mentioned two cases of subluxation inwards,

' Hallam, Amer. Joum. Med. 8ci., vol. xix. p. 251.

8 Pitt, Ibid., vol. xxxi. p. 465.

» B. Cooper's ed. of Sir Astley, op. cit., pp. 111-18.

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and Mr. B. Cooper has added to these a third. Sir Astley remarks
that in the first accident, the only one indeed which he had himself
ever seen, he was struck with three, circumstances: first, the Rreat
deformity of the knee from the projection of the tibia; second, the
ease with which the bone was reduced by direct extension ; and third,
by the little inflammation which followed. The second case of which
Sir Astley speaks was communicated to him by a Mr. Bichards. In
this case the fibula was also broken, and the reduction was accom-
plished only after extension had been made by
Fig. 811. several persons for half an hour. The limb became

excessively swollen, and remained so for many
weeks. Eighteen months after the accident the
knee continued somewhat stifi^ and there was an
unnatural lateral motion in the joint, from the in-
jury which the ligaments had sustained. The pa-
tient referred to by Bransby Cooper had met with
the accident by a fall upon the foot, with his leg
bent under him ; and a fellow- workman had re-
duced the bone by extension and pressure. Mr.
Cooper thinks that not only the internal lateral
ligament was torn, but also some fibres of the vas-
tus externus and the crucial ligaments. Violent
inflammation ensued, which did not permit him to
leave the hospital until after about two weeks.'
Fergusson has seen two examples of unreduced
subluxation inwards, in both of which the patients
8abiu«iionofthehe»d j^^j regained useful limbs.«

of the ilbia inwards. "^ri- • i-r^ >n,,, j

Malgaigne mentions that Boyer, Gostallat^ ana
Key had each seen one similar example; and he also enumerates two
additional cases of complete luxation attended with a protrusion of
the bone through an external wound; in both of which the reduction
was easily effected and the patients recovered.^

§ 5. Dislocations op the Head op the Tibia Backwards and Outwabps.

In June, 1853, Henry J., of Dansville, N. Y., aet 24, was thrown by
an enraged bull, and his left leg being caught under the knee by tbe
horns, was twisted violently. Dr. Prior, of Dansville, and Batton, of
Burns, were called, and found the left knee completely dislocated;
the tibia being displaced backwards beyond the condyles of the femur,
and also a little outwards. The foot and leg were inclined outwards.
With the assistance of four men, extension and counter-extension were
made in the line of the axis of the limb, and the reduction was easily
accomplished. Pasteboard splints, bandages, &c., were applied to
maintain the bones in place; but the swelling came on rapidly, and
in the evening these dressings were removed. The limb was now hid
over a double-inclined plane carefully padded, in order to press the

> B. Cooper's ed. of Sir Astley, op. cit, pp. 111-13.

* Fergusson, op. cit., p. 284.

* Malgaigne, op. cit., torn. 11. p. 956.

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upper end of the tibia forwards, as it manifested a constant inclination
to become displaced backwards. This apparatus was employed six
weeks, with the exception of two or three days, during which the
limb >rvas laid upon pillows, but as the pillows did not sufficiently
support the back of the tibia, the double-inclined plane was resumed.
After the removal of the plane, during seven weeks longer, an angular
splint -was kept closely applied to the back of the limb.

Seven months after the accident, on the 23d of January, 1854, Dr.

Robinson, of Hornellsville, brought the gentleman to me. I found the

bones displaced backwards about three-quarters of an inch, and half

an inch outwards, or to the fibular side. This was the position of the

bones when he was sitting with his leg bent at a right angle with the

tbigb, but when he stood erect and bore some weight upon the foot,

the outward displacement ceased, and the backward displacement only

remained. It was very easy, however, in whatever position the leg

might be, to push the bones forwards by the hands until nearly all

deformity had disappeared. He could flex the leg to a right angle

with the thigh, and straighten it completely, but he could not lift the

foot and le^ from the floor while sitting with his limb extended in

front of him. He was unable to bear sufficient weight upon his foot

to use it at all in progression, on account of the inability to fix and

steady the limb, but not on account of any pain or soreness which it


It was very plain that the surgeons were not in fault for this un-
fortunate condition; indeed, they seem to have exercised throughout
great ingenuity and skill in its management.

I directed the young man to Mr. John C. SeiflFert, of Buffalo, a very
ingenious instrument-maker, who has since succeeded, I learn, in
adapting to his knee a mechanical contrivance which enables him to
walk quite, well

Thomas Wells, of Columbia, South Carolina, has described a similar
accident, the tibia being dislocated outwards and backwards, which
terminated fatally on the fourth day in consequence mainly of ex-
posure, intemperance, and neglect to apply for surgical aid. The
bones were never reduced, and the autopsy dislosed also a fracture
of the internal condyle of the femur.^

§ 6. Internal Derangement of the Knee-Joint.

8yn. — "Slipping of the semilunar fibro-cartilages;*' Hey. ''Partial dislocation
of the thigh-bone from the semilunar cartilages ;" Bir Astley Cooper. ''Subluxa-
tion of the semilunar cartilages ;'' Malgaigne. "Subluxation of the knee;'' Erich-
sen. To these we think it proper to add, as giving rise to the same class of symp-
toms, "Floating cartilages in the knee-joint.'*

We have already expressed our opinion that this accident is in no
proper sense a subluxation of the knee ; and we should not, therefore,
think it worth while to make any farther allusion to it,^ were it not neces-
sary in order to enable the student of surgery to distinguish between
the phenomena which belong to it and those which belong strictly to
subluxation of this joint.

Wells, Amer. Joum. Med. Sci., vol. x. p. 25, May,


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Symptoms. — The patient is Boddenly thrown to the ground while
walking, as if by an instantaneous loss of power in the affected limb,
this loss of control over the limb being accompanied usually with
sharp pain, referred to the region of the knee-joint ; or he trips his
toe against something in his path, and the toes becoming eVerted, the
leg suddenly gives way under him ; in some cases it has happened
when the patient was turning in bed, the weight of the bedclothes
hanging upon the toes so as to occasion a strain and rotation outwards
at the knee-joint, or it follows upon a subluxation of the joints as in
one example which I shall presently relate.

If the patient is walking when the accident takes place, and he falls
to the ground, he finds himself unable to move the limb, or to stand
upon it; but by manipulation, the difficulty is, in most cases^ as easily
overcome as it occurred, when immediately the motions of the joint
become free, and he walks off as if nothing had happened.

When the accident has once taken place, it is afterwards exceed-
ingly liable to occur from very slight causes, and eventually the knee-
joint becomes tender and the capsule fills with synovia, indicating the
existence of subacute synovitis.

A single example will illustrate the usual history of these cases.

A young man, from Golesville, N. Y., »t. 23, consulted me on the
27th of Oct. 1868, in relation to the condition of his knee-joint He
stated that on the 13th of Aug. 1858, while standing with the whole
weight of his body resting upon the left leg, a mate struck him on tbe
inside of the lower end of the left femur. The blow was made with
the palm of the hand, but with sufficient force to throw him down. It
was immediately noticed that the tibia was partially dislocated inwards
at the knee-joint. The whole lower part of the limb was inclined
outwards. A person present in the room seized upon the foot and
by extension easily brought it back to place ; the bone resuming its
position with an audible snap. After this he continued to walk about
until night. Two days after, the knee had become so much inflamed
that he was obliged to take to his bed, on which he was confined three
weeks. Gradually the swelling subsided, and in about five weeks
after the accident he began to walk on crutches. On the 23d of Sept^
he was walking in the store without crutches, when he suddenly telt
a sensation of slipping in the joint, and he fell to the floor as if he
had been tripped up. At the time when he called upon me, this had
happened many times, but had never been attended with pain. The
joint was filled with synovia, and tender, yet I could distinctly feel a
hard body just to the inside of the ligamentum patellse, and which
moved freely under the finger.

Pathological Anatomy. — The same class of symptoms, with only
very slight modification, belongs probably to several varieties of "in-
ternal derangement of the knee-joint;" and first it will be remembered
that the semilunar cartilages upon which the margins of the condyles
of the femur rest, are attached to the tibia by several ligaments; but
when, from relaxation or a violent strain, any one of these ligaments
becomes elongated or gives way, tbe portion of cartilage which it

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restrains is permitted to become partially displaced, and by interposing
its thick margin between the deeper articulating surfaces the bones are

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 82 of 100)