Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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furnishes the following example, presented to him in 1830, by M.
Loir : '' The abnormal position which the head of either radius had
assumed was at the back part of the lower extremity of tlie humerus^
beyond which it extended for the space of at least an inch. This
disposition of parts was absolutely identical on the two sides, and had
all the characters of a congenital affection."^



» Rodrigue, loc. cit., Jan. 1854, p. 272. « Gufiiin, op. dt,, p. 31.

> Chaussier, from Malgaigne, op. cit., t. ii. p. 268.
» Dupuytren, Injuries and Dis. of Bones, p. 117.



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CONGENITAL DISLOCATIONS OF THE WBIST. 771

In Jan. 1866, John Fitzmorris, »t. 19, was admitted to the Belleyue
Hospital, laboring under a general scrofalous cachexy, in whose
person I found a congenital dislocation of the heads of both radii, out-
wards. The luxations are complete. The ulnas are in place and of
natural form, but their articulations at the wrist are loose. The same
remark applies to all the other joints in the body. The power of pro-
nation ana supination is unimpaired, as well, also, as the power of
flexion and extension.

In the example of outward luxation, mentioned by Deville, there
was an almost complete absence of the ulna, the head of the radius
mounting upwards more than three centimetres above the level of the
articulation.^

Gu^rin, who has described the only example of a forward luxation,
says it was observed by him in a girl of seven years, and that it was
symmetrical. The two radii lay in front of the humeri, near the coro-
nary fossettes.*

§ 11. CONOKNITAL DiSLOOATZONS OF THE WbIST.

Gu^rin thinks he has seen three forms of congenital luxation of the
wrist. First, a dislocation forwards characterized by a sliding of the
wrist before the bones of the forearm, and by the projection posteriorly
of the lower ends of the radius and ulna; seen in an infant of six
months, and in two adults. Second, backwards and upwards; seen
in a child of six years, and accompanied with an incomplete paralysis
of all the muscles of the forearm and hand. Third, backwards and
outwards ; in a girl of fourteen years, accompanied with incomplete
paralysis.'

Gu^rin has also seen three examples of dislocation outwards in
foetal monsters, and one of dislocation inwards, as the result of arrest
of development.

Bobert Smith believes that the case of simple dislocation of the
wrist or of the carpus forwards, mentioned by Cruveilhier in his
Anatamie Pathohgique, was an example of congenital luxation ; and he
relates two other cases equally remarkable which came under his own
observation. One was in the person of Deborah O'Neil, a lunatic and
epileptic, who died when thirty-six years old. Both upperextremities
were deformed from birth; the right presenting an example of dislo-
cation of the carpus forwards, and the left of dislocation of the carpus
backwards. The dissection showed that there had been an arrest of
development, especially in the bones of the forearm and carpus. The
second was in the person of a young woman who died of phthisis in
the Bichmond Hospital; the right wrist presenting an example of
congenital dislocation of the carpus forwards from arrest of develop-
ment also.^

Marrigues describes a very singular congenital displacement which
he found upon a newly-born infant. The radius and ulna were widely

1 Deville, BulletinB de la Soc. Anat., 1840, p. li(8.

« Gu^rin, op. cit., p. 81. * Ibid., p. 717.

« R. Bmith, op. cit., pp. 288, 251.



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772 CONGENITAL DISLOCATIONS.

separated below, and in the interspace was lodged tlie whole of the
first range of the carpal bones ; the hand being strongly turned in-
wards.*

§ 12. GoiiaiNITAL DiSLOOATIOHS OT THS FlNGIBS.

Chaussier found in a foetus the last three fingers of the left hand
dislocated at the metacarpo-phalangeal articulation. The thighs^ knees,
and feet were also dislocated.'

A. Bdrard speaks of an incurvation backwards of the last two pha-
langes of the nngers as having been occasionally seen in newly-born
children of the female sex ; and Malgaigne adds that he has himself
seen a woman who had, from birth, all the phalangettes carried back-
wards to an an^le of 185^, leaving the heads of the phalanges project-
ing forward under the skin.*

Kobert has seen, in a girl six years old, a congenital lateral luxation
of the phalangette of the index finger, which was inclined outwards at
an obtuse angle. The external condvle of the lower extremity of the
proximal phalanx was slightly atrophied, and the internal presented a
corresponaing projection. Robert cut the internal lateral ligament by
a subcutaneous incision, but without any favorable result.*

§ 13. CoNGiNiTAL Dislocations or thi Hip.

Dupuytren thought that double dislocations of the hip-joint, as
congenital accidents, were more common than single dislocations, but
in the experience of Pravaz the rule has been reversed, he having met
with but four double dislocations in a total of nineteen.

Congenital dislocations of the femur have been noticed much oftener
in females than in males. Of forty-five examples mentioned by Da-
puytren and Pravaz, only seven or eight were males.

They may be complete or incomplete. Of the complete luxations,
four varieties have been noticed.

Upwards and backwards, upon the dorsum ilii. This variety is by
far the most common.

Upwards and forwards; the head of the femur resting upon the
eminentia ilio-pectinea.

Downwards and forwards into the foramen thyroideum ; of which
variety Chaussier alone mentions one example ; but Delpech found in
an infant, born paralytic, the head of the femur lodged habitually near
the foramen thyroideum.

Directly upwards ; seen by Gu^rin, Pravaz, and others ; the head
of the femur being placed immediately without the anterior inferior
spinous process of the ilium.

Gu^rin has observed, moreover, a single variety of subluxation;
characterized by the incomplete displacement of the head of the femnr

1 Marrigues, Malgaigne, fW>m Joum. de M^., 1775, t. ii. p. 81.
s Chaussier, Malgaigne, op. cit., t. ii. p. 751.
* B^rard, Malgaigne, op. cit., p. 773.
^ Robert, from Malg., op. cit., p. 778.



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CONGENITAL DISLOCATIONS OF THE HIP. 773

in the direction upwards and backwards, so that it rested upon the
edge of the cotyloid cavity: "observed often in newly -born children,
and with those in whom the muscular dislocations are effected sponta-
neously after birth."

Through the courtesy of Dr. Davis, of this city, I was permitted, in
March, 1865, to see a child, the daughter of a gentleman residing in
Victor, Monroe Co., N. Y., who was born in 1860, with dislocation of
, "both knees and both hip-joints. The legs at the time of birth were
doubled forward upon toe thighs, the heads of the tibias resting upon
the front of the femurs, one inch above the condyles, the thighs being
at right angles with the body and the feet touching the abdomen. The
knees were drawn closely together. The dislocation of the heads of
the femurs was not at this time recognized. By constant pressure Dr.
J. B. Palmer had succeeded, at the end of one year, in restoring the
leg to position, the thighs remaining flexed; but when two years
old she began to walk with her body bent forwards. The displace-
ment of the hip-bones was then first discovered. When four years
old the sartorius and tensor vaginae femoris were severed, but with
very little benefit. At the time of my examination she was five years
old. The thighs were still flexed and adducted ; by pressure upon the
knees the femurs could be slid upwards and backwards upon the ilium
one inch : on rotating the femurs the trochanters were observed to
move upon a very short radius, indicating the entire absence of head
and neck. She walked with the gait peculiar to these conditions.

Both Delpech and Gu^rin have called attention to two varieties of
what the latter terms pseudo-luxations : of which the first simulates
a dislocation upwards and backwards, and the second a dislocation
downwards and forwards. In these examples, the extreme adduction
or abduction of the thighs might lead to a belief that the bones were
dislocated, when in fact the abnormal position of the limbs is due
only to muscular contraction, without actual articular displacement.

In the remarks which follow we shall have special reference to that
form of congenital dislocations of the femur in which the head of the
bone rests upon the dorsum ilii, as being that which will be presented
in a vast majority of cases, and which, characterized by the same
general phenomena, may be regarded as typical of all the others.

Symptomatology, — First. When the dislocation is double.

In these examples the deformity is often found to be symmetrical ;
the opposite limbs being precisely the same length, and in the same
relative positions ; a circumstance which, when it exists, may render
the diagnosis more difficult, or may caase it to be for. a long time
entirely overlooked. It is in such cases especially that the deformity
is not usually discovered until the child begins to walk.

The first circumstance which would naturally arrest our attention
if the person who is the subject of this double dislocation is stripped
and placed erect before us, is the great apparent length of the arms
and of the body in comparison with the lower extremities. We may
next observe that the great trochanters are carried upwards and back-
wards, so as to make a remarkable projection in this direction ; the
lumbar portion of the spinal column is thrown very much forwards



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774 CONGENITAL DISLOCATIONS.

and the dorsal portion backwards. The thighs incline inwards, so as
almost to cross each other ; the whole of the lower extremities are
imperfectly developed and feeble ; the toes are generally pointed di-
rectly forwards, or they may be noticed to turn inwards.

When the person stands, and his limbs are not in motion, the heel
is usually brought down fairly to the floor; bnt in walking, and
especially in the attempt to run, he touches only the balls and toes of
his feet. " When they are about to walk," says Pravaz, " we see them
lift themselves upon the points of the feet^ to incline the superior part
of the trunk toward the member which is about to support the weight
of the body, and to lift the other from the ground with an effort^ in
order to carry it forwards. At this moment one of the trochanters,
that which corresponds to the column of sustentation, appears to
approach the iliac crest more nearly than when the patient is standing
upon his two feet." In consequence of which mobility of the thigh-
bones, the patient assumes a peculiar waddling gait, which is not only
ungraceful, but exceedingly fatiguing.

The difficulty of progression is, however, very variable in different
persons. Sometimes the patient requires no aid whatever, and at
other times he cannot walk without assistance. Generally it increases
with age. It is especially deserving of notice that in rapid progression
the mobility of the heads of the femurs is appreciably less than in
slow progression, which is explained by the more constant and vigor-
ous contraction of the muscles about the joints when the motions of
the limb are rapid.

In the recumbent posture, the thighs nmy be drawn down easily to
almost their natural positions. The only exception to this rule, accord-
ing to Camochan, ** is when the head of the femur has escaped from
the natural capsule in which it was originally inclosed, and a new
socket has been formed upon the dorsum of the ilium."

Abduction is performed with difficulty; adduction and rotation,
especially inwards, being less restricted.

Second. When the dislocation is only upon one side.

In these cases the symptoms are essentially the same as in the double
dislocation ; with only such slight differences and peculiarities as would
naturally suegeat themselves to the surgeon, and which will not, there-
fore, demand from us a special consideration.

Paihohgy. — ^The head of the femur is sometimes merely changed in
form and consistence, the neck also undergoing corresponding altera-
tions in its size, form, direction, &c. ; at other times the head is absent
altogether, and with it a considerable portion or the whole of the neck
has disappeared.

The pelvic bones are usually more or less deformed. The acetabu-
lum may be entirely deficient, or it may present itself as an irregular
bony protuberance, without cartilage, fibro-cartilage, or ligaments.
Sometimes it exists as an oval or triangular cavity, which is expanded
at its superior and posterior margin into a distinct fossa, where the
head of the femur, descending from the dorsum ilii, occasionally rests.
A new cavity is formed usually upon the side of the pelvis, which is
shallow and without an elevated margin, or it may be deeper, and more



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CONGENITAL DISLOCATIONS OP THE HIP. 775

complete in its coDStruction, by the addition of an osseous border. In
either case, the new socket is often lined with a true periosteum and
synovial membrane ; but not unfrequently it is unprotected by any
soft tissue, the surface being hard and polished like ivory.

The head of the femur, having escaped from its original capsule,
til rough a button-like opening, rests in this socket constantly. In still
other examples the head of the femur remains within its capsule, and
may be observed to play backwards and forwards between the two
sockets ; or the head and neck being absorbed, and the capsule remain-
ing entire, the latter is converted into a long narrow sac, somewhat
contracted in its centre, or finally into a firm ligamentous cord, which
"being attached to the stunted upper extremity of the femur, limits its
motions in the direction of the crest of the ilium. In this case no new
socket is formed.

A portion of the pelvi-femoral muscles are contracted, in conse-
quence of an approximation of their points of origin and insertion, and
remaining in a state of comparative, if not absolute, inertia, they
become atrophied, or pass into a condition of fatty degeneration, while
other muscles, in consequence of the increased labor which they have
to perform, become hypertrophied, or degenerate into a fibrous tissue.
Ih'eatmenL — Says Dupuytren : " Of what possible utility can it be to
practise extension of the lower extremities in these cases, even sup-
posing the limbs could be thus brought to their natural length? Is
it not evident that the head of the femur, finding no cavity fitted to
receive and hold it> would, when abandoned to itself, resume its former
abnormal position ? There is something more rational and feasible
in adopting a palliative course of treatment. When we call to mind
the natural proneness which the heads of thigh-bones have to ascend
to the external iliao foss®, and that this tendency is partly due to the
superincumbent weight of the body, and in part to muscular action, a
just conception may be formed of the indications on which the employ-
ment of palliative remedies should be founded. The object should be
to relieve the lower limbs of the superincumbent weight on the one
hand, and on the other to moderate the muscular action. Both of
these indications are in part fulfilled by repose; and the attitude most
conducive to this effect is the sitting posture, in which the weight of
the'upper part of the body is not transmitted to the lower extremities,
but is centred in the tuberosities of the ischia. Therefore, laboring
persons afflicted with this infirmity should be recommended to adopt
a sedentary occupation, as a calling which requires much standing and
walking about would dangerously aggravate their deformity. Yet
one would scarcelv be willing to condemn such individuals to per-
petual repose; and to avoid this it is necessary to discover some means
for diminishing the inconveniences which attend the upright posture,
the act of walking and other exercises. Experience has taught me
hitherto but two methods of obtaining this important object: the first
consists in the daily employment of a perfectly cold bath, in which
all the body should be immersed for the space of three or four min-
utes, the head being protected by an oiled-silk cap; the water may be
fresh or salt ; and the only precautions necessary to take are to avoid



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776 CONGENITAL DISLOCATIONS.

bathing when the body is in a state of perapiration, or when the cata-
menial discharge is present. These baths have a local, as well as
general, tonic effect. The second method consists in the constant nae,
at least during the day, of a belt, which embraces the pelvis, fitting
closely over, the great trochanters, and keeping them at a constant
height, so as to bind the parts together, and prevent that continual
unsteadiness of the body which results from the loose connections of
the heads of the thigh-bones. For the proper fulfilment of these in-
dications, certain precautions are necessary in the construction of this
cincture ; in the first place, it should occupy the narrow interval be-
tween the crest of the ilium and great trochanters, completely filling
this space, and therefore being about three or four fingers' breadth,
accoraing to the age and size of the patient It should further be
well padded with wool or cotton, and covered with doe-skin, so that
it may not abrade the parts to which it is applied ; and there shoald
be a piece let in on either side, so as to receive and support the tro-
chanters without entirely covering them ; it should be buckled behind,
and padded straps be carried under the thigh, and across the tuberosity
of the ischium, on either side, to prevent the zone from slipping up.
I do not mean to assert that I have ever succeeded in completely get-
ting rid of the inconveniences of congenital dislocations of the thigh-
bones, but I have prevented their increasing, and have rendered
supportable what I could not cure. The testimony of some patients
to the value of this treatment has been of a most unequivocal charac-
ter; for being worried by the pressure of the belt^ they have laid it
aside, but have speedily restored it again, as the;^ found that withoot
it they had neither a sense of firmness in the hip, nor confidence in
walking."

In relation to which opinions the same excellent writer subsequently
made the following candid admission: ''I at first thought that no
benefit would be derived in these cases from the employment of con-
tinual traction on the lower extremities, for reasons already stated;
but the experiments of MM. Lafond and DuvAl tend to throw some
doubt on the correctness of this conclusion. These distinguished
practitioners tested the influence of extension, in their orthopsodic in-
stitution, on a child eight or nine years of age, who was the subject
of double congenital dislocation of the hip ; after the uninterrupted
employment of this treatment for some weeks, I satisfied myself that
the limbs had resumed their natural length and direction ; but I was
not a little astonished to find that, after extension had been persisted
in for three or four months continuously, the greater part of the bene-
ficial results remained for several weeks undiminished. It would be
idle, it is true, to generalize on this single case; but as an isolated
example of the utility of extension it is interesting, and it may be the
forerunner of more important results."*

Since which time Humbert and Jacquier, who, as well as Duval
and Lafond, confined themselves to the treatment of deformities, claim
to have met with equal success in the management of these cases bjr

» Dupuytren, cp. cit., pp. 176-178



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CONGENITAL DISLOCATIONS OP THE HIP. 777

extension alone; and, still more lately, Gu^rin of Paris, and Pravaz
of Lyons, by the adoption of the same general principle more^r less
modified, have added new triumphs, and greatly enlarged its applica-
tion.

The means recommended and practised by Gu^rin, are : first, pre-
paratory extension destined to elongate the muscles as much as pos-
sible ; second, subcutaneous section of the muscles which mechanical
extension has not sufficiently elongated ; third, extension of the liga-
ments, and even, if extension does not suffice, their subcutaneous sec-
tion ; fourth, manoeuvres destined to efiect reduction ; fifth, treatment
designed to consolidate the reduction, and consisting in the applica-
tion of the apparatus proper to maintain the extension and separation
of the divided tissues, and to retain the head of the femur in its place ;
finally, in the gradual execution of movements proper to complete the
coaptation of the surfaces, and to establish, little by little, the physio-
logical movements of the joint.

Other surgeons have confined their efforts to the reduction of the
dislocation, and tl^ey ha,ve, consequently, abandoned all those cases in
"which, owing to the complete absence of the natural socket, or to the
want of sufficient mobility in the limb, the reduction was deemed
impossible ; but Gu^rin has gone a step farther, and has sought to es-
tablish a new socket upon some pbint of the pelvic bones as near as
possible to its natural articular fossa. " The means which I adopt,"
says Gu^rin, " are based upon a recognition of the processes which
nature employs for the attainment of the same purpose, and of which
mine are but an imitation. I have shown that the essential condition
of the formation of artificial cavities is perforation of the articular
capsule, and the placing in contact of the luxated extremity with an
osseous surface, and that the condition of the maintenance of this ab-
normal rapport is the intimate adherence of the borders of the rent
with the circumference of the new cavity. Now it appeared to me
that art could realize, in all points, the conditions which preside at
the spontaneous formation of artificial joints. To this end I commence
by practising under the skin, and at the point corresponding to that
where it is most convenient to fix the luxated extremity, scarifications
of the capsule, down to the bone to which it is attached. By this
means the dislocated extremity is placed in immediate contact with
the bony surface upon which it reposes. It makes upon this point a
beginning of the work of organization resulting from the adhesion
and fusion of the scarified points with the corresponding points of
this surface. Then, in order to circumscribe and imprison the lux-
ated extremity, in this place of election, I practise all about deep scari-
fications, which tend to excite the same work of organization and to
establish fibro-cellular adhesions between the incised borders of the
capsule and the contiguous bony surfaces.

"Finally, when the fibro-cellular adhesions are supposed to be suf-
ficiently solid to resist the movements of the new articulation, I pro-
voke, little by little, the development of the cavity destined to embrace
the luxated extremity by the means which nature herself employs in
60



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778 CONGENITAL DISLOCATIONS.

analogous circamstances ; that is to saj; by circumscribed and fre-
quent movements of this articulation."^

The treatment ought to be commenced as early as possible, no ex-
amples of success having been recorded in persons over fifteen years
of age ; while the youngest child whose treatment is reported as suc-
cessful was three years of age.

For the purposes of making the requisite extension, and of main-
taining the bone in place, Pr^ivaz (who does not, however, adopt
Gu^rin's practice of establishing for the head of the bone a new
socket, but only seeks to reduce and maintain it in its old socket) has
invented several forms of apparatus adapted to the different stages of
progress in the treatment. Heine of Gannstadt, Gu^rin, and others have
also suggested special contrivances for the same purpose ; but no sur-
geon who understands fully the principle upon which the cure is sup-
posed to be accomplished, will be at a loss for apparatus suitable for
making the necessary extension, or for maintaining the redaction
when once it has been effected.

The length of time required for the completion of a cure, where a
cure is possible, must vary according to the age and health of the
patient, and according to the pathological condition of the joint, and
may be found to extend from a few months to one or more years. It
is unnecessary to say that where the accomplishment of the cure de-
mands a period of several years, the treatment must be intermittent



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 90 of 100)