anterior convexity of the limb being lost. The trochanter was about an inch and a half behind and above its usual position, and, during etherization, it was quite movable on attempting rotation of the limb. Finally, the head of the femur could be felt obscurely but pretty certainly rotating in the ischiatic notch, low down, and in contact with its posterior margin. The anterior convexity of the spine at the loins was also very much increased, so that under ether more than the width of the hand could be passed between it and the surface of the bed. Thus the case presented all the classical features of luxation into the ischiatic notch, and more than usually well marked, with the exception of adduction of the lower end of the femur and inversion of the foot.' After several failures to reduce by manipulation and traction downward, reduction was effected by traction while the limb was flexed at right angles to the pelvis, followed by abduction and extension. In 1864 Symes1 reported a case, and suggested for the variety the name of "dorsal with eversion." This was subsequent to Bigelow's researches but previous to his publication of them, except in his lectures. The limb was shortened two inches, the foot extremely everted, the buttock flattened, and the head of the femur two inches below the anterior superior spine of the ilium. By flexion of the limb the dislocation was made dorsal, and a feature of special interest is that then, as the limb lay untouched upon the table, eversion gradually took place under the influence of gravity, and the head returned to its former place. In 1874 Kocher2 observed a similar case in a woman, forty-nine years old; the limb was fully extended, markedly everted, and shortened three centimetres; the head could be felt below and to the outer side of the anterior superior spine of the ilium. By flexion and inward rotation the dislocation became dorsal with the characteristic symptoms, and then by extension and outward rotation the original symptoms were reproduced. Pathology-At the autopsy in the fresh case observed at St. George's Hospital, the head of the femur lay about an inch below and to the outer side of the anterior superior spinous process of the ilium, and the trochanter was still further to the outer side and behind, resting on the dorsum of the ilium, so that the toes pointed outward and slightly backward. The gluteus medius and minimus were extensively lacerated and nearly torn through at about two inches from their attachment to the trochanter; the gemelli and quadratus femoris were slightly lacerated; the capsular ligament was extensively lacerated at its upper part, and the ligamentum teres ruptured. The trochanter minor rested on the outer edge of the acetabulum. In a case which I reported to the New York Surgical Society, December, 1887, and January, 1888,3 which had been subjected to many attempts to reduce, the outer branch of the Y-ligament was ruptured and the muscles behind the trochanter extensively lacerated. Complete reduction was prevented by interposition of the antero-inferior part of the capsule. In Cadge's autopsy of Travers's case (Fig. 131), the head of the femur lay in the interval between the anterior superior 1 Symes: Dublin Quart. Journ. Med. Sci., 1864, vol. 38, p. 272. FIG. 131. and anterior inferior spinous processes of the ilium, and was covered by a complete bony cap lined with a dense, pearly white tissue resembling fibro-cartilage. The edge of the new cavity was connected with the neck of the thigh bone by a thick capsular ligament. The rectus muscle, which had been torn from its origin, was inserted upon the edge of the new cavity, a condition which, as Bigelow says, suggests the ascent of the bone above the inferior spinous process of the ilium at the time of the injury, with rupture of the Y-ligament. Van Buren's case, and a very similar one reported by Annandale,' show that the head may lie much further to the outer side, at or near the sciatic notch. Old everted dorsal dislocation. Cadge's case. a, new bony cap, with its fractured margin, b. Bigelow's experiments show that this eversion depends upon the rupture of the outer branch of the Y-ligament. The head of the femur escapes at the back of the joint while the limb is flexed, adducted, and rotated inward, and then by external rotation the outer branch is torn; if, then, the head remains in its position opposite or below the sciatic notch, the position and symptoms are such as are noted in Van Buren's and Annandale's cases, the flexion and slight adduction being due to the remaining untorn branch of the ligament. The change in the position of the head noted in the other cases Bigelow was able to reproduce experimentally from a common dorsal dislocation by carrying the limb "across the symphysis, so that the outer and convex surface of the socket shall correspond to the hollow beneath the neck of the femur. With some force the thigh can now be everted, and afterward brought down across the upper part of its fellow." (This is the form to which he gave the name "anterior oblique.") "If, in this position, it is desired to bring the limb toward a perpendicular, the outer branch of the Y-ligament must be ruptured. Thus liberated, it hangs suspended by the inner ligament, and becomes capable of lateral motion and of rotation; and this is probably the condition under which supra-spinous luxation, although rare, usually occurs." Fig. 132 shows in the dotted lines the head of the femur thus hooked over the remaining part of the ligament. The anterior oblique is a variety which I feel some hesitation in preserving, because Bigelow appears to have observed it only in experiments upon the cadaver, and to have known of only one recorded case (Oldnow, 1 Annandale: Lancet, 1876, i. p. 208. in Guy's Hospital Reports, 1836, vol. i. p. 97) in which the attitude resembled that found in his experiments. The specimen in that case Anterior oblique dislocation. position indicated by the dotted line, only the inner branch of the Y-ligament remains untorn. (BIGELOW.) is represented in Fig. 133. Figs. 134 and 135 show the attitude and specimen obtained from the cadaver; the mode of production has been quoted in the preceding paragraph. The Y-ligament is untorn. If the primary dorsal dislocation has been below the tendon of the obturator internus, this muscle is ruptured in the subsequent change of place. The symptoms of the everted dorsal may be the same as those of the common dorsal dislocation, with the exception that there is marked or slight eversion of the limb instead of inversion; or, if the head of the femur has moved forward above the anterior inferior spinous process, they may differ widely, for the limb is then shortened about two inches, slightly abducted, more or less everted, and fully extended (Fig. 136). The eversion of the limb is liable to lead to the mistake of supposing the injury to be a fracture of the neck of the femur, especially in the cases in which the head is brought forward above the acetabulum and in which the limb is also extended. The greater fixation of the limb and the recognition of the position of the head and of its continuity with the shaft, as shown by its sharing in the movements communicated to the latter, will establish the diagnosis. The rupture of the outer branch of the Y-ligament is the explanation of the failures noted in some of the cases to reduce by manipulation alone; traction in the flexed position is needed to bring the head forward into the socket; abduction fails to do it because of the loss of the support of the outer branch of the ligament. Treatment. The method of reduction so long in use, and which left so many dislocated hips unreduced, that in which it was sought to draw the bone into place by traction upon it with compound pulleys while the limb was almost as fully extended as possible, has at last been abandoned in favor of the methods of simple manipulation or of moderate traction in the flexed position, or of a combination of the two. The advantages of the flexed position, the possibility of reducing by the aid of moderate traction when the thigh is flexed at a right angle with the trunk, were repeatedly pointed out by different writers during the last century and the first half of the present one, and the possibility of reducing by manipulation alone (flexion, outward rotation, and abduction) was also demonstrated, but neither seems to have had any influence in modifying the general practice, although some surgeons, notably Prof. Nathan Smith, of New Haven, taught and habitually practised traction with the limb flexed at a right angle, and he also, in 1831, formulated a method by manipulation alone. 1 Desprès, in 1835, independently formulated the method by flexion and outward rotation; and Reid, in 1851, did the same, preceding the flexion with marked adduction; but they assumed that the principal obstacle to reduction lay in the resistance of the muscles, and their manipulations were designed to overcome or avoid this. Bigelow quotes Smith's description of this method by manipulation from his Medical and Surgical Memoirs, edited in 1831 by his son, Nathan R. Smith, as follows: "The first effort which the operator makes is to flex the leg upon the thigh, in order to make the leg a lever with which he may operate on the thigh bone. The next movement is a gentle rotation of the thigh outward, by inclining the foot toward the ground, and rotating the knee outward. Next, the thigh is to be slightly abducted by pressing the knee directly outward. Lastly, the surgeon freely flexes the thigh upon the pelvis by thrusting the knee upward toward the face of the patient, and at the same moment the abduction is to be increased." Bigelow adds "this covers the ground of priority of invention. It belongs to Nathan Smith. In 1835, Desprès, and in 1852, Reid, of Rochester, enunciated the same views, the practice was good, but both Prof. Smith and Dr. Reid based the method and sought its mechanism in the erroneous theory of muscular resistance." After 1850 the attention of surgeons and anatomists began to be directed more specifically to the opposition offered by the untorn portions of the capsule and to the position of the rent in it, and many experiments were made upon the cadaver to obtain a more accurate knowledge of the matter. Among these may be mentioned those of Meyer, Gunn, Roser, Bigelow, Gellé,8 Busch, and Tillaux.10 Of these Bigelow's researches were by far the most complete and accurate, and to his classical work must be referred the popularization and general acceptance of the views now held and the methods of treatment based upon them. The importance of the anterior portion of the capsule, the Y ligament, had 1 Desprès: Bull. de la Soc. Anatomique, Sept. 1835, p. 4. 2 Reid: Buffalo Med. Journal, Aug. 1851. 3 Bigelow: Lancet, 1878, I. p. 861. H. Meyer: Zeitschrift für rat. Med., 1850, vol. 9, p. 250. 5 Gunn Penins. Journ. of Med., 1853-4, vol. i. p. 97. 6 Roser: Archiv für Phys. Heilkünde, 1857, vol. i. p. 42. 7 Bigelow: The Hip, 1869. Experiments made in 1860. 8 Gellé: Arch. gén. de Méd., 1861. 9 Busch Arch. für klin. Chir., 1863, vol. iv. p. 11. |