Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

In cases of long standing, beginning in childhood, the shortening is still further added to by deficient growth in length of the femur, and it may be of all the bones of the limb; even the foot is smaller on the affected side.

The most reasonable explanation of the attitudes assumed in hip disease is that given by König. If the patient walks without crutches, as he is usually able to do at an early stage of the disease, the attitude of abduction, eversion, and slight flexion enables him to save the limb to the utmost extent; on the other hand, if he uses a crutch, as he is obliged to do at a more advanced stage, he no longer uses the limb for support, and therefore draws it upwards and medially into the position of adduction, inversion, and greater flexion. Similarly, if he is confined to bed, he lies on the sound side, and the affected limb sinks by gravity so as to lie over the normal one in the position of adduction, inversion, and flexion. König's explanation accords with the fact that in the exceptional cases which begin with adduction and inversion we have usually to deal with a severe type of the disease, associated with grave osseous lesions—precisely those cases in which the patient is compelled from the outset to lie up or to adopt the use of crutches. Further, the transition from the abducted to the adducted position usually follows upon such an aggravation of the symptoms that the patient is no longer able to walk without the assistance of a crutch.

During the third stage the other signs and symptoms become more pronounced; the patient looks ill and thin, he is usually unable to leave his bed, his sleep is disturbed by startings of the limb, and the rigidity of the joint and the wasting of the muscles are well marked. The temperature may rise slightly after examination of the limb, or after a railway journey.

Abscess Formation in Hip Disease.—The formation of abscess is not related to any stage of the disease; it may occur before there is deformity, and it may be deferred until the disease is apparently cured. Its importance lies in the fact that if a mixed infection with pyogenic organisms occurs, the gravity of the condition is greatly increased.

An abscess may appear in the thigh in front or behind the joint. The anterior abscess emerges on one or other side of the psoas muscle; from the resistance offered by the fascia lata, the pus may gravitate down the thigh before perforating the fascia. It has occasionally happened that when such an abscess has been opened and become infected with pyogenic organisms, the femoral vessels have been eroded, and serious or even fatal hæmorrhage has resulted. The posterior abscess appears in the buttock and may make its way to the surface through the gluteus maximus; more often it points at the lower border of this muscle in the region of the great trochanter, or it may gravitate down the thigh.

Abscesses which form within the pelvis originate either in connection with the acetabulum or in relation to the psoas muscle where it passes in front of the joint. Those that are directly connected with disease of the acetabulum may remain localised to the lateral wall of the pelvis, or may spread backwards towards the hollow of the sacrum. They may open into the bladder or rectum, or may ascend into the iliac fossa and point above Poupart's ligament ([Fig. 115]), or descend towards the ischio-rectal fossa. The abscess which develops in relation to the psoas muscle may be shaped like an hour-glass, one sac occupying the iliac fossa, the other filling up Scarpa's triangle, the two sacs communicating with each other through a narrow neck beneath Poupart's ligament.

So long as the skin is intact, the abscess is unattended with symptoms, and may escape notice. If it bursts externally, pyogenic infection is almost inevitable, and the patient gradually passes into the condition of hectic fever or chronic toxæmia; he loses ground from day to day, may become the subject of waxy disease in the viscera, or may die of exhaustion, tuberculous meningitis, or general tuberculosis.

Dislocation is a rare complication of hip disease, and is most likely to occur during the stage of adduction with inversion. It has been known to take place during sleep, apparently from spasmodic contraction of muscles. In the dorsal dislocation, which is the most common form, adduction and inversion are exaggerated, the trochanter projects above and behind Nélaton's line, and the head of the bone may be felt on the dorsum ilii. It is a striking fact that after dislocation has occurred there is less complaint of pain or of startings than before, and passive movements may be carried out which were previously impossible.

Diagnosis of Hip Disease.—The diagnosis is to be made not only from other affections of the joint, but also from morbid conditions in the vicinity of the hip, as in any of these the patient may seek advice on account of pain and a limp in walking. The patient should be stripped, and if able to walk, his gait should be observed. He is then examined lying on his back, and attention is directed to the comparative length of the limbs, to the attitude of the limbs and pelvis, and to the movements at the hip-joint, especially those of rotation. When there is any doubt as to the diagnosis, the examination should be repeated at intervals of a few days. In children, there are three non-febrile conditions attended with a limp and with shortening of the limb, which may be mistaken for hip disease,—congenital dislocation, coxa vara, and paralysis following poliomyelitis—but in all of these the movements are not nearly so restricted as they are in disease of the joint.

In tuberculous disease of the sacro-iliac joint, while the pelvis may be tilted, and the limb apparently lengthened, the movements at the hip are retained. In tuberculous disease of the great trochanter, or of either of the bursæ over it, while there may be abduction, eversion, impairment of mobility, and swelling in the region of the trochanter followed by abscess formation, the movements are less restricted than in disease of the joint.