A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

Desault having examined the parts, discovered, from the following appearances, not a fracture, but a luxation upward and forward. The limb was nearly an inch shorter[31] than natural; the point of the foot was turned outwards; the thigh being in a state of painful extension, could not be flexed on the body; adduction and abduction were alike painful; the great trochanter, being more approximated than usual to the anterior and superior spine of the os ilium, was also too far forward; finally, the projecting head of the bone could be felt, as I have already said, in the groin.

The reduction was effected in the following manner. The patient being laid on a firm table, spread with a mattress, a strap was fastened above the ancle, for the purpose of extension; another, intended for counter-extension was placed between the scrotum and the thigh of the sound side, and brought up the back and front of the pelvis, along the body, till it passed over the shoulder, where it was twisted together and secured.

Extension was then begun, precisely in the direction in which the thigh pointed; and, during the execution of it, a rotatory motion inwards was given to the limb. At the expiration of a few minutes, the head of the bone remaining almost immoveable, notwithstanding the efforts to dislodge it, Desault directed extension to be discontinued, and, taking hold of the thigh, moved it in every direction, with a view to enlarge the opening in the capsule, the narrowness of which he suspected to be the cause that prevented the reduction.

Extension was then resumed, and varied in every direction, while the surgeon endeavoured to give assistance by pushing the head of the bone forcibly downwards, with his thumbs, and the palms of his hands. Useless efforts; the displaced bone remained stationary.

Desault ordering extension to be again discontinued, recommenced the motions of the os femoris, and even increased their force, changing them in every direction, for the purpose of lacerating the capsule. After this, extension was again renewed, with better success than before. Indeed, on the very first effort, the head resumed, of itself, its natural situation, without any further assistance on the part of the surgeon.

The sufferings of the patient ceased almost instantaneously; towards evening a slight swelling appeared around the joint, over which an emollient cataplasm was applied. On the day following, all the unfavourable symptoms were gone, and in about a fortnight the patient was able to return to his usual exercises, which, however, he was directed to pursue, for some time, with moderation.

2. There are, in this case, two circumstances, on which the practitioner should fix his attention, and which may throw great light on the reduction of all luxations of the os femoris, as they will be found applicable to most accidents of the kind. These are, 1st, The narrowness of the opening in the capsule. 2dly, The inutility of the motion or process of conformation, when that opening has been enlarged.

3. We formerly observed, when treating of luxations of the humerus, that one of the obstacles to reduction was, the narrowness of the opening in the capsule; the same circumstance occurs here. That membrane, lacerated at the time when the head of the os femoris is driven against it, is dilated sufficiently to let the head escape: but, the edges of the lacerated membrane, coming together again, and being thus drawn tight around the neck of the bone, retain it in that position, and prevent the head from re-entering the acetabulum. Thus, in a fracture, where one of the extremities of the bone is protruded through the integuments, the opening in the skin, by closing tightly round that extremity, sometimes prevents its reduction.

4. In such a case, what is the first and most obvious indication? It is necessary to increase the extent of the opening in the capsule, by moving the limb in every direction. Some persons have deemed it impossible to tear this membrane anew. But, if we recollect, that the neck of the os femoris, being placed between the edges of the opening, must necessarily draw them asunder by the motions impressed on it, it is easy to conceive, that the angles, where these edges unite, will be torn, if the motions be carried to an inordinate degree: besides, experience proves here, as well as with regard to the humerus, the truth of the doctrine contended for. Are we to apprehend, as these same persons will have it, that serious accidents may be produced by such violent motions? Experience again answers in the negative. Nothing, then, can be more certain, than that this observation, respecting the opening in the capsule, is a great stride towards perfection in the treatment of luxations in general, and particularly of that now under consideration.