Elements of Surgery

by Robert Liston

The reduction is in many cases difficult. In young and muscular individuals, after the lapse of some hours, when reaction has occurred, the muscles are rigidly contracted, and the head of the bone is not easily dislodged. Extension, made to a certain extent and continued, is not so useful or essential here as in other forms of luxation of this joint. Adduction, carrying the injured thigh quickly and forcibly over the other, is generally successful; and the reduction is favoured by at the same time raising up the neck of the bone, by means of a towel or wooden roller passed under the upper part of the thigh. There is also no such advantage from rotating the bone as in other luxations. It is very often necessary, even in recent cases, to adopt measures to weaken muscular exertions; and again, in cases of three weeks’ duration, I have found no difficulty.

The head of the bone, when dislodged from the foramen obturatorium, may slip past the cotyloid cavity, for it is impossible to regulate its direction; it comes to be acted upon by muscles which have been displaced, some being compressed and partially paralysed, whilst others are excited; they have been put out of their usual condition and relation, and act irregularly. The head of the bone may, from this cause, get into the sacro-ischiatic notch. This has occurred to me; but I have found no difficulty in removing it from thence, and effecting reduction satisfactorily.

Displacement into the sacro-ischiatic notch is attended with great and remarkable inversion of the toes, slight shortening of the limb, the prominence of the head of the bone felt under the gluteus maximus. It is the least common form of luxation. Reduction is attempted by extension and rotation outwards, at the same time pulling the head of the bone towards the acetabulum by means of a towel passed under the thigh.

Luxation of the head of the femur on the pubes is perhaps more frequent than any other, excepting that on the dorsum of the ilium. The limb is not much shortened, the toes are everted, the trochanter major is depressed, and nearer to the anterior superior spinous process of the ilium than usually, and the head of the bone is both seen and felt prominent in the groin. Much pain, swelling, and sometimes more or less paralysis of the limb, are occasioned by this displacement; the femoral artery and vein lie immediately interior to the head of the bone, and are compressed, and the crural nerves are stretched over it. In attempting reduction, rotation inwards should be employed during extension, accompanied with endeavours to lift the upper part of the bone towards the acetabulum.

[Congenital Luxation of the Hip-joint is sometimes met with, though on the whole a very rare affection, especially in this country. Female children are more apt to suffer from it than males, and it is also more common in such as are of a scrofulous habit than in such as are endowed with a good constitution. Of twenty-six cases of this malformation observed by Dupuytren, not above three or four were males; a disproportion probably not altogether dependent upon chance. The immediate causes of this variety of displacement are, first, shortness, total absence, or extreme obliquity of the neck of the thigh-bone; secondly, partial or entire obliteration of the cotyloid cavity; thirdly, deficiency, extraordinary elongation, or complete absence of the round ligament.

The characters of this malformation are, shortening of the affected limb, unnatural projection of the great trochanter, ascent of the head of the femur into the iliac fossa, inversion of the leg, and obliquity of the pelvis. The motions of the joint, particularly those of abduction and rotation, are constrained and imperfect; the muscles of the upper part of the thigh are retracted, or drawn towards the iliac crest; the limb is thin, wasted, and out of all proportion to the rest of the body; the tuberosity of the ischium is almost uncovered, and consequently unusually prominent; the upper part of the trunk is thrown backwards, while the lumbar portion of the spine projects forwards, being concave behind; the pubes is placed almost horizontally on the thighs; and the ball of the foot alone touches the ground when the child stands erect.

In the recumbent posture, when the weight of the trunk is taken off, and the muscles are relaxed, most of the symptoms of the luxation disappear, and the limb may be shortened or elongated at pleasure. In walking, the body is inclined towards the sound side, and the head of the dislocated bone sinks towards the cotyloid cavity by its own weight. As age advances, the limb becomes shorter, in consequence of the femur ascending higher and higher on the ilium; the obliquity of the pelvis augments; and the power of locomotion, already so much impaired, is completely destroyed.

Congenital dislocation of the hip-joint may, in general, be easily distinguished from other accidents or maladies, by the affection being observed at or soon after birth, by the obliquity of one or both thighs; by the absence of pain, swelling, and ulceration; by the head of the femur being displaced without any external violence; and by the ability of the surgeon to lengthen or shorten the limb at pleasure. In disease of the hip there is always more or less pain, with a feverish state of the system, and gradual failure of the strength; the parts about the joint are tense and swollen; the limb, at first somewhat lengthened, becomes afterwards shortened, and cannot be extended without the greatest suffering; and the motions of the ileo-femoral articulation are forever impaired.

The post-mortem appearances vary. In general the cotyloid cavity is partially obliterated, or entirely deficient, being replaced by a small, irregular, osseous prominence, devoid of cartilage and synovial membrane; the head of the femur, often flattened at its antero-internal aspect, rests in a sort of superficial fossa on the dorsal surface of the ilium; the round ligament, as was before remarked, is elongated, partially worn away, or even altogether absent; and the surrounding muscles are either atrophied, transformed into a species of yellowish fibrous tissue, or preternaturally developed. In the latter case, their action is preserved; in the former, it is very much restricted, or totally impeded.