The principles and practice of modern surgery

by Roswell Park

1. Pain.

—This is referred most commonly to the knee because of the relations of the obturator nerve to the hip-joint and to the region of the knee. Pain may also be radiated in other directions, but the complaints made of pain in the knee are classical. Pain is not, however, a pathognomonic feature and may be almost wanting, but the evidences of tenderness, if not of pain, are invariably seen in the unconscious protection of the joint afforded by muscle spasm. It is perhaps in hip-joint disease that night pains and cries are most frequently heard.

2. Muscle Spasm.

—Fixation of the affected joint is always noted. It begins as a limitation of motion, naturally first noticed in the extremes of rotation, flexion, and extension, and is perhaps the most important early sign of the disease. It furnishes the explanation for the subsequent postural features, as well as an index regarding the gravity and extent of the morbid process. It may be seen even in the lower spinal muscles, where it is detected by laying the patient upon the face, lifting first one leg and then the other, noting the freedom of hyperextension; in fact, this spinal muscular involvement is sometimes so marked as to give rise to the suspicion of low Pott’s disease, from which it is to be distinguished by the fact that the spasm affects one side rather than both.

3. Muscle Atrophy.

—This involves in time all the muscles concerned about the hip. It begins early, but may not be very pronounced until quite late. It can usually be determined by measurement if not apparent upon inspection and palpation. There will also be noted more or less obliteration of the gluteal crease or fold.

The three cardinal features—pain, spasm, and atrophy—having been thus considered, we can better appreciate the characteristic gait and postures peculiar to this disease. Limping is an early feature, sometimes insidious at first, sometimes abrupt. Patients will avoid coming down quickly upon the heel, while they walk with the knee slightly flexed, in order to give more spring. Stiffness is most apparent on rising from bed in the morning, while the limp is more pronounced at night, and it is at this stage especially that night cries are most frequent. To mere limping succeeds actual lameness with more constant pain. Muscle spasm now leads to malpositions, no one of which is necessarily first to appear, and any of which may occur with others in various combinations, although flexion and adduction are usually the first to be seen, the patient unconsciously assuming that position which happens to give him most relief.

It is important to realize that a marked degree of adduction will cause apparent shortening, and of abduction apparent lengthening, and it is very important to demonstrate that these variations in length are apparent and not actual. This is to be done by placing the patient upon a hard surface with the pelvis at right angles to the spine and the limbs in absolutely symmetrical position. If there be adduction it may mean that the limbs should be crossed; while if there is abduction the healthy limb should be abducted to the same degree as the one affected. Careful measurement will show that the differences are apparent rather than real. The same care is needed in regard to rotation, and particularly in regard to psoas contraction which leads to flexion. One of the most characteristic evidences of hip-joint disease is flexion of the thigh, which, when the thigh is brought down to the proper level, will cause an arching upward of the lumbosacral region. By this time also will be found well-marked limitations of motion in every direction. All of these features should be ascertained without an anesthetic, as they depend upon muscle spasm, which anesthesia would subdue. It is somewhat difficult with intractable young children to make a thorough examination of this kind, but a second or third effort will usually succeed when the first has failed.

Peri-articular symptoms affording corroboration are found in thickening of the tissues about the joint, especially enlargement of the upper end of the femur, or increase in thickness of the pelvis, which may perhaps be felt from the outside or be detected by rectal examination. There is usually involvement of the inguinal lymph nodes, and there is frequently prominence of the superficial veins, due to infiltration of the deeper tissues and obstruction to the return circulation. A good skiagram will also render much aid.

As the disease progresses there will appear evidences of deep suppuration, as abscess is frequent in the advanced stages. This may be peri-articular or may connect with the joint. It may cause separation of the epiphyses of the femoral neck and complete loosening of the head of the femur, which will then become a foreign body in a joint cavity probably filled with pus. Perforation of the acetabulum may also occur. Much of this abscess formation goes on insidiously and without marked increase of symptoms. There is no fixed date when pus may begin to form. It may occur relatively early or late. It is possible for small amounts of pus to absorb in whole or in part, or to leave a residue more or less encapsulated, which will frequently lead later to a secondary abscess, the latter tending to burrow along between the fascial planes or muscle sheaths and appear at some distance from its origin. Pelvic abscesses result from perforation of the acetabulum and may break internally or externally. Nearly all of these collections are of the cold type, and after a long time, if they have opened, may cease to discharge characteristic pus or even pyoid, and simply give vent to a watery seropus. Pus left to itself usually escapes anteriorly to the tensor vaginæ femoris, but it may travel in any direction.