Manual of Surgery Volume II Part 15

Extension is obtained by the same appliances as are used in fracture of the shaft, and the limb should be kept in the abducted position.

Fracture of the #greater trochanter# occurring apart from fracture of the neck usually results from direct violence, but may be due to muscular action. The trochanter is displaced by the gluteal muscles, causing broadening of the lateral aspect of the hip. In young persons the _epiphysis_ of the great trochanter may be separated, but this is rare. The treatment consists in retaining the fragments in position by keeping the limb abducted between sand-bags, or by pegs driven in through the skin.

#Fracture immediately below the lesser trochanter# may be produced by direct or by indirect violence, and the displacement depends largely on whether the line of fracture is transverse or oblique. The proximal fragment is kept tilted forward, rotated laterally, and abducted by the ilio-psoas muscle and the lateral rotators inserted in the region of the great trochanter. The lower fragment pa.s.ses upward, and is rotated laterally by the weight of the limb; the displacement is aggravated by the contraction of the flexor and adductor muscles. The tilting of the proximal fragment may be increased by the displaced distal fragment pus.h.i.+ng it forward.

On account of the difficulty of controlling the short proximal fragment, union is liable to take place with considerable shortening and deformity (Fig. 69).

[Ill.u.s.tration: FIG. 69.--Fracture of the Femur just below the Small Trochanter united, showing flexion and lateral rotation of upper fragment.]

_Treatment._--When it is found, under an anaesthetic, that the displacement can be completely reduced, and does not tend to recur, this fracture is treated on the same lines as fracture of the shaft of the bone.

In cases in which the proximal fragment cannot be brought into line with the distal one, however, it is necessary to flex, evert, and abduct the thigh in order to get the fragments into apposition and into line. A Hodgen's splint (Fig. 77) is applied with the highest sling under the upper end of the lower fragment and with sufficient extension to correct overriding. The upper end is then strongly lifted by a counter-weight of about 15 lbs. This secures apposition of the fragments with slight forward angulation at the seat of fracture. By the end of a month sufficient callus has formed to prevent re-displacement, and if the counter-weight is gradually diminished the two fragments sag back together into a normal alignment (J. N. J.

Hartley). A double-inclined plane (Fig. 70), with extension applied in the axis of the thigh, gives satisfactory results.

[Ill.u.s.tration: FIG. 70.--Adjustable Double-inclined Plane.]

DISLOCATION OF THE HIP

It is unnecessary for our present purpose to attempt a comprehensive cla.s.sification of the numerous varieties of dislocation that have been met with at the hip-joint. It will suffice if we divide them into those in which the head of the femur pa.s.ses backward, and comes to rest on the dorsum ilii, or in the vicinity of the great sciatic notch; and those in which it pa.s.ses forward and comes to rest in the obturator foramen, or on the p.u.b.es (Fig. 71).

[Ill.u.s.tration: FIG. 71.--Diagram of the most common Dislocations of the Hip.]

The backward are much more common than the forward dislocations, in contrast to what obtains at the shoulder, where the forward varieties predominate.

On account of the great strength of the hip-joint, dislocation is by no means a common injury. It occurs most frequently in strong adults after the epiphyses have ossified, and before the bones have commenced to become brittle; and it is much more common in men than in women. It is invariably the result of severe violence, the limb at the moment being in such a position that the ligaments are on the stretch and the muscles taken at a disadvantage. The head of the femur usually leaves the joint at the lower and back part, where the socket is most shallow and the ligaments weakest. The ligamentum teres is almost always torn from its femoral attachment, and one or more of the muscles inserted in the region of the trochanters may be ruptured. The [inverted Y]-shaped ligament, on the other hand, is seldom torn, and so long as it remains intact the dislocation belongs to one or other of the types above named. All atypical dislocations, such as the supra-cotyloid, infra-cotyloid, ilio-pectineal, are due to rupture of some part of the [inverted Y]-ligament, and are so rare as not to call for individual description. The central dislocation of German authors, in which the head is driven through the floor of the acetabulum, is described on page 126.

Like other dislocations, those of the hip may be complicated by laceration of muscles, blood vessels, or nerves, or by fracture of one or other of the bones in the vicinity.

#Dislocation on to the Dorsum Ilii.#--This, the commonest form of dislocation of the hip, is usually the result of the patient falling from a height, or receiving a heavy weight on the back while stooping forward with the thigh flexed, slightly adducted, and rotated medially. It is also said to have occurred from muscular action. The shaft of the femur acts as the long limb of a lever of which the neck is the short limb, the femoral attachment of the [inverted Y]-ligament forming the fulcrum. The head, thus brought to bear upon the lower and back part of the capsule, tears it and leaves the socket, pa.s.sing upwards and coming to rest on the dorsum of the ilium, above and anterior to the tendon of the obturator internus (Fig. 73). The articular surface is directed backward, while the trochanter looks forward.

[Ill.u.s.tration: FIG. 72.--Dislocation of Right Femur on to Dorsum Ilii.]

_Clinical Features._--The affected limb is flexed, adducted, and inverted, so that the knee crosses the lower third of the opposite thigh, and the ball of the great toe lies on the dorsum of the sound foot. There is shortening to the extent of from 1-1/2 to 2 inches, the trochanter being displaced above Nelaton's line, and lying nearer to the anterior superior iliac spine than on the normal side. The patient is unable to move the limb or to bear weight upon it; abduction and lateral rotation are specially painful; and traction fails to restore the limb to its proper length. On making these attempts a characteristic elastic resistance is felt.

The head of the femur in its new position may sometimes be felt through the fibres of the gluteus maximus, but swelling of the soft parts often obscures this sign. The normal depression behind the great trochanter is lost, the gluteal fold is raised, and there is often a degree of lordosis which compensates for the flexion. The fingers can be pressed more deeply into Scarpa's triangle on the dislocated than on the normal side--a point in which this injury differs from fracture of the base of the neck of the femur.

In a certain number of cases the lateral limb of the [inverted Y]-ligament is ruptured and the limb is everted--_dorsal dislocation with eversion_.

[Ill.u.s.tration: FIG. 73.--Dislocation on to Dorsum Ilii. Note relation of neck of femur to tendons of obturator internus and gemelli (diagrammatic).]

#Dislocation into the Vicinity of the Great Sciatic Notch#, or "_dislocation below the tendon_."--This variety of backward dislocation is less common than that on to the dorsum, although produced in the same way. The head of the femur pa.s.ses beneath the obturator internus, and this tendon, catching on its neck, checks its upward movement (Fig. 74).

The _clinical features_ are the same as those of the dorsal variety, but, on the whole, are less marked.

_Differential Diagnosis._--Backward dislocation of the hip is usually easily recognised. When dislocation below the tendon occurs in a stout person, however, it is liable to be overlooked on account of the difficulty of feeling the displaced bone, and of the comparatively slight amount of deformity present. The nature of the accident, the absence of broadening of the trochanter, and the adduction and inversion of the limb are usually sufficient to prevent a dislocation being mistaken for an impacted extra-capsular fracture.

#Dislocation into the Obturator Foramen# (Fig. 71).--This dislocation is produced by great force applied from behind while the thigh is flexed and abducted, as when a weight falls on the back of a man stooping forward with the legs wide apart. It may also result from violent abduction by wide separation of the thighs.

The capsule gives way at its medial and lower part, and the head of the femur comes to rest on the surface of the external obturator muscle, its articular surface looking forward, while the trochanter looks backward.

_Clinical Features._--In the standing position the thigh is slightly flexed and abducted, with the foot pointing directly forward or a little outward. The body is bent forward to relax the ilio-psoas muscle and the [inverted Y]-ligament, the foot is advanced and the heel drawn up. It is not uncommon for the patient to be able to walk after the accident, and only to seek advice some time later on account of inability to adduct and extend the limb. There is apparent lengthening of the limb due to tilting of the pelvis downward on the affected side. The hip is flattened, the trochanter less prominent than usual, and the head of the bone may sometimes be felt in its abnormal position.

[Ill.u.s.tration: FIG. 74.--Dislocation into the vicinity of the Ischiatic Notch. Note relation of neck of femur to tendons of obturator and gemelli, "Dislocation below the tendon" (diagrammatic).]

#Dislocation on to the p.u.b.es# is a further degree of the obturator form (Fig. 71). It is usually produced by forcible hyper-extension and lateral rotation of the hip, such as occurs when the body is bent back while the thigh remains fixed.

The capsule is torn farther forward than in the other varieties, and the head rests on the horizontal ramus of the p.u.b.es against the ilio-pectineal line.

_Clinical Features._--There is marked eversion, flexion, and abduction, but the shortening is inconsiderable. The ilio-psoas and [inverted Y]-ligament are tense. The head of the femur may be felt in the groin, with the femoral vessels over, or to one or other side of it. There is sometimes pain and numbness in the distribution of the femoral (anterior crural) nerve. The prominence of the great trochanter is lost.

#Treatment of Dislocation of the Hip.#--For the reduction of a dislocation of the hip complete anaesthesia is necessary, and the patient should be placed on a firm mattress on the floor to give the surgeon the best possible purchase upon the limb. The surgeon grasps the ankle with one hand, while the other is placed behind the head of the tibia, the leg being held at right angles to the thigh. An a.s.sistant meantime steadies the pelvis by making firm pressure over the iliac crests.

As the chief obstacle to reduction is the tension of the ilio-femoral ligament, the first indication is to relax this structure by flexing the hip _to its fullest extent_.

In the _backward_ varieties (dorsal and sciatic) the [inverted Y]-ligament is relaxed by flexing the thigh upon the pelvis in the position of adduction. The thigh is then fully abducted, to cause the head of the bone to retrace its steps forwards towards the rent in the capsule; and at the same time rotated laterally to relax the rotator muscles. This combined movement tends also to open up the rent in the capsule. Finally, the limb is quickly extended to cause the head to enter the socket. This object is often aided by making vertical traction or lifting movements on the abducted and laterally rotated limb before extending.

For the reduction of the _forward_ varieties (obturator and pubic), the thigh is first fully flexed on the pelvis, but in the abducted position. The limb is then strongly rotated medially and abducted, and finally extended. Lifting movements may be found useful in these cases also.

All methods of reduction by forcible traction on the extended limb are to be avoided, as they fail to meet the primary indication of relaxing the [inverted Y]-ligament.

After reduction, the limb is steadied by sand-bags; ma.s.sage is carried out from the first, and movement after a few days. The range of movement is gradually increased, and the patient is allowed to use the limb with caution in from two to three weeks.

When the rim of the acetabulum has been fractured, the patient must be confined to bed with extension for six to eight weeks, to avoid the risk of re-dislocation.

Changes of the nature of chronic arthritis are liable to occur in and around the joint in old and rheumatic subjects; and atrophy or paralysis of muscles may follow, if their nerves are implicated.

#Old-standing Dislocation.#--It is impossible to lay down any time-limit for attempting reduction in old-standing dislocations of the hip. Manipulation may succeed in cases of some months' standing, and may fail when the bone has been out only a few weeks. In certain cases, even after reduction has been effected, there is a marked tendency to re-displacement. In any case, the attempt does good by breaking down adhesions, provided no undue force is employed such as may damage the sciatic nerve or vessels, or fracture the neck of the femur, and success may attend on a second or even a third attempt at intervals of from three to five days. If manipulation fails, and if the deformity is great and the usefulness of the limb seriously impaired, an attempt may be made to effect reduction by operation; the operation, however, is one of considerable difficulty, and in the event of failure the head of the bone should be excised. If the head has formed a new socket for itself and there is a fairly useful joint, the condition should be left alone.

_Congenital dislocation of the hip_ is described with Deformities of the Extremities.

#Sprain# of the hip is comparatively rare. It results from milder degrees of the same forms of violence as produce dislocation. The ligaments are stretched or partly torn, and there is effusion of fluid into the joint. Pressure over the joint elicits tenderness; and the limb a.s.sumes the position of slight flexion, abduction, and lateral rotation, but there is no alteration in length. Such injuries, unless carefully treated by ma.s.sage and movement from the outset, are apt to be followed by the formation of adhesions, resulting in stiffness of the joint.

#Contusion# in this region, on the other hand, is not uncommon. It is produced by a fall on the trochanter, and gives rise to symptoms which simulate to some extent those of fracture of the neck. The limb lies in the position of slight flexion, but the bony points retain their normal relations.h.i.+p to one another, and there is no shortening. The swelling and tenderness often prevent a thorough examination being made, and when any doubt remains as to the diagnosis, the patient should be kept in bed till the doubt is cleared up by the use of the X-rays. If the bone has been broken, this will reveal itself in the course of a few days by the occurrence of shortening and other evidence of fracture.

In elderly patients, contusion of the hip may be followed by changes in the joint of the nature of arthritis deformans; and it has been stated, although proof is wanting, that absorption of the neck of the femur sometimes occurs. These injuries are treated by rest in bed, ma.s.sage, and the other measures already described as applicable to sprains and contusions.

FRACTURE OF THE SHAFT OF THE FEMUR

This group includes all fractures between that immediately below the lesser trochanter and the supra-condylar fracture.

_In adults_, when due to direct violence, the fracture is usually transverse, and may be attended with comparatively little displacement. Indirect violence, on the other hand, usually produces an oblique fracture, which is frequently comminuted and often compound. The break is most commonly situated a little above the middle of the shaft, the obliquity being downward, forward, and medially, and of such a nature that the fragments tend to override one another (Fig. 75). The most serious forms are those a.s.sociated with gun-shot wounds.

[Ill.u.s.tration: FIG. 75.--Longitudinal section of Femur showing recent Fracture of Shaft with overriding of Fragments.]

The direction and nature of the displacement depend more upon the fracturing force, the weight of the lower part of the limb, and the action of the muscles attached to the respective fragments, than upon the direction of the obliquity. As a rule, the proximal fragment pa.s.ses forward and laterally, and is maintained in this position by the ilio-psoas and glutei muscles, while the distal fragment is displaced upward and medially and is rotated outward by the combined action of the weight of the limb, the longitudinal muscles, and the adductors.

_Clinical Features._--The limb is at once rendered useless, and there is great swelling from effusion of blood in the region of the fracture. This, together with the muscularity of the part, often renders an accurate diagnosis as to the site and direction of the fracture exceedingly difficult. The shortening varies from 1/2 inch to 3 or 4 inches--averaging about 1 inch in adults--and eversion is always marked. Mobility may be detected and crepitus elicited without disturbing the patient, by placing the hand under the seat of fracture and gently attempting to raise the limb; or by fixing the proximal fragment by one hand placed in front of it while the distal part of the limb is carefully lifted. It will be found that the great trochanter does not rotate with the lower segment of the femur. These tests must be employed with great caution lest the deformity be increased or the fracture rendered compound.