REGION OF THE HIP. 



Signs. There is no eversion, no flexion on lying down in young cases, but 

 lordosis is seen on standing (Fig. 523) and in old cases, also on lying down. The 

 main point for diagnosis is shortening. The limb is shorter, measured from the 

 anterior superior spine, and the anterior iliotrochanteric angle (page 505) is dimin- 

 ished or lost ; the tip of the trochanter is above the Roser-Nelaton line, and the base 

 of Bryant's triangle is lessened or even obliterated on the affected side. By careful 

 palpation it can be recognized that the head is absent from 

 its normal position beneath the femoral artery. Frequently 

 the top of the trochanter is on a level with the anterior 

 superior spine. The use of the X-ray is necessary to ascer- 

 tain accurately the position of the head and as to whether 

 or not the bones possess their normal shape. 



Reduction. As the head is usually more or less 

 fixed in its abnormal position, force has to be used to 

 replace it. Paci of Pisa was the first to reduce them sys- 

 tematically by a modification of the circumduction method. 

 He flexed the thigh on the abdomen, then firmly abducted, 

 rotating outward, and used the edge of the table as a 

 fulcrum. 



Lorenz used Konig's padded, wedge-shaped block 

 under the trochanter as a fulcrum to pry the head forward. 

 The writer combined the direct and indirect methods 

 by placing the child face down on a table with the affected 

 hip on a sand pillow and the leg and thigh hanging over 

 the side. The operator or an assistant then raises (flexes) 

 the knee, bringing it toward the patient's axilla, while the 

 operator presses with his hands and body-weight down on 

 the trochanter. By gradually raising the knee and keeping 

 it close to the body and pushing the head forward it eventu- 

 ally slips from the posterior to the anterior plane and into 

 place (Fig 524). When the head has been brought onto 

 the anterior plane it is usually impossible to extend the 



knee, on account of tension of the hamstring muscles, as pointed out by Lorenz. 



After being reduced the thigh cannot be brought down at once to its normal 



position, as by so doing the head jumps out of its socket ; so it is put up 



in plaster of Paris in an abducted posi- 

 tion for some time and brought down 

 gradually. 



Hip-Disease (Coxitis or Cox- 

 algia). Disease of the hip in its early 

 stage is characterized by pain, limitation 

 of motion, and limping. The pain is 

 either a local one in the hip itself or a 

 referred one. The hip is supplied by 

 branches of the anterior crural, sciatic, 

 and obturator nerves, and as these also 

 supply the region of the knee, disease 

 of the hip causes pains to be felt around 

 the knee, most often on its inner side. 

 In an early stage the limitation of 

 motion is due to muscular contraction 

 and it disappears under anaesthesia. The 

 limb is held in a position of flexion, ab- 

 duction, and slight external rotation. The joint is more or less rigid. The loss of 

 motion is only complete in extreme cases. In mild cases the limitation is only pres- 

 ent as a reduction in the normal extent of movements, the joint may move freely and 

 without constraint over a limited arc. The abnormal changes produced are to be 

 recognized by careful inspection, measurements, and comparison with the opposite 

 healthy limb. 



FIG. 523. Child with con- 

 genital luxation of hips, show- 

 ing characteristic lordosis. 



FIG. 524. Author's method of reducing congenital lux- 

 ation of the hip. 



