APPLIED ANATOMY. 



Attitude. Owing to the pain in the affected limb the weight of the body is 

 borne mainly on the healthy limb. Viewing the patient anteriorly in an early case 

 of the disease the external rotation is readily seen in the eversion of the foot. If the 

 foot itself is normal, rotation takes place at the hip-joint and not at the knee or 

 ankle ; therefore a foot that is abnormally turned out indicates that there is some- 

 thing in the hip to cause it to turn out. The affected limb is seen to be held in a 

 position of abduction, out away from the healthy one. The flexion is evidenced by 

 the affected limb being placed a little in advance of the other and by the bending at 

 the groin. If the feet are placed together there may also be flexion of the knee 

 (Fig. 525). 



Tilting of the pelvis may or may not be apparent, but it exists and can be dem- 

 onstrated by a careful examination. Viewed posteriorly, besides the position of the 

 limb as seen from in front, there is in addition a change in the gluteal folds and 



buttock. The gluteal fold on the affected side is 

 lowered in position and shorter than on the healthy 

 side and the buttock is flattened. The flattening of 

 the buttock is caused by the flexion of the hip. This 

 flexion likewise tends to obliterate the gluteal fold. 

 The difference in height of the gluteal folds is caused 

 by the tilting down of the pelvis on the affected side. 

 An inequality in the lower limbs, whether due to 

 shortening or to malposition, such as flexion, will 

 be visible at once by an inequality of the gluteal 

 folds, one being higher than the other. Flexion 

 deformity is recognized when the patient is standing 

 by the bending at the hip-joint and by the lordosis 

 or hollowing of the back. When the patient is re- 

 cumbent on a flat surface and both legs are brought 

 straight down so that both knees are in contact with 

 the table, then if flexion is present it causes the lum- 

 bar vertebrae to arch and the back to rise from the 

 table. If now the thigh of the affected side is ele- 

 vated until the back again touches the table the de- 

 gree of elevation necessary to accomplish this will 

 be the measure of flexion. 



Measurements. The child being flat on its 

 back the pelvis is to be made level by seeing that 

 a line joining the two anterior spines is at right 

 angles to the median line. If abduction is present 

 the limb points away from the median line. It can- 

 not be brought straight down parallel with the 

 sound leg without tilting the pelvis. If measured 

 from the umbilicus to the internal malleolus the 

 affected leg measures more than the sound one. 

 This is called apparent lengthening. If when both 

 limbs are placed in the same degree of abduction 

 and are measured from the anterior spine to the internal malleolus they measure 

 the same, there is no real shortening. 



In advanced disease adduction is more common than abduction. This produces 

 an apparent shortening, as shown by measurement from the umbilicus to the internal 

 malleolus ; if the sound limb is placed in the same degree of adduction as the affected 

 one, the distances from the anterior spines will show no actual shortening unless there 

 is a loss of bone or displacement at the hip-joint. The pelvis, instead of being 

 tilted down on the diseased side, is tilted up. Flexion is usually more marked and 

 the foot is usually inverted instead of everted. 



Hip- Abscess. Tuberculosis of the hip probably begins in the neighborhood 

 of the epiphyseal line of the femur and involves the joint secondarily. The epiph- 

 ysis of the head begins above near the edge of the articular cartilage and runs 

 obliquely across upward and inward. It is thus entirely within the capsule and when 



FIG. 525. Early stage of coxalgia, 

 showing the affected left limb abducted, 

 thus lowering the pelvis on that side; 

 slightly flexed, thus obliterating the glu- 

 teofemoral fold, and slightly everted. 



