ABNORMAL CONDITIONS OF THE HIP-JOINT. 



815 



impaction of both of the fragments has taken 

 place, then under such peculiar circumstances 

 a firm bony consolidation of the fragments may 

 be expected. 



Finally, although this is not the place to 

 speak of the surgical treatment of such cases, 

 we may remark that the most valuable practical 

 information, in our mind, derivable from the 

 discovery of facts like the foregoing, is that the 

 lenient method of treatment, viz. by position 

 alone, and without splints, may be eminently 

 successful, so far as the accomplishment of a 

 firm reunion of the fragments is concerned. 



II. Luxations. Luxations of the head of the 

 femur from the acetabulum are by no means so 

 frequent as fractures of the bones which enter 

 into the composition of the hip-joint. 



This comparative immunity from this form 

 of accident arises from these circumstances, 

 that the acetabulum which lodges the head of 

 the femur has great depth, and that the fibrous 

 membranes which secure this bone in the coty- 

 loid cavity have great strength, and restrain 

 within certain limits its movements. Indepen- 

 dently, however, of congenital luxations, and 

 of those which are the result of disease, there 

 are six distinct forms of dislocation of the hip- 

 joint to be described as the result of accident 

 alone. 



The dislocations of the head of the femur from 

 accident may be classed as follows : a. dislo- 

 cation upwards and backwards on the dorsum 

 ilii ; b. directly backwards towards the ischiatic 

 notch ; c. downwards and inwards into the 

 foramen ovale ; d. upwards, forwards, and in- 

 wards on the horizontal ramus of the pubes. 

 Besides these, of late years two more unusual 

 luxations have been described and verified by 

 post-moitem examinations, viz. dislocation 

 downwards towards the tuberosity of the 

 ischium, and dislocation upwards between the 

 anterior inferior spine of the ilium and the ilio- 

 pubal eminence. 



a. Dislocation of the head of the femur 

 vpicards and backwards on the dorsum of 

 the ilium. When the head of the thigh-bone 

 is thrown on the dorsum ilii, the limb on the 

 luxated side is from one to two inches 

 shorter than the other ; the thigh is slightly 

 flexed, or a little advanced upon the other, and 

 carried into a state of abduction, and of marked 

 rotation inwards. The patella and inner side 

 of the dislocated limb look directly inwards, 

 and the great toe corresponds to the tarsus of 

 the opposite foot. The great trochanter, carried 

 forwards and upwards, approaches the crest of 

 the ilium and its anterior and superior spine, 

 and forms there a very well marked tumour ; 

 the nates raised up by the head of the femur is 

 very salient towards its superior and posterior 

 part. If we make attempts to bring the limb 

 backwards into a state of extension or abduc- 

 tion or of rotation outwards, we find we give 

 much pain to the patient, and that we cannot 

 move the bone in any of these directions. \Ve 

 can, without causing suffering to the patient, 

 augment a little the flexion towards the abdo- 

 men, and adduct the dislocated thigh, and we 

 can also increase the rotation inwards already 



existing, or, to use the words of Sir A. Cooper, 

 " when the leg is attempted to be separated 

 from the other it cannot be accomplished, as 

 the limb is firmly fixed in its new situation, so 

 far as regards its motion outwards. The thigh 

 can be slightly bent across the other and towards 

 the abdomen, but extension of the thigh and 

 rotation outwards are impossible." Rotation 

 inwards, on the contrary, is to a great extent 

 permitted, so much so indeed that we have 

 seen the back part of the heel turned forwards, 

 while the toes pointed backwards. During 

 these extreme motions of rotation inwards, if 

 the hand be pressed on the dorsum of the 

 ilium deeply, the head of the femur will be 

 perceived to roll on the ilium, and its tro- 

 chanter major also can at this time be felt to 

 be nearer than natural to the anterior superior 

 spinous process of the ilium ; the trochanter is 

 less prominent than that on the opposite side, 

 for the neck of the bone and the trochanter are 

 resting in the line of the surface of the dorsum 

 ilii. Upon a comparison of the two hips, the 

 roundness of the dislocated side will be found 

 to have disappeared. A surgeon, then, called 

 to a severe and recent injury of the hip-joint, 

 looks for a difference in length, change of posi- 

 tion inwards, diminution of motion, and de- 

 creased projection of the trochanter. 



The explanation of the manner in which the 

 dislocation of the head of the femur upwards 

 and backwards on the dorsum ilii takes place 

 has been the subject of some difference of sen- 

 timent. The late Mr.Todd has, in our opinion, 

 given some judicious observations on this sub- 

 ject ;* he says, " the elementary work on luxa- 

 tions most generally read and referred to in 

 this country, is Dr. Farrell's translation of 

 Boyer's Lectures, arranged by Richerand. The 

 following is the description therein given of the 

 manner in which the luxation of the femur, at 

 present under consideration, is produced. 



" When by a fall from a place, more or 

 less elevated, on the soles of the feet, or on 

 the knees, the thigh is pushed forwards and 

 inwards, the head of the femur, forced to- 

 wards the superior and external part of the 

 acetabulum, breaks the internal and orbicular 

 ligaments, escapes through the laceration in 

 the latter, and ascends on the external face of 

 the os ilium ; but as the part of the os ilium 

 immediately above and at the external side of 

 the cavity is very convex, the head of the 

 femur soon abandons its first position, and 

 slides backwards and upwards into the ex- 

 ternal fossa of the os ilium, following the in- 

 clination of the plane towards the fossa, and 

 obeying the action of the glutaei muscles, 

 which draw it in this direction. The head 

 of the femur, in ascending thus on the ex- 

 ternal face of the os ilium, pushes upwards 

 the glutaeus minimus, which forms a sort of 

 cap for it, and the glutaeus maximus and me- 

 dius are relaxed by the approximation of the 

 points into which they are inserted. The pyri- 

 formis is nearly in its natural state ; the gemini, 

 obturatores, and quadratus femoris are a little 



* Dublin Hospital Reports, vol. iii. p. 397. 



