LUXATION. 



1)C cflabliflicd as a general rule, tliat luxated members al- 

 ways take a direSion determined by tlie elongation of the 

 mufcles of the fide oppoiite that to whieli the luxated bone 

 is carried ^ ilius, in luxation of tlie arm downwards and in- 

 wards, the deitoides and infrafpinatns mufcles, lengthened 

 by the feparation of tlieir points of infertion, move the elbow 

 out from the body, and give the arm an oblique direction. In 

 tliia cafe, the obluratoros, gemini, and cjuadra'iis femoris, 

 being elongated, the point of the foot ought to be turned 

 outwards. This phenomenon depends perhaps on the ex- 

 ternal portion of the orbicular ligament which comes from the 

 anterior and iiiftrior (pine of the os ihum ; this portion, 

 which is very thick, being elongated in tlie luxation out- 

 wards, draws the great trochanter forwards, and confequeiit- 

 ly t"rns i'uvards the entire limb. 



Tlie difficulty of reducing luxations of the thigh, from 

 the llrenglh and number of its mufcles, renders every diflo- 

 cation of which it is fufceptible very dillrefiing. The 

 laceration and injury done to the foft parts are nearly as 

 coufiderahle as in diflocation of tlie ginglimoidal articu- 

 lations. 



To effeiS: the redu£lion, the patient is extended on a table 

 firmly fixed, and covered with a niattivfs, which is to be 

 tied to it.; a (heet, folded longitudinally, is applied to the 

 groin of the found fide, in order to inake counter-extenfion. 

 The middle part is applied again'.l the fuperior and inter- 

 nal part of the thigh, and the two ends pafied before and 

 behind the pelvis, crofs on the hip, and are held by a frffici- 

 ent number of afflflants. By this means the trunk is fixed, 

 ■but there is nothing to prevent the pelvis from yielding to the 

 .extending force. To anfwcr this purpofe, another tlieet^ 

 folded in a fintilar manner, is placed tranfverfely on the 

 fpine of the os ihum, and its ends are brought liorizontally 

 before and behind the abdomen towards the hip of the oppo- 

 /ite llde, where they are held by airiftant.s. This apparatus, 

 fimihir to that placed on the point of the fhoulder in a lux- 

 ation of the arm, anfivers the fame purpofes, as it prefl'es 

 only on.the.luperiov part of the gluteus maximus and mtdius, 

 and does not IlimulKte them to contract. The extending 

 force is to be applied to tlie inferior part of the leg, in 

 order to have it as far as pollible from the parts which refill 

 the return of the head of the femur. The number of 

 aiTiftants for making extenfion and counter-extenfion is to be 

 propertioned to tUe exigencies of the circumftances and 

 the power of mufcles. The furgeon, placed at the 

 external fide of the limb, prefTes on the great trochanter, 

 and when the head of the bone has been brought on a 

 level with the acetabulum, he endeavours to force it 

 into it. 



In this country, as we have previoufiy explained, fur- 

 gecns generally apply the extenfion to the difiocated bone 

 hfelf, jull above the knee. The difappearance of all the 

 fymptoms, and efpecialiy the noife made by the head of the 

 femur on re-entering its cavity, indicate the fuccefs of the 

 operation. This fuccels is fcldom obtained without having 

 previoufiy irnde ieveral fruitlefs endeavours, whether from 

 not employing lufiicient foi'ce to make extenfion and counter- 

 extenfion, or from a fpafmodic contradlion oPthe mufcles 

 obfti'.-ately rcfithng the reduction. 



When the bone is reduced, it is prevented from leaving its 

 place by bringing the thighs together by means of a band- 

 age placed above th« knees. In the generality of cafe.f, it 

 Will be advil'ab'.c to lake fome blood from the patient, and 

 confine him for a few days aft«\- .the accident to a very low 

 .diet ; and in all cafes the hip is to be covered with emollient 

 and refolvent applij;;t:ons, which may be kept on by means 

 £>.i the fpica bandage for the groin. This bandage is well 



adapted to this ufe, but is not at all fit for keeping the 

 luxated bone in its proper place, as its aflion is male too 

 near the centre of motion. Tlie patient fliould be parti- 

 cularly directed not to walk too foon, nor at any time to 

 fatigue too much the afieflcd joint. 



Luxation of the thigh downwards and inwards, or into the 

 foramen ovale, is nearly as frequent as that iull defcribed ; 

 it is iavoured, as we have faid, by the great extent of the 

 motion of abduClioii of llie thigh ; by the notch at the 

 inferior ai.d internal part of the acetabulum ; by tlie weak- 

 nefs of the orbicular ligament at this fide ; and lallly, by 

 the fituation of the round ligament, tlie rupture of whic'i 

 is not a necetTary conlequence of it. It is occafinned by a 

 fail on the feet or knees confiderably feparalod from one 

 another. The head of the femur fiides from without in- 

 wards on the bv»ttom of the acetabulum, and corre.-v againii 

 the inferior and int- rnal portion of the orbicular ligament, 

 which it lacerates, and padi's on to the foramen ovale be- 

 tween the ligament and the obturator externuF. 



In this fpecies of luxation of the femur, the (late of the 

 foft parts lurrounding the articulation is as follows : the 

 gluta:!, gemini, obturatores, quadratus femoris, pfoas ir.ag- 

 nus, and iliacus internus, are elongated by the feparation of 

 their points of infertion. The rotation of the limb out- 

 wards is produced by the elongation of thefe ir.ufc'es. The 

 adduftors, elongated, form at the interior part of the thigh 

 a tenfe cord, which is felt from the pubis to below the mid- 

 dle of the thigh. 



The affected thigh is longer than the found one ; the 

 head of the femur being placed lower than the acetabulum, 

 the great trochanter is removed to a greater dillance from 

 the anterior and fuperior fpinous procefs of the os ollurn, 

 and the thigh is flattened in confequence of the elongation 

 of the mulcles. The adduflor.-J, extended obliquely from 

 the pubis to the femur, form a cord which elevates the ikin 

 of the internal part of the thigh. A hard round tumour i.< 

 felt at the inner and fuperior part of the thigh, formed by the 

 head of the femur, which elevates the foft parts filnated be- 

 fore the foramen ovale. The leg is flightly bent ; the knee 

 and foo', turned outwards, cannot be brought back to their 

 proper direclion. If the patient attempt to walk a few 

 fteps, he makes a femicircular motion with the foot, and 

 places at once the entire fole pn the ground ; and though 

 he keep the knee bent, flill the limb is too long, and occa- 

 fions lamenefs. The mode of progrelTion of perfons whofe 

 thigh is luxated in this direftion may be compared to that 

 of a mower : the elongated extremity, like the leg whicli 

 the mower keeps forwards, defcribes a femicircular motion 

 outwards. 



Ail thefe fymptoms, taken together, form a combination 

 too llriking to admit of error in our diagnofis, or to allow 

 us to confound this luxation with any other, or even with 

 fracture of the neck of the femur. 



The progiiofis is fomewhat lefs unfavourable in this than 

 in luxation upwards and outwards. The Jiiufclcs, which 

 might oppofe the reduClion, being all elongated by the very 

 circumftan^e of the luxation itlelf, render the redudioii 

 eafier ; befide.";, the contufion of the ioft parts is lefs conll- 

 derable, and the round ligament is ftretched, but not broken. 

 It is reduced in the fame manner as the other, except that 

 the extenfion is to be made at firll downwards and out- 

 wards, before bringing the li«i b to its natural direfticn. 



Luxation upwards and forwards is much rarer than the 

 preceding, and more than one pradlitiojier has defcribed it 

 rather as poffible than as liaving abfolutely taken p'ace. It 

 has been alfo called luxation on f.he pubis, though it may 

 be reaConably prefumcd that the head of the femur is re- 

 moved 



