752 
SURGERY. 
of the bone is a little below, and anterior to the axis of the 
acetabulum, and there is a hollow below Poupart’s ligament. 
The dislocation happens when the thighs are widely sepa¬ 
rated from each other. The ligamentum teres is torn ; to¬ 
gether with the lower part of the capsule. 
The reduction is effected by fixing the pelvis, by means 
of a circular belt passed round it, and fixed to some point 
on the sound side; another round the thigh, to which 
pullies must be applied, so as to make extension outwards 
and slightly upwards when he is on his back, or directly 
upwards when he his on his side. The circular belt must 
be passed within the femoral one. The large one reduces 
the bone, by bringing the dislocated leg across the sound 
one, taking care not to raise it much anteriorly, lest the 
head of the bone slip back into the ischiatic notch, fig. 2, 
In recent cases, if the patient be laid on a bed and drawn 
down till the bed-post be in contact with the ramus of the 
ishium, the drawing the legs across may then reduce the 
bone. 
In the dislocation backwards, the head of the thigh bone 
is placed on the pyryformis, between the edge of the bone 
which forms the upper part of the ischiatic notch, and the 
sacro.sciatic ligaments behind the acetabulum, and a little 
above the level of the middle of that cavity. The distortion 
and reduction are both difficult. The limb is generally half 
but sometimes one inch shortened. The trochanter behind 
its usual place, but still nearly at right angles with the 
ilium, and slightly inclining to the acetabulum. In very 
thin persons, if the bone is rolled far forwards, we may feel 
the head in the ischiatic notch. The toe is turned inwards 
till it rests against the ball of the opposite great toe, which 
is much less inverted than we find in the dislocation up¬ 
wards. In the standing posture the toe touches the ground; 
not so the heel; the knee is not so much advanced as in the 
dislocation upwards, and is slightly bent. The limb is 
fixed. 
This accident happens when the trunk being bent on the 
thigh, or, vice versa, force is applied against the knee, the 
reduction is effected by fixing the pelvis and drawing down 
the thigh, as in dislocation on the dorsum ilii; but further, 
a napkin must be placed round the thigh. Traction being 
then made in such a direction that the dislocated femur 
crosses its fellow about its middle, the surgeon, by means of 
the napkin or a towel long enough to pass over the neck, 
lifts the head of the bone over the acetabulum while he 
presses the spiue of the ilium ; the patient being on his side. 
Dislocation on the pubis happens from falling backwards, 
while the foot is prevented from sliding forwards, as when 
a man slips into a hole and falls back. The limb is short¬ 
ened an inch, turned outwards, cannot be rotated inwards, 
but slight flexion forwards and outwards remains; the grand 
criterion, however, is to feel the head of the bone, or the 
fore part of the pubis above the level of Poupart’s ligament 
and outside of the femoral artery and vein. The situation 
of the bone is as follows:—The crural nerve passes over the 
fore part of the neck, upon the psoas muscle, so that the 
head rests between the crural sheath, and anterior inferior 
spine of the ilium ; bony deposits growing from the pubis sur¬ 
round the cervix of tire bone. The feeling of the head on the 
pubis distinguishes this accident form fracture of the neck of 
the femur. It is thus reduced:—In the dislocation rewards, 
put one girth round the innominate®, one round the lower 
part of the thigh; but fix the first in a line before the axis of 
the body, and the other considerably behind it: when it is 
drawn some way down, raise the head over the pubis and 
edge of the acetabulum, by means of a napkin passed round 
the thigh. The patient, being in this, as in the last accident, 
laid on his side. Of these dislocations the proportions may 
be thus stated:—12 in 20 on the dorsum ilii, 5 in the ischi¬ 
atic notch, 2 in the foramen ovale, and I on the pubis. 
Fractures of os innominatum must be carefully dis¬ 
tinguished from femoral dislocations, because pulling down 
the thigh does in the former accident create much mischief. 
When the acetabulum is broken, the head of the thigh is 
drawn up and the toes inverted; the trochanter being for¬ 
wards. If the os innominatum be disjointed from the 
sacrum, and the pubis and ischeum broken, the limb is short¬ 
ened but not altered in its axis. 
Fractures of the upper part of the femur, which are much 
more common accidents thandissolation,are of three kinds: 
1. When the fracture happens through the neck of the bone 
entirely within the capsule. 2. When at the junction of the 
neck, and trochanter when it is external to the capsule, and 
3. When the fracture is through the trochanter beyond this, 
junction.—In the first, the leg is shortened from one to two 
inches; for the connection being destroyed between the head 
and trochanter, the latter is drawn up as far as tire ligament 
will allow, and thus rests on the acetabulum or dorsum ilii 
above it: the retraction of the limb to its original position 
may be made by slight pulling; and this repeatedly, till the 
muscles acquire a fixed contraction, which happens in some 
hours. The limb is turned outward with rare exceptions, 
(Mr. Langstoff had a case where it was inverted), a circumstance 
which happens from the power of the strong rotators; not, 
as some have thought, from the mere weight of the limb, as 
may be inferred from the difficulty of rolling the limb 
inwards. Pain is felt on rotation inwards, opposite the in¬ 
sertion of the psoas and ilicacus, or, sometimes below that 
point. 
Though extension, of the limb may be made, flexion is 
difficult and highly painful, at least in the duration forwards 
and inward; outwards it is not so bad. In this accident 
the trochanter being drawn upwards on the ilicu® with the 
broken cervix'nearerthe spine of the ilicum,the trochanter pro¬ 
jects less on the injured side. Indeed it is much concealed 
till the wasting of the muscles allows it to be felt. In the 
patient he put in the erect position the shortening of the 
limb, smallness of the trochanter, eversion of the limb are 
rendered more apparent, and if directed to stand on his injured 
thigh the first attempt is attended with much pain, and there 
will be more or less projection of the trochanter. Crepitus, 
is only felt when the limb is pulled down either by force or 
its own weight. 
1 'he horizontal portion of their eervius femoris, and the 
feebleness of their constitution, render women more liable to. 
this accident than men. Weakness of the bones in the aged 
render them also liable to this fracture; hence it rarely occurs 
under fifty. 
“ For from the different state of the bone, the same vio¬ 
lence which would produce dislocation in the adult, occa¬ 
sions fracture in old age.” Very slight injuries cause this 
accident. A person slipping from an elevated pavement, 
slips down on the carriage-way only a few inches in descent, 
and the muscles being off their guard, fracture takes place. 
A frequent cause is a slight fall upon the trochanter. The 
bone thus broken never has been known to unite by bony 
union, but the possibility may be allowed, for there may be 
fracture through the head, which does not separate the frac¬ 
tured ends, or the bone may be broken without its perios¬ 
teum, and the reflected ligament torn, or it may be broken 
obliquely; partly within and partly without the capsular 
ligament. The first cause why union does not regularly 
happen, is want of apposition in the fractured surface—this, 
being prevented by those powerful muscles which pass from, 
the pelvis to the thigh. The next reason is the want of pres¬ 
sure between the two broken surfaces, even when the length 
of the bone is preserved; for if the capsule be unbroken, it 
will be distended by synovia, and this distension will pre¬ 
vent the due apposition of the broken pieces. And when 
this fluid becomes absorbed, the inflammatory process has 
ceased, and ligamentous matter has been secreted. But the 
third and chief reason of want of union, seems to be, that 
the ossific action cannot take place from the inner fractured 
portion, because it receives blood only from the vessels of 
the ligamentum teres. Naturally the head and neck are 
supplied with blood by the periosteum of the cervix and. 
reflected membrane which covers it, and so when these are 
torn, we find no ossific, but merely a ligamentous deposits 
a& 
