1. Few kinds of luxation of the os femoris occur in practice more
rarely than this. Practitioners who have seen it, and those who,
on the authority of others, have described it, without having seen
it, have all given an unfavourable prognosis respecting it, for the
following reasons: 1st, on account of the inevitable rupture of the
round ligament: 2dly, on account of the distension, and even laceration
of the capsule, and of the compression and overstretching of the
nerves and blood-vessels: 3dly, on account of the great difficulty of
reduction. The following case will prove, that in all these respects,
the apprehensions of authors have been exaggerated, that the obstacles
to reduction arise less from the nature of the displacement, than from
the nature of the means employed to remedy it; and that, if properly
directed, art would here be as successful as in other cases.
CASE. (Collected by C***). About the close of the winter
which preceded the death of Desault, a porter was brought to the
Hotel-Dieu, in consequence of a fall which he had received about two
hours before, in the following manner. As he was carrying on his
shoulders a heavy burden, his foot slipped, while his leg and thigh
were directed backwards: he fell on his knee, his thigh maintaining
still the same direction; so that the conjoined weight of his own body
and of the burden which he carried, aided by the velocity of the fall,
forcing the head of the os femoris, which pointed at the time forward
and upward, against the distended capsule, lacerated it and drove the
articulating end through the opening. Continuing still to act, it
ruptured the ligament, which connects the extremity of the bone to the
articulating cavity, and forced the head in front of the os pubis,
where it could be easily felt.
At the moment of the fall, an acute pain was felt in the part; and the
power of moving the limb was suddenly lost; the patient was carried
home, where a surgeon who visited him, considered the accident as a
fracture of the neck of the os femoris, and sent him to the Hotel-Dieu,
to undergo the necessary treatment.
Desault having examined the parts, discovered, from the following
appearances, not a fracture, but a luxation upward and forward. The
limb was nearly an inch shorter[31] than natural; the point of the
foot was turned outwards; the thigh being in a state of painful
extension, could not be flexed on the body; adduction and abduction
were alike painful; the great trochanter, being more approximated than
usual to the anterior and superior spine of the os ilium, was also too
far forward; finally, the projecting head of the bone could be felt, as
I have already said, in the groin.
[31] A case of luxation of the head of the os femoris in a
forward direction, but differing in some respects from the above,
occurred lately in the Pennsylvania hospital under the care of Dr.
Physick. The doctor reduced this luxation in the amphitheatre, in
the presence of his class, by a process which was also somewhat
different from that adopted by Desault.
In the case of Desault’s patient the luxated limb was shorter than
the sound one: in that of Dr. Physick’s it was evidently longer.
This was no doubt owing to the head of the os femoris having, in
the former case, passed farther up towards the superior rim of the
os pubis than it had in the latter. In both cases the protuberance
formed by the head of the bone in the groin could be readily felt.
For the purpose of making counter-extension, Desault passed a strap
between the scrotum and the thigh of the sound side: Dr. Physick,
for the same purpose, passed the strap between the scrotum and
the affected thigh. He conceived that by this mode he could act
with more effect on the pelvis, and more effectually prevent the
acetabulum of the affected side from being drawn in any measure
downward by the extending forces. It would seem, that by making
counter-extension, in such a case, on the sound side, the pelvis
is made to rotate, so to speak, on its own axis, in the direction
in which the counter-extension is made. The necessary effect of
this rotation must be, a slight descent of the acetabulum of the
affected side. But to retain the acetabulum firmly up is the true
and only end of counter-extension. Dr. Physick appears therefore to
have availed himself of the greatest mechanical advantage of which
the situation of the parts admitted.
Again: Desault placed the strap on which extension was made just
above the ancle: Dr. Physick placed the strap intended for the same
purpose above the knee. His object in this was, to have the leg
free and unincumbered, in order that he might be able to use the
limb with more advantage, as a lever of the first kind, to assist
in moving the head of the os femoris towards the acetabulum. The
fulcrum of the lever into which the limb was thus converted, was a
strap passed round the affected thigh a few inches below the groin,
and drawn laterally with great force in a direction opposite to
that in which the bone was displaced.
In this case extension and counter-extension were made by means of
powerful sets of pullies. Notwithstanding this, these forces were
not alone sufficient to subdue the resistance of the muscles. The
reduction was not completed till muscular contraction had been
weakened, and the patient reduced almost to a state of syncope, by
the loss of nearly two quarts of blood. This copious evacuation,
co-operating with the fatigue which the muscles of the limb
necessarily sustained, in consequence of the powerful extension
to which they were for some time subjected by the action of the
pullies, overcame all resistance and the head of the bone was
finally replaced. To exhaust the energy of the resisting muscles by
forcible and permanent extension, and to weaken the action of the
system generally, by copious blood-letting, appear to be the two
most effectual modes of ensuring success in the reduction of all
obstinate cases of luxation.
Another point of difference between these two cases of luxation
remains yet to be mentioned. In Desault’s case the head of the os
femoris was, as he tells us, displaced in a direction “upward and
forward.” In Dr. Physick’s case, the direction of the displacement
was downward and forward. This was proved beyond all doubt, by the
circumstance of the affected limb being longer than the sound one.
TRANS.
The reduction was effected in the following manner. The patient being
laid on a firm table, spread with a mattress, a strap was fastened
above the ancle, for the purpose of extension; another, intended for
counter-extension was placed between the scrotum and the thigh of the
sound side, and brought up the back and front of the pelvis, along the
body, till it passed over the shoulder, where it was twisted together
and secured.
Extension was then begun, precisely in the direction in which the thigh
pointed; and, during the execution of it, a rotatory motion inwards
was given to the limb. At the expiration of a few minutes, the head of
the bone remaining almost immoveable, notwithstanding the efforts to
dislodge it, Desault directed extension to be discontinued, and, taking
hold of the thigh, moved it in every direction, with a view to enlarge
the opening in the capsule, the narrowness of which he suspected to be
the cause that prevented the reduction.
Extension was then resumed, and varied in every direction, while the
surgeon endeavoured to give assistance by pushing the head of the
bone forcibly downwards, with his thumbs, and the palms of his hands.
Useless efforts; the displaced bone remained stationary.
Desault ordering extension to be again discontinued, recommenced the
motions of the os femoris, and even increased their force, changing
them in every direction, for the purpose of lacerating the capsule.
After this, extension was again renewed, with better success than
before. Indeed, on the very first effort, the head resumed, of itself,
its natural situation, without any further assistance on the part of
the surgeon.
The sufferings of the patient ceased almost instantaneously; towards
evening a slight swelling appeared around the joint, over which
an emollient cataplasm was applied. On the day following, all the
unfavourable symptoms were gone, and in about a fortnight the patient
was able to return to his usual exercises, which, however, he was
directed to pursue, for some time, with moderation.
2. There are, in this case, two circumstances, on which the
practitioner should fix his attention, and which may throw great light
on the reduction of all luxations of the os femoris, as they will be
found applicable to most accidents of the kind. These are, 1st, The
narrowness of the opening in the capsule. 2dly, The inutility of the
motion or process of conformation, when that opening has been enlarged.
3. We formerly observed, when treating of luxations of the humerus,
that one of the obstacles to reduction was, the narrowness of the
opening in the capsule; the same circumstance occurs here. That
membrane, lacerated at the time when the head of the os femoris is
driven against it, is dilated sufficiently to let the head escape:
but, the edges of the lacerated membrane, coming together again, and
being thus drawn tight around the neck of the bone, retain it in that
position, and prevent the head from re-entering the acetabulum. Thus,
in a fracture, where one of the extremities of the bone is protruded
through the integuments, the opening in the skin, by closing tightly
round that extremity, sometimes prevents its reduction.
4. In such a case, what is the first and most obvious indication? It
is necessary to increase the extent of the opening in the capsule,
by moving the limb in every direction. Some persons have deemed it
impossible to tear this membrane anew. But, if we recollect, that the
neck of the os femoris, being placed between the edges of the opening,
must necessarily draw them asunder by the motions impressed on it, it
is easy to conceive, that the angles, where these edges unite, will
be torn, if the motions be carried to an inordinate degree: besides,
experience proves here, as well as with regard to the humerus, the
truth of the doctrine contended for. Are we to apprehend, as these same
persons will have it, that serious accidents may be produced by such
violent motions? Experience again answers in the negative. Nothing,
then, can be more certain, than that this observation, respecting the
opening in the capsule, is a great stride towards perfection in the
treatment of luxations in general, and particularly of that now under
consideration.
5. When this obstacle to reduction has been removed, it is then very
readily effected, and that without the process of conformation. Indeed
that process is almost always unnecessary. For what purpose should
it be employed? Is it to increase the effect of extension, and thus
disengage the head of the bone from the place which it accidentally
occupies? In this point of view, it is nothing but a very feeble force,
added to a very powerful one, which receives from it, therefore, but
little assistance: it is much better, if necessary, to augment the
extending forces themselves. Is it to push the head of the bone into
its cavity, after the extensions have dislodged it? It is to the
muscles, and not to the efforts of the surgeon, that the performance
of this office belongs. Indeed, the surgeon must act altogether in the
dark in this respect, as he cannot possibly ascertain the precise point
where the opening in the capsule exists: he may, therefore, even push
the head of the bone against a sound part of the capsule, and thus
himself create an obstacle to the reduction, which he is attempting to
favour.
6. The muscles, on the other hand, by their contraction, naturally draw
the head of the bone into its place, because the direction of their
fibres is such as obliges them to do it. The great art of managing
luxations, then, consists, in ascertaining clearly the obstacles that
prevent reduction, in removing them, and, then, committing the rest to
extension, and the powers of nature properly directed.