when severe bruise of the glutei has been inflicted without breach of
continuity in any part of the bone, and without displacement. In the
first stage of morbus coxarius, too, a somewhat similar appearance
and position of the limb is presented; there is lengthening, but then
there is also more or less wasting of the muscles, more mobility than
in the dislocation, and a marked history attached. Complicated cases
occasionally occur—as when a patient who has been labouring under
hip-joint disease, perhaps not in an aggravated form, falls heavily,
and on being lifted up is found to be incapable of moving the joint,
the limb at the same time being elongated, and having a distorted
appearance. An instance of this nature impressed strongly upon me the
great necessity for accurate diagnosis in the first instance, and
that such was to be acquired only by taking every circumstance into
consideration. A young man was engaged in cleaning a slaughter-house,
standing on two blocks of wood with his legs considerably apart. One of
the blocks suddenly slipped from under him, and he fell with his limbs
spread. He was carried home in great pain, and next day I was asked to
visit him. The limb was elongated, and the hip flattened; the joint was
stiff, and attempts at motion produced great pain; but by perseverance
the limb could be put in various positions, and the trochanter was not
so much depressed as in luxation downwards. By cross-examination it
was discovered that the patient had halted in walking for many weeks
previously, had felt as if the limb was longer than the other, had pain
in the groin and knee; in fact, morbus coxarius had been advancing, and
the pain, immobility, and greater elongation had been occasioned by
the fall, causing violent excitement of the morbid action previously
in progress. Dreadful consequences must have resulted from mistake
in diagnosis and practice founded upon it. I have observed, in other
cases, great and rapid elongation of the limb in consequence of injury
to the hip-joint previously diseased; and I have known instances in
which persevering and forcible efforts were made to reduce the supposed
luxation.
The reduction is in many cases difficult. In young and muscular
individuals, after the lapse of some hours, when reaction has occurred,
the muscles are rigidly contracted, and the head of the bone is not
easily dislodged. Extension, made to a certain extent and continued, is
not so useful or essential here as in other forms of luxation of this
joint. Adduction, carrying the injured thigh quickly and forcibly over
the other, is generally successful; and the reduction is favoured by at
the same time raising up the neck of the bone, by means of a towel or
wooden roller passed under the upper part of the thigh. There is also
no such advantage from rotating the bone as in other luxations. It is
very often necessary, even in recent cases, to adopt measures to weaken
muscular exertions; and again, in cases of three weeks’ duration, I
have found no difficulty.
The head of the bone, when dislodged from the foramen obturatorium,
may slip past the cotyloid cavity, for it is impossible to regulate
its direction; it comes to be acted upon by muscles which have been
displaced, some being compressed and partially paralysed, whilst
others are excited; they have been put out of their usual condition
and relation, and act irregularly. The head of the bone may, from this
cause, get into the sacro-ischiatic notch. This has occurred to me; but
I have found no difficulty in removing it from thence, and effecting
reduction satisfactorily.
Displacement into the sacro-ischiatic notch is attended with great and
remarkable inversion of the toes, slight shortening of the limb, the
prominence of the head of the bone felt under the gluteus maximus.
It is the least common form of luxation. Reduction is attempted by
extension and rotation outwards, at the same time pulling the head of
the bone towards the acetabulum by means of a towel passed under the
thigh.
Luxation of the head of the femur on the pubes is perhaps more frequent
than any other, excepting that on the dorsum of the ilium. The limb
is not much shortened, the toes are everted, the trochanter major is
depressed, and nearer to the anterior superior spinous process of the
ilium than usually, and the head of the bone is both seen and felt
prominent in the groin. Much pain, swelling, and sometimes more or
less paralysis of the limb, are occasioned by this displacement; the
femoral artery and vein lie immediately interior to the head of the
bone, and are compressed, and the crural nerves are stretched over it.
In attempting reduction, rotation inwards should be employed during
extension, accompanied with endeavours to lift the upper part of the
bone towards the acetabulum.
[_Congenital Luxation of the Hip-joint_ is sometimes met with, though
on the whole a very rare affection, especially in this country.
Female children are more apt to suffer from it than males, and it is
also more common in such as are of a scrofulous habit than in such
as are endowed with a good constitution. Of twenty-six cases of this
malformation observed by Dupuytren, not above three or four were males;
a disproportion probably not altogether dependent upon chance. The
immediate causes of this variety of displacement are, first, shortness,
total absence, or extreme obliquity of the neck of the thigh-bone;
secondly, partial or entire obliteration of the cotyloid cavity;
thirdly, deficiency, extraordinary elongation, or complete absence of
the round ligament.
The characters of this malformation are, shortening of the affected
limb, unnatural projection of the great trochanter, ascent of the head
of the femur into the iliac fossa, inversion of the leg, and obliquity
of the pelvis. The motions of the joint, particularly those of
abduction and rotation, are constrained and imperfect; the muscles of
the upper part of the thigh are retracted, or drawn towards the iliac
crest; the limb is thin, wasted, and out of all proportion to the rest
of the body; the tuberosity of the ischium is almost uncovered, and
consequently unusually prominent; the upper part of the trunk is thrown
backwards, while the lumbar portion of the spine projects forwards,
being concave behind; the pubes is placed almost horizontally on the
thighs; and the ball of the foot alone touches the ground when the
child stands erect.
In the recumbent posture, when the weight of the trunk is taken off,
and the muscles are relaxed, most of the symptoms of the luxation
disappear, and the limb may be shortened or elongated at pleasure. In
walking, the body is inclined towards the sound side, and the head
of the dislocated bone sinks towards the cotyloid cavity by its own
weight. As age advances, the limb becomes shorter, in consequence of
the femur ascending higher and higher on the ilium; the obliquity of
the pelvis augments; and the power of locomotion, already so much
impaired, is completely destroyed.
Congenital dislocation of the hip-joint may, in general, be easily
distinguished from other accidents or maladies, by the affection being
observed at or soon after birth, by the obliquity of one or both
thighs; by the absence of pain, swelling, and ulceration; by the head
of the femur being displaced without any external violence; and by the
ability of the surgeon to lengthen or shorten the limb at pleasure. In
disease of the hip there is always more or less pain, with a feverish
state of the system, and gradual failure of the strength; the parts
about the joint are tense and swollen; the limb, at first somewhat
lengthened, becomes afterwards shortened, and cannot be extended
without the greatest suffering; and the motions of the ileo-femoral
articulation are forever impaired.
The _post-mortem_ appearances vary. In general the cotyloid cavity
is partially obliterated, or entirely deficient, being replaced by a
small, irregular, osseous prominence, devoid of cartilage and synovial
membrane; the head of the femur, often flattened at its antero-internal
aspect, rests in a sort of superficial fossa on the dorsal surface of
the ilium; the round ligament, as was before remarked, is elongated,
partially worn away, or even altogether absent; and the surrounding
muscles are either atrophied, transformed into a species of yellowish
fibrous tissue, or preternaturally developed. In the latter case, their
action is preserved; in the former, it is very much restricted, or
totally impeded.
The prognosis is always unfavourable, as the patient dies either young,
or remains permanently lame and deformed.
The treatment can be only palliative; and as the weight of the trunk
is the main agent in aggravating the displacement, repose is obviously
indicated: but it is not necessary to confine the patient to the
recumbent posture; since, in the act of sitting, there is no stress
on the femur, the body resting principally on the tuberosities of the
ischia. Dupuytren thought favourably of the cold bath: it should be
strongly impregnated with salt, and the body immersed for three or four
minutes at a time. He was also in the habit of using a well-stuffed
belt, about four inches wide, for surrounding the pelvis and fixing the
great trochanters; thus binding the ill-adapted parts together, keeping
them at the same height, and preventing that continued motion to which
they are otherwise so much exposed.]
_Luxation of the Bones of the Leg._—separation of them from the end of
the femur—seldom occurs. It can be the effect only of great violence
and great laceration. Most frequently fracture is concomitant, perhaps
with wound; and such accidents require amputation, either primarily
or secondarily. Subluxation, from laceration of the internal lateral
ligament, is not so unfrequent. It is most common in females, the
natural conformation of their thigh-bones disposing them to bend
inwards; and from falling awkwardly, particularly if carrying a weight,
the ligament is apt to give way. The limb is pained, deformed, and
unable to support the body, and swelling to a considerable extent soon
follows. Reduction is extremely easy; and the parts are retained in
site by the application of a wooden splint, to either the outer or
the posterior side of the joint, the leg and foot being previously
bandaged. The joint remains long weak, and never recovers entirely; a
sustaining apparatus, fitted on the outside, retained by straps, and
with a joint opposite to the articulation, is required to be constantly
worn when the patient wishes to use the limb.
_Luxation of the Patella_ is spoken of by some as common. Others of
much experience have not met with a single instance of it. I have
never seen this accident. The bone, it is said, may be displaced
outwards, inwards, or upwards. The first form of luxation is the
most frequent, and is caused by a severe fall, with the foot twisted
outwards and the knee inwards. Displacement inwards is produced by
direct violence applied to the outer part of the bone, or by the foot
being turned inwards in a fall. Displacement upwards can occur only
after laceration of the ligamentum patellæ, the bone being then drawn
up by the unresisted action of the muscles on the fore part of the
thigh. In dislocation outwards, the bone has been found “resting with
its inner edge upon the outer surface of the condyle, the fore part
facing obliquely forwards and inwards.” In this last form of accident,
sudden, forcible, and complete flexion of the limb is said to produce
immediate reduction. In dislocation outwards or inwards, the muscles
are to be relaxed by raising the heel, extending the limb, flexing the
thigh, and then forcing the bone to its proper site by manipulation. In
the dislocation upwards with rupture, the limb is to be kept extended
and raised, and the bone is brought as nearly into its place as
possible by bandaging. When a peculiar laxity of the apparatus about
the joint exists, whether as a cause of luxation or not, the support of
a well-made knee-cap is required.
As formerly stated, _Dislocation of the Ankle_ cannot take place
inwards or outwards, without fracture of the end of the tibia or of the
fibula, either above the articulation, or where they project by the
sides of the astragalus for the greater security and strength of the
joint. Subluxation, however, or sprain, may occur without injury of
the bones: in this accident, should the parts not have spontaneously
resumed their original situation, no difficulty is experienced
in putting them to rights; simple manipulation is sufficient.
Occasionally, the foot is luxated forwards, by force applied either
to the heel or to the fore part of the leg whilst the limb is fixed.
The heel is shortened, the foot elongated; indeed, the marks of the
injury are so distinct, that comparison of the limbs is sufficient for
diagnosis. Luxation may also take place backwards; and in this case
the heel is elongated and the foot shortened. In these accidents it
is not unfrequently found that one or other malleolus has given way,
or that the lower end of the tibia is split. Reduction is sometimes
difficult. Extension is to be made by grasping the foot and pulling
whilst the limb is fixed, at the same time making pressure either
backwards or forwards, as may be required. To retain the bones in their
proper situations, it is always necessary, at least prudent, to apply a
paste-board or leathern splint to each side of the limb, particularly
when fracture of the malleoli is conjoined.
_Displacement of the Bones of the Tarsus_ may result from great force;
for example, when the foot is squeezed under a heavy weight, one or
more bones may escape from their connections, and project. Reduction of
such displacement is exceedingly difficult at any period, and becomes
almost impossible when inflammatory action is allowed to supervene
previously to attempts being made. The astragalus is sometimes pushed
out of its place; though it is difficult to conceive how, to a bone so
hid and so firmly connected, such force should be applied as to cause
protrusion of it from its natural situation. It has been found lying
on the dorsum of the foot, causing swelling, lameness, great pain,
shortening and deformity of the limb; and the shape of the bone can, in
such circumstances, be distinctly felt and seen through the integument.
As already observed, reduction is almost impracticable, and, with
the view of remedying deformity, it has been proposed to cut out the
displaced bone; but as to the expediency of such practice I can give no
opinion.
I have seen but one instance of displacement of this bone backwards,
and most probably another will never occur to me. A heavy young man,
in a state of utter intoxication, fell backwards down a stair, and in
the fall his foot became entangled in the railing. The astragalus was
found lying betwixt the back of the tibia and the tendo-Achillis, its
upper articulating surface facing forwards, the lower in contact with
the tendon. All attempts to reduce the bone proved fruitless. Violent
inflammatory action followed, but was reduced by active measures; and
the limb ultimately became very useful; in fact, though not till after
many months, little lameness or shortening was perceptible.
By _Sprain_ is understood subluxation or partial displacement of a
joint, with stretching, and more or less laceration of the articulating
apparatus—ligaments, tendons, sheaths, and bursæ, being all involved
in the injury. Sometimes small portions of the processes of bone are
separated, being torn away, attached to ligament or tendon. All joints,
both large and small, are liable to the accident. In the proximal,
or in the middle joints of the finger, for example, one or other
lateral ligament is stretched or torn; the finger is twisted to a
side; the joint is swelled; and this swelling, with pain, is of long
continuance, perhaps increased by repeated twists, or by imprudent
use of the joint. The elbow and shoulder are frequently sprained, as
also the hip and knee; but the injury most frequently occurs in the
wrist and ankle. It is generally occasioned by a fall, the foot or
hand coming awkwardly to the ground, the muscles being at the time
relaxed and unprepared; by over-exertion in lifting heavy weights; by
entanglement and twisting of the limb, &c. The ankle is often sprained
by what is called a false step; the fore part of the foot comes in
contact with an obstacle unexpectedly, the foot is twisted under the
limb, the weight of the body is thrown on the apparatus of one side
of the joint, and this is in consequence immoderately and unnaturally
stretched. Violent pain immediately occurs, and the patient is sick and
faint. Discoloration and rapid swelling take place from extravasation
of blood into the cellular tissue, into the sheaths of the tendons,
and perhaps into the synovial pouches, in consequence of laceration of
the bloodvessels. Effusion of serum and increased secretion of synovia
afterwards occur, from incited action of the vessels. Thus the joint is
deformed. Attentive examination is required to guard against mistakes;
the existence or non-existence either of displacement or of fracture
must be at once ascertained by determined and perfect manipulation; the
parts must be pressed and moved, to such an extent as is necessary,
notwithstanding the pain thereby occasioned, and notwithstanding the
resistance afforded by the patient. It has been already stated that
luxation of the wrist is not uncommon; that separation of the one bone
of the forearm from the other, and transverse fracture or splitting of
the radius, at the distal extremity, are accidents by no means rare.
Great disfiguration follows simple sprain, much swelling taking place
on the fore part of the limb from effusion under the fascia, and there
is also much serous and bloody infiltration of the cellular tissue on
the back of the hand and forearm. In the ankle, the ends of the bones
must be carefully examined, and also the fibula in its whole extent,
that the existence or non-existence of fracture may be ascertained, and
that the surgeon may be guided to a correct mode of treatment. If the
joint is not put at rest immediately, the extravasation is increased,
and, in consequence, the pain and inflammatory swelling also; and parts
of the joint at first not involved in the injury may thus be made to
suffer. Many diseases of synovial membrane and articulating cartilages
are attributable, and can be traced, to badly managed sprains; and
in some constitutions, but slight injury, combined with a little bad
treatment, suffices to destroy a joint. When, the case is well managed,
the pain is never great, and soon abates; the swelling after a few days
slackens; the discoloration becomes greater, the serum being absorbed,
and the effused blood shining through the skin; the integuments
appear green, blue, red, purple—these hues either being present all
at the same time, or occurring successively; the discoloration often
extends far from the joint. The mobility and strength of the joint are
recovered gradually.
Perhaps no injury is more frequently mismanaged, by those both in and
out of the profession. Every old woman thinks she can cure a sprain;
most absurd and hurtful measures are resorted to; the injured parts
are kept in motion; cold lotions and cold effusions are employed, and
at the same time stimulating frictions: probably attempts are made,
either by leeching or by puncturing, to extract the effused blood; and
many similar follies are committed. The proper treatment certainly
appears to consist principally in absolute rest and position. If there
is any displacement it must be rectified immediately. If there is any
fracture; or if there is a tendency to redisplacement after reduction;
or if the patient is restless either from folly or from insensibility,
as when the head has been injured by the accident, when the patient
is under the influence of strong liquors, or when he labours under
delirium tremens,—a splint or splints must be applied to secure
immobility of the parts, at the same time without such compression as
may interfere with swelling from effusion; the effusion is a salutary
process, and should be encouraged, not repressed. By absolute rest
and elevation of the limb, the extent of the swelling is limited, and
inflammation warded off. Fomentations, properly employed, afford much
relief; at first they probably encourage the serous effusion. The
integuments soon become relaxed, during the regular use of fomentation,
and tension and vascular action subside, as also pain. The swelling
then abates, and is no longer hard; it pits on pressure, and the skin
has a puckered appearance. Then gentle friction becomes advantageous,
and uniform support should be afforded by the application of a flannel
roller. The longer the limb is disused, the more perfect and rapid is
the recovery, provided the rest of the cure be properly conducted. In
general nothing more than what has been stated is required. But if
the limb be moved, or stimulated in any way, early, then necessity
will arise for antiphlogistic measures—perhaps venesection, certainly
copious and repeated abstraction of blood by leeches, accompanied with
fomentations, and the internal exhibition of antimonials, purgatives,
&c. When such is the case the cure is tedious, the joint long remains
swelled and stiff, the patient is lame and incapable of exertion.
Leeching or puncturing at an early period, with the view of allowing
extravasated blood to escape, is useless and hurtful. The effused and
coagulated blood cannot be evacuated, and suppuration, followed by
destruction of the cellular tissue, has often been the consequence of
such ill-advised proceedings. Friction with stimulating liniments,
or even simple friction, at an early period, is also hurtful, as
tending to excite vascular action, and to convert simple swelling
into inflammatory. The application of cold at any period is of little
use, and ought certainly to be avoided immediately after the injury,
as adding to the sufferings of the patient, and interfering with the
natural processes which have commenced for the reparation of that
injury.
In limbs that have remained stiff after severe and mismanaged sprain,
the dashing of water, either cold or tepid, has been strongly
recommended. The practice is not ineffectual; the vessels of the
surface are excited, perhaps as by other friction, and perhaps by
the reaction which follows the chill. But the limb is apt to become
rheumatic; and, on this account, the state of matters will not be
improved by this proceeding, unless it be resorted to with proper
precautions.
In severe sprains there is reason to think that sometimes even the
tendons yield a little—that many of the fibres give way, and that
thus the tendon is thinned and elongated. Such injury happens often
in horses, in what is called breaking down. In them the tendon is
occasionally snapped entirely through, and the ends widely separated.
The same occurs in the human subject. Separation of the muscular
fibres, however, is rare; laceration of the tendon itself, or
separation of the tendon from the muscle, is more common. The yielding
of the broad tendons on the upper and fore, lateral and under parts
of the abdomen, affords an example of laceration of tendinous fibre
from violent exertion. The tendons of the limbs are more frequently
injured, and in the lower oftener than in the upper. I have more than
once seen the tendon of the biceps torn in violent exertion. In the
thigh, too, some fibres occasionally give way from a similar cause.
The supra-muscular fascia in the arm and thigh is apt to give way at
one or more points during powerful exertion of the muscles, causing
deformity by protrusion of muscle through the torn space. But it is
in the apparatus for extending the foot, and raising the weight of
the body, that laceration of tendon most frequently takes place.
The accident is uncommon till after the middle period of life, when
the body has become heavier, when muscular exertions have been less
habitually practised, and when the fibre has grown more rigid. The
person in raising himself over some slight obstruction in walking,
perhaps attempting to pass a small ditch or stile, suddenly “breaks
down.” Or in dancing,—an amusement which he has long discontinued—a
sudden snap is felt, with immediate lameness and slight pain in the
back of the limb; swelling and discoloration follow; and these symptoms
and signs vary in intensity according to the extent of the injury.
Laceration may have been slight; the pain, swelling, and lameness are
proportional, and at first an inconsiderable void can be felt at the
upper part of the tendinous termination of the gastrocnemii. Sometimes
no change is perceptible, and in such cases some have been of opinion
that the slender tendon of the plantaris has given way and caused
the lameness; but this is doubtful, and it seems more probable that
stretching and yielding has taken place in some part of the tendon
of the gastrocnemii, which had been in powerful action—probably,
the tendinous and muscular tissues have been separated to a slight
extent. Occasionally the tendo-Achillis is found completely torn
through, and its upper end retracted; in such cases a large space is
occasioned at the injured part, when the knee is extended and the
foot bent. Sometimes the tendo-Achillis is cut through; I have seen
both completely divided in the same individual—he received a wound
by a cutlass across the back of both limbs, while endeavouring to
escape from the mate of a vessel, in which he had been stealing. In
rupture without breach of surface, the torn bloodvessels pour out their
contents into the cellular tissue to a considerable extent, and if a
proper mode of cure be not adopted immediately, inflammation quickly
supervenes; and this is apt to terminate very unfavourably in the
infiltrated tissue.