CHAPTER VI

INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH

FRACTURES OF PELVIS: _Varieties_--INJURIES IN REGION OF HIP: Surgical anatomy; _Fracture of head of femur_; _Fracture of neck of femur_; _Fracture below lesser trochanter_--DISLOCATION OF HIP: _Varieties_--Sprains--Contusions--FRACTURE OF SHAFT OF FEMUR.

FRACTURE OF THE PELVIS

For descriptive as well as for practical purposes, it is useful to divide fractures of the pelvis into those that involve the integrity of the pelvic girdle as a whole, and those confined to individual bones.

In all, the prognosis depends upon the severity of the visceral lesions which so frequently complicate these injuries, rather than upon the fractures themselves.

#Fractures implicating the pelvic girdle as a whole# usually result from severe crushing forms of violence, such as the fall of a mass of coal or a pile of timber, or the passage of a heavy wheel over the pelvis. The force may act in the transverse axis of the pelvis, or in its antero-posterior axis. The pelvic viscera may be lacerated by the tearing asunder of the bones, or perforated by sharp fragments, or they may be ruptured by the same violence as that causing the fracture.

As a rule, more than one part of the pelvis is broken, the situation of the lesions varying in different cases.

_Separation of the pubic symphysis_ may result from violence inflicted on the fork, as in coming down forcibly on the pommel of a saddle; from forcible abduction of the thighs; or it may happen during child-birth. In some cases the two pubic bones at once come into apposition again, and there is no permanent displacement, the only evidence of the injury being localised pain in the region of the symphysis elicited on making pressure over any part of the pelvis. In other cases the pubic bones overlap one another, and the membranous portion of the urethra, or the bladder wall, is liable to be torn. The displaced bones may be palpated through the skin, or by vaginal or rectal examination.

The _pubic portion_ of the pelvic ring is the most common seat of fracture. The bone gives way at its weakest points--namely, through the superior (horizontal) ramus of the pubes just in front of the ilio-pectineal eminence, and at the lower part of the inferior (descending) ramus (Fig. 55). The intervening fragment of bone is isolated, and may be displaced. These fractures are frequently bilateral, and are often associated with separation of the sacro-iliac joint, with longitudinal fracture of the sacrum (Fig. 55), or with other fractures of the pelvic-bones.

Injuries of the membranous urethra and bladder are frequent complications, less commonly the rectum, the vagina, or the iliac blood vessels are damaged.

Localised tenderness at the seat of fracture, pain referred to that point on pressing together or separating the iliac crests, and mobility of the fragments with crepitus, are usually present. The fragments may sometimes be felt on rectal or vaginal examination. In all cases shock is a prominent feature.

_The lateral and posterior aspects_ of the pelvic ring may be implicated either in association with pubic fractures or independently. Thus a fracture of the iliac bone may run into the greater sciatic notch; or a vertical fracture of the sacrum or separation of the sacro-iliac joint may break the continuity of the pelvic brim. In rare cases these injuries are accompanied by damage to the intestine, the rectum, the sacral nerves, or the iliac blood vessels.

_Treatment._--It is of importance that the patient be moved and handled with care lest fragments become displaced and injure the viscera. He should be put to bed on a firm mattress, which may be made in three pieces, for convenience in using the bed-pan and for the prevention of bed-sores.

Before the treatment of the fracture is commenced, the surgeon must satisfy himself, by the use of the catheter and by other means, that the urethra and bladder are intact. Should these or any other of the pelvic viscera be damaged, such injuries must first receive attention.

The treatment of the fracture itself consists in adjusting the fragments, as far as possible by manipulation, applying a firm binder or many-tailed bandage round the pelvis, and fixing the knees together by a bandage (Fig. 57).

When there is displacement of fragments extension should be applied to both legs, with the limbs abducted and steadied by sand-bags.

Compound fractures, being commonly associated with extravasation of urine, are liable to infective complications. Loose fragments should be removed, as they are prone to undergo necrosis.

The patient is confined to bed for six or eight weeks, and it may be several weeks more before he is able to resume active employment.

The #acetabulum# may be fractured by force transmitted through the femur, usually from a fall on the great trochanter, less frequently from a fall on the feet or other form of violence. It may merely be fissured, or the head of the femur may be forcibly driven through its floor into the pelvic cavity, either by fracturing the bone or, in young subjects, by bursting asunder the cartilaginous junction of the constituent bones. When the femoral head penetrates into the pelvis--the _central dislocation of the hip_ of German writers--the condition simulates a fracture of the neck of the femur, but the trochanteric region is more depressed and the trochanter lies nearer the middle line. The limb is shortened, and movements of the joint are painful and restricted, especially medial rotation. In some cases there is pain along the course of the obturator nerve.

On rectal or vaginal examination there is localised tenderness over the pelvic aspect of the acetabulum, and in some cases a convex projection, or even crepitating fragments can be detected. The diagnosis is completed by an X-ray picture.

When the head of the femur penetrates the acetabulum, reduction should be attempted by traction and manipulation. The pelvis is held rigid, and the thigh is flexed and forcibly adducted, while the medial side of the thigh rests against a firm sand-bag; the femoral head is thus lifted out of the pelvis. In a recent injury the amount of force required is relatively slight. The head is kept in its corrected position by extension.

Fracture of the _upper and back part of the rim_ of the acetabulum may accompany or simulate dorsal dislocation of the hip. Crepitus may be present in addition to the symptoms of dislocation, and after reduction the displacement is easily reproduced. The treatment is by extension with the limb adducted.

#Fracture of Individual Bones of the Pelvis.#--_Ilium._--The expanded portion of the iliac bone is often broken by direct violence, the detached fragments varying greatly in size and position (Fig. 56).

The whole or part of the _crest_ may be separated by similar forms of violence.

When the fracture implicates the _ala_ of the bone, it usually starts at the triangular prominence near the middle of the crest, and runs backwards or forwards, passing for a variable distance into the iliac fossa. The displaced fragment can sometimes be palpated and made to move when the muscles attached to it are relaxed. This is done by flexing the thighs and bending the body forward and towards the affected side. Pain and crepitus may be elicited on making this examination.

These fractures are treated by applying a roller bandage or broad strips of adhesive plaster over the seat of fracture, and by placing the patient in such a position as will relax the muscles attached to the displaced fragment--in the case of the iliac spine by flexing the thigh upon the pelvis; in the case of the crest or ala by raising the shoulders. Union takes place in three or four weeks.

In young persons, the _anterior superior spine_ has been torn off and displaced downwards by powerful contraction of the sartorius muscle; and the _anterior inferior spine_ by strong traction on the ilio-femoral or [inverted Y]-shaped ligament. These injuries are best treated by fixing the displaced fragment in position by a peg or silver wire sutures and relaxing the muscles acting on it.

Fracture of the _ischium_ alone is rare. It results from a fall on the buttocks, the entire bone or only the tuberosity being broken. There is little or no displacement, and the diagnosis is made by external manipulation and by examination through the rectum or vagina.

A longitudinal fracture of the _sacrum_ may implicate the posterior part of the pelvic ring, as has already been mentioned. In rare cases the lower half of the bone is broken _transversely_ from a fall or blow, and the lower fragment is bent forward so that it projects into the pelvis and may press upon or tear the rectum, or the sacral nerves may be damaged, and partial paralysis of the lower limbs, bladder, or rectum result. These fractures are frequently comminuted and compound, and the soft parts may be so severely bruised and lacerated that sloughing follows. On rectal examination the lower segment of the bone can be felt, and on manipulating it pain and crepitus may be elicited.

Fracture of the _coccyx_ may be due to a direct blow, or may occur during parturition. As a result of this injury the patient may have severe pain on sitting or walking, and during defecation. The loose fragment can be palpated on rectal examination. There is considerable difficulty in keeping the fragment in position, and if it projects towards the rectum it should be removed. If the lower fragment unites at an angle so as to cause pressure on the rectum, it gives rise to the symptoms of _coccydynia_, which may call for excision.

INJURIES IN THE REGION OF THE HIP

These include the various fractures of the upper end of the femur; dislocation and sprain of the hip-joint; and contusion of the hip.

#Surgical Anatomy.#--The strength of the hip-joint depends primarily on its osseous elements--the rounded head of the femur filling the deep socket of the acetabulum, to the bottom of which it is attached through the medium of the ligamentum teres. The edge of the acetabulum is specially strong above and behind, while at its lower margin there is a gap, bridged over by the labrum glenoidale (cotyloid ligament).

In relation to fractures of the upper end of the femur, it is to be borne in mind that as the antero-posterior diameter of the neck is less than that of the shaft, and as a considerable portion of the great trochanter lies behind the junction of the neck with the shaft, the greater part of any strain put upon the upper end of the femur is borne by the neck of the bone and not by the trochanter. The head and neck of the femur are nourished chiefly by the thick, vascular periosteum, and through certain strong fibrous bands reflected from the attachment of the capsule--the retinacular or cervical ligaments of Stanley. The integrity of these ligaments plays an important part in determining union in fractures of the neck of the femur, both by keeping the fragments in position and by maintaining the blood-supply to the short fragment. Whether it be true or not that an alteration in the angle of the femoral neck takes place with advancing years, it is generally recognised that this change is of no importance in relation to fractures in this region.

The articular capsule of the hip is of exceptional strength. It is attached above to the entire circumference of the acetabulum, and below to the neck of the femur in such a way that while the whole of the anterior and inferior aspects of the neck lies within its attachment, only the inner half of the posterior and superior aspects is intra-capsular. The capsule is augmented by several accessory bands, the most important of which is the _ilio-femoral or [inverted Y]-shaped ligament_ of Bigelow, which passes from the anterior inferior iliac spine to the anterior inter-trochanteric line, its fasciculi being specially thick towards the upper and lower ends of this ridge. The medial limb of this ligament limits extension of the thigh, while the lateral limits eversion and adduction. The weakest part of the capsular ligament lies opposite the lower and back part of the joint.

The hip-joint is surrounded by muscles which contribute to its strength, the most important from the surgical point of view being the obturator internus, which plays an important part in certain dislocations, and the ilio-psoas, which influences the attitude of the limb in various lesions in this region.

Except in thin subjects, the constituent elements of the hip-joint cannot be palpated through the skin. A line drawn vertically downwards from the middle of Poupart's ligament passes over the centre of the joint, which in adults lies on the same level as the tip of the great trochanter. In children it is somewhat higher.

For purposes of clinical diagnosis it is necessary to locate certain bony prominences, the most important being--(1) The _anterior superior iliac spine_, which is most readily recognised by running the fingers along Poupart's ligament towards it. (2) The _ischial tuberosity_, which in the extended position of the limb is overlapped by the lower margin of the gluteus maximus muscle, and is therefore not easily located with precision. By flexing the limb and making pressure from below upwards in the gluteal fold, the smooth, rounded prominence can usually be detected. (3) The quadrilateral _great trochanter_ is readily recognised on the lateral aspect of the hip. Its highest point or _tip_ can best be felt by pressing over the gluteal muscles from above downwards.

_Clinical Tests._--If a line is drawn from the anterior superior iliac spine to the most prominent part of the ischial tuberosity, it just touches the tip of the great trochanter. This is known as _Nelaton's line_ (Fig. 58).

_Bryant's test_ (Fig. 59) is applied with the patient lying on his back, and consists in dropping a perpendicular AB from the anterior superior iliac spine, and drawing a line CD from the tip of the great trochanter to intersect the perpendicular at right angles. This is done on both sides of the body, and the length of the lines CD compared. Shortening on one side indicates an upward displacement of the trochanter, lengthening a downward displacement. The third side AC of the triangle indicates the distance between the anterior spine and the tip of the trochanter.

_Chiene's test_, which is simpler than either of these, consists in applying a strip of lead or tape across the front of the body at the level of the anterior superior iliac spines, and another touching the tips of the two trochanters. Any want of parallelism in these lines indicates a change in the position of one or other trochanter.

FRACTURE OF THE UPPER END OF THE FEMUR

The fractures of the upper end of the femur that are liable to be confused with one another and with dislocations of the hip, include fractures of the head, the neck, the trochanters, and separation of the upper epiphyses, and fracture of the shaft just below the trochanters.

Fracture of the #head of the femur# is rare, and is usually a complication of backward dislocation of the hip. It takes the form of a split of the articular surface caused by impact against the edge of the acetabulum, and is analogous to the indentation fracture of the head of the humerus, which may accompany dislocation of the shoulder.

The #epiphysis of the head#, which lies entirely within the capsule of the joint (Fig. 60), is occasionally separated, and the symptoms closely simulate those of fracture of the narrow part of the neck. If the condition is overlooked or imperfectly treated, it may in course of time be followed by coxa vara.

FRACTURE OF THE NECK

It has long been customary to divide fractures of the neck of the femur into two groups--"intra-" and "extra-capsular"; but as in a considerable proportion of cases the line of fracture falls partly within and partly without the capsule, this classification is wanting in accuracy. It is more correct to divide these fractures into (1) those occurring _through the narrow part of the neck_, which are nearly always purely intra-capsular; and (2) those occurring _through the base of the neck_ in which the line of fracture lies inside the capsule in front, but outside of it behind.

It is of considerable importance to distinguish between fractures in these two positions. The first group occurs almost exclusively in old persons as a result of slight forms of indirect violence, and it is liable, on account of the feeble vascular supply to the upper fragment, to be followed by absorption of the neck, which delays or may even entirely prevent union (Fig. 61). The second group usually occurs in robust adults, and results from severe forms of violence applied to the trochanter. In this group firm osseous union usually takes place.

#Fracture of the Narrow Part of the Neck# or #Intra-capsular Fracture#.--This fracture is most frequently met with in elderly persons, especially women, and is usually produced by comparatively slight forms of indirect violence--such, for example, as result from the foot catching on the edge of a carpet, a stumble in walking, or missing a step in going downstairs.

The line of fracture, which is usually transverse but may be oblique or irregular, lies for the most part within the capsule, and the posterior part of the neck is more comminuted than the anterior. The distal fragment, which includes the base of the neck, the trochanters, and the shaft, is usually displaced upward and rotated laterally. If the periosteum and the retinacular ligaments remain intact, displacement is prevented and union favoured.

Impaction is less common than in fracture through the base of the neck; it usually results from the patient falling on the trochanter, the distal fragment being driven as a wedge into the proximal (Fig. 62).

_Clinical Features._--In non-impacted cases the limb is at once rendered useless, and the patient is unable to rise. There is pain and tenderness in the region of the hip on making the slightest movement; and a specially tender spot may be localised, indicating the seat of fracture.

On placing the pelvis as square as possible, and comparing the measurements of the limbs from the anterior superior spine to the medial malleolus, shortening of the injured limb to the extent of from 1 to 3 inches may be found. On applying Nelaton's, Bryant's, or Chiene's test, the tip of the great trochanter will be found elevated. It is also farther back and less prominent than normal.

The whole limb is usually everted to a greater or less degree, and is slightly abducted. In some cases, when the impaction is of the anterior portion of the neck, the limb is inverted. On comparing the ilio-tibial band of the fascia lata on the two sides, it is found to be relaxed on the side of the injury.

The violence being as a rule indirect, there is at first little or no discoloration in the vicinity of the hip, but this may appear a few days later.

Crepitus is not a constant sign, and should not be sought for, as the necessary manipulations are liable to disengage the fragments and to increase the deformity. For the same reason rotatory movements are to be avoided.

In all cases in which the diagnosis is uncertain, the patient should be put to bed, and treated as for a fracture. In the course of a few days it is nearly always possible to make an accurate diagnosis.

In examining an old person who has sustained an injury in the region of the hip, it should be borne in mind that the limb may be shortened and everted as a result of arthritis deformans, and that the symptoms of that disease may simulate those of fracture. In arthritis deformans, however, the ilio-tibial band of the fascia lata is not relaxed as it is in fracture.

In some cases, and particularly in those in which the periosteum of the neck and the retinacular ligaments remain intact, the shortening does not become apparent till a few days after the accident. As the other symptoms are correspondingly obscure, the condition is apt to be mistaken for a bruise. In all doubtful cases the part should be examined from day to day, and, if possible, the X-rays should be used.

In _impacted_ cases the signs of fracture are often obscure, and the patient may even be able to walk after the accident. The skin over the trochanter is generally discoloured from bruising. Eversion is usually present, but there may be little shortening. Crepitus is absent. In old people it is never advisable to undo impaction, as the interlocking of the bones favours the occurrence of osseous union.

_Prognosis._--A fracture of the neck of the femur in an old person is always attended with danger to life, a considerable proportion of the patients dying within a few weeks or months of the accident from causes associated with it. In some cases the mental and physical shock so far diminishes the vitality of the patient that death ensues within a few days. It is possible that fat embolism may account for death in some of the more rapidly fatal cases. In others, the continued dorsal position induces hypostatic congestion of the lungs, or, owing to the difficulties of nursing, bed-sores may form and death result from absorption of toxins. Frequently the prolonged confinement to bed, the continuous pain, and the natural impairment of appetite wear out the strength. In many cases the patient becomes peevish, irritable, or mentally weak.

Osseous union is the exception in intra-capsular fracture, especially when the periosteum and the retinacular ligaments have been completely torn, but in sub-periosteal and in impacted fractures it sometimes occurs. As a rule, however, the neck of the femur becomes absorbed and disappears, the head of the bone comes to lie in contact with the base of the trochanter, and a false joint forms (Fig. 64). Chronic changes of the nature of arthritis deformans may occur in and around such false joints.

When osseous union fails to take place, although the patient may eventually be able to get about, he can do so only with the aid of a stick or crutch, and as there is marked shortening, he walks with a decided limp. There is considerable antero-posterior thickening of the neck of the femur, and the femoral vessels may be pushed forward in Scarpa's triangle.

_Treatment._--In treating a fracture through the narrow part of the neck, it is necessary to consider the age and general condition of the patient; whether the fracture is impacted or not; and the site of the fracture--whether in the narrow part of the neck or at its base. "The first indication is to save life, the second to get union, and the third to correct or diminish displacements" (Stimson).

In old and debilitated patients, bony or even firm fibrous union seldom takes place, and it is generally advisable to get them out of bed as speedily as possible. For the first few days the patient may be kept on his back, the limb massaged daily, and in the interval steadied by sand-bags; but on the first sign of respiratory or cardiac trouble he should be propped up in bed, and as soon as possible lifted into a chair. In all such cases care should be taken to avoid undoing impaction.

When the general condition of the patient permits of it, an attempt should be made to secure bony union.

_Extension_ is applied by one or other of the methods described for fracture of the shaft (p. 149), so modified as to maintain the limb _in the abducted position_, which ensures the most accurate apposition of the fragments (Royal Whitman). This position may be maintained by a hinged long-splint, an adaptation of Thomas' hip splint. The fragments may be fixed to one another by a long steel peg introduced through the skin over the great trochanter, and passed so as to transfix them; or they may be exposed by operation and sutured together. Albe uses a bone peg.

#Fracture of the Neck of the Femur in Children.#--The use of the X-rays has shown that this fracture is comparatively common in children, as a result of a fall or a forcible twist of the leg. The fracture is most frequently of the greenstick variety; when complete, it is usually impacted. There is shortening to the extent of a half or three-quarters of an inch, a slight degree of eversion, the movements of the hip are restricted, and there is some pain. The patient is often able to move about after the accident, but walks with a limp. Unless the use of the X-rays reveals the fracture, the condition is liable to be overlooked.

When the lesion is diagnosed, the deformity should be completely corrected, any impaction that exists being undone; and the limb is put up in a wide abduction splint (p. 221) or in a plaster-of-Paris case in the position of extreme abduction.

If the condition is not recognised and treated, it is liable to be followed by the development of coxa vara (Royal Whitman) (Fig. 65).

#Fracture through the Base of the Neck.#--This fracture is usually produced by a fall on the great trochanter, although it is occasionally due to a fall on the feet or knees.

Although often spoken of as "extra-capsular," the line of fracture is generally partly within and partly without the capsule. The fracture usually lies close to the junction of the neck with the shaft, and in the great majority of cases is accompanied by breaking of one or both trochanters. This is due to the neck being driven as a wedge into the trochanters, splitting them up. When the fragments remain interlocked, the fracture is of the _impacted_ variety (Fig. 67).

_Clinical Features._--Although this fracture is commonly met with in strong adults, it may occur in the aged.

The lateral aspect of the hip shows marks of bruising, and there is severe pain and a considerable degree of shock. The limb lies helpless; there is generally marked eversion, with shortening, which, in _non-impacted_ cases, may amount to 1-1/2 or 2 inches, and is evident immediately after the accident; it is due to the distal fragment being drawn up by the muscles inserted into the great trochanter and upper end of the shaft. In a limited number of cases the distal fragment lies in front of the proximal, and there is inversion of the limb.

On applying the various tests, the great trochanter is found to be displaced upwards, there is some antero-posterior broadening of the trochanteric region, and the ilio-tibial band is relaxed. On pressing the fingers into the lateral part of Scarpa's triangle, a mass consisting of the bony fragments may be felt, and is tender on pressure. Unnatural mobility with crepitus may be elicited.

In the _impacted variety_, the shortening seldom exceeds one inch; the eversion is less marked; there is some power of voluntary movement; and crepitus is absent. The broadening of the trochanteric region is greater, and the great trochanter is approximated to the acetabulum.

_Prognosis._--The risks to life in the aged are similar to those of intra-capsular fracture. In youths and healthy adults the chief danger is that the limb may be shortened and its function thereby impaired.

As the periosteum and retinacular ligaments which transmit the blood vessels to the proximal fragments are intact, bony union is the rule. There is always, however, considerable thickening in the region of the trochanter due to displaced fragments and callus, and in a certain number of cases, even with the greatest care in treatment, there is a varying degree of shortening and eversion of the limb. In cases in which the distal fragment lies in front of the proximal there is permanent inversion.

_Treatment._--As this fracture usually occurs in robust patients, there is no danger from prolonged confinement to bed; and as union without deformity can be attained in no other way, this is always advisable. When the shortening and eversion are excessive, they should be completely corrected under anaesthesia before the retentive apparatus is applied, any impaction that exists being undone. When the deformity resulting from impaction is slight, however, it is best to leave it, as it facilitates speedy and firm union.

Extension is obtained by the same appliances as are used in fracture of the shaft, and the limb should be kept in the abducted position.

Fracture of the #greater trochanter# occurring apart from fracture of the neck usually results from direct violence, but may be due to muscular action. The trochanter is displaced by the gluteal muscles, causing broadening of the lateral aspect of the hip. In young persons the _epiphysis_ of the great trochanter may be separated, but this is rare. The treatment consists in retaining the fragments in position by keeping the limb abducted between sand-bags, or by pegs driven in through the skin.

#Fracture immediately below the lesser trochanter# may be produced by direct or by indirect violence, and the displacement depends largely on whether the line of fracture is transverse or oblique. The proximal fragment is kept tilted forward, rotated laterally, and abducted by the ilio-psoas muscle and the lateral rotators inserted in the region of the great trochanter. The lower fragment passes upward, and is rotated laterally by the weight of the limb; the displacement is aggravated by the contraction of the flexor and adductor muscles. The tilting of the proximal fragment may be increased by the displaced distal fragment pushing it forward.

On account of the difficulty of controlling the short proximal fragment, union is liable to take place with considerable shortening and deformity (Fig. 69).

_Treatment._--When it is found, under an anaesthetic, that the displacement can be completely reduced, and does not tend to recur, this fracture is treated on the same lines as fracture of the shaft of the bone.

In cases in which the proximal fragment cannot be brought into line with the distal one, however, it is necessary to flex, evert, and abduct the thigh in order to get the fragments into apposition and into line. A Hodgen's splint (Fig. 77) is applied with the highest sling under the upper end of the lower fragment and with sufficient extension to correct overriding. The upper end is then strongly lifted by a counter-weight of about 15 lbs. This secures apposition of the fragments with slight forward angulation at the seat of fracture. By the end of a month sufficient callus has formed to prevent re-displacement, and if the counter-weight is gradually diminished the two fragments sag back together into a normal alignment (J. N. J. Hartley). A double-inclined plane (Fig. 70), with extension applied in the axis of the thigh, gives satisfactory results.

DISLOCATION OF THE HIP

It is unnecessary for our present purpose to attempt a comprehensive classification of the numerous varieties of dislocation that have been met with at the hip-joint. It will suffice if we divide them into those in which the head of the femur passes backward, and comes to rest on the dorsum ilii, or in the vicinity of the great sciatic notch; and those in which it passes forward and comes to rest in the obturator foramen, or on the pubes (Fig. 71).

The backward are much more common than the forward dislocations, in contrast to what obtains at the shoulder, where the forward varieties predominate.

On account of the great strength of the hip-joint, dislocation is by no means a common injury. It occurs most frequently in strong adults after the epiphyses have ossified, and before the bones have commenced to become brittle; and it is much more common in men than in women. It is invariably the result of severe violence, the limb at the moment being in such a position that the ligaments are on the stretch and the muscles taken at a disadvantage. The head of the femur usually leaves the joint at the lower and back part, where the socket is most shallow and the ligaments weakest. The ligamentum teres is almost always torn from its femoral attachment, and one or more of the muscles inserted in the region of the trochanters may be ruptured. The [inverted Y]-shaped ligament, on the other hand, is seldom torn, and so long as it remains intact the dislocation belongs to one or other of the types above named. All atypical dislocations, such as the supra-cotyloid, infra-cotyloid, ilio-pectineal, are due to rupture of some part of the [inverted Y]-ligament, and are so rare as not to call for individual description. The central dislocation of German authors, in which the head is driven through the floor of the acetabulum, is described on page 126.

Like other dislocations, those of the hip may be complicated by laceration of muscles, blood vessels, or nerves, or by fracture of one or other of the bones in the vicinity.

#Dislocation on to the Dorsum Ilii.#--This, the commonest form of dislocation of the hip, is usually the result of the patient falling from a height, or receiving a heavy weight on the back while stooping forward with the thigh flexed, slightly adducted, and rotated medially. It is also said to have occurred from muscular action. The shaft of the femur acts as the long limb of a lever of which the neck is the short limb, the femoral attachment of the [inverted Y]-ligament forming the fulcrum. The head, thus brought to bear upon the lower and back part of the capsule, tears it and leaves the socket, passing upwards and coming to rest on the dorsum of the ilium, above and anterior to the tendon of the obturator internus (Fig. 73). The articular surface is directed backward, while the trochanter looks forward.

_Clinical Features._--The affected limb is flexed, adducted, and inverted, so that the knee crosses the lower third of the opposite thigh, and the ball of the great toe lies on the dorsum of the sound foot. There is shortening to the extent of from 1-1/2 to 2 inches, the trochanter being displaced above Nelaton's line, and lying nearer to the anterior superior iliac spine than on the normal side. The patient is unable to move the limb or to bear weight upon it; abduction and lateral rotation are specially painful; and traction fails to restore the limb to its proper length. On making these attempts a characteristic elastic resistance is felt.

The head of the femur in its new position may sometimes be felt through the fibres of the gluteus maximus, but swelling of the soft parts often obscures this sign. The normal depression behind the great trochanter is lost, the gluteal fold is raised, and there is often a degree of lordosis which compensates for the flexion. The fingers can be pressed more deeply into Scarpa's triangle on the dislocated than on the normal side--a point in which this injury differs from fracture of the base of the neck of the femur.

In a certain number of cases the lateral limb of the [inverted Y]-ligament is ruptured and the limb is everted--_dorsal dislocation with eversion_.

#Dislocation into the Vicinity of the Great Sciatic Notch#, or "_dislocation below the tendon_."--This variety of backward dislocation is less common than that on to the dorsum, although produced in the same way. The head of the femur passes beneath the obturator internus, and this tendon, catching on its neck, checks its upward movement (Fig. 74).

The _clinical features_ are the same as those of the dorsal variety, but, on the whole, are less marked.

_Differential Diagnosis._--Backward dislocation of the hip is usually easily recognised. When dislocation below the tendon occurs in a stout person, however, it is liable to be overlooked on account of the difficulty of feeling the displaced bone, and of the comparatively slight amount of deformity present. The nature of the accident, the absence of broadening of the trochanter, and the adduction and inversion of the limb are usually sufficient to prevent a dislocation being mistaken for an impacted extra-capsular fracture.

#Dislocation into the Obturator Foramen# (Fig. 71).--This dislocation is produced by great force applied from behind while the thigh is flexed and abducted, as when a weight falls on the back of a man stooping forward with the legs wide apart. It may also result from violent abduction by wide separation of the thighs.

The capsule gives way at its medial and lower part, and the head of the femur comes to rest on the surface of the external obturator muscle, its articular surface looking forward, while the trochanter looks backward.

_Clinical Features._--In the standing position the thigh is slightly flexed and abducted, with the foot pointing directly forward or a little outward. The body is bent forward to relax the ilio-psoas muscle and the [inverted Y]-ligament, the foot is advanced and the heel drawn up. It is not uncommon for the patient to be able to walk after the accident, and only to seek advice some time later on account of inability to adduct and extend the limb. There is apparent lengthening of the limb due to tilting of the pelvis downward on the affected side. The hip is flattened, the trochanter less prominent than usual, and the head of the bone may sometimes be felt in its abnormal position.

#Dislocation on to the pubes# is a further degree of the obturator form (Fig. 71). It is usually produced by forcible hyper-extension and lateral rotation of the hip, such as occurs when the body is bent back while the thigh remains fixed.

The capsule is torn farther forward than in the other varieties, and the head rests on the horizontal ramus of the pubes against the ilio-pectineal line.

_Clinical Features._--There is marked eversion, flexion, and abduction, but the shortening is inconsiderable. The ilio-psoas and [inverted Y]-ligament are tense. The head of the femur may be felt in the groin, with the femoral vessels over, or to one or other side of it. There is sometimes pain and numbness in the distribution of the femoral (anterior crural) nerve. The prominence of the great trochanter is lost.

#Treatment of Dislocation of the Hip.#--For the reduction of a dislocation of the hip complete anaesthesia is necessary, and the patient should be placed on a firm mattress on the floor to give the surgeon the best possible purchase upon the limb. The surgeon grasps the ankle with one hand, while the other is placed behind the head of the tibia, the leg being held at right angles to the thigh. An assistant meantime steadies the pelvis by making firm pressure over the iliac crests.

As the chief obstacle to reduction is the tension of the ilio-femoral ligament, the first indication is to relax this structure by flexing the hip _to its fullest extent_.

In the _backward_ varieties (dorsal and sciatic) the [inverted Y]-ligament is relaxed by flexing the thigh upon the pelvis in the position of adduction. The thigh is then fully abducted, to cause the head of the bone to retrace its steps forwards towards the rent in the capsule; and at the same time rotated laterally to relax the rotator muscles. This combined movement tends also to open up the rent in the capsule. Finally, the limb is quickly extended to cause the head to enter the socket. This object is often aided by making vertical traction or lifting movements on the abducted and laterally rotated limb before extending.

For the reduction of the _forward_ varieties (obturator and pubic), the thigh is first fully flexed on the pelvis, but in the abducted position. The limb is then strongly rotated medially and abducted, and finally extended. Lifting movements may be found useful in these cases also.

All methods of reduction by forcible traction on the extended limb are to be avoided, as they fail to meet the primary indication of relaxing the [inverted Y]-ligament.

After reduction, the limb is steadied by sand-bags; massage is carried out from the first, and movement after a few days. The range of movement is gradually increased, and the patient is allowed to use the limb with caution in from two to three weeks.

When the rim of the acetabulum has been fractured, the patient must be confined to bed with extension for six to eight weeks, to avoid the risk of re-dislocation.

Changes of the nature of chronic arthritis are liable to occur in and around the joint in old and rheumatic subjects; and atrophy or paralysis of muscles may follow, if their nerves are implicated.

#Old-standing Dislocation.#--It is impossible to lay down any time-limit for attempting reduction in old-standing dislocations of the hip. Manipulation may succeed in cases of some months' standing, and may fail when the bone has been out only a few weeks. In certain cases, even after reduction has been effected, there is a marked tendency to re-displacement. In any case, the attempt does good by breaking down adhesions, provided no undue force is employed such as may damage the sciatic nerve or vessels, or fracture the neck of the femur, and success may attend on a second or even a third attempt at intervals of from three to five days. If manipulation fails, and if the deformity is great and the usefulness of the limb seriously impaired, an attempt may be made to effect reduction by operation; the operation, however, is one of considerable difficulty, and in the event of failure the head of the bone should be excised. If the head has formed a new socket for itself and there is a fairly useful joint, the condition should be left alone.

_Congenital dislocation of the hip_ is described with Deformities of the Extremities.

#Sprain# of the hip is comparatively rare. It results from milder degrees of the same forms of violence as produce dislocation. The ligaments are stretched or partly torn, and there is effusion of fluid into the joint. Pressure over the joint elicits tenderness; and the limb assumes the position of slight flexion, abduction, and lateral rotation, but there is no alteration in length. Such injuries, unless carefully treated by massage and movement from the outset, are apt to be followed by the formation of adhesions, resulting in stiffness of the joint.

#Contusion# in this region, on the other hand, is not uncommon. It is produced by a fall on the trochanter, and gives rise to symptoms which simulate to some extent those of fracture of the neck. The limb lies in the position of slight flexion, but the bony points retain their normal relationship to one another, and there is no shortening. The swelling and tenderness often prevent a thorough examination being made, and when any doubt remains as to the diagnosis, the patient should be kept in bed till the doubt is cleared up by the use of the X-rays. If the bone has been broken, this will reveal itself in the course of a few days by the occurrence of shortening and other evidence of fracture.

In elderly patients, contusion of the hip may be followed by changes in the joint of the nature of arthritis deformans; and it has been stated, although proof is wanting, that absorption of the neck of the femur sometimes occurs. These injuries are treated by rest in bed, massage, and the other measures already described as applicable to sprains and contusions.

FRACTURE OF THE SHAFT OF THE FEMUR

This group includes all fractures between that immediately below the lesser trochanter and the supra-condylar fracture.

_In adults_, when due to direct violence, the fracture is usually transverse, and may be attended with comparatively little displacement. Indirect violence, on the other hand, usually produces an oblique fracture, which is frequently comminuted and often compound. The break is most commonly situated a little above the middle of the shaft, the obliquity being downward, forward, and medially, and of such a nature that the fragments tend to override one another (Fig. 75). The most serious forms are those associated with gun-shot wounds.

The direction and nature of the displacement depend more upon the fracturing force, the weight of the lower part of the limb, and the action of the muscles attached to the respective fragments, than upon the direction of the obliquity. As a rule, the proximal fragment passes forward and laterally, and is maintained in this position by the ilio-psoas and glutei muscles, while the distal fragment is displaced upward and medially and is rotated outward by the combined action of the weight of the limb, the longitudinal muscles, and the adductors.

_Clinical Features._--The limb is at once rendered useless, and there is great swelling from effusion of blood in the region of the fracture. This, together with the muscularity of the part, often renders an accurate diagnosis as to the site and direction of the fracture exceedingly difficult. The shortening varies from 1/2 inch to 3 or 4 inches--averaging about 1 inch in adults--and eversion is always marked. Mobility may be detected and crepitus elicited without disturbing the patient, by placing the hand under the seat of fracture and gently attempting to raise the limb; or by fixing the proximal fragment by one hand placed in front of it while the distal part of the limb is carefully lifted. It will be found that the great trochanter does not rotate with the lower segment of the femur. These tests must be employed with great caution lest the deformity be increased or the fracture rendered compound.

In many fractures of the thigh, and especially in those produced by indirect violence, the knee is sprained, and there is a considerable effusion into the joint, and this may lead to stiffness unless massage is employed from the outset.

_Treatment._--Fracture of the shaft of the femur is one of the most difficult fractures in the body to treat successfully. In cases of oblique fracture, the patient should be warned that shortening to the extent of from 3/4 to 1 inch is liable to result, however carefully the treatment may be carried out. This does not necessarily imply a permanent limp, as by tilting the pelvis he may be enabled to walk quite well; if this is not sufficient to equalise the length of the limbs, the sole of the boot may be raised. A general anaesthetic is necessary to ensure accurate reduction, and extension must be applied to maintain the fragments in apposition and prevent shortening. The splint which has been found most generally useful is the Thomas' knee splint, the ring of which rests against the ischial tuberosity. To admit of flexion at the knee the Thomas' splint should have a hinged attachment on which the leg is supported. This leaves the knee free and allows of movement being made to prevent stiffness. The limb is suspended by broad strips of flannel or linen, fixed to the side bars of the splint by means of safety pins or strong spring paper clips.

In simple fractures extension may be obtained by means of broad strips of adhesive plaster applied to each side of the thigh and reaching well above its middle. The plaster is secured by a bandage, and to its lower ends are attached broad tapes which are buckled to a stirrup through which traction is made by means of a cord passing over a pulley fixed to an upright at the foot of the bed.

The lower end of the splint is suspended, and the counter-extension is obtained by pressing the ring against the ischial tuberosity. To prevent the ring overriding the tuberosity and pressing on the soft tissues of the buttock, it is slung by the rope to a cross-bar above the bed, _e.g._ the Balkan frame (Fig. 81).

In compound fractures the presence of a wound may prevent adhesive plaster being used, and it is necessary to take the extension directly through the bone. A posterior gutter splint is applied to prevent sagging. After pulling the skin upward, a small incision is made over the upper expanded border of each condyle, and the points of an ice-tong calliper are made to grip the bone without penetrating into the cancellous tissue. A cord attached to the handles of the calliper passes over a pulley and supports the weight necessary to give the desired amount of traction (Fig. 81).

An alternative method of exerting traction directly through the bone is by means of Steinmann's apparatus (Fig. 76). In a moderately muscular adult, a weight of from 12 to 15 pounds by means of strips of plaster applied to the skin, or 10 to 25 pounds by direct traction on the bone, should be applied in the first instance. The correct weight to employ is that which maintains the length of the limb at its normal, and is therefore liable to revision from time to time.

_Hodgen's splint_ is a comfortable and efficient means of treating these fractures, as it allows the patient a certain amount of movement, admits of the part being massaged, and facilitates nursing.

It consists of a wire frame (Fig. 77) to one side of which a series of strips of flannel about 4 inches wide are attached. Extension strapping is first applied, and then the frame, which extends from the level of Poupart's ligament to well beyond the sole, is placed over the front of the limb, and the loose ends of the flannel strips brought round behind the limb, and fixed to the other side of the frame, convert it into a sling. The tapes attached to the extension strapping are now tied to the end of the frame. By suspending the limb in this splint by means of cords passing obliquely over a pulley attached to an upright at the foot of the bed, the weight of the limb is made to act as the extending force.

The retentive apparatus should be worn for from six to eight weeks, after which the patient is allowed up with crutches, which he usually requires to use for three or four weeks longer, before he can bear his weight upon the limb. The old dictum of Nelaton, that the treatment of fracture of the thigh should last for a hundred days, is a safe working-rule. In fractures of the shaft an ordinary Thomas' knee splint, or a "walking calliper splint" which is fixed to the heel of the boot, may be worn when the patient gets up.

Union may be exceedingly slow in fracture of the femur, and may even be delayed for months. Mal-union sometimes occurs, the fracture uniting with an angular deformity outward and forward.

Re-fracture is liable to occur if the patient falls or twists the limb within a few months of the original injury. It has happened not infrequently just after the retentive apparatus has been removed from the nurse raising the limb by the foot in order to wash it.

_Liston's long splint_ is only employed as a temporary expedient for immobilising the fragments during transport; a Thomas' splint, if available, is better for this purpose.

_Operative treatment_ is sometimes called for when simpler measures fail to reduce the displacement, and in cases of un-united fracture or of vicious union. The incision, which must be free, is preferably placed in the line of the lateral intermuscular septum; the periosteum is interfered with as little as possible. The application of extension by the calliper method is often of great service, during the operation, in enabling the operator to get the fragments into position; sometimes no fixation is required, but, if necessary, recourse is had to plating or pegging, or an intra-medullary pin. The extension apparatus is retained for three or four weeks. The after-treatment is carried out on the same lines as for simple fracture, but the retentive apparatus must be worn for a considerably longer period.

#Fracture of the Femur in Children.#--In children, especially below the age of ten, this fracture is quite common. It is often of the greenstick variety, or, if complete, is transverse and sub-periosteal, and as it is accompanied by few symptoms and but little deformity, is liable to be overlooked.

When there is displacement, the deformity is similar to that in adults, and the treatment is carried out on the same lines.

In young children the nursing is greatly facilitated by applying vertical extension to one or both lower extremities (Fig. 79). If the fracture is transverse and shows little tendency to displacement, the local Gooch splints may be dispensed with; in any case, massage should be employed from the first.

The patient may be allowed out of bed in from three to four weeks, wearing a retentive apparatus.

The shaft of the femur is sometimes fractured _during delivery_, particularly in breech cases. The simplest and most efficient means of controlling the fracture is by extension strapping fixed to the lower end of a Thomas' knee splint.