from the other, any attempt to approximate them causing pain. The pubes was tender when pressed. Under ether the leg resumed its normal position. No crepitus was discovered, although the patient had complained of a sense of grating in the perinæum. A broad strap was placed around the pelvis, and in six weeks the patient was well enough to be discharged, walking on crutches. It is difficult in this case to account for the position of the limb before etherization, except on the supposition that it may have afforded relief to pain. To the eye its position was that of a thyroid luxation.1 ANGULAR EXTENSION. POUTEAU2 first remarked upon the disadvantage of traction with counter-extension in the perinæum, which brings the thigh into a straight line with the trunk. Most surgeons have observed the tendency of the pelvis, when pulleys are used, to escape from the counter-extending bands in the direction of the applied traction. It is believed that the apparatus here described will be found efficient, both in confining the pelvis and in enabling the operator to apply extension to a limb which has been flexed for the purpose of relaxing the Y ligament. Lateral extension, with or without pulleys, can then be made in any desired direction by a towel passed round the thigh at the groin. The patient being laid upon his back, the pelvis is secured to the floor by a T band passing across it laterally in front, between the superior and inferior spinous processes of each side, and vertically over the pubes and perinæum. The three extremities, each terminating in a strap and buckle, are fastened to the floor beneath the margin of the pelvis by 1 Massachusetts General Hospital Records, vol. cxxvii. p. 210. common dislocation-hooks. The entire band, with the exception of its extremities, is cylindrical, about two inches in diameter, well padded and covered with buckskin. It firmly holds the pelvis by its pressure between the spinous processes on each side and upon the pubes. To apply it, the three pointed hooks are screwed into the floor, one near each tro chanter, and one near the perinæum; the band is then adjusted, and the pelvis buckled to the floor, after which it will be found that the thighs can be freely flexed. A tripod is now erected over the pelvis, consisting of three stiff poles about eight feet high, and held together at the top by a coni 1 Apparatus for angular extension. This woodcut represents the conical leather cap and rings, the angular splint, with rings above and below the knee for the passage of a transverse wooden lever, and of a longitudinal one beneath the calf, the padded T pelvis band, and the hooks to attach it to the floor. cal leather cap, with three short, dependent straps and rings from which the pulleys are suspended. It remains only to FIG. 44.1 attach the pulleys to the limb. This is effected by means of a strong right-angled splint of sheet-iron, extending nearly from the hip to the ankle, made concave so as to embrace the under surface of the thigh and leg, and padded, within which the limb, flexed at right angles, is confined by bandages or straps. Two iron rings riveted to the splint near the condyles of the femur receive a wooden rod about two feet in length and an inch in diameter, which crosses the ligament of the patella transversely above the head of the tibia; and to this rod, between the rings, the pulleys are attached by a strap or cord. Vertical traction is thus made exactly in the axis of the shaft of the femur. Powerful rotation can be made by grasping the extremities of this transverse rod, while another useful movement, called by the French bascule, or tilt, may be effected by a similar 1 Angular extension. The pelvis is buckled to the floor. The flexed leg is suspended from the cap at the summit of the tripod by pulleys which are attached to a transverse wooden rod across the patella. This rod passes through rings on the angular splint, and serves to rotate the limb. A similar rod is seen beneath the leg. rod in the axis of the leg below the knee, passed through two rings beneath the splint, one near the ham, the other near the heel, beyond which it projects a foot or more, — to afford a handle. By vertically raising this rod at its extremity we carry the head of the bone from the dorsum, or pubes, in the direction of the tuberosity. Oblique extension may be made by changing the position of the tripod. Although the need of this apparatus may be rare, it will prove occasionally efficient in reducing a luxation of long standing or complicated with fracture. At any rate, I cannot believe that the period is remote when longitudinal extension by pulleys to reduce a recent hip luxation will be unheard of. ON DISLOCATION OF THE HIP.1 THE simplicity of the principle which controls hip reduction is as yet scarcely appreciated by the majority of practitioners into whose hands the scattered cases fall. Writers also, until very lately, have seemed disposed to consider" manipulation" as but one of several means of reduction of equal value, - occasionally available, indeed, but complicated with many methods, and by conflicting opinions regarding its essential features, -by perplexing talk of abduction and inversion, of flexion and partial flexion, of rotation and circumduction. I have, perhaps, myself unintentionally contributed to this erroneous belief. But my paper upon this subject 2 was based upon the analysis of a large number of dissections, experiments, and cases of reduction, which could neither be condensed advantageously nor yet omitted; while its object was to show the relation between hip dislocation and the ilio-femoral ligament, then generally unrecognized. The whole matter is really very simple. The word "manipulation" is an unfortunate one; "flexion" is better. The modern method of hip reduction, whether by lifting or by mere abduction, is the "flexion method;" and it supersedes all others. A common way of describing dislocation is by the terms. 66 backward," "forward," " in front," and "behind." It should be borne in mind that when the body is erect the pelvis is oblique, the acetabulum standing in like manner obliquely, at an angle of about 45°, facing the front and outside of the thigh, at a point an inch or two below the trochanter; so that what 1 The Lancet, June 15, 22, 29, 1878. 2 The Mechanism of Dislocation and Fracture of the Hip. (Henry C. Lea, Philadelphia, 1869.) |