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Dislocations of the

bone, socket, head, limb, thigh, bent, force, body and backwards

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DISLOCATIONS OF THE (Femur).

Considering the depth of the socket in which the head of the thigh-bone moves, and the powerful muscles by which it is surrounded, this bone is dislocated with great frequency. This is, doubtless, because of the great range of movement permitted by the joint and the long leverage supplied by the leg to any displacing force. It requires both considerable force and a certain position of the limb to effect it. The accident is commonest in middle life, but may happen to children.

There are two classes of dislocation : I. One class, in which the head of the bone, displaced from its socket, rests behind the socket; and II. Another class in which it rests in front of the socket.

I. In the backward displacement it will be seen from Fig. 61 that the head of the bone, displaced from its socket (a), may lie (1) on the back of the iliac portion (A) of the hip - bone, in which case, besides being backwards, it is also up wards; or (2) the head of the bone may slip down and rest on the notch between the ilium and ischium, the sciatic notch (behind 13 in the fig.), and in this case the displacement is backwards, and not nearly so much upwards as in the former case.

II. In the forward dislocations (1) the head of the bone may drop down into the ob turator foramen (o), or (2) it may be pulled up wards so as to rest on the body of the pubis (c).

I. (1) The common form is backwards and upwards, on the back of the ilium.

It will easily understood that if the thigh be bent strongly up on the body, or, what is the same thing, the body bent, as in the stooping posture, and the limb at the same time brought close to the middle line of the body, the head of the femur will be brought to such a position in its socket that a sudden force may twist the bone out of the socket from its under side up on to the back of the hip. This is indeed the frequent way in which the dislocation is pro duced—a heavy weight, say a mass of earth, falling on the back whilst the body is bent forwards.

Signs.—When the patient stands on the sound leg the affected limb is seen to be shortened and turned inwards, so that the knee is in front of and above that of the unaffected side. The limb is slightly bent and supported by the toe, which rests on the opposite instep (Fig. 62, a). The head of the bone being directed backwards, and resting on the back of the hip, causes a marked prominence in that region, while the great trochanter, the process of the thigh-bone, which should project directly outwards, is now felt in front. The limb cannot be moved by the patient, and only very slightly by another per son, and then with great pain. For distinctions between this accident and fractured thigh refer to FRACTURE OF UPPER END OF FEMUR, and see Fig. 44.

(2) The second form of this dislocation, in which the head of the bone rests on the sciatic notch, is a variety of (1), and is not half so frequent.

Its Signs are similar to those of (1), but less marked, as may be seen by reference to Fig. 62, b. The shortening is less, rarely ex ceeding inch, while the shortening in the first form may be from l to 2i inches. The point of the great toe rests on the ball of the great toe of the opposite side, a considerably less amount of support than in the former case. The pro jection backwards of the head of the bone is also less marked. These differences are well represented in the figure.

Treatment.--The treatment of Loth these forms is the same. Formerly sheer force alone was resorted to to effect reduction. Fig. 63 represents this method, in which the hip is fixed by a band passing between the legs and over the dislocated thigh, pressing, on the inside, against the front of the hip-bone, not against the thigh-bone. The band is attached to a staple in the wall or on the floor behind, and rather below the patient. Then, a padded leather belt is buckled to the lower part of the thigh and attached to one end of a pulley, which is fixed to the wall in front of the patient. The knee should be slightly bent and carried across the opposite thigh, as represented in the figure. The pulley or extending force, and the baud or counter-extending force, should act in the same straight line, and that ought to be the line of the displaced limb. When they are adjusted properly in this way extension is to be made by pulling slowly and steadily on the pulley until the head of the bone is brought down towards its socket, into which it may be caused to slip by gently rotating the limb. It some times catches on the edge of the socket, over which it may be lifted by means of a towel passed under the thigh as near the joint as pos sible. This method by force is, at least in recent cases, now superseded by a method by manipu lation. It has been pointed out that the action that displaces the thigh-bone backwards is one which forcibly twists the limb inwards when it happens to be bent up on the body and carried towards the middle line. In other words, the dislocation is produced by flexion, adduction, and rotation inwards. Now, by reproducing these manoeuvres and reversing one of them the bone may be returned to its place. Thus the limb is bent, that is flexion ; the knee is carried over the opposite thigh, that is adduction; but just at this point the dislocating action is reversed, and the limb is rotated outwards, so that the head of the bone is caused to return to the socket along the same path as that on which it had passed out from the socket, and is rolled back to its proper place. To carry out this procedure the patient is placed on his back.

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