The operator stands in front of him, and, taking the affected limb, bends the knee on the thigh and the thigh on the body, and carries the knee so that it points over the opposite thigh. He then grasps the ankle with one hand and the knee with the other, and carries the limb upwards to and over the belly, passing out wards in a half sweep,and so back to its old position alongside the other leg. The rolling of the limb outwards must not be carried too far, lest the head of the bone he not rolled into its socket but round it, and the dislocation be changed from one backwards to one forwards. The sweep should, therefore, not be carried further outwards than the side of the body (Fig. 64).
Another and simpler method, described as the "ready method," may be practised before trying the method by manipulation. It consists in laying the patient on his back on the ground.
Let the operator stand over him, with the patient's injured leg between his legs, so that the ankle is between his thighs and the back of the foot pressing on his buttocks. Then the operator clasps his hands below the patient's beaded knee, and by this means slowly lifts till the lower part of the patient's body is raised from the ground. After holding him so a few seconds he may hear the snap, which indicates the return of the bone to its socket. If this fails, then try manipulation ; if manipulation fails, pulleys may be necessary, but these should be used only by a surgeon. Chloroform is also frequently necessary.
After reduction the limb should be strapped to its fellow, and the patient kept at rest in bed for a fortnight.
II. The dislocations forwards are infre quent.
(1) When the dislocation is into the obturator foramen (o, Fig. 61) the limb is lengthened about 2 inches, drawn away—abducted—from the other, and in advance of it, and the foot points directly forwards. The body is bent forwards, and to the injured side. See Fig. 65, d.
(2) The second form, where the head of the bone rests on the body of the pubis, is the least frequent of all the dislocations of the hip.
Signs.—The limb is shortened about 1 inch, drawn away from its fellow, and turned out wards (Fig. 65, c). The roundness of the hip is lost. On moving the limb the head of the bone is seen rolling high up in the groin. The person cannot straighten himself, because the head of the bone stretches the muscles passing down the front of the thigh.
The force that causes either of these two forms differs in the method of its application from that causing the two backward tions. A violent separation of the thighs from one another may cause the first, such as a heavy weight falling on the back and forcing the limbs apart. To produce the second the thighs must
be stretched out—extended—when a sudden forcing of the body backwards will cause it, or a sudden extension of the thighs when the body is fixed. The kind of movement most fitted to produce it is a sudden drawing outwards of the ex tended limb—extension and abduction — combined with twisting of the leg out wards — rotation outwards. These are the exact opposite of the movements necessary to produce the backward dis locations.
The Treatment by manipulation is best, and applicable to both. It takes into view the movements that cause the dislocation, and reverses them to some extent. Thus the dislocating movements have been considered as extension, ab duction, and rotation ou twurds, a n d there fore the manoeuvres of reduction must be forced extension, abduction, and rotation inwards. The patient lies on his back, the operator stands over him, and grasps the ankle with one hand and the knee with the other.
The thigh is bent so as to be perpendicular to the body, and the knee is bent. The limb is then taken well out from its fellow and carried in a sweep inwards, rotating the bone towards the body, the sweep ending when the limb is brought down straight alongside of the other (Fig. 66).
In performing this movement one is apt, in stead of reducing the dislocation, to convert it into one on the back of the hip, owing to the head of the bone travelling round the outside of its socket. If this has happened the manipulation for backward dislocation must be employed, and, to prevent the bone simply rolling round the socket, a towel may be used under the thigh with which to lift the head of the bone over the edge, as already described.
Another method of reducing (1) is to place the patient in bed with a bed-post close up between his legs, a small pillow being inter posed between the post and the person. The operator stands on the sound side, and, passing his hand under the sound leg, grasps the ankle of the injured side, and pulls the foot and leg inwards across the middle line. By this means the bed-post is made to act as a fulcrum and the leg a lever for forcing the head of the bone outwards into its place. The object of passing the hand under the sound leg is to prevent raising the foot of the injured side, which would cause the head of the bone to roll round the socket into a notch behind. As in the former eases, after reduction the two legs should be bound together at the knee, and the patient should rest in bed for two weeks.
Congenital Dislocation at the Hip is considered in the Section on DP3E/isEs OF CHILDREN.