Part 41

Tanner, Sc.]

EXPLANATION OF THE SECOND PLATE.

For an account of an improvement of the splint, represented in this plate, projected by Dr. Physick, and now used in the Pennsylvania hospital, see Article II. of the Appendix. TRANS.

This figure represents the apparatus for permanent extension, employed by Desault in oblique fractures of the os femoris.

AA. The external splint, with a notch and a mortise in it at the lower end to fix the inferior extending roller.

BB. A bandage passing round the body, intended to secure this splint against the pelvis.

CC. The anterior splint, reaching only to the knee.

d d d d. The anterior bolster, extending along the whole limb, and secured by pieces of strong tape.

EE. A portion of the bandage of strips, seen between the anterior and the external lateral bolsters.

FF. The junk-cloth intended to be folded round the two lateral splints.

g g. The superior extending roller, passing round the end of the external splint, and fixed underneath on the tuberosity of the ischium.

H. The sub-femoral roller or strap, intended to prevent the bandage BB, which passes round the body, from slipping upwards.

K k. A roller usually passed round the foot, to prevent it from turning.

L. The inferior extending roller, fixed in the mortise and the notch of the external splint.

THOUGHTS

ON LUXATIONS OF THE OS FEMORIS, UPWARD AND FORWARD.

1. Few kinds of luxation of the os femoris occur in practice more rarely than this. Practitioners who have seen it, and those who, on the authority of others, have described it, without having seen it, have all given an unfavourable prognosis respecting it, for the following reasons: 1st, on account of the inevitable rupture of the round ligament: 2dly, on account of the distension, and even laceration of the capsule, and of the compression and overstretching of the nerves and blood-vessels: 3dly, on account of the great difficulty of reduction. The following case will prove, that in all these respects, the apprehensions of authors have been exaggerated, that the obstacles to reduction arise less from the nature of the displacement, than from the nature of the means employed to remedy it; and that, if properly directed, art would here be as successful as in other cases.

CASE. (Collected by C***). About the close of the winter which preceded the death of Desault, a porter was brought to the Hotel-Dieu, in consequence of a fall which he had received about two hours before, in the following manner. As he was carrying on his shoulders a heavy burden, his foot slipped, while his leg and thigh were directed backwards: he fell on his knee, his thigh maintaining still the same direction; so that the conjoined weight of his own body and of the burden which he carried, aided by the velocity of the fall, forcing the head of the os femoris, which pointed at the time forward and upward, against the distended capsule, lacerated it and drove the articulating end through the opening. Continuing still to act, it ruptured the ligament, which connects the extremity of the bone to the articulating cavity, and forced the head in front of the os pubis, where it could be easily felt.

At the moment of the fall, an acute pain was felt in the part; and the power of moving the limb was suddenly lost; the patient was carried home, where a surgeon who visited him, considered the accident as a fracture of the neck of the os femoris, and sent him to the Hotel-Dieu, to undergo the necessary treatment.

Desault having examined the parts, discovered, from the following appearances, not a fracture, but a luxation upward and forward. The limb was nearly an inch shorter than natural; the point of the foot was turned outwards; the thigh being in a state of painful extension, could not be flexed on the body; adduction and abduction were alike painful; the great trochanter, being more approximated than usual to the anterior and superior spine of the os ilium, was also too far forward; finally, the projecting head of the bone could be felt, as I have already said, in the groin.

A case of luxation of the head of the os femoris in a forward direction, but differing in some respects from the above, occurred lately in the Pennsylvania hospital under the care of Dr. Physick. The doctor reduced this luxation in the amphitheatre, in the presence of his class, by a process which was also somewhat different from that adopted by Desault.

In the case of Desault’s patient the luxated limb was shorter than the sound one: in that of Dr. Physick’s it was evidently longer. This was no doubt owing to the head of the os femoris having, in the former case, passed farther up towards the superior rim of the os pubis than it had in the latter. In both cases the protuberance formed by the head of the bone in the groin could be readily felt.

For the purpose of making counter-extension, Desault passed a strap between the scrotum and the thigh of the sound side: Dr. Physick, for the same purpose, passed the strap between the scrotum and the affected thigh. He conceived that by this mode he could act with more effect on the pelvis, and more effectually prevent the acetabulum of the affected side from being drawn in any measure downward by the extending forces. It would seem, that by making counter-extension, in such a case, on the sound side, the pelvis is made to rotate, so to speak, on its own axis, in the direction in which the counter-extension is made. The necessary effect of this rotation must be, a slight descent of the acetabulum of the affected side. But to retain the acetabulum firmly up is the true and only end of counter-extension. Dr. Physick appears therefore to have availed himself of the greatest mechanical advantage of which the situation of the parts admitted.

Again: Desault placed the strap on which extension was made just above the ancle: Dr. Physick placed the strap intended for the same purpose above the knee. His object in this was, to have the leg free and unincumbered, in order that he might be able to use the limb with more advantage, as a lever of the first kind, to assist in moving the head of the os femoris towards the acetabulum. The fulcrum of the lever into which the limb was thus converted, was a strap passed round the affected thigh a few inches below the groin, and drawn laterally with great force in a direction opposite to that in which the bone was displaced.

In this case extension and counter-extension were made by means of powerful sets of pullies. Notwithstanding this, these forces were not alone sufficient to subdue the resistance of the muscles. The reduction was not completed till muscular contraction had been weakened, and the patient reduced almost to a state of syncope, by the loss of nearly two quarts of blood. This copious evacuation, co-operating with the fatigue which the muscles of the limb necessarily sustained, in consequence of the powerful extension to which they were for some time subjected by the action of the pullies, overcame all resistance and the head of the bone was finally replaced. To exhaust the energy of the resisting muscles by forcible and permanent extension, and to weaken the action of the system generally, by copious blood-letting, appear to be the two most effectual modes of ensuring success in the reduction of all obstinate cases of luxation.

Another point of difference between these two cases of luxation remains yet to be mentioned. In Desault’s case the head of the os femoris was, as he tells us, displaced in a direction “upward and forward.” In Dr. Physick’s case, the direction of the displacement was downward and forward. This was proved beyond all doubt, by the circumstance of the affected limb being longer than the sound one. TRANS.

The reduction was effected in the following manner. The patient being laid on a firm table, spread with a mattress, a strap was fastened above the ancle, for the purpose of extension; another, intended for counter-extension was placed between the scrotum and the thigh of the sound side, and brought up the back and front of the pelvis, along the body, till it passed over the shoulder, where it was twisted together and secured.

Extension was then begun, precisely in the direction in which the thigh pointed; and, during the execution of it, a rotatory motion inwards was given to the limb. At the expiration of a few minutes, the head of the bone remaining almost immoveable, notwithstanding the efforts to dislodge it, Desault directed extension to be discontinued, and, taking hold of the thigh, moved it in every direction, with a view to enlarge the opening in the capsule, the narrowness of which he suspected to be the cause that prevented the reduction.