Fragments of the book
Cooper AP. A Treatise
on Dislocations and Fractures of the Joints (1851) dedicated to ligamentum
capitis femoris (LCF). The author discusses changes in the LCF during hip
fractures, dislocations and role of its blood vessels in supplying the femoral
head.
Quote pp. 51-52
ON DISLOCATIONS IN GENERAL.
…
Mr. Howden, who was one of our most intelligent
apprentices at Guy's Hospital, and was afterwards surgeon in the army, related
the following case: - A man had his thigh dislocated upwards and backwards on
the ilium, which was soon after reduced; the next day a considerable swelling
was observed on the part, which continued to increase, accompanied with rigors,
and in four days the patient died. On dissection, the capsular ligaments, and
ligamentum teres, were found entirely torn away, and a considerable quantity of
pus extravasated in the surrounding parts." * (See Minutes of the Physical
Society, Guy's Hospital, Nov. 12th, 1791.) I attended the master of a ship, who
had dislocated his thigh upwards; an extension was made, apparently with
success; but in a few days a large abscess formed on the thigh, which destroyed
the patient. Fortunately, however, such a result is by no means common. † (A
case of the kind is described among the cases of dislocation on the pubes.)
APPEARANCES ON DISSECTION. - On examination of
the bodies of persons who die in consequence of recent dislocations arising
from violence, the head of the bone is found completely removed from its socket.
The capsular ligament is torn transversely to a great extent; the peculiar
ligaments of joints, as the ligamentum teres of the hip, are torn through; but
the tendinous origin of the biceps, in dislocation of the os humeri, remains
uninjured, as far as I have been able to ascertain by dissection; although I
would by no means be understood to say that this is universally the case. (It
is sometimes ruptured. - Ed.)
…
The appearance of joints which have long been
dislocated, depends not only on the length of time that has elapsed from the
accident, but also on the structure upon which the head of the dislocated bone
is thrown; for if it be found imbedded in muscle, its articular cartilage remains,
and a new capsular ligament forms around it, which does not adhere to its
cartilaginous surface. This ligament in dislocations of the femur contains
within it the head of the bone, with the lacerated portion of the ligamentum
teres united to it. In these instances, the bones themselves undergo little
change.
Quote p. 74
ON DISLOCATIONS OF THE HIP-JOINT.
SECTION I. ANATOMY OF THE JOINT.
…
 |
| Fig. 7. |
The ligamentum teres, or interarticular
ligament, is somewhat triangular in figure, and is attached by its apex to a
depression on the head of the femur, and by its base to the notch of the
acetabulum. Its base is bifurcated, and divided into two flattened bands, which
are continuous, with the fibrous part of the cotyloid ligament.
The cotyloid ligament, as we have already said,
completely surrounds the edge of the acetabulum, and passes over the notch on
its inner side, so as to convert it into a foramen, through which pass the vessels
that supply the synovial membrane. It is prismatic in shape, being attached by
a broad base to the edge of the acetabulum, while its apex is a free border, a little
inclined inwards, so as to embrace the head of the bone closely. It is invested
on both surfaces with synovial membrane. Of the synovial membrane we need only
say that it covers the head and neck of the femur and the ligamentum teres, and
that at its reflection from the inside of the capsular ligament to the neck of
the femur it is curiously folded. There are under it at this part certain small
granular bodies of a fatty appearance, and that depression in the acetabulum
near the insertion of the ligamentum teres, which is not covered with
cartilage, is filled with a similar fatty matter, which is supposed by some
people to be composed of synovial glands or follicles.
Quote p. 92
SECTION III. DISLOCATION DOWNWARDS, OR INTO THE
FORAMEN OVALE.
…
CAUSES. -Dislocation of the femur into the
foramen ovale is generally caused by a heavy weight falling upon the pelvis,
whilst the back is bent forwards, and the thighs are separated from each other.
The ligamentum teres and the lower part of the capsular ligament are torn through,
and the head of the bone becomes placed in the posterior and inner part of the
thigh, upon the obturator externus muscle.
It has been erroneously supposed that the
ligamentum teres is not torn through in this dislocation ; because in the dead
body, when the capsular ligament is divided, and in the living body in certain
cases of relaxation, the head of the bone can be drawn over the lower edge of the
acetabulum without tearing the ligamentum teres. But this ligament is of
necessity torn through in the ordinary dislocation from violence.
Quote p. 93
The original acetabulum was half filled by
bone, so that it could not have received the head of the thigh-bone if an
attempt had been made to return it into its natural situation. The head of the
thigh-bone was very little altered; its articular cartilage still remained; the
ligamentum teres were entirely broken, and the capsular ligament was partially
torn through; the pectinalis muscle and adductor brevis had been lacerated, but
were united by tendon; the psoas muscle and iliacus internus, the glutei and
pyriformis, were all upon the stretch. Nothing can be more curious, or, to the
surgeon and physiologist, more beautiful, than the changes produced by this
neglected accident. * (See the figures at pages 53 and 54.)
Quote pp. 101-102
SECTION IV. DISLOCATION BACKWARDS, OR INTO THE ISCHIATIC NOTCH.
…
DISSECTION. - There is a good specimen of this
accident in the collection at St. Thomas's Hospital, which I met with
accidentally, in a subject brought for dissection. The original acetabulum is
entirely filled with a ligamentous substance, so that the head of the bone
could not have been returned into it. The capsular ligament is torn from its
connexion with the acetabulum, at its anterior and posterior junction, but not
at its superior and inferior. The ligamentum teres is broken, and an inch of it
still adheres to the head of the bone. The head of the femur rests behind the
acetabulum on the pyriformis muscle, at the edge of the notch, above the
sacro-sciatic ligaments. The muscle on which it rests is diminished, but there
has been no attempt made to form a new bony socket. Around the head of the
thigh-bone there is a new capsular ligament; it does not adhere to the cartilage
of the head of the bone which it surrounds, but could, when opened, be turned
back to the neck of the thigh-bone, so as to leave its head completely exposed.
Within this new scapular ligament, which is formed of the surrounding cellular
membrane, the broken ligamentum teres is found. The trochanter major is placed
rather behind the acetabula, but inclined towards it.
 |
| Fig. 13. |
Quote p. 111
SECTION V. DISLOCATION ON THE PUBES.
…
DISSECTION. - I dissected the first of these
dislocations, and it is preserved in our anatomical collection. It shows
changes of parts nearly equal to those of the dislocation into the foramen
ovale. The original acetabulum is partly filled by bone, and partly occupied by
the trochanter major, and both are much altered in their form. The capsular
ligament is extensively lacerated, and the ligamentum teres is torn through.
The head of the thigh-bone had torn up Poupart's ligament, so as to penetrate between
it and the pubes. The head and neck of the bone were thrown into a position
under the iliacus internus and psoas muscles, the tendons of which, in passing
to their insertions over the neck of the bone, were elevated by it, and put on
the stretch.
Quote p. 118
Post-mortem examination.
The anterior part of the capsular ligament,
where covered by the tendons of the psoas and iliacus muscles, was the only
part not torn through. The ligamentum teres was torn from the head of the femur
and sloughy, and the head of the bone at the anterior and inner part absorbed.
The epiphysesquite loose, but the cartilage of the acetabulum was not
ulcerated, although there was a slight change from the ulceration of the
ligamentum teres. The trochanter major was still attached to the shaft of the femur
by epiphysis.
Quote p. 122
SECTION VI. ANOMALOUS DISLOCATIONS OF THE HIP-JOINT.
…
There seems something a little anomalous in the
frequency of the dislocation of the femur upwards and backwards upon the dorsum
of the ilium, for upon examination of the hip-joint it will be found that it is
the direction of all others in which there seems to be the greatest protection
against dislocation, the capsular ligament being there the strongest, the edge
of the acetabulum the most elevated, and the ligamentum teres offering the
greatest hinderance to displacement in that direction. There is comparatively a
much greater apparent facility to the dislocation into the foramen ovale, for
the under and inner part of the acetabulum is partly formed of fibro-cartilage;
the capsular ligament is much thinner here than at the upper part; and the
ligamentum teres does not offer the same resistance to the displacement in this
direction that it does to that over the upper part of the cotyloid cavity.
Quote pp. 126-127
CASE LXVIII. - During the summer of 1829, a man
about forty years of age was brought into St. Bartholomew's Hospital laboring under
pneumonia, of which he died. On examining his body, I observed that the left
limb was somewhat everted, a little separated from the right, and shortened to
the extent of half an inch. The head of the bone could be felt resting on the
ilium, between the acetabulum and the anterior inferior spinous process. On
dissecting the muscles of the hip-joint, I found them in a healthy condition,
excepting the obturator externus, which was small, of a brown color, with fat
deposited between its fibres, and the tendon was torn from its attachment to
the femur. The head of the femur, surrounded by its capsular ligament, rested
upon the ilium, between the acetabulum and the anterior and inferior spine, in
a cavity which was there formed, partly by a preternatural growth of bone, and
partly by what appeared to me to be the upper portion of the cotyloid ligament,
which was probably displaced at the time of the accident. The original
acetabulum was contracted, and filled up by a fibrous substance. The ligamentum
teres was entire, elongated and flattened. The cartilage covering the head of
the femur was in its natural condition, where it was in contact with the cavity
in which it was lodged, but at the inferior aspect of the head of the bone the
cartilage was irregularly absorbed.
On inquiring into the history of the patient, I
ascertained that when he was about fourteen years of age he fell from a ladder,
which produced the injury I have described. At the time of the accident he experienced
considerable pain, and for many months much difficulty in walking; but he
eventually recovered, and at the time of the attack of the inflammation of the
lungs, which destroyed him, he was actually engaged in carrying out beer for a
publican in Portugal-street. In this case, at the time of the accident the
cotyloid ligament must have been partially separated, and probably a portion of
the acetabulum was separated at the same time, which would allow the head of
the bone to occupy the situation which it maintained without the ligamentum
teres being necessarily ruptured. I cannot conceive it possible that any
dislocation can take place without rupture of the ligamentum teres, provided it
be of its usual length, unless indeed a portion of the acetabulum be separated
at the same time. In all the other cases which have come under my observation
where there has been fracture of the acetabulum, with displacement of the head
of the femur, the ligamentum teres has been destroyed. In this case, had any
attempt been made to replace the bone, perhaps much difficulty might have
occurred in keeping it in its natural position; since in cases where the
acetabulum has been fractured, although the head of the femur has been readily replaced,
I have seen it impossible to retain it in its proper position. This difficulty
I apprehend will depend upon the size of the portion of the acetabulum which is
separated.
This accident offers an illustration of the
circumstances which may prevent the head of the femur from being maintained in
the usual position of dislocation upon the pubes, which there can be no doubt
would have been the nature of this luxation had not the unruptured ligamentum
teres retained the bone upon the ilium, although the fracture of the acetabulum
permitted the head of the femur to leave its cotyloid cavity. But neither this
case nor the preceding one can be justly considered as a new kind of
dislocation; they are merely proofs of the variety of injuries which may occur
simultaneously with dislocation, and which may influence the position of the
displaced bone.
Quote pp. 145-146
CHAPTER III. ON FRACTURES OF THE PELVIS.
…
CASE LXXXI. -The following case I consider
worthy of narration, in consequence of the extent of fracture of the bones of
the pelvis, as well as of those of the lower extremities, as such a
complication requires strict examination to ascertain the degree of injury
sustained ; for however judiciously the treatment might have been applied to
the fractures of the lower extremities, it might have proved unavailing, unless
active means were employed to subdue the inflammation concomitant with fracture
of the pelvis. It is true in this case the patient did not survive; but Mr.
Vincent, by ascertaining the full extent of the injury, was enabled to
administer every remedy applicable to the condition of the patient.
A man sixty-five years of age was brought into
St. Bartholomew's Hospital, in consequence of a severe injury he had received
from a brewer's dray having passed over him. Upon examination after he was placed
in bed, a fracture of the right thigh was discovered, the bones overlapping
each other; and there was also an inversion of the left foot. On proceeding
carefully to examine the cause of this inversion, it was observed that on
attempting to rotate the left leg outwards, it suddenly regained its natural
position, accompanied with a noise as if the bone had slipped into its socket.
The hand being placed on the great trochanter, a crepitus was communicated
indicating fracture at its basis. The left fibula was also broken, and there
was a severe contusion of the right ankle. The patient on his admission was in
a state of collapse, his pulse small and weak, the surface of his body cold; he
discharged his fæces involuntarily, and his answers when questioned were
vacillating and confused; he was ordered wine and opium. The patient regained
in some measure the natural temperature of his body, but continued to pass his
fæces involuntarily, and died on the second day after his admission.
Upon examination of the body, it was found that
a portion of the bony ring of the left acetabulum was broken off, although in
some measure retained in position by the cotyloid ligament, which was entire; this
accounts for the inversion of the left foot, as well as for the noise which was
heard when the limb was rotated. The head of the femur probably rested on the
broken surface of the ilium; but the ligamentum teres was entire, so that the
attempt at rotation brought the head of the femur completely into the socket,
and permitted the fragment of the ilium to regain its natural position. A
fracture was discovered, as had been prognosticated, through the base of the
trochanter, but it did not include the shaft of the bone. The fracture extended
from the acetabulum through the os innominatum, so as to divide it into nearly equal
portions, the fractured edges overlapping each other to the extent of two
lines. There was also a partial dislocation of the sacroiliac symphysis of the
same side. The viscera were uninjured.
This case is recorded in Vol. I., new series,
of the Lancet.
Quote p. 160
SECTION II. FRACTURE OF THE NECK OF THE THIGH-BONE, WITHIN THE CAPSULAR LIGAMENT.
…
The third reason which may be assigned for the
general want of union of this fracture is the almost entire absence of
nutrition in the head of the thigh-bone when separated from its cervix, its
life being supported by the ligamentum teres, which has only a few minute
vessels ramifying from it to the head of the bone. It may be observed that the neck
and head of the thigh-bone are naturally supplied with blood by the periosteum
of the cervix, and that when the bone is fractured, if, as most frequently
happens, the periosteum be torn through, the means of ossific action are, in
consequence of such fracture and laceration, necessarily destroyed in the head
of the bone. Scarcely any change, therefore, takes place in the head or neck of
the bone attached to it; no deposit of cartilage or bone similar to that in
other fractures is produced; but the deposit which does take place, as may be
seen in the plates of fracture of the neck of the thigh-bone, consists of
ligamentous matter covering the surface of the cancellated structure, together
with the little patches like ivory on the head of bone.
Quote p. 161
The appearances which are found on the
dissection of these injuries are as follow: - The head of the bone remains in
the acetabulum attached by the ligamentum teres; there are, upon parts of the
head of the bone, very small white spots like ivory; the cervix is sometimes broken
transversely, at others with obliquity. The cancellated structure of the broken
surface of the head of the bone and of the cervix is hollowed by the occasional
pressure of the neck attached to the trochanter, and consequent absorption; and
this surface is sometimes partially coated with a ligamento-cartilaginous
deposit.
Quote p. 172
CASE LXXXIX.-A young man, in his eighteenth
year, fell from the top of a loaded cart upon his right hip, the injury of
which was attended with the following symptoms. He was wholly unable to move the
limb, and suffered great pain when it was moved by another person. The thigh
was bent to a right angle with the pelvis, and could not, by any means, be
extended. Abduction of the thigh was difficult. The limb was everted, at first
slightly, afterwards in a greater degree. There was no shortening, but rather
an apparent lengthening of the limb in the erect posture, probably from the
obliquity of the pelvis. No crepitus could be felt during any movement of the
limb. The soft parts about the hip were considerably swollen.
The case was considered doubtful, but more
probably a dislocation than a fracture; forcible extension was therefore made
with the pulleys, and the head of the bone was removed in various directions,
so as to restore it to its socket.
Three months after the accident the patient
died of small-pox. On examination of the body, the capsular ligament of the
injured hip was found entire, but a little thickened. The ligamentum teres was
uninjured. A line of fracture extended obliquely through the neck of the femur,
and entirely within the capsule. The neck of the bone was shortened, and its
head approximated to the trochanter major. The fractured surfaces were in the
closest apposition, and firmly united nearly in their whole extent by bone.
There was an irregular deposit of bone upon the neck of the femur, beneath its
synovial and periosteal covering, along the line of the fracture. * (Abridged
from Mr. Stanley's paper in the Med.-Chir. Trans. vol. xviii. p. 256. This case
corroborates Sir Astley Cooper's opinion, respecting the mode of reparation of fractured
neck of the thigh-bone, when neither the capsular ligament or periosteum are torn.
- Ed.)
Quote p. 863
PARTIAL DISLOCATION UPWARDS.
…
The head of the humerus is said to owe the security of its position rather to the combined influence of the capsular muscles, than to the ligamentous attachments of the humerus to the scapula; and the tendon is vaguely described as strengthening the joint, and in that respect, as bearing an analogy to the ligamentum teres of the femur.
External links
Cooper A. A Treatise on Dislocations and Fractures of the Joints. Philadelphia: Blanchard and Lea, 1851. [books.google]
Authors & Affiliations
Astley Paston Cooper (1768-1841) was a British surgeon and anatomist, professor of comparative anatomy to the Royal College of Surgeons. [wikipedia.org]
 |
| Sir Astley Paston Cooper, 1st Baronet (23 August 1768 – 12 February 1841) Published in London: George Lawford, 1825; original in the wikimedia.org collection (CC0 – Public Domain, no changes) |
Keywords
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, vascularization, fracture, dislocation, blood supply
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