1877BrookeC

 

Report by Brooke C. and discussion of the article Dislocations of the Thigh: their mode of occurrence as indicated by experiments, and the Anatomy of the Hip-joint. By Henry Morris. M.A., M.B. (1877). In the discussion, Dr. Barwell remarked that: «He agreed with Mr. Morris in regarding the ligamentum teres as of little importance in the prevention of dislocation; it probably did little more than protect the vessels passing to the head of the bone. He saw a case some years ago, in which there was congenital absence of the ligamentum teres; but he had no reason for believing that the man was more liable to dislocation of the femur than other persons.» The author of the article, Henry Morris, suggested that Malgaigne «... did not attach much importance to the ligamentum teres; and believed that it had no power to hold the bone in its place.».

 

ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, FEBRUARY I3TH, 1877.

CHARLES BROOKE, F.R.C.S., F.R.S., Vice-President, in the Chair.

DISLOCATIONS OF THE THIGH: THEIR MODE OF OCCURRENCE AS INDICATED BY EXPERIMENTS AND THE ANATOMY OF THE HIIP-JOINT. BY HENRY MORRIS, M.A., M.B.

The object of this paper was to show that dislocations of the thigh on to the dorsum of the ilium never occur, as is usually stated, while the limb is adducted, unless the dislocation is complicated with fracture; that all kinds of dislocation take place while the limb is abducted ; and that it depends upon the degree of extension or flexion, and of external or internal rotation associated with the abduction at the moment of accident, whether the head of the femur will be thrown forward or backward. The anatomy of the hip-joint, the results of experimental dislocations in the cadaver, and the positions of the body at the time when dislocation has actually occurred in the living, were adduced in support of this view. The conclusions arrived at in the paper were the following. I. The ilio-femoral ligament is a thickened triangular or fan-shaped area of the capsule of the hip-joint and not a Y-shaped ligament; besides the ilio-femoral band, there is a large portion of the capsule very thick and strong ; and, if two lines be drawn, one from the tuber ischii to the top of the trochanter major, and the other from the anterior inferior iliac spine to the trochanter minor, all the capsule between them above is thick and strong, whereas all below and between is thin and weak. 2. The thickened portion of the capsule determines the kind of manipulation necessary for reduction, and should be relaxed by flexion and abduction during any attempt to reduce a dislocation of the thigh. 3. The degree of extension or flexion and of external or internal rotation of the thigh at the time of luxation determines whether the dislocation will be pubic, thyroid, sciatic, or dorsal; and subsequently the "bridling" effect of the thickened portion of the capsule fixes and gives character to the dislocation. 4. All dislocations of the thigh, uncomplicated with fracture, occur while the limb is abducted. 5. Posterior dislocations result when flexion and inward rotation accompany abduction; and the anterior when extension with outward rotation accompany abduction; while the downward or thyroid variety occurs during extension and abduction. 6. Of the movements of the usually successful methods of manipulation, the head of the femur is brought (by flexion, abduction, and reverse rotation) to the part of the capsule through which it was displaced, viz., to the lower and inner side of it. 7. The new position of the head of the femur in the sciatic as in the dorsal dislocations is above the obturator internus muscle, though in both varieties the bone leaves the acetabulum through a rent in the capsule below the muscle; and for these reasons the classification of the posterior dislocations into "dorsal above" and "dorsal below" the obturator internus, as made by Bigelow and followed by others, is misleading if not invariably incorrect. 8. Dislocation through a " button-hole" is not possible, owing to the inelasticity of the capsule and the large size of the head of the femur compared with the width of the capsule from pelvis to femur; and in the reputed cases of unsuccessful efforts at reduction of this sort of dislocation, the real obstacle has been either a portion of muscle or of the capsule itself carried before the head of the femur into the acetabulum, or of a fragment of the head of the femur left in the acetabulum. 9. The rim of the acetabulum of itself offers no real resistance to reduction. 10. In the exceptional case of a direct dorsal dislocation, the untorn muscles and capsule would resist reduction by ordinary manipulation; and this resistance would be appreciable by the surgeon. 11. Direct dorsal dislocations, or those which are said to occur during adduction, are always the result of immense violence, and are always associated with fracture of the acetabulum, or of the head of the bone or of both. 12 Violent pain in dislocations at the hip is caused by the sciatic nerve being pressed upon or looped up by the femur; and pain or paralysis after reduction is due to dragging forward of the nerve upon the neck of the bone, or to its rupture in the act of reduction. 13. In reducing dislocations associated with great pain, it would be well to draw the head of the bone away from the side of the innominate bone during the movements of flexion and abduction, so as to disengage the sciatic nerve and thus prevent either of the accidents abovementioned.

Mr. WILLETT could not admit the novelty of Mr. Morris's views. Some years ago, a German surgeon-he believed Professor Busch-had visited the London hospitals and demonstrated that all dislocations of the thigh-bone occurred during abduction; that it depended on the subsequent arrangement of the limb whether the head of the bone should be thrown backward or forward. This doctrine had since been an article of faith at St. Bartholomew's Hospital; and Mr. Willett had for some time taught it to his class. Within the last ten or twelve years, also, it had been the almost universal custom to reduce dislocations of the thigh by manipulation, the whole process of which depended on the fact of the capsule being rent at the lower part. - Mr. MIAUNDER said that it was evident that the author of the paper had devoted much attention to the subject; and he thought he had proved his case. He had no doubt that Mr. Morris's researches were made quite independently of those of Professor Busch, with which they agreed; but he would ask how it was that Malgaigne, who had carefully studied the subject, had not found that the dislocation was produced in the way now described. Malgaigne spoke of rupture of the lower part of the capsule as the exception rather than the rule. - Mr. BARWELL had no doubt that dislocations of the femur were produced in the way described by Mr. Morris. He mentioned the case of a man on whom a mass of coal fell on his sacrum in a coal-mine; this, it might be supposed, would cause the head of the bone to be thrown backwards, whereas it was dislocated forwards on the anterior inferior spine of the ilium. He agreed with Mr. Morris in regarding the ligamentum teres as of little importance in the prevention of dislocation; it probably did little more than protect the vessels passing to the head of the bone. He saw a case some years ago, in which there was congenital absence of the ligamentum teres; but he had no reason for believing that the man was more liable to dislocation of the femur than other persons. - Mr. MACCORMNAC said that he had never been able to drive the head of the femur out of the acetabulum except at the lower part of the capsule. He asked if any observations had been made in which the head of the femur was embraced by the obturator internus. -Mr. MORRIS, in reply, said that he was not aware that the views which he brought forward had been already taught. It was stated in surgical books, even in the latest editions of the works of Bryant and Holmes, that dislocations of the femur occurred during adduction. As to manipulation, neither Bigelow nor Hamilton explained its results by assuming the theory of abduction, but by supposing that it broke down any portion of capsule that might prevent reduction. In the days of Malgaigne, experiments were probably not so often performed as now; and It was rare to have an opportunity of making a post mortem examination of a case of dislocated femur. He did not attach much importance to the ligamentum teres; and believed that it had no power to hold the bone in its place. He was not aware of any case in which the head of the bone was embraced by the obturator internus muscle.

External links

Brooke C. Dislocations of the Thigh: their mode of occurrence as indicated by experiments, and the Anatomy of the Hip-joint. By Henry Morris. M.A., M.B. Reports of Societies. Br Med J. 1877Feb17;1(842):203. [pmc.ncbi.nlm.nih.gov]

Morris H. Dislocations of the Thigh: their mode of occurrence as indicated by experiments, and the Anatomy of the Hip-joint. Medico-Chirurgical Transactions. 1877;60:161-186.1. [pmc.ncbi.nlm.nih.gov]

Morris H. Dislocations of the Thigh: their Mode of Occurrence. British Medical Journal, 1877;1(843)244-245. [pmc.ncbi.nlm.nih.gov]

Authors & Affiliations

Charles Brooke (1804-1879) was an English surgeon and inventor. [wikipedia.org]

Charles Brooke (before 1879)
Author unknown, image in wikipedia.org collection (CC0 – Public Domain, no changes).

Barwell, Richard (1827-1916) was an English surgeon, lecturer in surgery. [livesonline.rcseng.ac.uk]

Henry Morris (1844-1926) was a British medical doctor and surgeon. [wikipedia.org] 

Sir Henry Morris (before 1915)
 Author Anton Mansch, published by A. Eckstein, Berlin; 
original in the wikimedia.org collection (CC0 – Public Domain, no changes).

Keywords

ligamentum capitis femoris, ligamentum teres, ligament of head of femur, role, role, dislocation, absence

                                                                    

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