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The article: Birkett J. Description of a Dislocation of the Head of the Femur, complicated with its Fracture; with Remarks (1869). The author described the damage to the ligamentum capitis femoris (LCF) and its strength when observing a fracture-dislocation of the femoral head. The text in Russian is available at the following link: 1869BirkettJ.
Received Jan. 12th. - Read Feb. 23rd, 1869.
A WOMAN, et. 35, of rather short stature, was brought into
Guy's Hospital on account of the following injuries, the infliction of which
she survived a few minutes only. Tile skull was broken, and the brain
lacerated.
She had fallen from a second-floor window of a house on to
the pavement, the height of which, from the ground, was from twenty to
twenty-five feet.
After death it was observed that the left leg was slightly shorter
than the right, and the whole limb inverted; the left great toe rested on the
inside of the dorsum of the right foot, and there was considerable fulness in
the left gluteal region. On rotation of the left leg slight crepitus could be felt
in the region of the hip-joint.
When the gluteus maximus muscle was reflected the head of
the bone was seen lying upon the posterior border of the acetabulum, between it
and the great sacro-sciatic notch, about one inch from the base of the spine of
the ischium, above and anterior to it. At its upper border was the pyriformis
muscle, at its lower the obturator internus, with the gemelli. There was the
slightest laceration of the muscular fibres of the pyriformis. The
cartilage-covered head of the femur was uncovered by its capsular ligament, a
small piece of which lay torn upon it. At the edge of the fracture a few fibres
of the ligamentum teres remained attached to the usual depression on its
surface.
On further examination it was discovered that a portion of
the head of the femur had been broken off. This fragment, to which the greater
part of the ligamentum teres was still attached, remained in the acetabulum.
The fracture was remarkably even, and on a plane with the
vertical axis of the shaft of the femur. The flat face of the greater segment
lay upon the posterior surface of the os innominatum, just above the posterior
edge of the acetabulum, being prevented from ascending higher by its attachment
to the smaller segment, which was held in the cavity by the ligamentum teres.
The cartilage forming a hinge between the segments was in contact with the posterior
rim of the acetabulum.
The cotyloid ligament was detached from the posterior brim
of the acetabulum. A portion of it, an inch long, hung from its superior
border. The periosteum was stripped off the bone forming that portion of the
outside of the acetabulum against which the broken surface of the head of the
femur lay in close contact.
The rent in the capsular ligament was confined to its posterior
surface. It was about two inches in length. The site of the rupture was at the
iliac attachment for the upper part of the acetabulum and along its posterior
edge; it then extended midway beneath the iliac and femoral attachments beneath
the cervix, and ended at the lower part of the anterior surface. With this
exception the anterior capsular ligament was unhurt.
The shape of the bone was normal and its tissue quite healthy.
After replacing the head of the femur in the acetabulum, the line of fracture could be made to correspond with the posterior edge of that cup, when the shaft was flexed upon the pelvis to a right angle and slightly adducted.
Remarks. The dislocation of the head of the femur now described
belonged to that class termed by surgeons backwards and upwards, or on to the
dorsum ilii, although it was prevented ascending as high as usual on account of
its peculiar feature. That feature, fracture of the head, the rarity of which
will, I presume, be admitted, is the distinguishing characteristic of the
injury. It is to record this fact that I have ventured to relate the case to
the Society.
Authorities upon the subject of dislocations of the joints do
not even allude to this complication.
M. Malgaigne states - "The luxations of the femur are
but little complicated with fractures, either of the pelvic bones, the femur
itself, or more distant bones."
("Les luxations du femur ne sont guere compliquees que de
fractures, soit des os du bassin, soit du f6mur meme, soit d'autres os plus eloignes."1)
Having failed to find a parallel case in the book of Mr. Robert
W. Smith, of Dublin, I wrote to that gentleman, who did me the favour to reply
as follows: - "Although tolerably familiar with the literature of
fractures and luxations, I am not aware of any similar injury having been placed
on record as happening to the head of the femur."
We have then, probably, under observation an injury hitherto
undescribed.
The mode in which the head of the femur was broken is worthy
investigation. It may have happened in two ways. Either the head of the bone
was split by being forcibly driven against the strong edge of the acetabulum;
or the strength of the ligamentum teres and its attachment was sufficient to
overpower the cohesion of the bony tissue, whilst the femur was violently
driven upwards and backwards.
Perhaps both influences may have exerted combined action in
the production of the injury.
As displayed in the woodcut, Fig. 1, the close adaptation of
the broken surface of the head of the femur to the brim of the acetabulum, and
the neat way in which the latter fits in between the fragments, would seem to favour
the first explanation. On the other hand, as nearly the whole of the round
ligament still keeps its hold upon the lesser fragment, it would appear that
the bone tissue yielded to the traction exerted upon it, rather than the fibrous
structures.
This view of the mechanism of the injury is taken by Mr.
Smith. For with his letter to me he was so good as to send a drawing of an
injury to the articular head of the tibia, of which he thus writes: - "I
enclose a drawing of a lesion of the head of the tibia which I look upon as
being quite analogous. They are both, in my opinion, examples of a class of
injuries to which sufficient attention has not hitherto been devoted; they are
difficult of diagnosis and destructive in their results. I allude to the
violent tearing off of portions of the articular surfaces of bones by the traction
of powerful ligaments."
Lastly, the chief fact in this lesion may serve to explain some
of the difficulties experienced in keeping the head of the femur in the
acetabulum after its reduction. Most surgeons must have seen such cases, though
fortunately they are rare. In them "crepitus" is usually an attendant
circumstance, which is attributed to a fracture of the brim of the acetabulum,
but the injury may have been of the kind above described.
To conclude, I have to thank Mr. Davies-Colley, the registrar
at Guy's Hospital, for dissecting the preparation and describing it, as well as
Mr. G. Turner, a student, for executing the sketches, of which the woodcuts are
copies. The preparation is in the museum at Guy's Hospital.
FIG. 2.-a. Capsular ligament. b. Acetabulum, its bare edge
(1) exposed, and the bare surface (2) of os innominatum. c. Fragment of head of
femur. d. Cancellous tissue of the head of the femur. e. Cotyloid ligament torn
off from edge of acetabulum (1).
Birkett J. Description of a dislocation of the head of the femur, complicated with its fracture; with remarks by John Birkett (1815–1904). 1869. Clin Orthop Relat Res. 2000;377:4-6. journals.lww.com
Birkett J. Description of a Dislocation of the Head of the Femur, complicated with its Fracture; with Remarks. Med Chir Trans. 1869;52:133-8. pmc.ncbi.nlm.nih.gov
The work is cited in the following publications: LCF при переломе головки бедра. Обзор.
John Birkett (1815-1904) was an English surgeon at Guy's
Hospital.
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| John Birkett (1850s) Unknown author; original in the wikimedia.org collection (CC0 – Public Domain, fragment). |
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, pathology, acetabular labrum, dislocation, injury, damage, fracture, strength
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