Alexander Miles

“ On account of the great strength of the hip-joint, dislocation is by no means a common injury. It occurs most frequently in strong adults after the epiphyses have ossified, and before the bones have commenced to become brittle; and it is much more common in men than in women. It is invariably the result of severe violence, the limb at the moment being in such a position that the ligaments are on the stretch and the muscles taken at a disadvantage. The head of the femur usually leaves the joint at the lower and back part, where the socket is most shallow and the ligaments weakest. ”

“ In all cases of head injury, the questions that dominate the whole clinical outlook are, whether the brain is directly damaged or not, and whether it is likely to become the seat of infection.
It is impossible to consider separately in their clinical aspects injuries of the cranium and injuries of the brain. It seldom happens that one is seriously damaged without the other suffering to a greater or less extent. Sometimes the skull suffers comparatively little, while the brain is severely damaged, but it is rare for a serious injury to the bone to be unaccompanied by definite brain lesions. ”

“ There are certain fallacies to be guarded against. For example, a fracture may exist and yet unnatural mobility may not be present, because the bones are impacted into one another, or because the fracture is an incomplete one. Again, the extreme tension of the swollen tissues overlying the fracture may prevent the recognition of movement between the fragments. Deformity also may be absent—as, for instance, when there is no displacement of the fragments, or when only one of two parallel bones is broken, as in the leg or forearm. ”

“ If sepsis gains the upper hand in a compound fracture there is, firstly, the risk of infection of the marrow—osteomyelitis—which in former times was liable to result in pyæmia; in the second place, not only do loose fragments tend to die and be thrown off as sequestra, but the ends of the fragments themselves may undergo necrosis ”

“ The commonest error is to mistake a case of cerebral compression for one of drunkenness. It is scarcely necessary to say that a man who smells of alcohol is not necessarily intoxicated; the drink may have been given with the object of reviving him. It may be that one or other of the above-named conditions has caused the patient to fall, and in his fall he has incidentally sustained an injury to the head, which, however, is in no way responsible for his unconsciousness. Whenever there is the least doubt, therefore, the patient should be admitted to hospital. ”

“ About middle life more active growth begins, the swelling becomes more fixed and is painful, and once it begins to grow, it increases rapidly and within a month or two may reach the size of a child's head. In spite of its size, however, it seldom causes interference with breathing or swallowing, and it has comparatively little effect on the general health. Clinically, the induration and fixation of the tumour suggest its epitheliomatous character, but the absence of a primary growth in the mouth or pharynx excludes its being a metastasis in the lymph glands. ”

“ Thus the age of the patient is of importance. During infancy and early childhood, fractures are less common than at any other period of life, and are usually transverse, incomplete, and of the nature of bends. During adult life, especially between the ages of thirty and forty, the frequency of fractures reaches its maximum. In aged persons, although the bones become more brittle by the marrow spaces in their interior becoming larger and filled with fat, fractures are less frequent, doubtless because the old are less exposed to such violence as is likely to produce fracture. ”

“ The first attempt at reduction may fail, and yet subsequent efforts, at intervals of a few days, may ultimately prove successful; the vigorous traction and twisting of the soft parts, matted together as they are by scar-tissue, causes reactive changes in the vessels and tissues which render them more liable to yield on subsequent attempts at reduction. In old people, and where there is an absence of suffering from pressure on nerves or vessels, it may be wiser to leave the dislocation unreduced, and strive rather by massage and movement to obtain a useful variety of false joint. ”

“ In injuries resulting from indirect violence, however, pain localised to a spot at some distance from the point of impact is strongly suggestive of fracture—as, for example, when a patient complains of pain over the clavicle after a fall on the hand, or over the upper end of the fibula after a twist of the ankle. Pain elicited by attempts to move the damaged part, or by applying pressure over the seat of injury, is more significant of fracture. ”

“ The practical importance of a given fracture depends upon whether it is simple or compound, rather than upon the exact nature of the damage done to the bone. Compound fractures which open the dura mater are the most serious. Simple fractures result, as a rule, from diffuse forms of violence, and are liable to spread far beyond the seat of impact. Compound fractures result from severe and localised violence—for example, the kick of a horse or the blow of a hammer—and tend to be limited more or less to the seat of impact. ”

“ When the displaced head lies against a bone, the continuous pressure produces a new osseous socket, from the margins of which osteophytic outgrowths may spring, and as the surrounding fibrous tissue becomes condensed and forms a strong capsule, a new joint results. The occurrence of these changes in the direction of a new ball-and-socket joint is largely dependent on the behaviour of the patient: a vigorous man, anxious to recover the use of the limb, will employ it with a degree of determination and indifference to pain that could not be expected in a sensitive elderly female. ”

“ A dislocation or luxation is a persistent displacement of the opposing ends of the bones forming a joint. We are here concerned only with such dislocations as immediately follow upon injury. Those that are congenital or that result from disease will be studied later.
Causes.—The majority of dislocations are the result of indirect violence, the more movable bone acting as a lever, on a fulcrum furnished by the natural check to movement in the form of ligament, bone, or muscle. It is in this way that most dislocations of the shoulder, hip, and elbow are produced. ”

“ There is often considerable difficulty in distinguishing a sprain of the ankle from a fracture without displacement, as both forms of injury result from the same kinds of violence, and are rapidly followed by swelling and discoloration of the overlying soft parts. ”

“ Failure of Union—“Un-united Fracture.”—As the time taken for union varies widely in different bones, and ossification may ultimately ensue after being delayed for several months, a fracture cannot be said to have failed to unite until the average period has been long overpassed and still there is no evidence of fusion of the fragments. Under these conditions failure of union is a rare complication of fractures. In adults it is most frequently met with in the humerus, the radius and ulna (Fig. 6) , and the femur; in children in the bones of the leg and in the forearm. ”

“ Congenital tongue-tie is a condition in which the tip of the tongue is bound down to the floor of the mouth by an abnormally short and narrow frenum, or by folds of mucous membrane on each side of the frenum, so that the tongue cannot be protruded. Although this deformity is rare, it is common for parents to blame an imaginary tongue-tie when a child is slow in learning to speak, or when he speaks indistinctly or stammers, and the doctor is frequently requested to divide the frenum under such circumstances. In the vast majority of cases nothing is found to be wrong with the frenum. ”

“ In injuries about the elbow much aid in diagnosis is usually obtained by the use of the X-rays; but in young children it is sometimes impossible, even with excellent pictures, to make an accurate diagnosis by means of radiograms alone. In cases of suspected fracture, a radiogram should be taken with the back of the limb resting on the plate, the forearm being extended and supinated. If a dislocation is suspected and a lateral view is desired, the arm should be placed on its medial side. In obscure cases it is useful to take radiograms of the healthy limb in the same position. ”

“ Deformities of the Knee resulting from Anterior Poliomyelitis and from Spastic Paralysis.—When there is paralysis of all the muscles acting on the knee, the joint may be so flail-like that the patient is unable to stand without the aid of a crutch, or when weight is put on the limb, it assumes the attitude of genu recurvatum. The usefulness of the limb may be improved by the application of a rigid apparatus with a lock at the joint so that it can be used in the extended position for walking or in the flexed position for sitting. ”

“ At the onset of the paralysis the affected limb is helpless and relaxed, the reflexes are lost, the muscles waste, and those that are paralysed exhibit the reaction of degeneration. In severe cases, and especially if proper treatment is neglected, the nutrition of the limb is profoundly affected; its temperature is subnormal, the skin is bluish in cold weather and readily becomes the seat of pressure sores. In course of time the limb lags behind its fellow in growth, and tends to assume a deformed attitude, which at first can easily be corrected, but later becomes permanent. ”

“ Tenderness is elicited on making pressure over the joint, on pressing together the iliac bones, or on attempting to abduct the limb while the pelvis is fixed. The muscles of the buttock and thigh are wasted. As any attempt to bear weight on the affected limb causes pain, the patient walks with a limp, and to save the joint he assumes an attitude which is characteristic: he throws his weight on the sound limb, leans forward, using a stick for support, tilts the affected side of the pelvis downwards, and flexes the hip and knee-joints of the diseased limb. ”

“ In examining an old person who has sustained an injury in the region of the hip, it should be borne in mind that the limb may be shortened and everted as a result of arthritis deformans, and that the symptoms of that disease may simulate those of fracture. ”

“ Treatment of Deformities resulting from Antecedent Diseases of the Knee.—Flexion is the commonest of these; when due to contracture of the soft parts, these are either stretched by degrees, the limb being encased in plaster after each sitting, or they are divided by open dissection in the popliteal space. If there is fibrous or osseous ankylosis, the choice lies between arthroplasty, the removal of a wedge of bone which includes the joint, or, in patients who are still growing, of a wedge from the femur above the level of the epiphysial cartilage. ”

“ The use of a strong knee-cap may prevent falling, but as a rule an operation is required, and there is quite a number to choose from, the principle of them all being to prevent displacement of the bone without unduly restricting flexion of the joint. That devised by Goldthwait consists in exposing, by means of a vertical incision, the whole length of the patellar ligament, splitting it longitudinally, separating the lateral half from the tibia, passing it under the medial portion and suturing it to the periosteum; this gives the quadriceps a straight line of pull. ”

“ In transverse fractures of the patella or of the olecranon there is often distraction or pulling apart of the fragments (Fig. 35) . The broken ends, especially in oblique fractures, may override one another, and so give rise to shortening of the limb (Fig. 2) . Where one fragment is acted upon by powerful muscles, a rotatory displacement may take place, as in fracture of the radius above the insertion of the pronator teres, or of the femur just below the small trochanter. The fragments may be depressed, as in the flat bones of the skull or the nasal bones. ”

“ The causes of one leg being shorter than the other are numerous and varied; they include such conditions as unilateral congenital dislocation of the hip, fractures united with overriding of the fragments, diseases of the joints, e.g., hip disease, or of the bones, especially such as interfere with the function of ossifying junctions; and acquired deformities such as unilateral flat-foot, knock-knee, or bow-leg. Clinically, this type of scoliosis is identified by observing that when the patient sits down the deviation of the spine disappears ”

“ Prognosis.—After having once been dislocated, a joint is seldom as strong as it was formerly, although for all practical purposes the limb may be as useful as ever. Some degree of stiffness, of limited movement, or of muscular weakness, and occasional arthritic changes and a liability to re-dislocation, are the commonest sequelæ. Prolonged immobilisation is liable to lead to stiffness by permitting of the formation of adhesions; while too early movement tends to produce a laxity of the ligaments which favours re-displacement from slight causes. ”