Lower limb

“ In children, the most frequent subjects of such disease, excision of the lower limb may, by removing the epiphyses, cause to a very considerable degree disparity in their length, thus rendering them nearly useless, while in the upper such disparity is neither so extensive nor so injurious to the usefulness of the limb, which is not required for purposes of progression. ”

“ Clinical Features.—The affected limb is flexed, adducted, and inverted, so that the knee crosses the lower third of the opposite thigh, and the ball of the great toe lies on the dorsum of the sound foot. There is shortening to the extent of from 11/2 to 2 inches, the trochanter being displaced above Nélaton's line, and lying nearer to the anterior superior iliac spine than on the normal side. The patient is unable to move the limb or to bear weight upon it; abduction and lateral rotation are specially painful; and traction fails to restore the limb to its proper length. ”

“ The limb is retained in this position by the application of a straight splint behind, hollowed at the extremities, extending from a little below the tuberosity of the ischium to below the middle of the leg, and retained by a roller, not at all tight;583 the foot and lower part of the limb must be previously bandaged to prevent infiltration. All apparatus with straps, buckles, and apertures to receive the portions of the bone, are worse than useless. ”

“ Localised tenderness can almost always be elicited by percussion, or by compressing the bone between the fingers and thumb. The pain induced by the traction of muscles attached to the bone, or by the weight of the body, may interfere with the function of the limb, and in the lower extremity cause a limp in walking. The limb may be disabled from involvement of the adjacent joint, in which there may be an intermittent hydrops which comes and goes coincidently with exacerbations of pain; or the abscess may perforate the joint and set up an acute arthritis. ”

“ The anterior limb of P make like L inverted; but the posterior like the standard of I: at bottom, however, you are not to add an oblique square, but amputate the limb diagonally, & draw at the bottom a broad transverse limb, which likewise is to be cut off diagonally, so that the lower point shall project to the left, a distance of half the breadth of the limb. ”

“ The parts of the limb out of the course of this vessel and of the great superficial veins are comparatively much less painful than on the lower and anterior part of the thigh; for several inches above the knee firm and continued pressure is borne without complaint. The countenace is pale and sunk. The pulse rapid. There is great irritability and prostration of strength. ”

“ It was still early, and though the sun’s lower limb was just free of the hill, his rays, ungenial and peering, addressed the eye rather than the touch as yet. ”

“ Whenever a tight ligature applied to a limb makes the lower part swell, whenever too long standing, a perpendicular position of the superior extremities, &c. produce the same effect, it is to be presumed that the effusion depends upon the compression of the lymphatics, and takes place then like venous dilatations in similar circumstances, because the lymph finds it difficult to circulate. ”

“ Those who experience a dislocation backwards can neither extend the ham nor the knee, nor can they bend the limb before bending the groin also. The leg appears shorter, the groin looser, and the head of the thigh is to be felt at the buttock. When, then, from infancy, or simply, when for a length of time the limb has been neglected after being dislocated, and allowed to remain so, the cure is impracticable, callus having been already formed. But when the luxation is recent, it may be managed in the way recommended by Hippocrates. ”

“ 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. ”

“ The other bones of the human body sometimes undergo subluxation, and sometimes complete luxation, but the articulations at the hip and the shoulder are subject only to complete luxation, more especially the hip-joint, because it has a deep and round cavity which is further strengthened by a strong brim. The limb, then, being subject to displacement from its cavity by some great violence, many differences arise according to the greater or less degree of the dislocation. ”

“ In adolescents and adults the limbs seldom become affected; the bones composing the spinal column are the seat of the disease, and, along with the distortion of the spine, the position of the ribs is necessarily altered. Certain rare cases have occurred, in which all the bones of the adult were softened to a very great degree. In one remarkable instance, the patient complained of an annoying sense of tightness in the limb most affected, and, on examination, the softened bone was found greatly depressed at that point, as if a strong ligature had been drawn tightly round it. ”

“ Those at the knee, for example, contribute more to the length of limb than do those at the hip or ankle, and they are also the last to unite. In the upper limb the more active epiphyses are at the shoulder and wrist, and these also are the last to unite. ”

“ The pain which is felt at first a little behind the hip-joint steadily increases in severity and extends along the course of the nerve and its branches in many instances as far as the toes. The specially painful points are about the knee and ankle joints; besides which a feeling of numbness is experienced throughout the whole limb. In severe cases all movement of the limb aggravates the pain, and the patient is obliged to remain in bed. In prolonged attacks the limb may waste and be drawn up and fixed in one position. ”

“ For if the accident be recent and the patient young, we may sometimes succeed in reducing the limb by grasping and rotating the thigh this way and that. When the dislocation is inwards we may sometimes accomplish our purpose by bending the limb at the groin inwards frequently and strongly. If the dislocation does not yield to these means we must have recourse to extension, first with the hands, certain assistants grasping the thigh and leg and pulling the limb downwards, while others grasp the body at the armpits and pull upwards. ”

“ Sometimes the pain is confined to the knee, and if the examination is restricted to that joint the disease at the hip may be overlooked. At this stage the attitude of the limb is not constant; at one time it may be natural, and at another slightly flexed and abducted. Tenderness of the joint may be elicited by pressing either in front or behind the head of the bone, but is of little diagnostic importance. ”

“ If no means are taken to replace the bone, and painful feelings subside along with the swelling, the limb remains long useless, and is the seat of occasional lancinating pains, but at last motion and utility are to a certain extent restored by the formation of a new joint—the head of the bone, and the parts on which it rests, mutually accommodating themselves to each other, by degrees, and permitting a limited extent of motion. ”

“ Complicated cases occasionally occur—as when a patient who has been labouring under hip-joint disease, perhaps not in an aggravated form, falls heavily, and on being lifted up is found to be incapable of moving the joint, the limb at the same time being elongated, and having a distorted appearance. ”

“ The circumstances attending the first stage of the disease in childhood, in which the limb is lengthened, and there is no decrease, but rather an enlargement of the parts composing the joint, have been already described and illustrated. When, however, absorption occurs, and the articulation begins to be destroyed, the second stage of the disease commences, and the limb becomes then sensibly shortened; the toes are turned inwards or outwards; in many cases there is every appearance of dislocation of the thigh upward and backward ”

“ The limb is adducted, its normal range of abduction, and sometimes also of flexion, is restricted, and there is, as a rule, some degree of lateral rotation, so that the toes point outwards. It should be noted that the same picture—shortening with eversion and stiffness at the hip—results from the common fracture of the neck of the bone in old people. The adduction element of the deformity is partly compensated for by upward tilting of the pelvis on the affected side and curvature of the spine with its concavity towards the affected limb. ”

“ After a time, flexion can be made to a right angle; and the limb becomes tolerably useful. By unsuccessful attempts to restore the natural position, inflammation is excited; and thus the salutary processes, commenced by nature for reparation of the displacement, are interrupted and delayed; in young persons such disease of the joint may be produced as might lead to loss of the extremity.
Luxation of the Radius alone, backwards on the outer condyle, is sometimes met with; but this bone is seldom singly displaced far from its original site. ”

“ There may be a feeling of weight in the limb, and in the case of the knee and ankle the patient tires on walking and drags the leg with more or less of a limp. Movements of the joint are permitted, but are limited in range. ”

“ But the injured limb, in this case, can support the body much better than in dislocation inward, both because the head of the femur and the neck of its articular extremity, being naturally oblique, have formed a bed under a considerable portion of the hip, and because the extremity of the foot is not forcibly turned outward, but is nearly in a line with the body, and is even inclined more inwardly. ”

“ Again, and particularly in adults, the limb is easy only in certain positions, and cannot be moved without great suffering; pain is also complained of in the groin, and often immediately behind the trochanter major. ”

“ This is well seen in adults who have suffered from severe disease of the hip in childhood--the entire limb, including the foot, being shorter and smaller than the corresponding parts of the opposite side. ”

“ This may soon be absorbed and with it the articular ends of the bones wear away and break down into small fragments. The limb becomes atrophied and shrunken, and the joint itself becomes weak, often flail. ”

“ If he finds an arm has lost motion, he goes to arm to explore for cause. He can begin his hunt for cause at hand, explore it carefully for wounds, strains or any lesion that could injure nerves of the arm. If he finds no probable cause there, he should explore bones for dislocations or strains of ligaments at elbow; if he finds no defect there sufficient to locate cause in lower arm or hand; he has only two more places left to inspect, the shoulder and neck with their [Pg 42] articulations of bone and muscles. ”

“ The limb usually becomes flexed and adducted, and a swelling forms in front of the joint at the upper part of Scarpa's triangle; the upper femoral epiphysis may be separated and furnish a sequestrum.
The flexion and adduction of the limb favour the occurrence of dislocation. A child who has recovered with dislocation on to the dorsum ilii is usually able to walk and run about, but with a limp or waddle which becomes more pronounced as he grows up. ”

“ The reduction of a dislocated limb, in a person of muscular frame, is one of the most fearful and difficult operations in surgery; and in a lad or a female, there is much in the attending circumstances to excite the liveliest interest of the spectator. ”