excessive and unnecessary force and rupture of the ilio-femoral ligament. Reduction must be accomplished by manipulation. Fig. 581. — Reduction of the common backward dislocation of the hip (see text). In Bigelow's method the thigh is flexed to a right angle, adducted, rotated inward, 'lifted, circumducted outward and extended. The lifting of the thigh is the essential step in the reduction of backward dislocations and may be aided by counter-pressure with the unbooted foot as shown in this plate. In Bigelow's method of reducing anterior luxations the thigh is flexed to a right angle (as shown in this illustration), abducted, rotated inward, adducted and extended. This modification is readily understood if the position of the head in anterior luxations is kept in mind. In reducing a dorsal dislocation, the first step consists in flexing the thigh to a right angle, which move relaxes the Y-ligament. Traction is then made in the line of the axis of the semi-flexed femur, which draws the head of the bone up on to and over the acetabular rim. Outward rotation is then performed, and the thigh allowed to gradually assume the horizontal, or extended position. The head of the bone should slip back into the socket as outward rotation is commenced, or during the first part of extension. The most essential part of this manipulation (Bigelow's method) consists in drawing the femoral head forward from the dorsum of the ilium over the acetabular rim. <Callout type="important" title="Important">An anesthetic is often essential to the reduction of dislocations of the hip, especially in well-muscled persons.</Callout> Fig. 582. — Stimson's method of reducing posterior luxations. The weight of the lower extremity pulls in the direction indicated by the arrow and this alone may be sufficient to effect reduction. Downward pressure, however, with the hand, as shown, will render the method more certain. (See text.) Fig. 583. — Author's modification of Bigelow's method. The thigh is 'lifted' (raised sky-ward) by the surgeon's shoulder while counter-pressure is exerted on the anterior-superior iliac spine. While the opposite hand exerts divert pressure on the trochanter and prevents it from moving adduct and anterio-lateral to the rim of the acetabulum. (See text.) It has been the author’s experience that difficult cases may be handled in this way after the unmodified Bigelow's method has failed. An anesthetic is often essential to the reduction of dislocations of the hip, especially in well-muscled persons. <Callout type="important" title="Important">An anesthetic is often essential to the reduction of dislocations of the hip, especially in well-muscled persons.</Callout> The author has found the following original method of accomplishing this result successful in instances in which the above manipulation failed. With the hip and knee flexed at right angles the surgeon places his shoulder under the bend of the knee, one hand is placed on the anterior superior iliac spine, while the opposite hand grasps the trochanter, and exerts pressure in the desired direction. In this position forward traction is made by raising the shoulder, direct manipulation is had by the hand on the tro- chanter, while counter-traction is exerted through the hand resting on the iliac spine. During this manipulation an assistant should securely hold the patient's ankle, thus fixing the lower leg. According to instructions issued by the surgeon to his assistant during manipulation the ankle may be carried away from, or toward the median plane, thus producing inward or outward rotation of the thigh as desired. In this way the head may be controlled, and forced up on to the slope of the acetabulum, rather than allowing it to ride about the margins of the rim. (See Fig. 583.) No originality is claimed for the principles involved in this manipulation since it is only a modification of Bigelow's method. When, however, difficulty is experienced in forcing the head of the femur over the rim of the acetabulum this manipulation will be found much more efficient than the regular Bigelow's method. Stimson's method is as follows: The patient is placed face downward on a table. The injured thigh is allowed to hang over the edge of the table at a right angle, while the uninjured extremity is maintained in the horizontal position by an assistant to stead}^ 528 FRACTURES AND DISLOCATIONS the pelvis. The surgeon then tiexes the knee, and the weight of the knee, with the muscles relaxed, is said to be sufficient to effect reduction. Slight rotation and downward traction will assist in accomplishing the return of the head to the acetabulum. This method works nicely in some cases, though it is by no means as efficient as Stimson's method of eft'ecting reduction in dislocations of the shoulder. All of the above methods are based on the same principles: namely, bringing the head opposite the capsular rent by flexion and rotation of the thigh, and then forcing the head over the acetabular rim and through the capsular rent by traction in the line of the axis of the femur. Allis fully appreciated the value of fixation of the pelvis and advises having it secured to the floor by means of a system of screw eyes and bandages (see Fig. 584) or else by means of assistants. This however will not be necessary if the author's modification of Bigelow's method is employed. The reduction of anterior displacements is accomplished by the same principles as already described, although the difference in the position of the head will necessitate different manipulations to bring the head opposite the capsular rent. The ilio-pectineal dislocation and its variations along the horizontal ramus of the pubis are reduced as follows : extension is made to bring the head downward as far as possible so that flexion can be accomplished. The thigh is then flexed at a right angle with the body, while direct pressure is made upon the head to prevent its slipping upward. Inward rotation and traction in the line of the axis of the femur are then performed to return the head to the socket. The last step in this manipulation is similar to that already described under dorsal dislocations. The obturator dislocation and its exaggerated form, the perineal type, are reduced in much the same manner as dorsal dislocations after the head has been brought opposite the capsular rim. The steps are : flexion of the thigh to a right angle, traction in the line of the axis of the femur, and then, abduction and outward rotation. The limb is then extended. Central dislocations of the hip are reduced by outward traction on the upper end of the thigh while the knee is fixed. The condition is more properly a fracture than a dislocation. Buck's extension is indicated for from six to eight weeks and direct outward traction on the upper portion of the thigh should be maintained, according to the Ruth-Maxwell method, to prevent the muscles attached to the upper femur from pulling the head through the acetabulum into the pelvis. (See 'Ruth-Maxwell method,' page 545.) The strength of the muscles and the pain accompanying manipulations renders an anesthetic essential in the reduction of hip dislocations. Operative Treatment. — Nearly all dislocations of the hip can be reduced by proper manipulation under anesthesia, though occasionally it is impossible to return the head to the socket, unless recourse is had to operative methods. A vertical incision in the region of the trochanter can be so made as to expose the parts involved. When inward rotation is present the incision should be made a little behind the trochanter; when outward rotation is present the incision should be anterior to the trochanter to properly expose the head and neck. With the parts opened, the capsular rent and the course taken by the head after leaving the cavity of the acetabulum may be readily recognized, and by the proper manipulation, the head may be made to retrace its course back to the socket. Obstructions to reduction are to be removed when present. With the head again in the acetabulum, the capsular rent should be sutured, muscular structures approximated and the skin incision closed. Old, unreduced dislocations are the ones most frequently demanding operative reduction. When the head of the bone has been out of the socket for some time, fibrous tissue forms about it in such a manner that partial restoration of function results. The action of the thigh, however, is always more or less impaired because, if for no other reason, the upper end of the femur is 'off-center' with relation to the muscles of the hip. Partial or complete healing of the capsular rent often renders it impossible to accomplish reduction by simple manipulation. If some months have elapsed since the accident the acetabulum may become filled with fibrous tissue, which must be removed with a heavy curette or chisel before the head of the bone can be made to fit it. The joint is approached through a lateral, vertical incision, as already described, which varies somewhat with the type of dislocation present. 530 FRACTURES AND DISLOCATIONS Contractures in the thigh muscles sometimes necessitate transverse cutting of either tendons or muscles before the head of the bone can be returned to the socket. After-Treatment. — Following reduction of a recent dislocation the patient should be kept at rest in bed for a period of from two to four weeks, according to the age of the individual and the severity of the condition. Massage and passive motion are of service in maintaining the muscular tone of the lower extremity. In the performance of passive motion, however, abduction should be avoided, since this is the position in which the head probably left the cavity. Central dislocations and dorsal dislocations complicated by fracture of the acetabular ring require Buck's extension apparatus to maintain reduction. In addition central dislocation calls for lateral traction of the thigh. These appliances should be kept in use for a period of six weeks. During the after-treatment the weights employed in the traction apparatuses may be reduced as the muscular spasm grows less. The resumption of function should be gradual after the patient has recovered sufficiently to leave his bed. He should be instructed to particularly avoid any position of the thigh similar to the attitude in which dislocation occurred. Prognosis. — The outlook in uncomplicated dislocations of the hip is good if reduction is accomplished early and sufficient time allowed for the repair of the parts before function is resumed. Central dislocation of the hip is a much more serious condition, since it includes fracture of the pelvis and may be accompanied by injury to the pelvic viscera. Proper operative procedures are usually followed by improvement of function, though it is seldom possible to secure a perfect restoration, if the head of the bone has been out of the socket for any considerable length of time.
Key Takeaways
- Use anesthetic when reducing hip dislocations, especially in well-muscled individuals.
- Employ various reduction methods based on the type of dislocation (posterior, anterior, dorsal).
- Post-treatment involves bed rest and gradual resumption of function.
Practical Tips
- Always ensure proper immobilization before attempting to reduce a hip dislocation.
- Use traction and rotation techniques carefully to avoid further injury.
- Be prepared for the possibility of operative reduction if simple methods fail.
Warnings & Risks
- Avoid unnecessary force that could cause additional damage or complications.
- Do not attempt reduction without proper training, as improper technique can lead to severe injuries.
- Be aware that old dislocations may require more invasive procedures due to fibrous tissue formation.
Modern Application
While the specific techniques described in this chapter are historical and may not be directly applicable today, the principles of careful manipulation and immobilization remain crucial for survival scenarios. Modern medical practices have improved diagnostic tools and pain management, but understanding these foundational methods can still provide valuable insights for emergency preparedness.
Frequently Asked Questions
Q: What is Bigelow's method for reducing a backward dislocation of the hip?
Bigelow’s method involves flexing the thigh to a right angle, adducting and rotating it inward, lifting it, circumducting outward, and extending. The key step is 'lifting' the thigh, which can be aided by counter-pressure with the unbooted foot.
Q: Why is an anesthetic often necessary when reducing hip dislocations?
An anesthetic is often required because of the strength of the muscles around the hip and the pain associated with manipulating a dislocated joint, especially in well-muscled individuals.
Q: What are some post-treatment care instructions for a patient who has undergone reduction of a hip dislocation?
The patient should be kept at rest in bed for 2-4 weeks, and passive motion can help maintain muscle tone. Abduction should be avoided to prevent the head from slipping back out.