Congenital Luxations Of The Hip

In congenital luxations the acetabulum may be shallow, the head deformed, and the neck somewhat twisted on its shaft. These luxations are usually posterior.

Signs

There is no eversion, no flexion on lying down in young cases, but lordosis is seen on standing (Fig. 523) and in old cases, also on lying down. The main point for diagnosis is shortening. The limb is shorter, measured from the anterior superior spine, and the anterior iliotrochanteric angle (page 505) is diminished or lost; the tip of the trochanter is above the Roser-Nelaton line, and the base of Bryant's triangle is lessened or even obliterated on the affected side. By careful palpation it can be recognized that the head is absent from its normal position beneath the femoral artery. Frequently the top of the trochanter is on a level with the anterior superior spine. The use of the X-ray is necessary to ascertain accurately the position of the head and as to whether or not the bones possess their normal shape.

Reduction

As the head is usually more or less fixed in its abnormal position, force has to be used to replace it. Paci of Pisa was the first to reduce them systematically by a modification of the circumduction method. He flexed the thigh on the abdomen, then firmly abducted, rotating outward, and used the edge of the table as a fulcrum.

Lorenz used Konig's padded, wedge-shaped block under the trochanter as a fulcrum to pry the head forward. The writer combined the direct and indirect methods by placing the child face down on a table with the affected hip on a sand pillow and the leg and thigh hanging over the side. The operator or an assistant then raises (flexes) the knee, bringing it toward the patient's axilla, while the operator presses with his hands and body-weight down on the trochanter. By gradually raising the knee and keeping it close to the body and pushing the head forward it eventually slips from the posterior to the anterior plane and into place (Fig 524). When the head has been brought onto the anterior plane it is usually impossible to extend the knee, on account of tension of the hamstring muscles, as pointed out by Lorenz.

After being reduced the thigh cannot be brought down at once to its normal position, as by so doing the head jumps out of its socket; so it is put up in plaster of Paris in an abducted position for some time and brought down gradually.

Hip-Disease (Coxitis Or Cox-Algia)

Disease of the hip in its early stage is characterized by pain, limitation of motion, and limping. The pain is either a local one in the hip itself or a referred one. The hip is supplied by branches of the anterior crural, sciatic, and obturator nerves, and as these also supply the region of the knee, disease of the hip causes pains to be felt around the knee, most often on its inner side. In an early stage the limitation of motion is due to muscular contraction and it disappears under anaesthesia. The limb is held in a position of flexion, abduction, and slight external rotation. The joint is more or less rigid. The loss of motion is only complete in extreme cases. In mild cases the limitation is only present as a reduction in the normal extent of movements, the joint may move freely and without constraint over a limited arc. The abnormal changes produced are to be recognized by careful inspection, measurements, and comparison with the opposite healthy limb.

Fig. 523.   Child with congenital luxation of hips, showing characteristic lordosis.

Fig. 523. - Child with congenital luxation of hips, showing characteristic lordosis.

Fig;. 524.   Authors method of reducing congenital luxation of the hip.

Fig;. 524. - Authors method of reducing congenital luxation of the hip.