Anterior Displacement of the Hip (Con= 
genital), by DeForest Willard, M. D., 
Philadelphia, Pa., Clinical Professor of 
Orthopaedic Surgery, University of 
Pennsylvania; Surgeon to the Pres= 
byterian Hospital, etc., etc. 
PEDIATRICS ANTERIOR DISPLACEMENT OF THE HIP (CONGEN- 
ITAL).* 
By Deforest Willard, M.D., 
Philadelphia, Pa., 
Clinical Professor of Orthopaedic Surgery, University of Pennsylvania ; Surgeon 
to the Presbyterian Hospital, etc., etc. 
Anterior displacements of the head of the femur from con- 
genital deformation of the acetabulum, or of the head 
and neck of the femur, are quite rare ; only two or three 
American cases having been reported. Hence this record. 
The patient was a boy, aged n years. No history of injury at 
birth or later. Began to walk at one year of age, but parents were 
not positive as to whether they noticed any peculiarity of gait until 
he was three years of age. Gait at present is a decided limp, from 
shortening of the leg, but the waddle is not characteristic as seen 
in cases of posterior displacement. There is only a moderate 
amount of lordosis, since the position of the head of the bone does 
not necesitate marked accommodation of the spine. 
Viewed anteriorly, two inches below the right anterior superior 
spinous process, and in a line with it, is a hard prominence which 
rotates in unison with all the movements of the femur. The neck 
of the bone can also be easily distinguished. The trochanter is 
more prominent than normal and broadens the limb at this point. 
The head apparently lies upon the ilium directly above the normal 
position of the acetabulum ; it does not slide during locomotion. 
Adduction and rotation can be performed to nearly the usual 
limits, but abduction is interfered with when the limit- reaches ten 
degrees outside of the straight line. Flexion is normal ; extension 
slightly limited. The head can be outlined without much difficulty, 
and the peri-articular muscles all seem in good condition. The 
head does not lie upon the ramus of the pubes, nor in the thyroid 
foramen, as ordinarily seen in anterior traumatic dislocations, but is 
directly above the socket. 
Posteriorly, the right buttock is broadened and slightly flat- 
tened and the trochanter more prominent. 
The boy can stand upon tip toe on the right side, but the leg 
and thigh are slightly atrophied, being half an inch less in circum- 
ference. The distance from the anterior spinous process to the 
knee is one and a quarter inches less than the left, when the leg is 
* Read before the American Orthopaedic Association, May, 1896. PEDIATRICS. 
straight; but when the thigh is flexed to the right angle the knees 
are in line owing to the upward position of the displacement. It is 
probable that the deformation consists in a false acetabulum above 
the site of the true one, rather than that the acetabulum is oval in 
shape. 
The motions of the femur nearly approximate the normal, and, 
as there is no sliding motion, shortening is the only practical de- 
formity. It is difficult to see how any operative interference would 
be beneficial, since lordosis is slight, and the power of the muscles 
connecting the trunk with the femur would certainly be diminished 
by interference. Lengthening the limb artificially is all that is ad- 
visable. As this procedure corrects the limp and the interference 
with locomotion is so moderate, it is difficult to see how a Hoffa or 
Lorenz operation would improve him. 
I have seen a number of cases of variations in the hip articu- 
lation which have differed markedly from the typical condition of 
congenital dislocation. Some of them have very probably been 
from fractures or dislocations or epiphyseal separations. In some 
cases the femoral neck has been shortened and even distorted and 
twisted possibly coxa vara ; while in other instances there has been 
an appearance of an old injury. In the majority of cases the injury 
has been unrecognized (according to the history), thus leaving the 
question of pre-natal or puerperal injury uncertain. The first evi- 
dence of the condition has been the irregular gait which the child 
exhibited when commencing to walk ; or, perhaps, the disability 
was not noticed until a year or two later. In the majority of cases 
the growth of the limb has been so altered that there has been a 
difference of from half an inch to two inches in length. 
When the head of the femur is fairly well confined in its move- 
ments upon the ilium, diagnosis is sometimes difficult. It is prob- 
able that although the condition has existed from birth, the cause 
may have been traumatic even within the uterus. In this deformity, 
as in others, it is quite possible that violent coition during the first 
month of pregnancy may influence the embryonic mass, especially 
if the ovum has attached itself in the lower segment of the uterus. 
The diagnosis of anterior position of the head of the femur 
from acute bending of the neck of the femur, as described by 
Whitman {Trans. Am. Orthopedic Assoc.), is not difficult. 
About the trochanter the conditions are similar. In misplace- 
ment, however, the head of the bone can be plainly distinguished 
in its abnormal position. Trochanteric rotation is altered. Bend- 
ing of the neck mayor may not be associated with rachitic deformi- PEDIATRICS. 
3 
ties; yet it must be due to some softening of the bone akin in char- 
acter. 
The trochanter in acute bending is above Nelaton’s line, while 
in anterior displacement it is both above and in front of its normal 
position. Mutter, of Germany, in 1889, first described this condi- 
tion, as it usually occurs in children about the age of puberty, 
probably due to causes similar to those which produce lateral cur- 
vature 
Leeser (Presse Medicale, Oct. 3, i8gf) states that rachitic 
symptoms co-exist. 
Acute bending is most liable to occur in those who have heavy 
weights to carry, or who are subjected to prolonged standing while 
in a debilitated condition ; but there must be some local fault to 
cause the deformity, as it frequently occurs on one side. 
Drs. Ridlon and Phelps have both reported cases of anterior 
dislocations. 
In Dr. Phelps’ case [Trans. Am, Orthopcedic Assoc. Vo/, iv., 
p. 132), the child died of acute spinal meningitis one and a half 
years after treatment was commenced. The specimens showed that 
the case was one of congenital dislocation, probably in utero, with 
non-development of the acetabulum. Whether this occurred from 
traumatism, or from some reflex spasm of the muscles caused by 
central nerve lesion in early foetal life is uncertain. 
Ketch [Keating's Encyclopedia of Children) does not believe 
that the condition is due to injuries at birth. 
In Phelps’ case, the head of the bone lay in front of its normal 
position. The leg was shortened and the toes were rotated inward. 
The acetabulum was angular in shape, small and undeveloped. 
My own belief is that traumatism inflicted during delivery is 
productive of fractures or dislocations to which the plastic anatomy 
of the infant adapts itself and gives only a moderate amount of sub- 
sequent deformity. In breech presentations a hook is frequently 
placed over the thigh of an infant and strong traction made upon 
the tissues ; certainly sufficient to displace a bone or break the rim 
of the acetabulum. 
The treatment proposed is prolonged extension in bed, followed 
by the use of an apparatus to continue extension, as recommended 
by Bradford [Trans. Am. Ortho. Assoc. Vol. iv, p. 308), the indi- 
vidual being kept under extension in all positions of the limb. For 
locomotion, a long fixation splint may be used, or a jointed locking 
and unlocking splint with leg and thigh envelopment. The method 4 
PEDIATRICS 
of forcible manipulation during the process of extension probably 
produces a certain amount of adhesive inflammation. 
In Ridlon’s case (7"rans. Am. Orthopaedic Assoc. Vol. 2,p. y6, 
i88p) the head of the femur lay almost directly below the anterior 
iliac spine. The leg was shorter than its fellow. Forcible traction 
by Taylor’s extension hip splint was continued in bed for an entire 
year, after which the child walked upon a long traction splint, the 
shortening being reduced from three inches to half an inch, although 
at the time this case was reported continuous traction was still in 
force and no weight had been borne upon the limb. 
In another case which I have recently seen (a girl two years of 
age), the left leg was three-quarters of an inch shorter than the 
right one, and she walked with a decided limp. The head was 
freely movable upon the ilium, nearly an inch, in an upward direc- 
tion. The trochanter was prominent, but was not displaced back- 
wards. The head of the bone could be distinctly outlined, appa- 
rently lying upward and slightly forward. Published on the 1st and 15th of the Month, $2.00 or 8 Shillings a Yeat*. 
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Angel Money, M. D., Sydney, Australia. For- 
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Hospital, and to the Great Ormond Street Hospital 
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Dawson Williams, M. D., London, Physician to 
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