4 */f/.f. tiol.. 
A Contribution to a Knowledge of Fracture of 
the Rim of the Acetabulum, Based on the 
Reports of Twenty-Seven Cases and 
Experiments on the Cadaver. 
BY / 
Nicholas Senn. M. D., 
OF MILWAUKEE. V . 
Reprint from the Transactions of the State Medical Society of Wisconsin. 
MILWAUKEE: 
PRINTED BY TIIE SENTINEL COMPANY. 
1880. A Contribution to a Knowledge of Fracture 
of the Rim of the Acetabulum, Based on 
the Reports of Twenty-Seven Cases 
and Experiments on the Cadaver. 
By N. Senn, M. D., Milwaukee. 
Proposition First.—Fracture of the rim of the acetabulum is an 
extremely rare accident, being less frequent than fractures involving the 
floor of the acetabulum. 
Proposition Second.—Fracture of the rim may be the result of 
direct or indirect violence, the force required being greater than is neces- 
sary to fracture the floor of the acetabulum. 
Proposition Third.—This injury may be completely repaired, pro 
vided the dislocation attending it is reduced early, and the head of the 
femur is retained for a sufficient length of time for bony union to take place. 
Proposition Fourth.—Crepitus, easy reduction, and difficult reten- 
tion are the most constant and reliable diagnostic symptoms. 
Proposition Fifth.—The best method of reduction is to relax the 
untorn portion of the capsular ligament, and, by making extension, draw 
the head of the femur towards the broken portion of the rim. 
Proposition Sixth.—The best method to prevent reluxation is to 
make the unbroken portion of the rim a support for the head of the 
femur, and to secure immobility to the hip joint, by applying a perma- 
nent dressing, including the pelvis and both lower extremities. 
Proposition Seventh.—When not a sufficient depth of the rim is 
left to prevent reluxation by muscular contraction, permanent extension 
and fixation are necessary for the maintenance of retention. 
The acetabulum is so called from its resemblance to an ancient 
vinegar cup. Primarily, three bones enter into its formation, of which 
the ilium occupies a little more than two-fifths, the ischium a little less 
than two-fifths, and the pubis the remaining fifth. It is a deep, hem- 
ispherical depression on the outer surface of the os innominatum, where 
the primary segments of that bone unite. In the erect position, its direc- 
tion is downwards, outwards, and slightly forwards, so as to receive the 
head of the femur obliquely. In the dry bone, it forms between 175 and 
180 degrees of a circle, but in the recent state it is deepened and con- 
ANATOMY OF THE ACETABULUM. 2 
Senn—Fracture of the Rim of the Acetabulum. 
stricted by a ring of fibro-cartilage, called the limbus cartilagineus 
acetabuli, which is firmly attached to the bony margins of the cavity. 
The rim of the acetabulum, for convenience sake, may be divided 
into three divisions, corresponding to its original component parts. The 
upper, or iliac portion, has to support the whole weight of the body when 
in the erect position, and constitutes the strongest portion of the rim. Its 
line of juncture with the pubic portion in front is marked by a shallow 
indentation, over which passses the ileo-psoas muscle. Its posterior limi- 
tation and union with the ischiatic portion, is indicated by a ridge, which 
extends from the middle of the great sciatic notch to the edge of the rim, 
where it terminates in a slight elevation. Its anterior third is strength- 
ened by a broad, rough ridge, which blends it with the anterior inferior 
spinous process, and gives attachment to a part of the capsular ligament, 
and one point of origin for the rectus femoris muscle. 
The ischiatic portion extends from its point of junction with the 
preceding portion to the cotyloid notch, where it terminates in a sharp 
projection which partly overlaps this depression, and then turns towards 
the interior of the joint, and marks the boundary between the articular 
and non-articular portion of the joint. 
The pubic portion commences near the middle of the cotyloid notch, 
at a point corresponding to the junction of the middle with the upper 
third of the external margin of the obturator foramen. It gradually 
ascends until it reaches its greatest height opposite the center of the 
horizontal portion of the pubis, where it gradually slopes backwards 
until it terminates at the upper depression in the rim, where it joins 
with the iliac portion. 
We have, then, two depressions in the rim, the upper and lower. 
The former, marking the junction of the pubic with the iliac portion, per- 
mits more complete flexion; the latter is located at the most dependent 
portion of the joint, and is formed at the expense of the lower portion of 
the ischiatic and pubic rim. 
The cotyloid notch is converted into a foramen, transmitting the 
vessels and nerves to the interior of the joint, by the transverse ligament 
which connects the ischiatic and pubic portions, and thus completes the 
defect in the bony part of the rim. 
The interior of the cavity may be divided into articular and non- 
articular. The articular portion is lined with cartilage, and corresponds 
to the inner surface of the rim, and the adjoining part of the floor of the 
joint. It presents the shape of a horse shoe, with the open extremity 
directed downwards towards the cotyloid notch. This surface is in im- 
mediate contact with the head of the femur. The non-articular surface 
covers about one-third of the interior of the joint. It corresponds to the Senn—jFracture of the Rim of the Acetabulum. 
3 
area enclosed by the horse shoe, and extends from above the center of 
the joint to the margin of the obturator foramen; it is devoid of cartilage, 
and is separated from the head of the femur by the transverse and round 
ligaments and a quantity of adipose tissue. 
The deepest part of the acetabulum is near the center, where the 
angles of the original bones meet; here the bony wall is sufficiently thin 
to be translucent if held towards the light. 
In most specimens the thinnest part is a little below the center, at the 
junction of the ischiatic with the pubic portion. It is here where per- 
foration occasionally takes place in disease of the hip joint; it is also 
here where one line of fracture is usually found in stellate fractures of 
this bone. The absence of or imperfections in the rim determine the 
weakest points in the acetabulum. 
Anatomy and experience teach that these points exist at the upper 
and lower depressions, or at the junction of the pubis with the ilium and 
ischium. The strongest part of the rim and cavity is the iliac, and, 
therefore, the least likely to become the seat of fracture. 
The margin of the acetabulum is composed of cancellated tissue, 
covered on the inner side by cartilage, and on the outer by a very thin 
layer of compact tissue. At the margin the cavity is nearly circular, the 
diameter being the same in every direction. The measurements of 12 
acetabula of adults yielded an average of 2% inches. 
The cavity is deeper in males than in females, and in adults than in 
children and the aged. In children the rim is not fully developed, and in 
old age it atrophies. The same bones gave an average depth of inches. 
The Y shaped cartilage at the bottom of the acetabulum begins to 
ossify at the period of puberty. 
In regard to the ligaments, I will simply say, that there are attached 
to the margins of the joint, the transverse, capsular, and the ligamentum 
teres. The transverse ligament, with the circular fibro-cartilage, com- 
pletes the brim over the cotyloid notch. The capsular ligament is at- 
tached to the outer surface of a greater part of the rim, and over a 
considerable surface of bone at its base, as well as the transverse liga- 
ment, and includes the limbus cartilagineus, without being attached 
to it. Over the anterior aspect of the joint the margin is free, the liga- 
ment being attached to the bone around it, while posteriorly it reaches 
the edge within a few lines. It is important to remember, in this connec- 
tion, the extensive insertion of this ligament, far beyond the base of the 
rim, and that the edge of the rim, and the fibro-cartilage have no connec- 
tion with it; were the ligament inserted only into the edge of the rim, the 
latter would be frequently chipped off in cases of dislocation of the femur, 
by traction of the ligament, as often happens in some other joints. 4 
Senn—Fracture of the Rim of the Acetabulum. 
The ligamentum teres takes its origin from the margin of the cotyloid 
notch and the transverse ligament, ascends to near the middle of the 
joint, and is inserted into the dimple on the articular surface of the femur. 
This ligament takes no part in retaining the head of the femur in the 
joint, but, according to the experiments of Mr. Morris,* it checks rotation 
outward during flexion, and adduction during flexion. 
These experiments were made for the purpose of ascertaining what 
part of the acetabulum would be most likely to be broken on the appli- 
cation of direct or indirect violence, and to determine the amount of 
force necessary to fracture its rim. The force was applied by means 
of a very heavy iron sledge hammer, a three-inch plank being placed 
over the part to which the blows were directed. 
I. Subject, aet. 40, suicide. The body was well developed, the bony 
structure large. Force was applied to the sole of the foot, with negative 
result, the pelvis being fixed, and the limb in the extended position. The 
leg and thigh were then flexed at a right angle, the latter slightly abduct- 
ed, and the force applied to the knee, the result being an oblique fracture 
of the femur at the junction of the middle with the lower third. The 
subject was then placed on the opposite side of the pelvis, and the blows 
directed against the great trochanter, which caused an oblique fracture 
of the neck of the femur, extending from within the capsule on the 
upper border of the neck, downwards and outwards to near the junction 
of the shaft with the neck; ligamentum teres, and capsular ligament, 
except at the point of fracture, intact. 
II. Subject, aet. 47, died of phthisis. Bones well developed and 
strong. The body was placed on the back, knee and hip bent at a right 
angle, thigh slightly abducted, pelvis fixed, and the force applied over the 
knee. Repeated blows produced a fracture through the lower third, the 
fracture extending into the knee joint, half way between the condyles. 
A rent was found in the posterior part of the capsular ligament. The 
subject was then placed on the opposite side and the force applied directly 
over the trochanter. On examining the hip joint, the acetabulum was 
found to be fractured, the line of fracture extending from near the middle 
of the socket to the upper depression in the rim, and downwards to the 
cotyloid notch, the detached portion including a little more than the 
pubic portion of the joint. Ligamentum teres partially ruptured. 
III. The subject, same as in No. II, was placed in the knee elbow 
position, thigh flexed at a right angle and abducted, and the force applied 
over the posterior aspect of the pelvis, which resulted in a fracture of the 
EXPERIMENTS ON THE CADAVER. 
♦The Anatomy of the Joints of Man: By Henry Morris, M. A., M. B., London, 
F. It. C. S., Philadelphia, 1879. Senn—Fracture of the Rim of the Acetabulum. 
sacro iliac junction, the fracture being at the expense of the sacrum. 
Hip joint not injured. 
IV. Subject, aet. 35, died of phthisis. Bones large and strong. Body 
placed on the back, pelvis fixed, and the force applied to the sole of the 
foot, while the limb was slightly raised. The first blow caused a com- 
minuted fracture of the os calcis and malleolus externus, and by 
subsequent blows, the tibia sustained a fracture about four inches below 
the knee joint. The leg and thigh were then flexed at a right angle, and 
the force applied to the knee, the thigh being slightly adducted. After 
many hard blows, something was felt to give way, and, on making an 
incision down to the hip joint, the head of the femur was found to be in 
the ischiatic notch, the neck being embraced by the rent in the posterior 
portion of the capsular ligament. Rim of the acetabulum intact. Liga- 
mentum teres ruptured completely. 
Y. Same subject as in No. IV. Force applied to knee-joint, the 
limb being in the same position, except that the thigh was slightly 
abducted. The fracture thus produced was compound, and affected the 
femur at the junction of the middle with the lower third. No lesions of 
the acetabulum or capsular ligament. 
YI. Subject, aet. 17, died of renal disease. Body was placed on the 
back, knee flexed at a right angle, thigh semifiexed and abducted, and pel- 
vis fixed. A blow over the knee joint fractured the femur at the junction 
of the upper with the middle third, the line of fracture being nearly trans- 
verse. The body was then placed upon the abdomen and face, and while 
the pelvis was firmly fixed, Ihe blows of the hammer were directed 
towards the posterior margin of the trochanter on the same side. On 
examination of the hip joint, a portion of the ischiatic rim, adjacent to 
the cotyloid notch, was found detached and adherent to the capsular 
ligament. Ligamentum teres intact. 
VII. Subject same as in No. VI. The last experiment was repeated 
and produced the same lesions, with the exception that the fracture in 
the acetabulum involved its floor, the line of fracture extending from 
the depression in the upper part of the rim, vertically downward, to the 
cotyloid notch, separating the pubic portion of the acetabulum without, 
however, following the line of the Y cartilage. A fracture also took 
place through the body of the pubis, and through the ascending ramus 
of the ischium. 
These experiments demonstrate how difficult it is to fracture the rim 
of the acetabulum, and they tend to corroborate the views of the majority 
of surgeons, who consider this injury one of the rarest accidents in 
surgery. They are also instructive in showing where bones are most 
RE M ARKS. 6 
Senn—Fracture of the Rim of the Acetabulum. 
likely to break, when a sufficient amount of violence is brought to bear 
upon certain parts of the skeleton. Thus, although in every experiment 
the limb was placed in the most favorable position, and the force applied 
in such a manner as to expend itself on the inner surface of the acetabu- 
lum, fracture of the rim was produced only once, and then by forcibly 
rotating the femur inwards, and by applying the force to the posterior 
margin of the trochanter. 
The rest of the fractures were distributed among different bones, as 
follows: Shaft of femur, 5; neck of femur, 1; malleolus externus, 1; os 
calcis, 1; ascending ramus of ischium, 1; body of pubis, 1; acetabulum, 
2; sacro-iliac synchondrosis, 1. The head of the femur was dislocated 
into the great sciatic notch by flexing and adducting the thigh and apply- 
ing the force to the knee, the pelvis being fixed. It is a noteworthy fact 
that when the femur in adults was broken, this fracture was very oblique 
and below the middle of the bone, while in the subject aged 17 years, the 
fracture was in both instances above the middle, and nearly transverse. 
This limited number of experiments would lead me to the conclusion 
that fractures through the floor of the acetabulum are of more frequent 
occurrence than simple fractures of the rim, and are the result of a less 
degree of violence, and that the greater mortality attending them is due 
to the presence of visceral lesions, rather than the, greater extent of 
injury to the bone. 
REPORTS OF CASES. 
Case I. Reporter, Astley Cooper.*—A man was run over by a heavily 
loaded wagon. On examination it was found that he had suffered a frac- 
ture of the right femur above its middle third; the left foot wras dis- 
located outwards, and fibula fractured two inches above the ankle joint; 
the left thigh was rotated inwards; on making extension and rotating it 
outwards, a sensation was imparted to the hands, of the head of the femur 
gliding into the acetabulum, but as soon as the extension was discon- 
tinued, the limb assumed its former abnormal position. The patient died 
on the third day. At the post mortem examination, the posterior portion 
of the rim of the acetabulum was found detached, and another line of 
fracture extending into the innominate bone. The ligamentum teres was 
not ruptured. The head of the femur was slightly dislocated backwards, 
resting upon the broken edge of the acetabulum. 
Case II. Reporter, Bardinet.f—A young man was thrown violently 
upon the ground by the upsetting of a wagon. He suffered great pain 
in the left hip, and could not lie on the affected side. By measurement 
the limb was found to be two inches shortened, foot and knee inverted, 
*Emmert, Lehrbuch der Speciellen Chirurgie, Stuttgart, 1862, Band iii, s. 750. 
t Locus Cit., 8. 750. Senn—Fracture of the Rim of the Acetabulum. 
gluteal fold higher, and nates flattened; trochanter displaced backwards 
and upwards. Rotation was impossible, but adduction could be made 
without resistance. No crepitation could he felt. The head of the femur 
was distinctly felt under the gluteal muscles, and was affected by all 
movements of the thigh. The case was diagnosed as a dislocation of the 
femur upwards and backwards. The reduction was easily accomplished, 
and was attended by distinct crepitation. Re-dislocation took place three 
times, and the reduction was always accompanied by crepitation. It 
now became evident that the dislocation was complicated by a fracture of 
the rim of the acetabulum, consequently a permanent dressing 
applied, after the fourth reduction, and retained for four weeks, when the 
patient was discharged, having good use of the limb. 
Case III. Reporter, Maisonneuve.*—This case demonstrates beyond 
all doubt the existence of this rare injury of the acetabulum, and illus- 
trates the process of repair. 
A laborer was severely injured by the caving in of the wall of a 
stone-quarry. A fracture of the arm was detected; the left liip joint was 
very tender and painful; shortening of limb three centimetres; knee 
Hexed and foot turned inwards; great trochanter displaced backwards, 
and more prominent. On moving the thigh, crepitation could be dis- 
tinctly felt; on making extension, the limb could be brought down to its 
natural length, and when held in this position, rotation, flexion and 
abduction could be freely made, but as soon as the extending force was 
removed, and especially if the limb was adducted at the same time, the 
shortening and deformity reappeared at once. Simultaneous with the 
slipping of the bone into the socket, a loud crepitation was heard. 
The treatment consisted in fixing the limb in a flexed, abducted and 
inverted position. Twenty days after the injury was received, the patient 
died of pyamiia. On examining the joint after death, the head of the 
femur was found in the socket. The posterior and upper rim of the 
acetabulum had been broken into three fragments, the lowest and largest 
of which had formed bony union; the two upper were firmly adherent 
by means of fibrous union. The rupture in the posterior portion of the 
capsular ligament was indicated by a cicatrix two centimeters in length. 
The ligamentum teres was not completely ruptured. 
Case IV. Reporter, James Morton .f—The patient was a miner 18 
years of age, who was injured, while at work, by a beam striking against 
his right hip. Three months after the accident chloroform was admin- 
istered, and, on examination, the head of the femur was found dislocated 
upwards and backwards; a portion of the rim of the acetabulum could 
* Loc. Oit., s. 750; L. Union Med., 1854, 98. 
t British Med. Journ., May 37, 1871; Schmidt’s Jahrbuecher, Band 152, s. 179. 8 
Senn—Fracture of the Rim of the Acetabulum. 
be felt just above the head of the femur. The dislocation was reduced 
by manipulation. The patient was discharged after six weeks, with some 
shortening of the limb. 
Case V. Reporter, T. Holmes.*—“I saw a case once of dorsal dis- 
location in which all the symptoms were strongly confirmatory of the 
diagnosis of fracture of the acetabulum. The dislocation was reduced 
without difficulty, and nothing peculiar was noticed; but, on visiting the 
patient next day, the surgeon was surprised to find that it had been re- 
produced. It was again reduced, but the reduction was found to be 
quite insecure, for it slipped out as easily as it was put in; and now it 
was thought that crepitus could be detected. The limb was p.it up as 
carefully as possible, but I believe some deformity persisted.” 
Case VI. Reporter, Frederick 8. Eve.f—1This and the following case 
were reported by Dr. Eve, at the meeting of the Royal Medical and Chi- 
rurgical Society, held Jan. 13, 1880. 
“A middle-aged man threw himself from an upper story window, 
and, in addition to fatal injuries to the head, sustained a sciatic disloca- 
tion of the right femur, which presented the usual appearances. On 
dissection, the head of the femur was found on a level with the lesser 
sciatic notch. The tendon of the obturator internus muscle crossed the 
upper part of the articular surface, binding the head slightly down, and 
thus occasioning extreme rigidity of the limb. The posterior portion of 
the rim of the acetabulum was torn up. Only the posterior segment of 
the capsule was lacerated. Of the muscles, the gemellus inferior alone 
was torn. After the dissection was completed, the femur was readily re- 
duced through the cotyloid notch.” 
Case VII. Reporter, Frederick 8. Eve.j:—“A man, aged 55, had his 
left femur dislocated in the neighborhood of the great sciatic notch, by a 
fall of earth upon his back while he was stooping at work. The disloca- 
tion presented no unusual character. Reduction was effected by traction 
on the slightly Hexed and adducted thigh, the ordinary manipulations 
having failed. He died from a rupture of the intestine. On dissection 
the head of the femur was found to have passed through the posterior 
portion of the capsule, on a level with the great sciatic notch, and appa- 
rently above the obturator internus. The posterior portion of the rim of 
the acetabulum was torn up as in the first case. The pyriformis, gemellus 
superior and obturator externus muscles were lacerated.” 
Case VIII. Reporter, E. Ried.||—A healthy laborer, aged 40, was 
injured in a quarry by several large stones falling upon the posterior 
* T. Holmes’ Surgery, 1876, p. 243. 
t British Medical Journal, January 24, 1880. 
X Loc cit. 
|| Deutsche Zeitschr. fuer Chirurgie, Band XII., Heft 1-2. Senn—Fracture of the Rim of the Acetabulum. 
9 
aspect of the pelvis, the man being at work in a stooping position. The 
physician who was called first diagnosed dislocation of the femur, but 
failed to reduce it. The patient was admitted to the hospital, when the 
right limb presented the following appearances: It was adducted and 
flexed, the knee with its inner surface came in contact with the left thigh 
above the knee; the foot was inverted, the big toe resting on the dorsum 
of the opposite foot; the hip was swollen, painful and tender. On 
account of the swelling it was with some difficulty that the trochanter 
major could be felt a little higher up and farther back than when in its 
normal position. The head of the femur could not be felt. The shorten- 
ing of the limb corresponded to the displacement of the trochanter 
upwards. Flexion could be effected only to a moderate extent; abduc- 
tion and rotation were impossible. Chloroform was administered and 
reduction effected by making extension in the direction of the axis of 
the limb. As the head of the bone descended crepitation was heard dis- 
tinctly, after which it slipped into its socket, and the limb dropped into 
its natural position. On flexing and rotating the limb slightly all the 
symptoms of the previous displacement returned. The limb was again 
reduced without the least difficulty, and the patient was conveyed to his 
bed on a stretcher. On making another examination, all the symptoms 
of dislocation had reappeared. It was now evident that the dislocation 
was complicated with a fracture of the upper and posterior rim of the 
acetabulum. The next day chloroform was again administered, and 
the limb, having been restored to its natural position, was dressed and 
rendered immovable by means of Hagedorn-Dzondis’ apparatus. As 
another means of retention, a pelvic band was applied with a compress 
between the great trochanter and the anterior superior spinous process 
of the ilium. Four weeks subsequently he was allowed to sit up, and in 
two weeks more he was discharged, being able at the time to walk with- 
out difficulty. 
Case IX. Reporter, E. Iiied.*—November 24, 1873, a young man was 
riding down a steep hill on a hand-cart, guiding the vehicle by the han- 
dle held between the outspread legs, Iris back resting against a barrel of 
beer behind him. While the cart was in rapid motion his right knee 
struck against the wheel of a heavy wagon standing by the roadside. 
He immediately experienced a severe pain in the right hip; the thigh 
was flexed and immovable. His companions attempted to straighten the 
limb, but were only partially successful. A physician, who was called, 
found the thigh shortened six centimetres, and slightly rotated inwards; 
leg and thigh flexed and firmly fixed, as in cases of dislocation. On 
account of the extensive swelling, the head of the femur could not be 
*Loc. cit. 10 
Senn—Fracture of the Rim of the Acetabulum. 
felt. A dislocation of the femur was suspected, and reduction was 
attempted by making traction in the direction of the axis of the limb. 
This procedure diminished the amount of shortening and produced a 
rough crepitation, which led the physician to the belief that he had to 
deal with an extra capsular fracture of the neck of the femur. He ap- 
plied a temporary dressing only, and sent the patient to the hospital. 
On admission he presented the following status: Extravasation of blood 
in the right knee-joint, excoriation, suggillation over the posterior spinous 
process of ilium; on the same side trochanter major above Nelaton’s line; 
right leg shortened nearly two inches; femur flexed, adducted, and rotated 
inwards; toes directed inwards; abduction impossible; rotation, which 
was limited, caused crepitus; trochanter major moves in the normal 
circle; pelvis is inclined on the right side, so that when the limb was 
brought down a large hollow space appeared at the lumbar and upper 
pelvic region, which disappeared when the thigh was flexed at a right 
angle; the head of the femur could not be felt on account of the swell- 
ing. A dislocation of the femur, with fracture of the posterior rim of 
the acetabulum, was diagnosed. The diagnosis was based on the symp- 
toms and the manner in which the injury was produced. Chloroform 
was administered and traction made, the limb being flexed and adducted; 
the head of the bone was lifted by a towel placed around the upper 
part of the thigh, and traction made outwards. The bone returned to 
its normal place, the reduction being attended by distinct crepitation; 
retention was maintained without difficulty, as the upper portion of the 
rim remained intact. 
The patient was placed in Bonnet’s wire breeches. On the 23d ot 
December he made his first attempt at walking, and on the 16th of Janu- 
ary he was discharged, having perfect use of the limb. 
Case X. Reporter, Theodore A. McGraw.*—“ I have recently had a 
case of fracture of the rim of the acetabulum, in which the patient 
recovered completely, and which I will describe in short. 
Miss P , aged 25 years, was riding on a ‘ buckboard,’ sitting upon 
it with the left side towards the horse. The wagon wheel struck a stump, 
and she was thrown on the ground in such a way that she rested for a 
moment upon her knees and face. The hinder wheel struck and passed 
over her left hip while she was in this position. She lived at Leesville, 
five miles from this city, and Dr. Jones, of Leesville, was called to attend 
her. Recognizing the serious nature of the case, lie sent for me. We 
put the patient under an anaesthetic. I found her left thigh dislocated 
on the dorsum. In that position the whole shape of the head and neck 
of the femur could be felt with the hand; it seemed normal in every 
* Communication from Prof. Theo. A. McGraw, Detroit. Senn—Fracture of the Rim of the Acetabulum. 
11 
respect, except as regards its abnormal position. The luxation was easily 
reduced, but its reduction caused audible and distinct crepitus. When 
reduced, the two extremities measured the same, and the position of the 
injured limb was perfect. Adduction produced redislocation with loud 
crepitus; reduction again caused crepitus. Fracture of the femur was 
excluded by the equal length and proper position of the thigh after 
reduction, and by the evidently normal shape of the head and neck of 
the femur, as ascertained before reduction, also by the ease of reduction. 
The ease of the redislocation on adduction, and the loud, positive and 
certain crepitus are my proofs of the existence of fracture. 
1 fastened the patient, as recommended by Bigelow, with the body on 
one side of the bed, and the injured extremity fastened in the position of 
abduction to the other side. Recovery was perfect, and in two months 
she was able to walk as well as ever.” 
Case XI. Reporter, II. O. Walker.*—“T. S., aged 78, a street laborer, 
in attempting to avoid an approaching street car, was knocked down by 
one of the horses. He fell upon his hands and knees, with his back to 
the car. In this position the platform of the car struck upon the lower 
portion of his back, and, as the sequel® will show, the thigh must have 
been at right angles with the pelvis, or nearly so, when he received the 
blow. The injuries received, were a severe scalp wound, a compound com- 
minuted fracture of the forearm, with a number of contusions on different 
parts of the body. Aside from these there was an injury to the left hip. 
He was taken to Harper Hospital and examined by Drs. G. A. Foster 
and M. K. Ross, who recognized a displacement of the head of the femur 
upon the dorsum ilii. By manipulation, they detected a distinct crepitus, 
but w'ere unable to determine positively tiie exact nature of the fracture. 
Reduction was easily accomplished. The accident occurred at 4 p. m., 
and the patient died early next morning, evidently as the result of shock, 
due to the combination of injuries received. At the inquest the coroner 
directed me to make a post mortem examination, and I will here only 
make mention of that part pertaining to the injury at the hip joint. In- 
spection revealed the head of the femur still in position, but, on slight 
manipulation of the leg by flexing, and abducting the thigh, the head of 
the femur readily slipped out of place, accompanied by a marked and 
distinct crepitus. Further, there was inversion of the foot, marked 
adduction and flexion of the thigh, with the head of the bone distinctly 
felt high up on the dorsum ilii, and shortening about three inches. After 
several attempts it was found that reduction could best be effected by 
* Fracture of the Posterior Lip of the Left Acetabulum, with Specimen. By H. O. 
Walker, M. D., Lecturer on Anatomy and Genitourinary D’sea«es in Detroit Med. 
College. ‘‘Detroit Lancet,” July, 1879. 12 
Senm—Fracture of the Rim of the Acetabulum. 
flexing, extending, adducting, and straightening the thigh. On exposing 
the femur and contiguous parts, it was observed that the head of the bone 
had been forced upwards between the wings of the ileo-femoral ligament, 
extending nearly up to the brim of the pelvis, midway between the 
anterior and posterior superior spinous processes. 
The ligamentum teres, and the greater part of the posterior half of 
the capsular ligament, was torn away, leaving a part of the anterior por- 
tion, together with the ileo-femoral or Y ligament. The muscles of the 
lower gluteal region at the femoral attachment were more or less rup- 
tured. The fracture of the rim of the acetabulum can be better appre- 
ciated by the specimen which I removed, and herewith present for your 
inspection. 
DR. WALKER’S CASE OF FRACTURE OF RIM OF ACETABULUM. 
The fragments which you see, were all detached and picked out from 
the cavity that had been made by the head of the femur. You will notice Senn—Fracture of the Rim of the Acetabulum. 
13 
that the greater part of the posterior lip of the acetabulum is torn away, 
making an opening through which the head of the bone could readily 
escape, leaving a little less than a third of the depth of the cotyloid 
cavity intact, as a support to the head of the bone posteriorly.” 
Case XII. Reporter, J. H. Beech.*—11 On July 1, 1872, Mr. S. J. 
B , a young farmer of fine proportions, sound constitution, and of 
good habits, aged 21 years, was upon the top of a large load of hay, 
driving into his barn, when he was caught by the frame-work over the 
door, and rolled into an irregular heap, from which his associates and 
himself found it impossible for them to straighten him. He stated that 
after he discovered that the load was too high for the doorway, and that 
his horses were under too strong headway to be stopped in time to save 
him, he endeavored to straighten himself as flat as possible upon his 
back, but that his ‘ left knee was caught,’ with the result as above stated, 
and that he felt a crushing, as if he was being torn in pieces. It was 
probably less than an hour before I was at his side, and found all the 
evidences required for a diagnosis of dislocation of the left ‘ caput 
femoris,’ upon the dorsum ilii. ****** 
Attempts to rotate the limb outwards caused great pain. No crepitus 
could be felt. Placing the patient upon a hard, level bed, and inducing 
anaesthesia by chloroform, we proceeded to flex the knee, carrying it at the 
same time across the right limb and keeping the heel well everted; when 
the knee was opposite the right hip, a little pressure toward the body was 
begun, and continued with slightly stronger eversion of the heel, until 
the knee was brought closely over and nearly past the umbilicus, when 
the forcible eversion of the heel was discontinued, the knee carried out- 
ward to a line with the left axilla, at which time a sensation as of gentle 
sliding of the caput femoris was felt, and the foot was immediately 
brought down to the side of its fellow, with the leg, knee and thigh in 
its proper relation to those parts of the limb. There was no doubt in 
my mind that I had reduced an outward and backward dislocation of 
the left caput femoris, by what is called Dr. Reed’s method, although 
there had been no audible snap, nor sudden motion, as I had felt in 
former cases. We now bound the patient’s knees and legs together by a 
wide, strong towel, reaching from above the patella to the malleoli. An- 
odynes were ordered to be given if he suffered much pain, or if the 
supine position became irksome for endurance. On the following day 
my surprise was great to find the injured limb one and one-half inches 
shorter than its fellow, and slight but not fixed eversion of the toes, all 
other positions being as we left them. The patient had not complained 
* Toledo Medical and Surgical Journal, April, 1877. 14 
Senn—Fracture of the Rim of the Acetabulum. 
of much pain, and had not been known to move the hips or lower limbs, 
nor had he been awrare of the shortening. 
Recalling to mind the quiet manner in which the final moves in my 
efforts at reduction had been effected on the previous day, I suspected 
fracture of the acetabulum, and, upon mature reflection, could but nega- 
tive any other supposition of error. Seating myself at the foot of 
the bed, in good position for protracted traction, I seized the heel 
and instep and commenced gentle extension, charging the patient to 
avoid [muscular resistence, and found him a model of courage, resig- 
nation, and confidence. After a moment of involuntary contraction, 
against which I did not apply additional force, I could feel a yielding to 
my effort, and in less than ten minutes the normal length of the limb was 
restored. The patient stated that ‘the stretching made it more comfort- 
able.’ Transferring my grip to other hands, 1 carefully examined the 
cresta ilii, and found them relatively correct. 
Having informed my patient and his attendant friends of what 
seemed to be the new revelation, we proceeded to the experimentum crucis, 
to wit: Having the extension gradually relaxed, watched, with my 
hands pi'essed over the trochanter major of either side, for tactile sensa- 
tions, I believed, but was not sure, that I felt crepitus. The retraction 
was extremely slow, and it was about twenty minutes before the patella 
appeared, an inch above its fellow Again traction was made by an 
assistant, and I felt the same individual crepitus, or, more properly, 
friction, in its progress. The patient said that “ it hurt a little, in one 
spot.” We now attached a weight of five pounds by a cord running over 
the roll at the foot of the bedstead, which we caused to be elevated two 
bricks’ thickness, and kept the patient secundum artem, for six weeks, 
with the usual minor details and modifications. After this period, he was 
careful in resuming the erect position, bearing no weight upon the foot 
for about one month longer, and finally resuming the use of the limb as 
far as practicable, which is to-day far from perfect.” 
Dr. Beech examined the patient four years after the injury, and found 
that he had to wear about one inch additional thickness under the heel 
of the injured limb, and that, even with this contrivance, he wralked with 
a decided halt. The foot could be inverted or everted, but when the 
whole weight of the body rested upon it, it was slightly everted. Imme- 
diately above the acetabulum a hard substance could be found, which 
was supposed to he provisional callus. 
Case XIII. Reporter, Julius F. Miner.*—This, in every respect a 
remarkable case, is the only one I have been able to find wdiere the rim 
♦Buffalo Medical and Surgical Journal, Vol. V., p. 383. Senn—Fracture of the Rim of the Acetabulum. 
15 
of the acetabulum was fractured by a gun-shot wound without producing 
a more extensive fracture of the joint. Prof. Miner very kindly sent me 
a photograph of the patient for inspection, which accurately shows the 
position of the limb after recovery. 
“ Lieut. Col. James Strong, of the Thirty-Eighth New York Volunteers, 
now Brigadier General of the Veteran Reserve Corps, was wounded May 5, 
1802, at the battle of Williamsburg, Va. The ball entered a little below 
the anterior superior spinous process of the ilium, and made its exit near 
the outer margin of the sacrum. The ball passed deeply, and fractured, 
in its course, the rim of the acetabulum, which was removed, an inch and 
a half in length, and of a diameter sufficient to show that the whole 
upper rim had been carried away. This fragment of bone was removed 
from the wound at the dressing made in the hospital, where he was 
carried after having lain on the field for some hours. Surgeon N. J. 
Berry first dressed the wound and removed fragments of bone and por- 
tions of pants and drawers. The wound was very large, and a thorough 
examination could be made by the easy passage of the finger.” 
For the purpose of giving the patient the best possible chance to 
recover, he was removed to his home in Buffalo, where he was placed 
under the care of Prof. Miner. * * * * * “The leg 
was partly flexed upon the thigh, and the thigh upon the body, the whole 
drawn internally to a considerable extent. In this position it was fixed; 
it could not be moved in the slightest degree without producing pain, 
which was absolutely unendurable.” 
“ The constitutional disturbance at length became very great, and the 
question of life, rather than the position of the leg, engrossed all atten- 
tion. Fragments of clothing and spiculae of bone were at various times 
extracted or washed from the wound, while great quantities of pus con- 
stantly issued. ***** jn this condition of extreme 
distress and uncertainty of life, he continued without great change for 
eight or ten weeks, when he gradually and very slowly commenced to 
improve, both in his general condition and in the appearance of the 
wound, until, after a few weeks more, he could be moved from one side 
of the bed to the other, and his comfort promoted by change of position. 
When at length it became evident that his recovery was probable, the 
question of the condition of the leg was again agitated, and efforts were 
early made to extend it and obtain motion in the knee joint. Extension 
and counter extension under the influence of chloroform was adopted, 
and persevering efforts made to obtain as favorable results as possible. 
Nothing, however, can be said to have obtained greater motion in the 
knee-joint, the hip being made neither better nor worse. Abcesses 
occasionally formed in the site of the old wound, and continued to 16 
Senn—Fracture of the Rim of the Acetabulum. 
do so for eighteen months or two years, each time indicating great 
constitutional disturbance, sometimes so great as to excite fears of his 
life.” 
When recovery finally took place, the following was his condition: 
“ The thigh is shortened nearly five inches, the head of the femur rests 
upon the ilium above the acetabulum, and a complete and bony anchy- 
losis exists; the knee is drawn inwards, and has good motion. The 
weight of the body can be borne upon the leg with comfort, and the 
twisting of the pelvis and the extension of the toes compensates for the 
shortening and stiffening, in a wonderful degree, so that he walks with 
or without a cane, with but slight disability, considering the severity of 
the injury and the unnatural condition of the articulation.” * * * 
“ A gun-shot wound, such as related, carrying away the rim of the 
acetabulum and allowing the muscular contraction to dislocate the femur, 
drawing the head upwards and backwards, must be a very severe and 
dangerous injury. If sucli cases have occurred, they have more generally 
died from either shock, hemorrhage, or inflammatory action and 
traumatic fever, within a few days—have rarely continued under observa- 
tion long enough to accurately determine their nature, or the results of 
imperfect recovery.” 
Case XIV. Reporter, J. H. Pooley.*—This case is reported by Prof. 
Pooley, more for the purpose of showing the utility of the fulcrum in 
reduction of dislocation of the hip, as advised by Dr. Sutton, than with 
any special reference to the fracture under consideration, but as both Dr. 
Dunlap and the reporter considered the existence of the fracture an 
obstacle to the reduction, I will report it in this connection. 
“ October 19, 1876, I was requested by Dr. Dunlap, of Springfield, 
Ohio, to see, in consultation with him, a case of dislocation of the hip, 
in which he had failed to effect reduction after a fair and repeated trial 
of the ordinary method of manipulation. 
“The patient, the wife of a farmer residing near Catawba, Clark 
County, Ohio, about fifteen miles from Springfield, had been thrown from 
a wagon the day before, about four o’clock in the afternoon, and had sus- 
tained a dislocation of the hip. She had been first seen by Dr. John 
Clark, of Mechanicsburg, who had been unsuccessful in his attempt at 
reduction. 
“ Dr. Dunlap had then been sent for, and had made repeated attempts 
to reduce the hip, but also without success. All the attempts had been 
manipulation. Pulleys had not been used. I arrived at the house on the 
next day, early in the morning. I found the patient, a spare, nervous 
* American Practitioner, December, 1876. Senn—Fracture of the Rim of the Acetabulum. 
17 
woman of thirty-three, in bed, suffering considerably from pain, and 
severely from nausea, the result of chloroform which had been admin- 
istered on several occasions. 
“The left limb was an inch and a half shorter than its fellow, the foot 
very slightly everted, and the head of the bone could be plainly felt 
in front of the ilium, just above the acetabulum. Dr. Dunlap informed 
me that the dislocation had been primarily on the dorsum ilii, and the 
present position of the head of the femur was the result of the last 
manipulation. It had been found, on manipulating it, to be extraor- 
dinarily movable, and had been carried once or twice into the thyroid 
foramen, and also up on the ilium just above the acetabulum, in which 
situation I found it. In fact it would go almost anywhere, except into 
the right place. Dr. Dunlap said that he had carried it right across the 
acetabulum on two occasions, and, as he did so, he felt a distinct crush- 
ing crepitus, but it went over and not in. His belief, which I presume 
was correct, was that a portion of the lip of the acetabulum was broken 
off, and, as the head of the thigh bone was brought up against this 
broken portion, it was forced before it, and, partially tilling up the 
acetabulum, prevented it from going in, and guided it over to the other 
side instead. I directed, according to Dr. Sutton’s plan, a firm cylinder 
to be made, by tightly and evenly rolling two sheets, which was three 
inches in diameter and about two feet in length; it was firmly tied round 
with narrow strips of bandage to prevent its unrolling. The patient 
was now anaesthetized and laid upon the floor; the cylinder was now 
placed across the upper part of the thigh in the groin, and firmly held at 
each end by an assistant; over this, as a fulcrum, Dr. Dunlap made the 
manipulation, while I attempted to follow the excursion of the bone 
with my fingers. The two first attempts failed, as I very plainly saw, 
from not fully carrying out the principle involved in the use of the ful- 
crum ; that is, by abducting the knee before complete flexion of the thigh 
over the cylinder had been accomplished. The first time the head of the 
femur lodged in the thyroid foramen, the second time at the top of the 
ilium, where it was when we began; it had skipped round the base of 
the acetabulum without rising to its level, much less going into it. The 
third trial, in which the principle of the fulcrum was deliberately and 
thoroughly carried out, was perfectly and speedily successful. The thigh 
was slowly and fully flexed on to the abdomen over the fulcrum, the 
head of the bone was lifted up to a level with the acetabulum, and when 
the knee was abducted, and the motion of bringing the thigh down barely 
commenced, it slipped in with a distinct snap; the limb was found to be 
restored in length and position and the dislocation was reduced. A broad, 
firm, pelvic bandage was applied, and the patient returned to bed. 18 
Senn—Fracture of the Rim of the Acetabulum. 
“ This may almost be looked upon as a test case for the new method. 
Ordinary manipulation had been tried by skillful hands, in which it had 
never before failed; and I think that there can be but little doubt that Dr. 
Dunlap’s explanation of his failure was the correct one. What was wanted 
there was some means by which the head of the femur could be carried up 
to a level with the top of the acetabulum, and thus prevented from push- 
ing the broken acetabular rim before it. This was found in Dr. Sutton’s 
method; the obstacle was overcome and the reduction accomplished.” 
Case XV. Reporter, Frank H. Hamilton.*—“ February 3, 1847, a 
strong German laborer was crushed under a mass of iron weighing 
several tons. Drs. Sprague and Loomis, of Buffalo, were called, and 
found the left thigh dislocated upwards and backwards, and, by the aid 
of six men, they succeeded in reducing it, the reduction being attended, 
as the gentlemen have informed me, with a slight sensation of crepitus. 
The legs were then laid beside each other, and the knees tied together, 
the patient lying on his back, and now the two limbs appeared to be of 
the same length. On the second and third days the injured limb was 
examined by the same gentlemen, and there was no displacement; on the 
fourth day I was invited to meet these gentlemen, the patient having had 
muscular spasms during the previous night, and the thigh being reluxated. 
I found the limb shortened one inch and a half, adducted, and the toes 
turned in. We immediately applied tlie pulleys, and soon drew the tro- 
chanter down to a point apparently opposite the acetabulum, and a care- 
ful measurement showed that the two limbs were of the same length. 
The pulleys being removed, the leg did not draw up again nor did the 
foot turn in, yet we had felt no sensation to indicate that the bone had 
slipped into its socket, nor had we felt crepitus. The legs and thighs 
were now laid over a double inclined plane and well secured. He 
remained in this condition for three days more, during which time Dr. 
Sprague saw him each day and found nothing disarranged. On the 
night of the seventh day the spasms returned, and in the morning the 
thigh was displaced. The next day we again applied the pulleys, but soon 
found that the bone would not remain in place one minute after the 
pulleys were removed. At this time, while moderate extension was being 
made at the foot, by rotating the foot inwards, we could distinctly feel a 
slight crepitus. A straight splint was applied and as much extension 
made as he could conveniently bear, and in this condition the limb was 
kept several weeks. Seven years after I found the thigh still displaced 
upon the dorsum ilii; he limped badly, but he could walk fast and per- 
form as much labor as before the accident.” 
*A Practical Treatise on Fractures and Dislocations. By Frank H. Hamilton, 
A. M., M. D., LL. D. Philadelphia, 1871. Sexn—Fracture of the Rim of the Acetabulum. 
19 
Case XVI. Reporter, Mr. Keate.*—This case is interesting from the 
fact that the lower portion of the rim was fractured and the femur dis- 
located downwards. The head of the femur could be felt lying against 
the tuber ischii, and a distinct grating of the broken oil' cartilaginous 
rim could he felt. The posterior and upper part of the rim being com- 
plete, there was no trouble in keeping the bone in its position after 
reduction had been accomplished. 
Case XVII. Reporter, Dr. McTyer.f—A man, aged 27 years, was 
injured by a number of bricks falling upon his back, his right knee 
being placed on the bank of a trench. His right leg was found shortened 
about an inch and a half, flexed, and the foot a little everted. Motion of 
the limb was not much impaired, but was attended by great pain and 
crepitus. On making extension the limb was easily brought to the same 
length with the other, but it became shortened again immediately when 
the extension was discontinued; the symptoms resembling fracture of 
the neck of the femur. 
The usual treatment for such cases was pursued. Subsequently the 
toes became slightly turned in, but this circumstance was not regarded 
as sufficient evidence to justify a change in the diagnosis. In a few days 
the patient died from his injuries. On dissection, about one inch and a 
half of the upper and posterior portion of the rim wras found completely 
detached and held in place by a portion of the capsular ligament; the 
bottom of the acetabulum was also fractured. The head of the bone 
could be easily dislocated upon the dorsum ilii, the fragment of the 
acetabular margin being moved aside and swinging upon its fibrous 
attachment as upon a hinge, but resuming its place again perfectly when 
the head of the femur was restored to the socket The femur was not 
broken. 
Case XVIII. Reporter, Dr. McTyer.j—“In this case the limb was 
found shortened, the knee slightly bent and turned a little forwards 
and inwards, and the toes pointing to the tarsus of the other foot. It 
was thought to be a fracture also of the neck of the femur, but the 
autopsy disclosed only a fracture of the upper margin of the rim of the 
acetabulum.” 
Case XIX. Reporter, Dr. McTyer.||—In this case, seen only after 
death, the limb was not shortened much, but the toes were stretched 
downwards, and turned slightly inwards. It was supposed at first to be 
simple dislocation, but on dissection, the posterior and inferior margin of 
* Ibid., and American Journal of Med. Sciences. Vol. XVI., p. 225. 
t Ibid., and Glasgow Medical Journal, February, 1830. 
t Ibid. 
1 Ibid. 20 
Senn—Fracture of the Rim of the Acetabulum. 
the acetabulum was found to be broken, and displaced towards the 
coccyx, while the head of the femur rested upon the pyriformis muscle, 
over the ischiatic notch. 
Case XX. Reporter, Dr. McTyer.*—This case came under observa- 
tion in the dissection room. A fragment of the superior and posterior 
margin of the acetabulum had been broken off, and had reunited, slightly 
displaced. 
Case XXI. Reporter, W. L. Faxon.f—Mrs. Faxon, aged thirty-five, 
wife of the reporter, was thrown from a buggy while driving, Oct. 1st, 
1877. When taken up, there were symptoms of .dislocation or fracture of 
the right femur. Examination proved the existence of a fracture of the 
lip of the right acetabulum, and dislocation of the head of the femur 
upwards and backwards, with about four (4) inches shortening. The 
fracture was so near the floor of the acetabulum that there was no sensa- 
tion of the head of the femur being lifted in its passage over the broken 
edge of the socket. Drs. John H. Gilbert, of Quincy, and Samuel Cabot, 
of Boston, assisted the husband of the patient, and confirmed the diag- 
nosis. Desault’s splint was applied, but the patient’s condition—she 
being five months pregnant, and suffering from constant vomiting from 
the time she was injured—necessitated its removal. Her husband then 
constructed a bed, of which a lengthy description is given, the most 
important features, however, being the use of sand-bags for the purpose 
of keeping the limb quiet and making gentle extension and counter- 
extension. The pain and vomiting ceased after this dressing was applied. 
On January 4, 1878, she was delivered of a healthy child. One year 
from the time of injury, she was able to walk, and the prospects were 
favorable towards a cofnplete recovery. 
Case XXII. Reported by John Eric Erichsen4—This case came 
under Mr. Erichsen’s observation at the University College Hospital. 
The patient was a strong, muscular man, about 30 years of age. It is not 
stated how the injury was. produced. The limb was shortened, inverted 
and the head of the femur could be felt in the sciatic notch. Reduction 
was easily effected by extension, and was attended with distinct crepitus, 
but as soon as extension was discontinued, the head of the bone slipped 
back to its former locality. 
Case XXIII. Reporter, D. Hayes Agnew.||—“ In a case of this injury 
recently under my care, in a very prominent citizen of Philadelphia, 
* Ibid. 
tThe Boston Medical and Surgical Journal, Feb. 20, 1879. 
fThe Science and Art of Surgery, by John Eric Erichsen, Philadelphia, 1873. 
Vol. I, page 364. 
|| The Principles and Practice of Surgery, by D. Hayes Agnew, M. D., L.L.D., Phil- 
adelphia, 1878, Vol. I, page 929, and communication from the author. Senn—Fracture of the Rim of the Acetabulum. 
21 
there was no shortening of the limb, although the most careful measure- 
ments were made. Pressure over the body of the pubis caused no pain, 
and the patient was able to sit up and ride a distance of nearly two miles 
to his home after the accident. He was able to raise the limb, and to flex 
the leg upon the thigh, and the thigh upon the abdomen; he could invert 
and evert the toes; there was no crepitus like that of fracture, and he 
had entire command over the bladder. The only movement that caused 
him pain was the attempt to turn upon the side, and this occasioned 
violent muscular spasms. When the thigh was flexed upon the pelvis, 
and then rotated, the arc of the circle described was uniform up to a 
certain point, but beyond that, the head of the bone appeared to slip. 
On the strength of this peculiar symptom, a fracture of the lip of the 
cotyloid cavity was suspected, and the treatment adopted accordingly. 
A subsequent autopsy not only proved that this was the case, but also 
revealed a fracture of the floor of the acetabulum, through which the 
finger could be thrust from the pelvic side.” 
Case XXIV. Reporter, James Dorland.*—Dr. Dorland informs me 
that wdiile on a visit to his former home in Canada, he wras called to see 
Mrs. J , aged 25 years, who had suffered an injury of the left hip joint 
three years before. At that time she was three months pregnant, and, 
while walking on the wet floor, slipped and fell heavily on the left side. 
In the evening a physician was called, wdio diagnosed a dislocation of 
the femur upwards and backwards, and proceeded to reduce it. This 
wras done without any difficulty, but the bone would not remain in place. 
The reduction w7as attended with crepitus, and the head of the femur 
could be distinctly felt when out of place. The bone was reduced on 
four different occasions, but reluxation followed every time, in spite of 
all measures employed to keep it in place. She was kept in bed for four 
weeks, and for five months subsequently she managed to move from one 
place to another by means of a chair. The delivery took place at full 
time, and was not attended by any special difficulties. When Dr. Dorland 
examined her, the limb was shortened two inches, and the toes turned 
inwards. She walked quite lame, but without the aid of either cane or 
crutches. 
Case XXV. Reporter, N. Senn.f—J. D , aet. 22, a strong, muscu- 
lar man, wras injured May 1,1872, while pushing a hand car before him ; 
another car, coming from behind with greater speed, knocked him down. 
He first fell on his knee, and then received the principal blow upon the 
posterior and left aspect of the pelvis, just above the great trochanter. 
♦Personal Communication by Dr. James Dorland, Milwaukee, Wis. 
tThree Cases of Rare Dislocation, by N. Senn, M. D., Milwaukee, Wis. The Med 
ical Examiner, Jan., 1873. 22 
Senn—Fracture of the Rim of the Acetabulum. 
The patient immediately experienced great pain in the left hip, and was 
unable to walk. The physician who was called diagnosed a dorsal 
dislocation of the femur, which he reduced very easily by slight manip- 
ulation. He saw the patient several times afterwards, and expressed him- 
self as satisfied with the progress of the case. 
For a number of days the pain continued to be severe, but gradually 
subsided. In a few weeks he attempted to walk, but found it impossible 
to rest the weight of the body on the afflicted limb. Two months after 
the accident he applied to me for treatment. I found the thigh flexed 
upon the pelvis, the knee and foot turned inwards, and the limb shortened 
two inches; the head of the femur could be distinctly felt upon the 
dorsum ilii, and responded to all movements of the thigh. Mobility 
very slight. The patient being desirous that at least a faithful attempt 
should be made to reduce the dislocation, I called Drs. Lohr and Lueck 
to render assistance. The patient was placed profoundly under the 
influence of ether. The adhesions were ruptured, and Reed’s manipula- 
tion repeated several times without accomplishing the desired object. 
Extension and counter-extension were now made by a number of 
assistants, with the result of lengthening the limb nearly, but not quite, 
to its normal length. The patient was then placed in bed, and permanent 
extension applied by means of a weight and pulley. One week subse- 
quently we again placed the patient under the influence of ether, and 
made extension with the pulley, the thigh being adducted and rotated 
inwards, proper counter-extension being made at the same time. After 
using considerable force, the head of the femur advanced with an ill- 
defined sensation of crepitation, to a point opposite the acetabulum. 
While an assistant continued the extension, the limb was brought down 
to its natural position, and, on accurate measurement, was found to be 
of normal length. 
The upper margin of the great trochanter was found to correspond to 
Nelaton’s line. While held in this position, rotation, abduction, adduc- 
tion and flexion could be made with ease, but as soon as traction was 
suspended, and especially if the thigh was adducted at the same time, 
the head of the femur slipped back upon the dorsum ilii, accompanied 
by the same rough, grating sound as it left the socket, as was heard and 
felt during reduction. I could distinctly feel the head of the femur glide 
over the smooth surface of the acetabulum, and, as traction ceased, it 
appeared to rise a little and pass over a rough edge, and then, without 
any further obstacle, it receded to its former abnormal position. We 
repeated this experiment several times with the same result. We were 
now satisfied that there existed with the dislocation, a fracture of the 
upper and posterior portion of the rim of the acetabulum. After bring- Senn—Fracture of the Rim of the Acetabulum. 
23 
ing the limb into its natural position, we applied extension by weight 
and pulley; at the same time we aimed to press the head of the femur 
against the floor of the acetabulum, by applying a broad, pelvic band. 
It was found impossible to keep the bone in place, and after three weeks’ 
persistent efforts, all further attempts were abandoned, the former de- 
formity having gradually returned. 
Case XXVI. Reporter, H. J. Bigelow.*—This case occurred at the 
Massachusetts General Hospital, under the care of Dr. Gay. 
“The patient, aged 86, a robust and healthy man, fell from the roof of 
a building, striking upon the right hip. In the recumbent position, the 
leg was shortened and inverted, the toes crossing the opposite instep. 
Being etherized, the thigh could be flexed at a right angle with the ab- 
domen, there being crepitus in the region of the neck of the femur. 
The limb, when drawn down, was still shortened half an inch. The 
patient having died of other injuries, the autopsy showed the head of the 
bone partially dislocated backwards and resting upon the posterior frac- 
tured edge of the socket, the whole posterior wall of the socket having 
been broken away in a mass. The detached fragment measured one and 
a half inches square. The posterior surface of the head of the bone waa 
deeply indented by the fractured edge of the acetabulum, against which 
it had impinged after displacing the portion broken oft'. A transverse 
crack extended through the acetabulum from the upper sciatic notch to 
the foramen ovale. The position of the limb in this case did not differ 
from that in the usual partial dislocation behind the tendon, and was 
determined by the same mechanism.” 
Case XXVII. Reporter, M. Ricliet.f—“ The patient, 58 years of age, 
was caught by a revolving belt The right limb was shortened a quarter 
of an inch, and so far everted and straight that the internal condyle of 
the left femur lay in the popliteal space of the injured one; the right 
groin was filled up; towards its middle, and outside the femoral artery, 
was a hard, resisting and obscurely spherical tumor, masked by the 
glands and swollen tissues. Flexion with outward rotation and local 
downward pressure failed to reduce the luxation; but, on a third trial, 
flexion and downward pressure during slight abduction, instead of out- 
ward rotation, succeeded. Seven months afterwards the death of the 
patient having occurred from another cause, a post-mortem examination 
showed a united fracture of the socket, comprising the external and 
anterior third of the rim with the two anterior spinous processes of the 
ilium.” 
*The Mechanism of Dislocation and Fracture of the Hip, by H. J. Bigelow, M. D., 
Philadelphia, 1869. 
t Ibid., and M. Berand, Bulletin de la Soc. de Chirurg., 1862. Tom. III., p. 185. 24 
Senn—Fracture of the Rim of the Acetabulum. 
The older works on surgery mention direct and great violence as the 
only cause of fracture of the acetabulum; indeed, until recently, it has 
been considered impossible for a fracture of the rim to take place without 
more extensive injury to the ilium. When the rim is broken by direct 
application of force, it is usually the result of a severe fall or blow upon 
the great trochanter or pelvis; or the producing cause may be still more 
direct, as when a bullet in its course chips away the brim, as was the 
case in the very interesting and, to my knowledge, unique case reported 
by Prof. Miner. When the force is applied over the center of the great 
trochanter, in the direction of the axis of the neck of the femur, the 
head of the bone is driven directly against the socket, and a stellate or 
perforating fracture of the acetabulum is the result; but if the force is 
applied in such a manner that it first rotates the femur outwards or 
inwards, then one margin of the acetabulum acts as a fulcrum to the 
neck, and the head is forced against the opposite side, and a linear frac- 
ture through the acetabulum (experiment No. YI), or fracture of the rim 
(experiment No. VII) may take place. In such cases, the traction of the 
capsular ligament may assist the head of the femur in producing the 
fracture of the rim, but without additional assistance such traction is 
not sufficient to produce the injury. When the force is applied to the 
posterior part of the pelvis, as was done in Cases III, VII, VIII, XI, 
XVII, and XXII, the pelvis becomes the movable point, and the foot, if 
the leg is extended, or more frequently the knee, becomes the fixed 
point and furnishes the necessary amount of resistance. 
At the moment the injury is received, it is essential for the thigh to 
be abducted, as adduction would favor a dislocation by the head of the 
femur gliding over the inclined plane of the internal surface of the 
acetabulum (Experiment No. IV.) The pelvis may be the fixed point, as 
in case IX, and the force transmitted through the femur by blows or falls 
upon the knee. In most of these cases the thigh was more or less flexed 
at the time of injury, hence, in the majority of cases, the upper and 
posterior segment of the rim was fractured, and the head of the femur 
dislocated into the upper sciatic notch, or upon the dorsum ilii. 
Of the twenty-seven cases, eighteen were males, four females, and in 
the remaining five the sex is not stated. The disproportion between the 
males and females is explained by the fact that the former are more 
frequently exposed to severe accidents. The same may be said in regard 
to age. The extremes of the ages were eighteen and seventy-eight years, 
so that most of these cases occurred during the time of life when most 
exposed to grave injuries. It is also well to remember that in young 
individuals, dislocation and diastasis occur in preference to fracture, 
CAUSES. Senn—Fracture of the Rim of the Aretahvlvm. 
25 
while in the aged, the altered position of the neck of the femur as wrell as 
the increased fragility of its substance, are potent predisposing causes 
of fracture of the neck of the femur. 
SYMPTOMS. 
The symptoms presented by a case of fracture of the rim of the 
acetabulum are those of dislocation and fracture combined, the symptoms 
of the former resemble ordinary dislocation, while the latter are directly 
referable to the broken bone itself. A certain degree of displacement of 
the head of the femur was present in all cases where a diagnosis was 
made during life. Benjamin Travers* believed that in some cases of frac- 
ture of the rim of the acetabulum, the displacement takes place gradually 
some time after the injury has been received, but it is more probable that 
these were cases known and described by Hueterf as inflammatory 
dilatation of the acetabulum, the interstitial absorption of the margin of 
the cavity permitting the head of the femur to glide upwards and back- 
wards. In twenty-four cases the direction of the dislocation is mentioned, 
of which in fifteen the head of the femur was dislocated upwards and 
backwards, in four into the great sciatic notch, in two directly back- 
wards, in two downwards, and in one case forwards. It will be seen, 
then, that in a large majority of cases, that portion of the rim is fractured 
which is in the direction of the usual form of dislocation, so that the 
same injury which produces a dislocation may also cause a fracture, 
provided it is sufficient in intensity and the limb abducted at the time 
the injury is sustained. 
The amount of shortening corresponds to the distance the head of the 
femur recedes from the socket. In Agnew’s case, no shortening could be 
detected on careful- measurement. In all of the other cases, where men- 
tion is made of this symptom, it was present, but varied in degree from 
one-fourth of an inch to four inches. If the head of the femur has left 
the socket, the position of the limb is the same as in simple dislocation, 
the direction being determined by the form of dislocation. 
Flexion to a greater or less extent was present in all cases where 
reference is made to this subject. Inversion of the foot and rotation of 
of the femur inwards, were present in fourteen cases, while the opposite 
condition existed in three cases, and in ten cases no mention is made 
this symptom. When the dislocation was complete, the limb remained 
immovable in its abnormal position, until reduction was effected. The 
characteristic symptoms of the injury are those which are referable to the 
* Further Observations in Surgery, 1860, p. 27. 
t Klinik dcr Oelenk-krankheiten von C. Hueter, Leipsig, 1876, Zweiter Theil, 
Seite 316. 26 
Senn—Fracture of the Rim of the Acetabulum. 
fracture itself, and these are crepitus, easy reduction, and difficult retention. 
Crepitus is always an important symptom in ascertaining the existence 
of a fracture. If it is distinctly felt, there can he no further doubt that 
a bone has been broken. The presence of this symptom is of special 
diagnostic importance, in connection with this subject, as the symptoms 
of dislocation are usually so prominent as to engage the whole attention 
of the surgeon. In the cases reported, this symptom is alluded to 
eighteen times, and in the following terms: distinct, eleven times; faint, 
once; marked, twice; indistinct, once; slight once, and in two cases it 
was absent. 
Bigelow places great stress on the presence of this symptom in ren- 
dering a diagnosis, when he says in his work previously quoted:* “To 
afford satisfactory evidence, cases of this sort should have been identified 
by autopsy or at least by crepitus.” I believe that the crepitus is not the 
same as in ordinary fractures, as in these instances it is the result of two 
rough, bony fragments rubbing against each other, while in these cases 
it is a roughness we obtain by rubbing an articular surface against a 
broken surface of bone, hence, not quite as loud and distinct. The de- 
tached margin of the acetabulum, unless comminuted, remains attached 
to the capsular ligament, and is pushed before or aside of the head of the 
femur at the time dislocation occurs, and is dragged after it when 
reduction takes place. In most of these cases it is clearly stated that 
crepitus was felt just before the head of the femur slipped into the 
socket, or at the moment reluxation look place, and in both instances it 
must have been produced by the head passing over the rough, broken 
edge of the acetabulum. In the few cases where crepitus was felt while 
the femur was in the dislocated position, it must have been the result of 
the head rubbing against the detached portion of the rim. 
The ease by which reduction was effected has attracted the attention 
of almost every observer. This is due to a more extensive laceration of 
the capsular ligament than in simple dislocation, and also to the removal 
of the obstacle offered by the intact margin of the acetabulum. By the 
fracture of the rim, a more direct and even route has been prepared for 
the head of the femur to return to its socket. 
Reluxation has always constituted the most perplexing feature of 
these cases. Its occurrence has usually led to a more thorough exami- 
nation and correct diagnosis. It is well known that in ordinary dislo- 
cations of the hip joint, when the bone has been once reduced, it remains 
in its place regardless of the after treatment, differing greatly in this re- 
spect from the same lesion of the shoulder joint, on account of the greater 
depth of the socket, and the action of more numerous and powerful 
* Page 159. Senn—Fracture of the Rim of the Acetabulum. 
27 
muscles for maintaining retention. Hueter* believed that the cases of 
habitual dislocation of the hip joint reported by Karpinskif may have 
been the result of injury to the rim of the acetabulum. 
Reluxation takes place from the inability of the defective margin to 
resist muscular contraction. The difficulty in retaining the bone is 
increased by the depth of the fracture, and its approach to the junction 
of the superior and posterior portions of the rim. In this connection it 
is important to determine what portion of the rim is most frequently the 
seat of fracture. In twenty of the cases, special mention was made of 
this fact, as follows: Superior portion of rim, two; superior and 
posterior, seven; posterior, five; posterior inferior, four; inferior, one; 
anterior, one. When the inferior or anterior portion of the rim is frac- 
tured, there is no tendency to reluxation, provided the limb is kept in 
the extended position and slightly inverted. 
A most thorough and critical examination, while the patient is 
profoundly under the influence of an anaesthetic, is always necessary 
to establish a positive diagnosis. If spontaneous reluxation does not 
follow immediately after reduction has been accomplished, and there are 
sufficient symptoms present to warrant a suspicion of the presence of the 
injury, it would be advisable to test the functional integrity of the 
acetabulum by flexion, adduction and rotation of the thigh; if any part 
of the rim has become defective by fracture, reluxation will be sure to 
take place. This maneuvre, associated with the presence of crepitus, 
may be regarded as the crucial test. 
The differential diagnosis must consider fractures of the neck of the 
femur with displacement, and simple dislocation. To distinguish this 
fracture from fracture of the neck of the femur, it is necessary to com- 
pare their most prominent symptoms: 
DIAGNOSIS. 
FRACTURE OF THE RIM OF THE FRACTURE OF THE NECK OF THE 
ACETABUUUM. FEMUR WITHOUT IMPACTION. 
Position of Limb. 
Thigh and leg flexed, adducted and 
rotated inwards. 
Thigh and leg straight and rotated 
outwards. 
Mobility of Limb. 
Mobility of limb is diminished. 
Arc of notation. 
Mobility of limb is increased. 
The trochanter rotates in its nor- 
mal arc. 
The arc of rotation of the tro- 
chanter is diminished. 
* Ibid., page 4&I. 
tDeutsche Militaer ierzt. Zeitsch. 1873. No. 3. 28 
Senn—Fracture of the Rim of the Acetabulum. 
FRACTURE OF THE RIM OF THE 
ACETABULUM. 
FRACTURE OF THE NECK OF THE 
FEMUR WITHOUT IMPACTION. 
Crepitus. 
Crepitation is not rough, and felt 
as the head passes over the bro- 
ken edge of the acetabulum. 
Crepitation is rough, and felt when 
the limb has been drawn down 
to its normal length. 
Head of Femur. 
The head of the femur is felt to be 
displaced. 
The head of the femur is normal 
in its position. 
Retention. 
The deformity reappears if by anjr 
movement of the limb the head 
of the femur is made to leave 
the socket. 
The deformity reappears as soon 
as extension ceases. 
History. 
Is most frequent in middle life and 
is the result of great violence. 
If intra-capsular in variety, it oc- 
curs in the aged, and is the re- 
sult of slight violence. 
Crepitus and a tendency to reluxation are the symptoms on which 
we place the most reliance, to differentiate this fracture from simple dis- 
location. The akystopeurastic of Middeldorpf may be of great service to 
determine the existence of fracture of the rim. After reduction has been 
accomplished, a long, stout needle is passed through the tissue to the 
supposed seat of fracture. By lateral movements of its point, the defect 
in the margin, as well as the roughness of its surface, is ascertained. An 
effort should now be made to fix the detached fragment with the point of 
the needle, and, by rubbing it over the broken margin, a rough crepitus 
is elicited. 
The prognosis must have reference to the preservation of life and the 
restoration of the utility of the limb. All of the old authors regarded 
fracture of the pelvic hones a grave lesion, almost necessarily leading to 
a fatal termination. I believe with, Dr. E. Andrews,* that all uncompli- 
cated fractures of these bones tend to recovery, and that death is attrib- 
utable in most instances to a lesion of some important pelvic or abdominal 
viscera. In twenty-three cases where the result is noted in this regard, 
thirteen recovered and ten died. The prognosis is less favorable if the 
floor of the acetabulum is also implicated in the fracture. Of four cases 
of this sort, only one recovered. In nine cases out of the thirteen that 
PROGNOSIS. 
* Transactions of the Illinois State Medical Society, 1873. Senn—Fracture of the Rim of the Acetabulum. 
29 
recovered, the limb remained in place after reduction, and the recovery 
was complete. In four cases redislocation took place, the limb assuming 
the same malposition as after simple, unreduced dislocation of the femur. 
TREATMENT. 
The indications to be fulfilled in the treatment of this class of 
injuries are: 1st. To reduce the dislocation; 2d. To retain the head of 
the femur in the socket until union has taken place between the 
fragments. 
The dislocation may be reduced by manipulation or by extension; in 
both instances, flexion constitutes an important step in the operation. 
Bigelow says:* “These displacements, especially the displacement 
backwards, demand the usual attempts at reduction by flexion. Although 
the bone inclines to slip from the socket, it can be retained there, in 
cases of a sort heretofore considered difficult of treatment, by angular 
extension, with an angular splint attached to the ceiling, or some other 
point above the patient; or if any maneuvre has reduced the bone, the 
limb should be retained, if possible, in the attitude which completed the 
maneuvre.” 
In seventeen of the case reported, the manner of reduction is specified 
as follows: By extension, eleven—in most of these cases extension and 
flexion were combined; by manipulation, two; by manipulation and 
extension, one; by manipulation over Sutton’s fulcrum, one; by extension 
with pulley, two. In all but one of the cases the displacement was cor- 
rected without difficulty. In Pooley’s case it was supposed that the 
detached fragment prevented reduction by being placed between the head 
of the femur and the acetabulum. In my own case, the use of the 
pulley was required from the length of time that had elapsed since the 
injury had been received. Had I been aware of the nature of the injury, 
no attempt would have been made to reduce the dislocation, as a restora- 
tion of the acetabulum could not be hoped for after such a long lapse of 
time since the injury was sustained. Permanent extension was applied 
more for the purpose of determining a favorable locality for the forma- 
tion of a new joint, than with a view of retaining the head of the bone 
in its socket. 
•As in most instances a diagnosis cannot be made before reduction 
has been accomplished, surgeons will resort to their favorite methods of 
reduction. Should the nature of the lesion be determined beforehand, 
traction in the direction of the broken edge of the rim, and rotation of 
the limb inwards, will readily restore the normal relation of the parts. 
* Dislocation hip joint. 30 
Senn—Fracture of the Rim, of the Acetabulum. 
As we possess no direct measures of keeping the fractured surfaces in 
apposition, all our efforts must be directed towards preventing reluxation, 
by appropriate position and fixation of the limb and pelvis. 
The depth and extent of the fractured margin, as well as the location 
of the fracture, will determine the difficulty in retaining the head of the 
femur in its normal position. If sufficient depth of the upper portion of 
the rim is left to serve as a support to the head of the bone, all that is 
necessary is to dress the thigh in the abducted position, so as to press the 
head of the femur against the floor of the acetabulum. As the contusions 
of the soft parts about the hips and pelvis are severe, a plaster-of-Paris 
splint cannot be applied as a primary dressing. The healthy limb and 
pelvis should always be included in fixe retentive dressing. 
Bonnet’s wire breeches, Dzondi-Hagedorn’s apparatus, or Hamilton’s 
splint, as advised by him in the treatment of fractures of the femur in 
children, will be found sufficient to maintain retention. 
After the swelling in the soft parts has subsided, nothing more per- 
fect could be devised than a plaster-of-Paris dressing, including both 
limbs and the pelvis. 
When nearly the entire depth of the upper or posterior portion of the 
rim has been detached, muscular contraction must be counteracted by 
permanent extension with the weight and pulley, and immobility of the 
joint secured by appropriate splints. In cases of this sort, angular ex- 
tension with an angular splint, as advised by Bigelow, will answer an 
admirable purpose. The unbroken part of the rim should be made the 
support for the head of the femur whenever practicable, as when the 
posterior part of the rim is fractured, the thigh should be dressed in the 
position of hyper-extension, a broad, firm, pelvic band, with a compress 
above the trochanter, will aid in keeping the bone in place, in approxi- 
mating the fractured surfaces, and in preventing muscular spasms. 
The treatment should be continued for a sufficient length of time to 
secure a firm union of the detached fragment with the broken rim, 
which, as in other fractures, generally requires from four to six weeks. 
The patient must be directed to exercise great care in the use of the limb 
for a considerable length of time after all dressings have been removed, 
so as to obviate any undue pressure against the recently repaired rim of 
the acetabulum.