Supracotyloid Dislocation. 
ET 
CONSULTING SURGEON TO THE TRANSFIGURATION CLINIC J 
JOHN EEDLON, M. D., 
ASSISTANT SURGEON TO THE VANDERBILT 
CLINIC, NEWYORK, 
REPRINTED FROM 
®J)e Ncte ¥orft fßel)ic«l .Journal 
for May 23, 1891. Reprinted from the New York Medical Journal 
for May 23, 1891. 
SUPRACOTYLOID DISLOCATION.* 
By JOHN RIDLON, M. D., 
CONSULTING SURGEON TO THE TRANSFIGURATION CLINIC ; 
ASSISTANT SURGEON TO THE VANDERBILT CLINIC, NEW YORK. 
Dislocation of the femur directly upward is an exceed- 
ingdy rare accident. Very few of the works on general sur- 
gery make any mention of this dislocation, and special 
treatises on dislocations are sufficiently barren of facts to 
make pardonable the recording of the following case: 
opinion by Dr. Charles F. Clark, of Brooklyn, was seen on May 
3,1890. About a year ago (i. e., before the date of the examina- 
tion), while attempting to bend backward, the feet being sepa- 
rated and the toes turned outward, he felt something give away 
at the right hip ;he suffered some pain, but, after resting for a 
short time, was able to walk to his home. He was treated by 
liniments, iodine, and other external applications. He was able 
to walk about without much suffering, but at night at times had 
starting pains, and these gradually grew worse until he came 
under the care of Dr. Clark some eight weeks ago, since which 
time he has been confined to bed and treated with weight (four- 
teen pounds) and pulley; during this period he has been free 
George A. Simpson, sixteen years old, referred to me for an 
from pain. 
* Read before the Hospital Graduates’ Club, New York, March 26 
1891. 
COPTBXGHT, 1891, BT D. APPLETON AND COMPANY. 2 
SUPHACOTYLOID DISLOCATION. 
Examination.—The patient walks without any evident pain. 
The right leg is short, rotated outward, and is not swung in ad- 
vance of the left in walking. The buttock at the back of the 
right great trochanter is flattened. Lying supine, the left thigh 
can be fully flexed on the chest without the popliteal space of 
the right leg leaving the table, and without the least discom- 
fort. Active or passive flexion of the right leg is not possible 
to any appreciable extent. The limb lies rotated outward about 
450, and can be passively rotated outward to 90° without dis- 
comfort ; inward rotation of the limb from the position in which 
it lies is not possible. The left leg is found to rotate outward 
to about 00°, but to lack inward rotation to the usual degree, it 
coming easily only so far as to bring the foot parallel to the 
antero posterior plane of the body. Lying prone, extension of 
the thigh on the pelvis is free and to the normal degree; in- 
ward and outward rotation are as already noted. Backward 
passive bending of the lumbar spine normal. The right great 
trochanter is three quarters of an inch above Nelaton’s line. 
Again lying supine, there is found to be three quarters of an 
inch shortening of the right limb when measured from the an- 
terior superior spine of the ilium to the inner malleolus, and 
the same when measured from the umbilicus to the inner mal- 
leolus. Ten inches below the anterior superior spine of the 
ilium the circumference of the right thigh is seven eighths of 
an inch, and the calf a quarter of an inch less than the left. 
There is no lateral deformity—i. e., abduction or adduction—of 
the limb, and very little passive motion in either direction. 
There is no apparent fullness in the right groin to sight or to 
superficial touch, but when the great trochanter is steadied with 
the fingers, the thumb being pressed firmly down over the point 
where the head of the femur ought to be found, and the limb 
passively rotated outward, the head of the femur can be dis- 
tinctly felt to rise up with each outward rotation. The patient 
was referred back to Dr. Clark with notes of the findings, but 
passed from under his control before any further treatment was 
attempted. 
I regret that I am unable to continue the record of the 
case. The gentlemen under whose care he has since been SXIFRACOTYLOID DISLOCATION. 
3 
in a hospital in a neighboring city have failed to respond 
to ray appeals for information as to the attempt at reduc- 
tion of the dislocation under an anaesthetic and the two 
subsequent cutting operations. One fact, however, sup- 
plied by the patient himself under date of November 21, 
1890, may be recorded—namely, that at that date, seven 
months after the operation, a sinus of the size and depth of 
a lead-pencil still remained. 
To recapitulate briefly: A heavy, rather flabby boy of 
sixteen years, with hip joints permitting unnatural out- 
ward rotation, and lacking normal inward rotation, stands 
with feet apart, toes turned out, and bends backward ; the 
head of the femur slips from the acetabulum, probably with 
little, if any, rupture of the capsule, and finds lodgment 
just above the acetabular rim beneath the strong bands of 
the Y-ligaraent and the rectus muscle, lie is able to walk 
immediately, and continues to walk for a year without 
much pain. Starting pains at night gradually come on, 
and are promptly relieved by recumbency and traction. 
Attempts at reduction by manipulation fail, and a sinus re- 
mains after a cutting operation is resorted to. 
Supracotyloid dislocation may occur in either of three 
ways, and a failure to recognize this and the manner of oc- 
currence of the dislocation account for much of the in- 
definiteness of the reported cases, and much of the diffi- 
culty in attempting reduction of the displacement. The 
first and most frequent form is that secondary to a back- 
ward dislocation and appears to result from extension, ab- 
duction, and outward rotation of the limb after the dorsal 
dislocation has occurred. In these cases the shortening is 
usually two or three inches, and the limb is held everted 
and somewhat flexed; further passive flexion to some ex- 
tent is possible, and there may or may not be abduction, 
this depending upon the distance forward to which the 4 
SUPRACOTYLOID DISLOCATION. 
femoral head has passed. In these cases the Y-ligament 
lies to the front of the head of the bone, and manipulation 
must be directed to return the bone to the dorsal disloca- 
tion before attempting to bring it into the socket. The 
next form, second as to frequency, is secondary to an ante- 
rior displacement, and results from the bone passing upward 
and somewhat backward. Shortening may be very little 
or very considerable, and there is eversion, usually extreme, 
abduction, and some flexion of the limb; the head of the 
bone can readily be felt and usually seen as a prominence 
below the anterior superior spine of the ilium. In this dis- 
placement the Y-ligament lies posterior to the bead of the 
bone, and reduction must be accomplished by first return- 
ing the head of the bone to the position of an anterior 
dislocation. The third form, that of displacement directly 
upward, with the Y-ligament stretched over the head of 
the bone, appears, from the literature on the subject which 
one is able to find, to be a very rare occurrence. The man 
ner of its production in the previously reported cases to 
which I have had access has been uncertain, and the ma- 
nipulations to be resorted to for its reduction have been 
based on purely theoretical grounds. From the manner of 
production of the dislocation in the case reported it would 
seem to indicate that the limb should be strongly rotated 
outward, moderately abducted, and extended to its fullest 
extent, then rapidly rotated inward, flexed, and adducted 
to the normal antero-posterior plane. In fully extending a 
limb the pelvis must be fixed, and I know of no way of 
doing this so effectually as by flexing the opposite thigh 
strongly on the trunk of the patient and strapping it there. 
With the patient in this position the pelvis is easily stead- 
ied for any desired manipulation. 
Only one further point needs to be considered—the 
differential diagnosis from fracture of the neck of the SUPRACOTYLOID DISLOCATION. 
5 
femur. In fracture of the neck of the femur the position 
of the limb is the same as in dislocation upward, but the 
disability of the limb is complete ; the patient is totally 
unable to walk, while with the dislocation he walks with 
comparative ease, perhaps without any pain at all. 
Bibliography. 
Allin. Arch, of Clinical Surg., April 15, 1877, p. 38. 
American Jour, of the Med. Sciences, vol. xvi, p. 14. 
Bigelow, H. J. Dislocations of the Hip, 1869. 
Blasius. Archiv fur Min. Ghirur., Bd. 16, lift. l.p. 207- 
Bryant. Surgery, 1860, p. 761. 
Cooper. Surgical Dictionary. Eighth edition, by S. A. 
Lane, 1861, vol. i. 
Cooper, Sir Astley. Dislocations and Fractures. American 
ed., 1844, p. 88. 
Cooper, Samuel. First Lines, vol. ii, p. 391. 
Delgarde. St. Barthol. Hasp. Reports, 1866, p. 183. 
Douglas. Edin. Med. Jour., December, 1843, p. 1064. 
Gibson. Surgery. Sixth Amer. ed., vol. i, p. 386. 
Guy's llosp. Reports, 1836, vol. i, pp. 79 97; 1838, vol. iii, 
p. 163. 
Hamilton. Fractures and Dislocations. Sixth ed., 1880, p. 
785; Bth ed., 1891, by Stephen Smith, pp. 687, 726, 727, 729, 
and 740. 
Harcourt. Buffalo Med. and, Surg. Jour., vol. x, February, 
1871, p. 241, 
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169; 1848, vol. i, p. 184. 
London Med. Gaz., vol. x, p. 19; vol. xix, pp. 657-659 ; vol. 
xxxiii, p. 404. 
Malgaigne. Traite des fract. et des lux., tom. ii, pp. 869 et 
seq. 
Medico-chirurg. Trans., vol. xx, p. 112. 6 
SUPRACOTYLOtD DISLOCATION. 
Milner. St. Barthol. Hosp. Reports, 1874. 
Morgan. Pirrie’s Surgery. Amer. ed., 1851, p. 276 
Philadelphia Med. Ex., No. 51. 
Shrady. N. Y. Med. Jour., January, 1860, p. 254.- 
Skey. Surgery. Amer. ed., 1851, pp. 110 et seq. 
Stlmson, Dislocations, 1888. 
Warren. Boston Med. and Surg. Jour., vol. xxiv, p. 220. 
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