165
Letters to the Editor
Letters
to the Editor
From H. Proctor Sir, Dislocations of the hip joint are variously described as anterior, posterior and central. The central type is generally associated with a stove-in pelvis or acetabulum. The anterior and posterior types are distinguished by the position of the head of the femur after dislocation as determined by X-ray or by clinical examination. In posterior dislocations the limb is internally rotated, flexed and adducted, whereas in anterior dislocations the lower limb is externally rotated, flexed and abducted. The dislocation occurs posteriorly or inferiorly and the head of the femur comes to rest either anteriorly or posteriorly depending on the continual force. Any force that tends to drive the head of the femur through the ilio-femoral ligament usually producesafractureof the neck of the femur, and this is an external rotation fracture. If the head of the femur was in fact dislocated anteriorly through the ilio-femoral ligament, then reduction should theoretically be achieved by flexing the hip, bringing the limb into a neutral position of rotation and pushing the femoral head backwards through the tear in the ligament. This method is seldom attempted and never succeeds. The only method of closed reduction that succeeds is to make the head of the femur retrace the path it took following dislocation and to reduce it through the tear inferiorly or posteriorly. Hence the classic description by Watson-Jones (Fractures and Joint Injuries, vol. 2): ‘ . . . the best method of manipulative reduction in both posterior and anterior dislocation is to flex the hip, rotate it into the neutral position so
Fig. 1.
An ‘ anterior ’ dislocation
of the hip.
that the femoral head lies just below the acetabulum, and then lift the head into the acetabulum . . . ’ This technique usually succeeds. If it should fail then open operation is indicated. For the ‘ anterior ’ dislocation the Smith-Petersen incision is recommended by some authors, but none of them describe what was found at such an operation or even make it clear if they have ever had to perform one.
Fig. 2. The ‘ anterior ’ dislocation has been reduced by the classic method and the posterior rim fracture of the acetabulum has been fixed with 2 screws.
Fig. 3. The lateral view of the same hip showing the 2 screws placed in the posterior acetabular rim.
Injury:
166 I have only once had to operate on an ’ anterior ’ dislocation and approached the hip joint posteriorly, reduced the dislocation posteriorly and then repaired the posterior acetabular rim fracture with 2 screws (Figs. 1, 2 and 3). No one has yet shown that an anteriorly placed dislocated head of the femur has ruptured- tie ilio-femoral ligament and was replaced by pushing the head back through the same ligamentous tear. Until such a manceuvre is observed at operation, I submit that a dislocation through the anterior capsule cannot be said to occur. Yours faithfully, H. Proctor, FRCSEd. Consultant Surgeon, Birmingham Accident Hospital.
From Dr Howard
Baderman
Sir, The article about the work of a Belfast Accident and Emergency Department is concerned with three separate topics; a description of the work of the department, a discussion of the terms ‘accident service’ and ‘accident and emergency department’, and a discussion of the specialty of clinicians in charge of accident and emergency departments. The author writes from the standpoint of a surgeon. He considers mainly the trauma content of accident and emergency work. This leads to analyses which may be of limited value. Assessment of the impact made by emergency cases of all types, on the work of all the specialties that receive them, is likely to be of greater significance in planning their availability, staffing levels, requirements for beds etc. Medical. paediatric and psychiatric emergencies are now a very significant case load in all urban accident and emergency departments. Discussion on the specialty of the doctor in charge of an accident and emergency department is still bedevilled by too great an emphasis on the trauma content of the work. The type of clinician required is determined by the nature of the work in a particular department. His main claim to have charge of such a
the British Journal of Accident
Surgery Vol. ~/NO. 2
department will be that he has been properly trained in this work, that is, as an expert diagnostician across the whole field of emergency medicine. His administrative, supervisory and teaching roles must be emphasized. Most orthopaedic surgeons would hold strenuously that the care of hand injuries is the responsibility of those with special training and is not to be offered to the accident and emergency consultant merely to bolster his job-satisfaction. In defining terms, the term ‘accident service’ in the American sense of a clinical service, one of several in a hospital, is a useful one. If one takes the broader view of the work load of the urban accident and emergency department, this might be only one of the services using such a department, but it might be the major or sole service in some departments, with a predominantly or totally trauma case load. The broader definition of ‘accident service’ to embrace all the resources involved in the care of the injured and their organization and integration is a valuable one, especially for planning purposes. In both definitions there should be no confusion with the term ‘accident and emergency department’. This is a clearly recognizable hospital department, even if its function, organization and staffing are still the subject of discussion. The term ‘casualty department’ is hallowed by usage, it is short and easy, and people believe they know what is meant by it. In fact they do not. Its very colloquial nature conveys little about the nature of such a department, what its work load is and far less about what it should be. The label ‘accident and emergency department’ is cumbersome, but it does represent an attempt to provide a more informative title. When one considers the work that most accident and emergency departments now do in district general hospitals, if any change is to be made at all, then they should be called ‘emergency departments’. Yours faithfully, Howard Baderman, BSc, FRCP Consultant Physician in Charge of Accident and Emergency Department, University College Hospital, London.
Book Reviews Current Management of Trauma in Surgery and General Practice. Edited by T. MATSUMOTO.14x 22 cm. Pp.
xvi+382 with 71 illustrations and index. 1975. Springfield, Illinois: C. C. Thomas. US $23.50. The choice of title of this book is a little diflicult to understand and it has nothing to do with general practice as British readers understand it. Also it covers only those sorts and effects of injury that carry a threat to life. but it does not do so in a svntematic__
and uniform manner. Lang&t’s chapter on head injuries, for example, is largely concerned with the more advanced methods of diagnosis and investigation of the injured brain than with the general care of the victim of such injury, and the methods are far beyond the reach of many that may turn to the chapter for guidance. The chapters on abdominal injuries and the genito-urinary .._ . .tract_. are also . well up _ to . date . on. radiological
methods
of mvestigatlon
but the book is not
Letters to the Editor
Letters
to the Editor
From H. Proctor Sir, Dislocations of the hip joint are variously described as anterior, posterior and central. The central type is generally associated with a stove-in pelvis or acetabulum. The anterior and posterior types are distinguished by the position of the head of the femur after dislocation as determined by X-ray or by clinical examination. In posterior dislocations the limb is internally rotated, flexed and adducted, whereas in anterior dislocations the lower limb is externally rotated, flexed and abducted. The dislocation occurs posteriorly or inferiorly and the head of the femur comes to rest either anteriorly or posteriorly depending on the continual force. Any force that tends to drive the head of the femur through the ilio-femoral ligament usually producesafractureof the neck of the femur, and this is an external rotation fracture. If the head of the femur was in fact dislocated anteriorly through the ilio-femoral ligament, then reduction should theoretically be achieved by flexing the hip, bringing the limb into a neutral position of rotation and pushing the femoral head backwards through the tear in the ligament. This method is seldom attempted and never succeeds. The only method of closed reduction that succeeds is to make the head of the femur retrace the path it took following dislocation and to reduce it through the tear inferiorly or posteriorly. Hence the classic description by Watson-Jones (Fractures and Joint Injuries, vol. 2): ‘ . . . the best method of manipulative reduction in both posterior and anterior dislocation is to flex the hip, rotate it into the neutral position so
Fig. 1.
An ‘ anterior ’ dislocation
of the hip.
that the femoral head lies just below the acetabulum, and then lift the head into the acetabulum . . . ’ This technique usually succeeds. If it should fail then open operation is indicated. For the ‘ anterior ’ dislocation the Smith-Petersen incision is recommended by some authors, but none of them describe what was found at such an operation or even make it clear if they have ever had to perform one.
Fig. 2. The ‘ anterior ’ dislocation has been reduced by the classic method and the posterior rim fracture of the acetabulum has been fixed with 2 screws.
Fig. 3. The lateral view of the same hip showing the 2 screws placed in the posterior acetabular rim.
Injury:
166 I have only once had to operate on an ’ anterior ’ dislocation and approached the hip joint posteriorly, reduced the dislocation posteriorly and then repaired the posterior acetabular rim fracture with 2 screws (Figs. 1, 2 and 3). No one has yet shown that an anteriorly placed dislocated head of the femur has ruptured- tie ilio-femoral ligament and was replaced by pushing the head back through the same ligamentous tear. Until such a manceuvre is observed at operation, I submit that a dislocation through the anterior capsule cannot be said to occur. Yours faithfully, H. Proctor, FRCSEd. Consultant Surgeon, Birmingham Accident Hospital.
From Dr Howard
Baderman
Sir, The article about the work of a Belfast Accident and Emergency Department is concerned with three separate topics; a description of the work of the department, a discussion of the terms ‘accident service’ and ‘accident and emergency department’, and a discussion of the specialty of clinicians in charge of accident and emergency departments. The author writes from the standpoint of a surgeon. He considers mainly the trauma content of accident and emergency work. This leads to analyses which may be of limited value. Assessment of the impact made by emergency cases of all types, on the work of all the specialties that receive them, is likely to be of greater significance in planning their availability, staffing levels, requirements for beds etc. Medical. paediatric and psychiatric emergencies are now a very significant case load in all urban accident and emergency departments. Discussion on the specialty of the doctor in charge of an accident and emergency department is still bedevilled by too great an emphasis on the trauma content of the work. The type of clinician required is determined by the nature of the work in a particular department. His main claim to have charge of such a
the British Journal of Accident
Surgery Vol. ~/NO. 2
department will be that he has been properly trained in this work, that is, as an expert diagnostician across the whole field of emergency medicine. His administrative, supervisory and teaching roles must be emphasized. Most orthopaedic surgeons would hold strenuously that the care of hand injuries is the responsibility of those with special training and is not to be offered to the accident and emergency consultant merely to bolster his job-satisfaction. In defining terms, the term ‘accident service’ in the American sense of a clinical service, one of several in a hospital, is a useful one. If one takes the broader view of the work load of the urban accident and emergency department, this might be only one of the services using such a department, but it might be the major or sole service in some departments, with a predominantly or totally trauma case load. The broader definition of ‘accident service’ to embrace all the resources involved in the care of the injured and their organization and integration is a valuable one, especially for planning purposes. In both definitions there should be no confusion with the term ‘accident and emergency department’. This is a clearly recognizable hospital department, even if its function, organization and staffing are still the subject of discussion. The term ‘casualty department’ is hallowed by usage, it is short and easy, and people believe they know what is meant by it. In fact they do not. Its very colloquial nature conveys little about the nature of such a department, what its work load is and far less about what it should be. The label ‘accident and emergency department’ is cumbersome, but it does represent an attempt to provide a more informative title. When one considers the work that most accident and emergency departments now do in district general hospitals, if any change is to be made at all, then they should be called ‘emergency departments’. Yours faithfully, Howard Baderman, BSc, FRCP Consultant Physician in Charge of Accident and Emergency Department, University College Hospital, London.
Book Reviews Current Management of Trauma in Surgery and General Practice. Edited by T. MATSUMOTO.14x 22 cm. Pp.
xvi+382 with 71 illustrations and index. 1975. Springfield, Illinois: C. C. Thomas. US $23.50. The choice of title of this book is a little diflicult to understand and it has nothing to do with general practice as British readers understand it. Also it covers only those sorts and effects of injury that carry a threat to life. but it does not do so in a svntematic__
and uniform manner. Lang&t’s chapter on head injuries, for example, is largely concerned with the more advanced methods of diagnosis and investigation of the injured brain than with the general care of the victim of such injury, and the methods are far beyond the reach of many that may turn to the chapter for guidance. The chapters on abdominal injuries and the genito-urinary .._ . .tract_. are also . well up _ to . date . on. radiological
methods
of mvestigatlon
but the book is not
