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·Injuries
and Surgical Diseases
of the Ischium
HENRY MILCH, MD
Attending Onbopedic Surgeon,
Hospital for Johat Diseases
Now I ork
(HH
A HOEBER HARPER BOOK

·INJURIES AND SUROICAL DISLALIS OF THE ISCHIUM
Copyrigbt 1938 by Paul B Horber I#
Vladical Book Department of Hapet + Brobots
Pitated be the United States of America
All rights reserted
For aforruttox ddrer Pad 8 Hoeber Ire
Medled Book Department of Hapart Brothers
49 for 33rd Street New I ark 16 NY
Library of Congren cailor card member 51-979

·DEDICATED TO THE BELOVED MIENIORY OF MY FATHER
JACOB VICTOR MILCH
1866-1945

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·Contents PREFACE 1K 1 12 24 32 42 48 76 AMATOWY OF THE ISCHIUMI 2 PHYSICAL AND ROENTGENOGRAPHIC EXAMINATION OF THE ISCHIUVI 3 ISCHIUV Varum 4 INTRAPELVIC PROTRUSION OF THE ACCTADULUM (Orto's Pelvis) 5 ISCHIOPUBIC OSTEOCHONDRITIS 6 FRACTURES OF THE ISCHIUVI 7 ISCHIAL APOPHYSIOLYSIS 8 PERIOSTEITIS OF THE ISCHIUY, Gracilis EXOSTOSIS, OSTEITIS OF THE ISCHIUM 9 PIOGENIC OSTEOVIYELITIS OF THE ISCHIUMI 10 TUBERCULOUS OSTEOMYELITIS OF THE ISCHIUVI 11 PERISCHIAL SOFT Tissur I JURI 12. ISCHIAL BURSITIS 13 ISCHIAL DECUBITUS ULCERS 14 TUVIORS OF THE ISCHIUVI 15 SURGERY OF THE ISCHIUVI AUTHOR INDEX SUBJECT INDES 88 98 104 113 117 123 129 145 157 161

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·Preface F TIJF THREE components that unite to form the os innominatum, the chium has special significance that warrants detailed studs While all urce portions of the bone exhibit an essentially similar response to various athological processes, their clinical manifestations are frequently different. The significant distinction lies in the fact that involvement of the illum pubs is usually manifested by localrzed signs and symptoms, which ren er diagnosis relatirely simplc, while identical pathological processes in the chuuni may first betray their existence by more diffuse symptomatology uch as a coxalgu or a sciance, which may arouse the erroneous suspicion f discasc located either in the hip joint or in the lumbar spinc. Indeed both the child and the adult, the eschium may be the site of typical disease rocesses that simulate affections of the hup characteristically seen in specific sc groups. As a consequence critical evaluation of the symptomatology pparently arising in either the hip or the louer spinal region is impossible Aithout conscious exclusion of the schium and, to a lesser degree, of the actum as the site of abnormality It is for the purpose of redirecting attention to these conditions that the following text has been prepared References to the literature are not prc ented as a bibliography of the manous subjects but rather as a list of the more nigruficant contributions that may be consulted. The author expresses his grateful thanks to Alrs. B I indemann for her arcles constancy in the preparation of the manuscript. He achnow ledges with warmest thanks the painstaling labors of Mrs. June 11 Dubovski in prepanng illustrations of high qualit and precise clarit, the seemingly endless efforts of Dr Robert Austin Alilch in both preparation and edıang of the manuscript, and, most especially the constant sumulation and counsel of hot wife who so enthusiastically performed the monotonous and unre warding tash of proofreading His thanks, too are doe the authors of totes and the editors of nous 1

·X
Preface
journals for their liod permission to reprmt here items from their works,
Finally the author wishes to express has very deep grantude to Mr Paul H.
Hocber and Alis Eunice Stevens, his editor for the courtesics and lind
coopengon shown him during the preparation and public aon of the work.
Η ML.
New York

·INJURIES AND SURGICAL DISEASES OF THE ISCHIUM ·- ·CHAPTER 1 Anatomy of the Ischium THE MAXIE ISCII" is denied from the Greek, meaning "to support in the seated position." In the older French literature, the ischium is designated as "os d l assiette" and in modern German It is stall called "Sitzbein,' in recog nition of the fact that the body weight is largely supported by the two ischial tuberosities in the seated position. In the baboon, which habitually assumes the seated posture the tuberosity of the ischium as correspondingly broader and thicker than in animals not characterized by sitting In humans as well 25 in the lower forms, the ischium forms a large part of the lateral wall of the truc pelvis. It is one of three bones that enter into the formation of the acetabulum, and is the only one of the three bones, the illum, the ischium, and the pubu, which is constantly represented in the formation of the acetabular cavity throughout the evolu don of the locomotor apparatus and the concomitant developmental history of the pelvic girdle. From its widespread presence, it is evident that the schium des cloped to subserre both the need of sitting and that of locomotion In the carly free-swimming vertebrates, pelvic fins, the homologues of the lower extremties, develop from a primitive tabilizing mechanism, the lateral folds. To afford a stable support for the action of these structures, basal elements of the appendages were modified and the pelvic girdle was developed. Romeral notes that “in fishes, ach half of the girdle is a small, simple ventral plate, often triangular embedded in the muscles and connective tissue of the abdomen, typically just anterior to the cloaca." Anteriorly the two plates male contact, but posteriorly there is no contact with the axial skele ton (Fig 14) "In the process of tetrapod development, the onginal ventral girdle on cither side becomes a large place of bone lying in a ulted position in the flan! This ossufies from the centers, the pubs antenorly and the Ischrum posteriorks and may be termed the pubo-schiadic plate (Fig 1B) ·2 Injuries and Surgical Diseases of the Ischlum In the later imphibians, the ilium develops posteriorhy and attaches first to one sacral nb and later to several (Fig 1C) During the course of crolution, the pelvic girdle undergoes many varr tons. In some, as in the birds, the pubic symphysis is lost entirely In others, as in the crocodile and the alligator the pubos is completely crcluded from A B lid turul no Fra 1 Lateral degrunds showing the developereat of the pelvic glodie from fish to the mophia 4 Post. The rentruly utwared pelrk girdle to developed entirely In the lateral musculture of the abdominal wall B proudye tetapod Bogo to the fouil tmphibmns The illum represented by a long porterorly directed place makes contact with the transverse process of one or more vertebra C mphibban. The ilram hus broadened and has made firm conact with the rortebrue. (Reproduced from Romper AS Tbe Verarbrate Body Philadelphia mod Loodoo, H1 B. Saunders Co 1949) participation in the formation of the acetabular cavity by overgrowth of the oschium Despite these changes, the persistence of the ischium in all forms 5 evidence of 103 mmportance in the statics and dynamics of the lower extremity In relapon to n hich it onginally developed. In on, the cortlaginous gnlage of the schlum appears during the second month of fetal life and chondnfiction os completed daring the churd month ·B D E Fra 2. Oraficioon of the promote bone 4, u the third intrauterme month Bu birth C durng the fire vear D ut six years of age Est about fifteen years of age. (Reproduced from Persol G A. HOROR Antony Philadelphia und London, J B Lippincott Co, 1906.) - At this time, the primary center of ossification for the ischium appears in the body of the bone. Secondary cen ters of Ossification for the acetabulu appear some time before the tenth year but secondary centers for the Eschul spine and the tuber osity do not become roent genographically apparent be fore the age of eleven. Oss fication in the body progresses so that at about the age of eight the epiphysis between the ischul rumus and the descending ramos of the pubs normally closes Complete ossification and uruon of the acetabular conters occurs at about the age of fifteen, but the cpiphysis of the tuberosiny does not fuse solidly anal about the twentieth year (Fig 2) The epiphysis of the is chual tuberosity has been de scribed by Poland as *wide and thich plate wider F 3 Secondan center of orgfiatron of the a mrommutum. The centers of omfiation of the illac Crot, the posterior iloc poc the interior mfcror spine of the Brm, the schal spinc, ind the schu! Tuberosity are shown The forward prolongation of dhe spophyts of the tuberosits indicate the line of itachment of the falciform portion of the microtuberos ligament (Reproduced from Hellmer H, A case of traumane sepanton of the opiphysa of the schrum Arcb Ortopedie a Uafalkrank beiten +3 45 1933 ) نیا ·4 Inturies and Surgkal Disease of the lachium than any of the other epiphyses of the hip bone. It extends from the lesser sacro-sciatic notch to the upper end of the descending reous of the pubis." Hellmer states that "the epiphysis includes not only the tuber schn but atends forward to the junction with the os pubis, which is interesting from the phylogenetic point of view Parsons thinks that the epiphysis of the uschium es homologous with the hypoischium of reptiles." (Fig 3) THE ADULT ISCHIUM The adult ischium, the thichest and stourost part of the os jonom natum, consists of (1) the body (2) the remus, and (3) the tuberosity (Fig 4) The body on cross section is somen hat triangular in outline with its apex directed outward. It presents three surfaces (enteroexternal, posterocyternal, and satemal) and three borders (antenor postenor extemal) The ontero- Order noch Acombatea Note Gerhe Lee 0. Wiener OLA hore ak Nuo FK. + + Lateral 1 of manculer structurend to the partice of the wchiam (After (72 H HER Awtomy Spazlı, Philadelphia, and lex lork, Lal Fahrger 1/3 ·Anatomy of the Ischlum 5 external surface is bounded antenorly by the antenor border and posteriorly by the external border Abore, this surface corresponds largely to the ischial component of the acetabular carity It is smooth, concats, and partly cov cred with cartilage for articulation with the head of the femur Below the acctabulum and just abore the external surface of the tubcrosity with which the anteroexternal surface of the body is continuous, there is a groove along which the tendon of the obturator extemus muscle glides as it passes bach ward to be inserted into the trochantenc fosse of the femur The posteroexternal surface is bounded antenorly by the eternal border and posterior by the posterior border Abore, it is continuous with the ilium and below with the ischial tuberositi It is broad smooth and somewhat quadrilateral in shape and provides the surface over which the PYTI formis, the gemelli superior and mfenor and the obturator internus muscles glide as they pass out of the pelvis to their insertion in the trochanteric fossa of the femur The louer portion of the surface presents the continuation of Crochet otot batch Lontora Lawak Oltrer Ostor Oroon for Led pudendal Го 4B Veulaal is of muscular atachments to the purtrets of the schium (Afrer Gm H Huur Anstonny Spitzka, Philadelphu, und eu lorb, La & Feliger 1913) ·6 Injuries and Surgical Diseases of the Ischlum the groove for the obturator esternos tendon seen on the gateroertermal sur face The infcror edge of the groove is formed by the projection of the tuberosity and as the site of ongin of the gemellus inferior muscle The material serface, which forms part of the lateral wall of the true pelvis, is sooth, concare, and affords attachment to a part of the obturator untemus musclc. The anterior border foms part of the outer arcumference of the obramtor for men. The external border separates the anteroexternal from the posteroexternal surfaces of the body The posterior border of the body of the ischium is continuous with the posterior border of the ilum and forms the larger part of the anterior circumference of the great sacrosciitc notch Somen hat belon the mid point of the postcnor border of the schuun, 1 thin, thangular prommence of bone the spine of the Iscbron, projects postenorly and medially The outer surface of the spine is the site of origin of the gemellus superior muscle its inner surface is the site of ongin of the coccygeus and part of the levator anı muscles, while its apex gives attach ment to the sacrospinous or lesser sacrosciatic ligament Below the schial spre, on the posterior border of the bone is a notch that transmits the ten don of the obturator internus muscle. This notch s conrerted into a foremen, the lesser secrosciatc foramen by the attachurnent of the sacrospinous liga ment to the spinc above and of the sacrotuberous ligament to the tuberosity below The ramms is continuous with the tuberosity and is considerably stouter than the descending namus of the pubis, which it runs inward and upward to meet to complete the ischiopubic arch. This portion of the bone is flat tened and presents two surfaces and two borders. The outer surface is rough and gives origin to part of the obturator externus and adductor pragnus muscles. Its nmet sterface is smooth and forms part of the outer wall of the truc pelva. The upper border I thin and sharp and fornis part of the lower cir cumference of the obturator foramen The inferior border os thuck and rough and present to edges with an mtervening space. The superficial layer of the triangular ligament of the perineum is attached to the mner edge of the infenor border The deep layer of the superficial penincal fasciis attached to the outer edge. The transventus penne and the crector pens or crector clitoridis muscles take their ongin from the surface between these tuo coges The tuberosity of the achium is thar portion of the bond between the body and the ramus On cross section it, like the body is triangular in out linc with the aper of the triangle directed outirard. It presents three airfaces and three borders. The apex, formed by the external border is collinear with the external border of the body and duides the external from the posterior surface of the tuberosity ·7 Anatomy of the Ischlum The external surface of the tuberosity is sonucu hat quadrilateral in outline and is continuous with the body above and with the ramus bielou It is bounded in front by its antenor border which forms part of the posterior and inferior margin of the obturator foramen, and behind by the cremal border which separates the catemal from the posterior surfaces of the tuber osity It gires ongin to the quadratus femons muscle and in front of this to some fibers of the obturator eternus and adductor magnus muscles The internal surface is bounded antenorly by the posterior margin of the obturator foramen and postenorly by the posterior border to which the falaform prolongadon of the scrotuberow ligainent is attached The posterior surface is quadnlateral in shape and is bounded above by the groove for the tendon of the obturator internus muscle, laterally by the external border and medially by the postenor border It is divided into an upper and a lower part. The inferior part trangular in shape is subdivided mto two smaller parts by a prominent vertical ndge. The outer of these subdivisions i rough and sends for the ongin of the postenor fibers of the adductor magnus muscle The inner subdivision serves for the attachment of the sacrotuberous ligament. The superior of the to main dursions es quadrilateral in outline and us, in tum, subdivided by an oblique rdge into an upper outer portion that affords attachment to the ongin of the settu membranosus muscle and a lower inner portion that gives rise to the semi tendinosus and biceps femoris muscles. Two ligaments are particular to the ischrum the sacrotuberous or great secrosciatic ligament and the sacrospinous or lesser scrosciatic bigament (Fig 5) These two ligaments serve to conrert the notch on the posterior border of the body into a formen, the lesser sacrosciatic foramen, which transtuts the tendon of the obturator internus muscle. In addition, it transmits the internal pudendal vessels that make their exit from the pelvis through the great scrosciatic foramen above the lerator ani muscle, wind around the base of the schual spine, and re-enter the pelvis through the lesser crosciatc foramen below the lerator anı muscle The sacrotuberous or greater scrosciatic ligament es flat and is nartou er in its mid portion than at either extremity It anses from the broad basc afforded by the postenor spine of the illum and the lower part of the lateral margin of the scrum. It passes obliquely downward forvard and outward to be attached along the inner margin of the tuberosity and, by its falciform prolongation, to the inner edge of the mmus of the ischium. Among others, Piersol has called attention to the fact that, at its insertion into the tuber Osit the ligament is continuous with the fibres of ongin of the breeps." This as especially interesting in vicu of the homology that has been establashed beth een the human biceps femons and the hamstring muscles of lower forms, the sacroperoncals and the iloperoncalis muscles. In these lower ·8 Injuries and Surgical Discosos of the Ischlum forms, the hamstring muscles attach either to the sacrum or the sum and act with other muscles that tend to tilt the pelvs upuud. Bland Sutton" has noted that in man "thc biceps femons tendon arises from the tuberosity of the ischium but when its tent don of ongin s arefully dissected, it can be traced into the great sacro-sciatic ligament. By pulling on the hamstring muscles and especially the biceps, the coccyt may be made to move on the sacruml" He noted further that "Weber found in a subject dissected at Guys Hospitol , 1 sasa maid m the tendon of the biceps and this tendon, wuch us direct conumuous With the great sacro-sciatic ligament, glided over but had no attich ment to thc wchual tuber osity The conclusion is ir B resistible that the great A sacro-sciatic ligament is the divorced tendon of the biceps ferons muscle" The sectospmous or les ser macrosciatic ligonrents much smaller than the sacrotuberous ligament. It As fan-shaped m outline and 2015es from 1 broad base Fros of The poetessor lignents of the actollac on the lateral margin uculation 4, the scrotuberous logament sborg the scrum und coccy. to falciform prolangaton B the minous attachment of the cromou gument. (Reproduced from anterior to the origin of Rovir, H Austomde Hument Vlason et Cie, the scrotuberous ligament. Pura, 1974) It courses douduard and outward and is attached by its aper to the ap of the sschul spine. Though jis fun oon in adult anatomi scems to be that of re-enforcing the stabilang action of the sacrotuberous ligament, its denvetion appears to be entirely ·9 Anatomy of the Ischlum different. Bland Sutton," who onginally crpressed the opinion that it represented the regressive remnant of an carlicr osscous union between the Echial spinc and the sacrum, later concluded that 'the coccygeus is, in man, a vestigial muscle and a superficial cumination is sufficient to shou thar it contains a large amount of fibrous tissue A study of comparative anatomy of musclos demonstrates satisfactonly that the lesser sico-sciatic ligament results from regression of a large tract of the coccygeus. In the first edition of tus booh, I regarded the lesser sacro-sciatic ligament as the fibrous repro sentation of the long ischual spine which in armadillos slorhs and other edentata, recent or extinct, reaches to the side of the pseudo-sacral vertebrac. The vicu that the coccygeus is responsible for it is simpler and more probable. A number of different bursae, by some alleged to be inconstant, have been described in relation to the ischium. The largest of these, when present, the bursa eschadica, is situated between the deep surface of the gluteus maximus and the tuberosity of the ischium Thu bursa is not be confused with the occasionally present subcutaneous brosa tuberis ischiadica described by Vulpian and Hyrtl. Another the bursa musculi obturatori mterm, probably more constant but clinically less important, is described as existing between the tendon of the obturator internus and the margin of the great sacrosciatic notch over which the muscle passes Several smaller muscular bursae exist between the ongins of the semimembranosus and semitendinosus muscles. The arterial supply and especially the renous drainage of the ischium arc of great interest and importance. The main artery of the ischium and the surrounding region, the obturator arten is estremely variable in ongin. In about half the cases, it anses from the antenor division of the internal iliac or hypogastric artery It may however anse from the common illac, the internal pudendal, the sciatic, or the gluteal artery In other instance, it has been described as brising from the enternal ilac, the deep cpigastric, or even the femoral arten Within the pelers, the obturator artery gives off three branches a pubic, a lesical and an uluc branch The artery makes its exit from the pelvis through the obturator cana] Just before it leaves the canal it divides into antenor or internal and posterior or cstermal branches chat lie between the obturator membrane and the obturator etternus muscle and diverge at almost ninety degrees from each other The interior brush follows the anterior outline of the obturator membrane and supplies the pubis and the muscles that arise from the pubis. The postenor branch, lying mamls along the postenor nm of the obturator membrane sends a branch through the measura acetabuli to supply the fat and ligamentum teres of the acctabular ann and then descends to terminate around the ischwal tuberosin ·10 Injuries and Surgical Diseases of the Ischlum Waldeyer 16 who made a special study of the terminal distribucon of the obturator artery noted that in fifty cases he invariably found an additional long branch that descended on the immer surface of the obturator membre to supply the tuberosity of the schrum. This small artery is a branch of the posterior division of the obturator artery that should properly be described * dividing into three branches (1) an acetabular branch supplying the acetabular centy (2) an internal branch, which descends along the inner Fc 6. Dribution of the obrontar urtery (After I aldeyer) The three muutn breaches (ecetubalar fatemu, and exterous) are clearly vylized. The termination of the branch to the Internal orfice of the tuberosur aangor be wen. (Reproduced from Spultehols, II Handalas der Aretom dir Weascben. Lepog $ Hozel, 1921) surface of the tuberosity und (3) an eternal branch that follows a simlar path along the outer surface of the obturator membranc. The schum is supplied with bone arteries through both of these branches but aspecully through the rumus internas" (Fig 6) The i enous drainage of the uchium into the inferior vena cava is effected through the obturator ren u hich, in general, follows the course of the ob turator uten There are, n addigon, important connections between the caral drainage of the ischium and the rertebral venous system, described m derail by Brescbet, and to which attention has been directed by the ·Anatomy of the Ischlum 11 studies of Batson2and others. These may be of iniportance in account ing for mfectious and neoplastic embolization specifically to the schiuni No information is availablc about thc lymphatic drainage of the ischium. The periosteum covering the bone, and possibly the eschium itself derive nene supply through the obturator nenc. REFERENCES 1 ANDERLOV R Drodrat gudies of the vertebral and cranal venous system. Neuronitg 8 411 1951 2. BATOY O The function of the vertebral vans and their role m the spread of metastasis. Am Surg 112 138 1970. 3 BATIO O The role of the rentebrel rens in metastatic processes. Am. In Med 16 38 1942 4 BRESCHLT G Recbercbes Anatomiques pbysiologiques et patbologiques SUT le système pemeur Paris, Villaret et Cie, 1832 5 COALAN DR and de Lorc, R. P Role of the vertebral nervous system in the metastasis of cancer to the spanal column. Cancer + 610 1951 6. Gray H Humon Antony, Am, ed. Spitzkoa Philadelphra, and New York, Lee und Fcbiger 1913 7 HELL, H. A case of UDACK sepertos of the epaphysis of the escluum Arcb Ortbopedie 11. Unfallkrankbetten 34 45 1933 8 HERLIHY WM Revision of the venous system. 11 ) Australia 34 661 1947 9 Pirol G A. Humion Anatomy Philadelphia mod London, J B Lippincott Company 1908, VOL 1 10 POLAND, J Trotonatlc Separation of tbe Eppbyses, London, Sporth, Elder & Co., 1898 P 614 11 Rove, A. B Tbe Vertebrate Body, Philadelphia and London, WB Saunders Con 1949 p 183 12 ROUE, H Anatonide Hioname, Paris, Alasson et Cie, 1924 13 SPALTEHOLL, W Hondatlas der Anatomie des Menscben, Leipzig S. Hirzel, 1921 14 SUTTOY Su Joux BLAND Selected Lectures London, Ilm Herman, 1920 15 SUTTOY SI JOHN BLAND Ligonetas 3rd ed., London, H h Lewis, 1902 16. WALDEYER, W Bemerkungen zur Anatomie der Artern obturator Anatomische Anzeiger Ergänzungsheft zwn Band Verbindlogen der Anatomiscbe Gesellscbaft 9th koogreth, 100 1895 ·CHAPTER 2 Physical and Roentgenographic Examination of the Ischium PHYSICAL EXAMINATION THE ETTTRI 4L OR femorel aspect of the ischium is covered by the heavy mass of the polufemoral musculature and is not easily accessible to physical examination. In extension or the crect position of the body the tuberosity of the schium is hidden bencath the lowermost fibers of the gluteus meumis muscle, but can be located by inserting the fingers under these fibers in the gluteal fold In feron, whether in the seated or the lichotomy posmos, the tuberosity glides from under its gluteal muscle corening and becomes practically subcutaneous In all positions, the sschal raimus os subcutaneous and can be readily examined in the perincum The whole of the internal or pelux spect of the ischuum, from the op of io spine to its junction with the pobrs, is readily palpable cither by rectal or agroal cwmnation By these routes the skrospinous ligument, the destal end of the sacrotuberous igament, the tuberosity and the body of the ischium, the lower part of the obturator membrane coi cred by the obturator intem muscle, and the entire length of the schel ronila are unulable for digital explompon. The existence of edene, point tenderness, uregulenties in cunfigurston, as well as localized accumulations of fluid that might other 11 IC be overlooked an be easily discorcred. Such cumination is of the utst importance and should never be neglected n rouane comunaton of 12 ·13 Physical and Roontgenographic Examination the ischium, or indeed, of any condition in which there is limitation of motion of the hup Topographically important structures about tlic ischium may be ac curately located by their rclation to a subgluteal triangle the apices of which are the posterior superior iliac spine, the up of the great trochanter and the ischual tuberosity (Fig 7) On the Imc draun from the posterior superior iliac spite to the great trochanter the gluteal artery and the supгopyri form portion of the great secroscratc fortonen lie at the junction of the moer and muddle thirds, while the base of the ischial spine and the head of the femur lie at the junction of the middle with the outer thirs. On the line drawn from the tro chanter to the ischmal tuberosity (the posterior half of Nelaton s line) the femoral nech lies at the junction of the outer and middle thurds, while the sciatic nerve lics at the junction of the muddlc ind inner thurds. On the line joinmg the posterior illac spine with the tuberosity the ischial spine, the mfrap nforın portion of Fic 7 The sbgtureal trungle The the great mcrosciatic foramen, and copenor gloteal artery and the suprapvrifor portion of the great acroscarc the structures entering the lesser forunca are located at the junction of scrosciatic foramen de the mner und muddlc thirds of the lme approxi AC The iníenor glutal artery the inmately at the level of its mid pomnt. frapynform portion of the grut scro- All these references are relative scats formen und the base of the chal me ure located at the mid-point of the and depend upon the assumption line AB Thc sciatic nerve lits at the that the points that determine the Junction of the macr and middle thirds of the line BC lines are in their relatively normal positions. Objective evaluation of the topographical relatonship of Nelatons line or Bryant s triangle is meaningless unless it can be established that the lines of reference are identical on both sides of the bod, It is common practice to describe the great trochanter of the femur as being above Nelaton s line" os "closer to the base of Bryants triangle" on one side or the other The clinical implication is that something has occurred between the great trochanter and the pelvis to warrant the suspicion, among others, of a fracture of the femoral nech, a dislocation of the femoral head, or 1 con una de form. This is not necessarily the case since it is crident that the change m relationship may just as well be due to a depression of the line of ·14 Injuries and Surgical Diseases of the Ischium A B C E Fra 8 Use of debtoos line. Whout mesurancut of the bancos between the ortenor quperior spine of the Iram, the ischal tubero try the top of the great trochanter and the internal mulleajos, elesition of the great trochanter above Velatons lore bias no significance. At the normal relationship, B the top of the trochanter aboro \claton s lme because of fructure of the trochanter with uprard displacement of the anal fngment. Tbo dostince from the tip of the trochroter to the malleolo b mereud. c the trochanter i aborce Velatoo's Ime because of con 1761fructure of the formon nect, or de ocioon of the head. The dboont from the schial tuberosity and the anterior superor illuc splne bo decreased us compart with the normal side. D the trochanter habere Nelacons Ihre bechere of fructure or the rschil tuberosity The docence from the chil tuberosity to the malleolus decreased buc the other measuremeno uro wental with those on the unaffected side E the trochunter xbore Melatoni me because of fracture of the entertor apertor lac spre The distance from this pont to the malleolus decreased while the other measurements are unchanged o compared with the normal ode.

·15
Physical and Rountgenographic Examination
B
A
B
C
D
FK 9 Use of Brunts tangle. A the normal relationship the lase
of Bani trangk o shortened at result of core muri, facture of the
femoral neck, or dslocation of the femoral herd C the base of the trungle
is shortened B i consequence of fructure of the great trochanter with up
and desplacent of the fragment D the base of the trengke a phionmed
15 1 repult of doinwad doplacetoont of the fractured anterar Ruperor Obc
pose.

·16 Injuries and Surgical Diseases of the Ischium reference as to an clevation of the trochanter Such situations may anse, for example from antecedent aruksion of the chual tuberosity Hue anterior supenor spine of the ilium or in fact, from a fracture of the trochanter itself without any change in the position of the femoral head or neck or any damage to the acetabular margi. The significance of Nelaton s linc lies in the accidentally discovered fact that the base of the great trochanter in the filexed posidon, or the up of the trochanter in the crtended position lies on the line that joins the anterior superior illac spine with the eschtal tuberosity The collinanty of any three points in space is an extremely fortuitous circumstance and a change in any one of the points necessarily unrolles a change in the geometrical relationship of the other rud This geometrical reladonship can acqwre meaning only if it is supplemented (Fig 8) by arithmetkal determnations of the actual distances of the three points from a fixed point of reference such as the internal malleolu. Thus, it is evident that elevation of the great trochanter above Nelerons Linc, mn the sense of a fracture of the femoral noch or 1 dislocaon of the head, acquires diagnostic significance only if the distance from the up of the trochanter to the malleolus is unchanged while the distances from the enterior superior ilac spine and the sschual tuberosity are less on the affected than on the opposite side. Increase in the distance from the top of the trochanter to the malleolus, the other to destances being unchanged ss compared with the opposite side, would be suggestive of a fracture of the great trochanter Diminution of the distance from the ischial tuberosity or from the interior superior iliac spine without any change in the trochanter malleolus distance, us compared with the opposite side would suggest 10 zrulsion fracture of the apophysts of the tuberosity of the schuum or of the anterior superor iluzc spine respectively rather than any pathology in the region of the femoral head or nech Precisely anular chacisin must be made of the routine use of Bryant's triangle (Fig 9) ROENTGENOGRAPHIC EXAMINATION In the last analyses, dragnosis in any condition involving the schmum will depend upon roentgenographic paualization of the part myolved all the surfaces and borders of the ischium can be readily submitted to x nay eramimacon by means of four etposures anteroposenor antenor oblique, posterior oblique, sod lateral. Examination of the schium should alway's begin with a simple anteroposterior view of the corre pelsus so that the topographical relationships as well as the comparatire appearance of both schra can be made Though it would hardly seem necesion to insist on matters of technique, disregard of standard poctice, especially with respect ·17 Physical and Roentgenographic Examination to the symmetrical placing of the patient, has led to numerous crroncops conclusons. For the normal anteroposterior view the patient should be in the supre position with the legs parallel and both iliac spincs at the same level, on a line perpendicular to the longitudinal 2ns of the body (Fig 10) If the pelvis cannot be brought into the standard position because of contracture of the hips or flepon of the lumbar spinc no effort should be made to ex tend the legs, and the r ray tube should be so alied as to give a relatively normal projection of the pelvi. Thus, if as a result of ankylosing spondy 4 meny F 10 Somal wateropostesor titw of the pelvis. The standard view perous napad anentation of boch schu pronded the crposure has been symmetrically made. ditus, the pelvis is alted upward fifteen degrces, the x ny tube should be sumularis alted fifteen degrees so that the central beam is directed from in front and abore. It is extremely important that absolutely symmetrical erposures be made and especial care must be taken to avoid rotatory displacement of the pelvis. Generally speaking the normal anteropostenor 17ch of the pelvis will present essentially the same appearance on both sides. Unilateral prominence of the rschual spme may occasionally be noted, but it may be considered as insignificant if there is indisputable evidence of a5 mmetrical exposure is evidenced by displacement of the mud sacral 2015 toward the side of the apparent lesion, relative diminution of the size of the obturator forumning, or relatire increase in the width of the illum As conipared with the opposite sude (Fig 11) ·18 Injuries and Surgical Diseases of the Ischium Lamy and Vincent, who became interested in this subject because of fake dugnoses of acctabular fractures in infants, showed that rotation of the pelvis resulted in prominence of the spine of the Ischium on the side toward which the pelvis vas rotated Similarly bilateral prominence of the Fre 11 False chmin rerum. The schial pene - perns aboormally promment. Asymmetrical powere betnyed by the difference in ite width of the illac olac, to bymmetry n contour of the pelvic inlet, and the difference in the pace of the obturator formim Fra 12 Bilaten fuse bachnum rurum. The pelvx mia abnormally large and round the beachtal plocs urt ubore their nog lesel, and the obrarutor forumine an barely be inloed because of the downrd tilt ne of the pels sschial spines resulted from excessive forward along of the pelvis. Thus projective illusion could be recognized by the fact that the ischial spines were projected at a higher level than normal, that the contour of the pelvic inlet us abnormally large, that thic sacrum was abnormally horizontal, and that the obturator foramina rere abnormally sml (Fig 12) ·19 Physical and Roentgenographk Examination The anteroposterior appearance of the pelvis will van with the agc of the patient up to the tinic when complete matunity has been reached. The first and nrost striking difference to be noted in the roentgenogram of the infanule pelvis, up to about the age of eight, as the disconanuity that exists IL Fw 13 Pelrxe roentgerbogrun mi child aged sur month There » descontmorty at the schiopubrc junction. The three components of the ecetubalum ut deady romlized. Fra 14 Peluxe rootgenogram in i chid aged eight ytin. The schiopub.c cprphyra hu closed with slight bulbows thuckening The icetabular cavity appear to be formed by all superior lac portion und large ofersor zich opubx portion Shenrons pubofemoral ime und Lamy inofemoral ime ure rosch 10 croton 100s. betueen the pubic and ischual ramı (Fig 13) This junction is cardlaginous and the defect becomes gradually smaller is the normal age of ossification of this area B approached Normal closure of this epiphyseal line occurs at about the 250 of eight. Closure may occur carlier or later and with or with our nodule formation. Although the bulbous form of closure has been con- ·20 Injuries and Surgical Diseases of the Ischium sidered pathognomonic of sscbiopubic Osteochondrots, it must be emphasized that nodular closure of the ischiopubic epiphy Is may occur normally In the absence of any specific symptomatology nodule formation m this region annot be considered os anythung more than a normal variation (Fig 14) The most striking appearance is that of the apparent discontinuity of the bones that enter into the formation of the acetabulum. The os innominatum developed from three separate centers of ossification that appear during Fra 15 Anteror oblique view of the pelos The thigh on the affected ude is flcted and rotated ouronn Tho central beum directed artropoeerorly affording • good view of the lateral and medal walls of the ischiam the second to fourth month of intrauterine ufc, At or shortly after birth, the y-shaped cartilage that separates these three centers divides the acetabulum into threc qual parts. Later the acetabulum appears, roent genographically to be divided into two unequal parts , sadler superior part, forming the roof of the acetabulum and denred enarely from the urum, and a larger infenor part, ufich forms the medial wall and can of the acetabulum and is derived from the ischium and pubr. (On an antero portenor vicii the descending branch of the partite cartilage separating the pubs and the ischium is not readily visualized.) The other fød branches ·Physical and Roentgenographic Examination 21 of the tripartitc canilage the limpulsic and thic lionsclusi cartilages do not lre in the sanic antcropartchor planc but arc largeli superinpixed one upon the other in the antcropstcrior rentgenogram of thic pelvis. As a consequencea single relaticly clear spacc appears bctueen the smaller superior illac of the acctabulum and clic larger infcrior ischiopubic portion of the acetabulum part Fec 16 Posterior obloque vx4 of the pelvis. The patent is turned about the degrees toward the ufected ade with the unaffected thigh bring above and in from of the involved ade The central beam b directly abore utfording tres of the enture outline of the obturator forunen On anteroposterior views of the peluzs, regardless of age, it will be found that a relaurely smooth curre can be drawn along the lower border of the femoral nech into the outline of the ascending ramus of the pubis This is known as Sheintons pubofeinoral Inie and a break in the normal smooth continuity of this line has been charactersacalls found in deslocations of the hip An ilofemoral linc drau n along the outer edge of the ulic wing then along the upper border of the femoral niech (Lons line) is of less diagnostic significance while the smooth connnuity of this line may be bmhen i cases of dislocation of the femoral had or fracture of the femoral ind ·22 Injuries and Surgkcal Diseases of the lochlum necb, the appearance of discontinuity may also arise from simple rotation of the pelvis. Though the normal anteroposterior view of the pelvis usually suffices for general survey of the whole of the ischium, it may occasionally be de sirable to obam specual views for the purpose of more carefully cramjong specific regions. For this reason anterior oblique, posterior oblique, and lateral views may be helpful. The antenor oblique vicu for examination of the lateral and medial 1 Tra 17 Lateral sex of the peur. The papent may be placed on the sopose portion with both thigtos completely flexed on the abdomen The central beun sorerbend und afforda a view of the posterior and inferor borders of the chul tuberosty, the potch for the page of the obturator estem tendoa and the lower margle of the uccubular X walls of the sschun, as obtained by flexion of the thigh on the affected ade and rotating the thugh outuud until it and the pelvic wall Lic in the plane of the x my table directy beneath the orerhead ny tube. This gives an oblique new of the pelries, but the central beam of the r ny is parallel to the oblrque position of the ramus of the schium (Fig 15) The posterior oblique VICH for examinason of the margins of the obturator for men and the posterior and inferior borders of the iscluum, is obtamed with the patient lying on the affected side. The body o rotated about twenry degrees so that the upper or involved limb lies anterior to the part being cxamined. Thos serra to bring the obturator foramen into the plane of the x ni film directly under the central beam of the ray tube (Fig 16) ·Physical and Roentgenographic Examination 23 The lateral cu for visualization of the posterior and inferior borders of the schuum, the mfcrior surface of the acetabulum, and the groove im medarch belon which transmits the obturator citernus muscle, is obtained with the patient lyng in the lateral position. The thughs are spread suffi ciently to permit passage of the ras beam that is directed from in front and below to above and behind against a scrtically placed film cassette. A similar exposure may be obtained with the patient in the supine position with the thighs flered to a night angle and the pelvis alted slightly upword (Fig 17) REFERENCES i Lumi L and VECENT J La fausse fructure du con le chez lenfant et l'ischrum rerum. Bull et mém Soc cbitirgiens Pans, 29 29 1937 2 λίπας, Η On the use of \elaton s line. A1 Rec 187 229 1938 ·CHAPTER 3 Ischium Varum m the HUVI VARUV" is a designation that has only recently acquired stature in topedic terminology Despite this, it has already been employed to de be tuo different conditions, one of which a characterized by e real, the er by an apparent decrease m the distance betti een the ischual spinas. point of view of the orthopedic surgeon, the interspinous distance, a when there is a real decrease, has little importance, except perhaps as canag a change in the obliquity of the ischium and therefrom a change he angle of inclination of the lateral wall of the pelos It is, of course, major importance to the obstetrician for whom ccessive narrowing of transverse diameter of the pelnic outlet may constitute a senous cause of toci TRUE ISCHIUM VARUM trictly defined "schium virum" indicates nothing more than an exul nge in the orientation of the schil wall to the mid linc. It should therc- :, be applied only to those instances in which, as in the funnel-shaped zs, there as an actual inwird deration from the normal in the mgular nonship of the plane of the schjum to the sagittal plane of the body dal innard angulation of the wall of the true pelvis may result from roacetabular fractures (Fig 18) or from more complicated pelu s sich us occur m Alalgaignes fracture. In one such case reported by itt, narrowing of the pelvic outlet wys so marked as to necessitate forceps ven during the course of which the schium was broken These inward angulations necessanly determine e medial approximanon he ischual spines and a consequent reduction in the interischrl or inter ous diameter The anteroposterior roentgenogram of the pelo in such ents will show an abnormal unilateral or bilateral prominence of the ·25 Ischlum Varum ischial spinc that is consonant with the obliquity of the pelvic wall and an actual decrease in the interspinous diameter. It is evident that truc ischium vrum must manifest not only a real decrease in the interspinous dianietor such as may be suspected from the roentgenographic evidence of prominent ischial spines but also afically actual increase in the obliqun of the pelvic wall. spc FALSE ISCHIUM VARUM True increase in the inclination of the pelvic wall must be carefully disan guished from false or apparent obliquin Decrease in the interspinous diameter Is not necessarily assocrated with increased obliquity of the pelvic wall and may be seen in the Roberts, the FK 18. True nchrum rerum in achioscetubular Nacgle, the transversely con fructure. The whole wall of the pelre has been tracted, the Ottos, the ostc dsplaced muud wrth nurowing of the pelvic omalaac, the android, the arity coxalgic, and other types of dystocic pelves. In all of these the position of the Echium is undoubtedly abnormal, but without evidence of increased obliquity specifically varus, with respect to the med line of the body Thc roentgenograms of such pelvos, naturally disclose abnormal medial approumaton of the schial spines resulong from their actual medial displacement. It is possibly 25 a consequence of this similarity with the funnel shaped pelvis that such roentgenographic evidence has been accepted as the hallmark of varus of the ischium. This is the more unfortunate in that the weight of authont has cloaked such evidence with a versimilitude that nxore critical analysis does not warrant. Influenced by the work of Le Demana' on the effect of interutenne pressure on the fetal hip and the work of Calot on the significance of the change from the half-orange shaped normal acetabulum to the half lemon-shaped dysplastic acetabulum, Murk Jansen' evolved a complicated theory that was intended to explain the pathogenetic equivalence of a whole senes of hup anomalies, any In these affections, there is not alanıt 1 flattening of the sochet through a thrchenmg of the floor In a relaovely large number of cases, the floor of the ·Injuries and Surgical Diseases of the Ischlum het is of normal thickness, but the os ischi has shimg on a tuming pout ured about the middle of the acetabulum, so that its low er part point ngard. e foramen obturatorun hos thus become smaller on that side than on the mal ade, so that, it first sight, one is inclmed to escribe the difference to mmctrical exposure. Honeter a hea ischhim ruums present, the difference found a ben the parts are coposed with perfect symmetry We hart sons for believing that the hip sochet muy not only become flat and wick, ko twisted In short, congenital hip dislocation is often found com red with a flat hup socle (through a thick socket floor or with a wide socket dogh schrum virum or a Vahaped pear figure) jusit B often comboxed h con 112, con fructe, cosa valg, cosi plane, slipping epiphyts, or malom While the somen hat indiscriminate grouping of conditions, as different tologically is Perthes descasc, slippmg of the upper femoral cpphyrs, and ngenital dislocation of the hip, cannot be accepted at the present tinse :IC are other equally valid grounds for a healthy shepacism with respect Jansens explanation and specifically hus validation of the concept of hium ritum. In the first place, there appears to be serious confusson in relatong the wide maternal pelvis, whuch is essential to delivery of the ge brained fetus, with the wide fetal pelvis, which is the alleged cause of : runous hup anomalies previously noted The former is concerned with : mterior of the maternal pelvis, the latter with the extenor of the fetal Ives. Eren of such a relationship could be established on teleological neces the relative infrequence of any one or all of the hup anomalies taken zether does not seem to have been substantiated on a statistical basis. In a ent study of tho hundred adult pelres (one hundred male and one huncd female) RA Vilch noted that there was no correlacion between the tror of the true pelvis and the external characteristics of the laceral pelvic all or the interacetabular distance. Sall more important is the fact that pracacally all the endence adduced Vurk Jansen is of a roentgenographic nature. Such dan are notonous ittustu orths with respect to line or angle measurements. Veither of these termmation is manably projective onless special attention B given to stre parallelsm of the roentgen plate with the part to be r nyed and per ndicularity of both to the central beam of the I ry Aware of these se Actions, Boerema' undertook to reticu (u mnty five cases of Perthes dosse in whom Jansen had postulared the existence of a fat xetabulum and hrum rarum us manifested by intrapelvic protrusion of the schul portes n the anteroposterior views of all these cases, Bocrema did, in fact, find ch protrusions. In nine cases, boucler a number of sen's other than the itcroposterior ucre made and these, strangely enough, did not show the aracteristic schrum rarum. Boerenta quichli noted that the so-called iterupertenor vicus nere not in fact entirely symmetrical and expressed ·lichlom Varum 27 the opinion that Jansens results were obtained on asymmetrically cxposed pelves, In confirmation of this opinion, Bocrema show ed that unilatcral promi nence of cither ischal spine could easily be produced by rotation of the pelvis toward the same side. This was mdependent of any hip ini olement. Its appearance in clinical cases tras due to the coexistence of hip contractures wtuch enforced apsilateral rotation of the pelvis (Fig 19) By appropriate positioning of the patient, so called ischium vtrum could be simulated on the completely normal side. This type of asi mmetri an be quickly recogruzed by comparson of the relatire size of the obturator fornung, or the aliac alac and the displace ment of the art of the scrum from the mid line of the symphysis pubis touard the side of the apparent ischium verum Hc shon cd further that apparent bilateral intrupelvic protrusions of the schral spine could be rouanely produced by copen mental tilang of the pelvis into i position of Jordosis such us Trould constantis be present in flcuon contractures of the hups! In extreme posjaons, this type Fra 19 Fake schrum rerum Tho prom mence of the schal me on the nght side of asymmetr would probably ures from the fact that the r-my wis made be readıls recognizable from the mm symmetrical posioon #th the pelva clerated position of the sacrum rotated ind flered, ou mg to fusion of the right hip jomt the configuradon of the pelvic nm, the foreshortening of the obturator foraruna and the high displacement of the ischual spines. In lesser degrees of flenon of the pelvis, these sugmata of 15mmetry might be easily overlooked or be impossible of Tenification, These observations are well illustrated in the following case Verged seien, had been under treatment for a var for Perthes drsers of the right hup Roentgenograms made in the symmetrical position disclosed the characteristic appearance of the condition without any protrusion of the schral spines (Fig 20) With the pelris rotated toward the side of the lesion, the ischia! fine imedustels execame prominent when the child was placed in the supune position with a pallon under the lumbar spine to simulate the tuung of the pelvis ·28 Infuria and Surgkol Diseases of the Ischlum } Fra 20 Fube schlum vurum fn Perthes docese. The bachial phae prombent owing to rotation of the pelro 15 indented by the wymmetrical appearance of the obturator forumu Fra 21 The etme F pure 20 The prominence of the schbal poc has been reduced by rating the pecent sighth to the left. Complete simetry of ctpoure has not been itabxed on endenced by the ipparence of the obxuritor forumima duc could result from flamion contructures of the hip both ischual spines were visualized. The greater prominence of the spine on the affected side was clearls due to rotation as Bus indicated by the disparity in Aze of the obturstor forumas (Fig 21) PSEUDOFRACTURE OF THE ISCHIUM Asymmetrical exposure of the pelvis and the failure to recognize the Iluson nature of the so-called schium warum to which it mas grit siselare ·29 Ischlum Yarum 1 } C A 1? LI D B Fra 22 Positions of the nchrom in rinons positions of the pelva. 4, the normal appearance In B the pelis has been rotated 30 to the right, the schel spune prominent. In the pelis hu been alted forward the pune's higher and a slighth prominent the schrum o foreshortened. In D rotation om Bhas been superimposed on the lordoss of C with routmg promience of the schal some. (Repro duced from Lom Land Vincent, J La frun fracture du cotite chez Infant Bull. et Hem Soc Chirurgiens Paris 2979 1937 ) led to other clm.cal misconceptions. Sporadically case reports have appeared in the literature that have been designated as unilateral protrusion of the acetabulum (Ottos pelos) fracture or dislocation of the ischium, or cpiphyseal separation of the schium These latter conditions have usually been described in young children in whom there have been physical signs of a coritos with fleuon and adduction deformiods of the hup on the affected side. The child has usually aalled with a limp and passic motion of the hip ·30 Infuries and Surakal Distoses of the Ischlum has usually been limited so that clinical and moon of the condition has been difficult. The diagnosis has almost maniably been made on the basis of a roentgenogram disclosing a unilateral abnormality on the ude of the hip Signs. Conadering the intrinsic strength of the peluk articulations, the possibility of such acute occurrences m the absence of a massic pellic injury sectus highly unlikely The possibility of reduction of such displacements by gentle manipulation such as has been described by Schoolfield seems not only w lilchi but highlı improbable Confronted on several occasions with situations in which the dognosis of fracture or dislocation of the acetabulum had been made but where in thar opinion, no such displacement etised Lam and Vincent' came to the conclusion thac the roentgenographe dagnosis represented "an crror of meer pretation" They called attention to the fact that, in all the cases seen or reported, the roentgenograms had been taken with the peltis 10 lordous and rotated touvrd the side of the affected hip (Fig 22) In tuo cises in which the present roentgenographic data they were able to "cure the lesion by simply correcting the pelrı malposition. Furthermore, they were able to produce an idential "lesson" on the opposite side by replacing the pelvis in lordosis but rotated toward the opposite, unaffected sade. Since the roentgenogram presents only an ophonal projection, an illusion, It is clear that the lesson" may be no "lesion" and the cure" no "cure" Before the diagnosis of a peluc displacement can be made there must be obsolute assurance that the pelvises placed in a completelt sowietrical posttion with respect both to the central beim of the rat and the i ras film. Where the assumprion of such standard position is possible, the root genologist as well as the clinican must be consciously aware of the rared appearances to which change in the posibon of the pelos on laad. As m all anul displacements, a snall x rai film disclosing only one adc or a shall portion of the pelvis a completel seless. A ru of the entire pelvas as fundenental to accurate diagnosis. Where doubt anses, rnays in the wind. and posiuon s well as the oblique posicons 17e essential to the avoidance of error in describing as actual pathology appearances that result from nothing more than umral shifting of the pelre. REFERENCES 1 Bout 1 Uber die Pertheschen hankheit mit besondere Berücksichoror des Ischium 1 arm und der Subluution dos Fernorkopfes Fortscbe Get Rongeostrabla 4 471 1931 2 CALOT F L'Oribopédie Indusprasable per Preticka Puris, Sortert Mlalons 9th ed., 1976 ·Ischlum Varum 31 3 JAVFY 11 The large brain, the wide pelv ind the mustandmg number of hup anomalies in marh J Bone Joint Surg 11 465 1929 4 LAVY L. and VINT J La fause fracture du cotyle chez lcnfant et l'oschiuni vurum. Bull et món Soc cbirurgiens l'aris 29 29 1937 5 LE DAVAN41 F La lutation congénitale de la Hincbe Pars, Flammarion, 1923 6. Vuay R A Roentgenographic audi of the angle of foclinagon of the Lateral pels wall and the mter acetabular distance normal adult pelich } Bone Jom Surg 36 A 533 1954 7 SCHOOLFER, B. L. Report of 1 case of cpaphrraal separation of the ischrum. Dallas II J 13 125 1927 also ) Bone Joint Surg 9 498 1927 ·CHAPTER 4 Intrapelvic Protrusion of the Acetabulum (Otto's Pelvis) INTRAPFLITC PROTRUSION OF the acetabulum ves first described as a patha logical enats bn Otto in 1824 The additional designation of "Chrobach pelvis" was made enurelt gratuitoush by Eppiogere and was not warranted by any contribution of Chrobach to a better understanding of the condition Ignoring Otto s specific etiology of “gout" which, with a more liberal connotation, might be extended to designate arthritis of a nonspecific ongm, nothing essentially new has been added to Otto s description Otto noted the acetabulum protrudes so far mto the peltos that it conturs not onh the head but also the nomulli loog neck of the femur and the upper acctabular margin amaculates with the great trochanter The entire inner spect of the acetabulum amooth as well as the had of the feinar Both are devoid of artilagmoos corening and have the abnded and polished apparmce of some gout joints, only the portion of the head opposite the metabrukar defect is roughened and croded br absorption. The acetabolar margin is rooghi und uneren slightly thickened, and to constructs the femoral had that the large had annot be removed from the aunts of the fount. The trimite ugement of the scrabulum s obfied (Since the rooghened large trochanter grate on the roughened toetabular margin und since the fermonal neck is someu hat mgular and the Arall trochanter hubs the sciati tuberonts on lack ud fienon of the fomor the femur 10elf an be rooted ools slighth forward and inxud but not outwurd and backward. This the joint a so restricted that the abdomen od thugh form a nght mgle in the standmg poston) ·33 Intropelyk Protrusion of the Acolobulum (Olto Polvis) Despite thus classic description of its pathologic anaton, the condition was clinically recognized onls marcs Up to 1889 Schauta" noted only thirteen true cases. With the development of a ras diagnosis and the careful descnpoon of 13 roentgenographuc appearance by hicnloch " the condition has been recognized more frequently and the symptomatology has been more clearly defined. Even so the condition is not comnion and up to 1932 Ponieranz" roentgenographically recognized only comcu hat oler forty The incidence of the affection appears to be definitely greater in females Fra 23 Unliverul merupelix protrusson. Female aged busy five years, History of fall three year car with the onset of signs of rheumatord molremont of the left knee, both hands, cervical spne, and both tempera mandirular jom one year later The une ruberouty doance on the affected sale saruch taller than on the nominal arde. than in males. It occurs predominantly in adults but has also been reported in lounger people, the youngest being a girl of ten (Esar) Though it may appear unilaterally (Fig 3) the condition is more commonly seen with bilateral inroliemens of the hips. Its onser is gradual with or without pain ind a hup lump suggesen c of cont. This may account for its designation, in the prerocniyeti tra as arthnos "While the presenting symptoms are frequently those of arthritis of the hip Joint, the question naturally arises as to whether arthntis is the primary cause of the affection or whether the disordered anatomy may not give rise to secondary Inthntis. Some students inclme to the opinon that the arthritis as ·34 Injuries and Surgical Diseases of the Ischlum pam or of the cause of the protrusion. Others have reported cases in which Ottos pelris 1115 a purels accidental finding in entirely 15ymptomatic andırduals. Dependmg on the severity of the process, patients may be entirely symptom free until some intercurrent injuny directos attention to one hup, at noch time the opposite ade may be found to present an identical intrupeloze pro- Teston widout any signs of an anhnac msolvement. The patient usually presents himself for the relief either of lontoon of motor On enmuon, he may be found to all the limp or waddle. In the unilateral cases, there may be a slight relore shortening of the affected limb and the distance between the great trochanter and the mud-lue of the body will be less on the affected than on the normalade Limitation of motion will be of varmble degree. Because of the gradual 10- ward protrusion of the acetabulum with gradual joward displacement of the femoral head and nech, abduction and rotation are first limited by conunct of the glenoidal margin against the femoral nech When the protruson has reached its maximum, about four cenameters, contact of the great trochanter with the acetabular margin leads to limitadon of abduction, while contact of the lesser trochanter with the sschval tuberosin pil lour back uud extension. On rectal palpation the inward bulging of the inner wall of the pelvis in the region of the acetabulum as readily recognizable. X-RAY STUDY Thermal appearance is pathognomonic of the condition (Fig 24) The mer wall of the pelvis bulges abnormally joward and the femoral head projects besond the arcuate line, u hich defines the inlet to the true pelrose The distance between the schial tuberosity and the lesser trochanter (inter tuberosity distance) is decreased as is the distance between the great trochanter and the glenoidal margin. The femoral nech appears foreshortened and the tar drop as distorted or may be curely absent kähler' uus the first to call attention to this phenomenon and l'ores concluded that the lateral border of the pelvic tar drop therefore, is made op of the corti al surface of the middle card of the acetabular fosen, commercig at the tomate surface prowwalli und erlendug to the con lord notch mferorlu Cootind 000 through the obturator forunen marks the mferior espect of the roentgenographic fructure The medal aspect of the tour figure o made op of the corual surface in the true pelvis, where a groore for the obturator rossets and nortos anos, cootmung in the same plane us far as the trouste line imunedinch posterior to the ilkopectual anuence. This description is clarlı n consonance with hohler s observation on the distortion of the tear drop and the known displacement or replacement of the medul wall of the acetabulum and the mner wall of the true pelos ·35 Intrapelvic Protrusion of the Acetabulum (Ottos Pelvis) FIG. 74 Bilateral mempelrx protrusion of the scetabulum. Apart from Hight luntaron of roution, the patient had no symptomes. The fanonl haads project beyond the arcuate line and to teardrop figure s seen on either side. There are no tigres of thitta. Fr. 5 Bilateral intrapelric protrusion. On the nght ade there *15 greater petletration, sagts of osteoarthritis , id cimiculk marloed pain. On the left sxe, there is no pain but moderare Immation of entersion and Tutton In some instances, the wall of the acetabular protrusion may be ven thin. In others, probably as the result of a reacure Osteoplastic process, it may be thich. los pelvic contour is usually smooth and hemispherical, but, m cases Such B anse as a result of acetabular fracture, the wall may be irregular and cu en sorten hat nodular ·36 Injuries and Surgical Diseases of the Ischlum Intrapelrı protrusions, when of moderate degree, may give rsc to few of any symptoms. When marhed protnsion occurs, limitation of hip rodon may follow but the appearance of pain is usually indicauve of the dertlopment of arthnaic manifestations. In such instances, the roentgenogram will present, in addition to the acetabular deformagon, the sclerosis, joint nertor ing and osteophytc formation charactersuc of hypertrophic arthnto (Fig 25) ETIOLOGY The most interesting of the discussions concerrung this condition hatt naturally centered about its etiology In most instances, and usually on the basts of relatively few observations, different students have attempted to en tablish a unique pathogenesis. Though most incline to the opinion that ar chotis es the predisposing cause leading to intrapelne protrusion, other etiologies have been described. It has been reported as occurnng in sociabon with tabes dorsalis, Paget s discase, and metastatic malignancy Valentine and Nailers and Zwicher lare described it as a sequel of tuberculous contes and Henschea'o recorded it in seren cases of ccchinococcus infestation. Esu observed the appearance of Otto s pelvis after osteomyelites and Hertzler" noted it in a woman of forty four who at the age of our years had suffered from an infection of the hip joint. Schlageplaufer" reported it after 1 Nesssenan infection of the hip joint and Sloane and Sloane" desenbed the case of a woman of eighteen from u hose hip joint the gonococcus vias recovered and in whom senal says taken over the course of a year clearly documented the development of a unilateral intrapelvic protron Schaap in commenang on . aase reported by Waller came to an enorely different conclusion Hus case was that of a woman of tirenty-016, who five years earlier had fallen off a bicycle landmg on her left hup. Vrat then at the time disclosed pre-existing bilateral intrapelvic protrusions . Tiro vars later the condition of the nght hip remained unchanged while the left hip showed evidence of progressive disability on the basis of the wellrecognized predisposition of the female pelves toward dysplasia of the hip, Schaap expressed the opinion that the primary cause of Otto s pelnus was congenitally deep acetabolum with decrease in the angle of the femoral neck oning to some ornan dysfunction. The progressive appearance of arthritic symptoms on the injured ada, however would appear to be better explained on the basis of a trauma super imposed on an underlying intrapelvic protrigon Froelich' reported : crse in which, following i fall on the nght hip, symptoms developed on that sdc only though anys demonstrated the custence of bilat eral intrapelvic protrusions. Simuladly Soupé" reported a case of bllateral Ottos pelyn in which unilateral symptoms appeared only on the ade of it ·37 Intrapelvic Protrusion of the Acetabulum (Ottos Palvis) jury and to other cases of unilateral intrapelvic protrusion that developed only on the ade previously injured Lewin' described the case of a man Slity four years old, who developed osteoarthritis of the left hip following a fall on both fcet cighteen years previously I ray cramınation revealed the typical appearance of an Otto s pelins on the left side, w huic thc nghe hip my completely normal While this seems to establsh the importance of trauma with respect to the onset of symptoms because of a secondan arthritis m a previously affected FK 26. Control frature of the icetabulam. The acetabular floor has been doplaced meard und the had of the femar protrudes beyond the normal position of the pointe mall hip jornt, it also raises the question as to the significance of trauma as a pn many cause of the condiaon Benda' reported the case of a nurse forty to scars old, who had limped for a penod of tienny scan following a fall. The Yral disclosed a unilateral intrapelvic protrusion at the femoral head, which was considered 33 owing to a traumatic arthnas. Though Benda catagoncally rejected fracture of the acetabulum as a cause of intrapelvic protrusion, this possibility cannot be dismissed too lightly There is no doubt that central fractures of the acetabulum con result in unilateral protrusion (Fig 26) In a case descobed by Delannow a man, for seven years old, fell a distance of no and a half meters, Janding on his nght sade. Though he presented signs of ecchymosis, su elling and pain over ·38 Injuries and Surgical Disease of the lichlum the great trochanter recteleromination was completely negaare unde dag nosis of contusion of the hip was made Re-examinagon performed several days later honerer disclosed a definite protrusion on rectal examination and an acetabular fracture similar to that seen in Fig 27 on I tay examination In another case reported by Lobel' a female age fifty-one complained of pain in both hips following a fall thirty three years earlier No evidence of injury we found at that aime but, subsequently the patient presented est dence of bilateral intrapelvic protrusions. While the pre-existence of ice Fra 27 Centru fructure of the acetabulum. Follow ing healing of the fncture, the mooch ner wall of the pelris ahora no eidoxe of the satecedent fructure, tabulir fractures cannot be objectively documented, it is noteworthy that the injury described in this case e precisely the same as that which has been described as one of the causes of acetabular fractures. In this context, it is interesting to dote a case of bilateral ecetubular frec ture following shock therapy reported by Haines, Roentgenograms token immediately after complaints of pain in the hup reitaled that bulateral ece tabular fractures had occurred in a young boy of seventeen afflicted with unrecogruzed bilateral intrapelvic protrusions. When the hotory los later reviened it was discovered that, at the age of seven, the young men had gone through an attack of inflammaton rheumatisn without any signs of hip ini olrement. It was only after t subsequent coniukire seizure of unde termined etiology that the patient began to limp K ray at that time was ·39 Intrapelvic Protrusion of the Actabulum (Ottos Pelvis) reported to have been negatise and a dragnosis of osteochondrits was inade In vich of the later muscular fractures of the acctabula following the shoch therapy it is probably not to far fetched to assume that the young man may have suffered similar but minunal central fractures, which led to the de clopment of the bilateral Otto spel is after the onginal convulsie serzurt. It will be recalled that They cnot," Fanton' Dupuy tren' and others have called attention to the fact that central fractures of the acetabulum were more frequent than was comnionly supposed that simple fractures could be casily overloohed or mesdiagnosed, and that central displacement could occur if waght beanng was permitted before complete bony union had taken place In such crent, it could be expected that the central porton Fig. 28. Bilateral moripelric protrusion Fusion wu unsuccessfully anttmpted on the left ode, with persostence of pam and lummatron of macion of the acccabulum would shou evidence of nonunion. Precisely this condi Don, 1 central defect, was noted both in the orginal observation by Otto and in the observations by Eppinger It may well be that Eppingers to jected concept of delayed ossificanon atmbutable to a disturbance m acetabular des clopment resulting from chondrodistrophuc or chondroepi physcal changes may with greater ment be attributed to nonunion resulting from unrecognized central fractures occurring during adolescence Considering all the cridence, it appears that intrapelvic promision of the femoral head is a clinical condition with pathognomonic r ras appearance chat mai are from a number of different causes. In general, these may be grouped mto those that anse from (1) condigons leading to weakening of the acetabular wall, such as infections, nonspecific inflammatiom, music drerse of bone, or tumor formation and (2) conditions in which the normal strength of the wall o exceeded by trauma or muscular contractions. Though intrepelvic protrusions may act as a cause for dystocia as in the cases reported by Benda? Henschen, and Chin' it is onli in the sticTC cases where marked limitation of motion of insufferable pain from the ·40 Infurlos and Surgical Diseases of the Ischium Associated arthritis supervenc that creatment is necessary As in the treatment of arthritis of the hip or of the late results from central fracture of the acetabulum, arthrodesus is completely out of the question in bilateral cases. In unilateral cases fusion may be considered if the patient is willmg to sacnfice the possibility of motion for the relief of pain, but fuaon is not always successful even in unilateral cases (Fig 18) From a consideration of the results obtained by any of the various prosthetic operations in the treat ment of the coxarthnades, the outlook is not hopeful. Where operations unavoidable, the resection-angulagon operation offers the best hope for relief (9) REFERENCES 1 BENDA, R. Kisuustik und Pathogenese der cantischen Pfanncoprotruson. Arcb Gynak 129 186 1927 2 CHARI, H Aetologie und Pathogenese der trapelvanen Pfannenprotruson. Bris' Bertr klm Cbr 102 318 1916. 3 DELANTOY E Fncture de la arité coryloide par enforcement a luxution centrul da fémur Red de cbir 59 317 1921 4 DUPUYTIAN G De traumatische lunguo centrals femork Bruns Bett kra Chur 62 294 1909 (Reference by Henschen ) 5 EPPINGER, H. Pelvis Chroback Courthrolithes da Beckens, Beltrige Geburtsbilfe imd Gynekolgre in Festschrift für Chroback, Wien, A. Holder 2 176 1903 6. EXAU P Akute osteomyelitis etc, und Zentrale pathologische luxatioo des Obcrrchenhels. Deutscbe Ztscbr f Cbir 91 611 1907 7 FANTOY (Reference by Dupont, J Fracture du fond du cotyle. Presse old 29 135 1921 ) 8. FROFHUICH, M Mligration intrapeltienne progretove de la tete femonke. Reo d'ortbop 17 353 1930 9 HAINE, H. H Unusual complication of contulsit therapy Psycbistric Quart 11 273 1814 10 HENCE R Die intrapevine Vorwölbung Brrous Beitr kh Chitr 65 641 1909 11 Hamu, A E Osteoarthnoc protrusion of the acetabulum Arcb Sorg 5 691 1922 12 KIENDOC, R Uber die mit protrusion des Pfannenboders einhergehenden Erkankrungen des Huftgelcakes, etc. Fortscbr Geb Röntgenstrables 11 280 1911 13 Kom, ALKAN Greiter der normalce und Anfärge des Pabologiscben in Roentgenbilde des Skelettes oth ed, Leipoog Georg Thieme, 1953. 14 LITIN P Oscourthritic protrusion of the acetabulum SHS Gynes Obst 41 449 1925 15 Loor, R. Protrusion der Hüftgelenkspfanne. Fortscbr Gel Rowiget sroblem 36 642, 1927 16 OTTO, A M Pfroncolecken mitaltungen nfolge deformierender Osteoarthritis. Neor seltene Beobecbtrenger zur Anstowle 2nd ed, Berlin, A Rücker 1824 ·Intrapelvic Protrusion of the Acatabulum (Ollos Pelvis) 17 POVFRANZ, M 11 Intrpelvic protrusion of the acetabulum (Otto s pelvis) J Bone Jom Surg 14 663 1932 18 SAUTE, E Sogenannten Protrio acetabuli Fortscbr Geb Rontgenstrable 371 1928 19 Saur C. Intrapelve protrusion of the acetabulum / Bone & Joint Sirig 16 811 1934 20. SCHALTA, F Die Beckenanomaliem m dullers Handbucb der Geburtscbelfe, 2 395 1889 21 SCHLAGEN LAUFFT, F Uber couus gonorrhoica in ihre Beziehung zur Proto des Pfannenbodens. Vircbor S Arcbr 194 182 1908 22 SLOLNE, D. and SLOAXE, V1 F Acute Neisserun intrapelvic protrusion of the acetabolom. J Bone & Jom Surg 19 843 1937 23 THETENOT L. Les fractures amplo et limites de la carité cotiloide. Reu dorthop2nd so, 5 263 1904 24 VALLSTIXE, B, and Muller, H. Intrapeluzne Pfannenroru olbung Arcbic klm Cbr., 117 523 1921 25 VAL V B Anatomy of the pelvic tear figure. J Bone & Joint Surg 34A 167 1952 26. Zakken Ober Pfannenboderorworbungen im Roentgenbild. Fortschr Geb Romgeristisblen 36 1008 1927 ·CHAPTER 5 Ischiopubic Osteochondritis region of the I 1924 VAN Nra" reported the histories of two patients who prescated a clinical picture to which he gave the name "osteochondros of the pubis,* but which was later definitely designated as "schopubic osteochondntos" by Voltancol?' The first patient, a gwl of cight, the only child of tuberculous parents, complained of sudden onset of pain in the night ingumai region There was some limitation of mooon jo the hip but no tenderness on pressure over the hip The night pubic ramus mes tender and the night Jabium was swollen, suggesting the presence of an abscess of Bartholios gland Rectal cranunaton disclosed a globular swelling in the night pelvic wall which on later ray ctamination was found to be in uchropubic junction. The temperature in elevated but tuberculin tests i crc negative Because of the possibility of a Bartholintan infection, the labrum 1 incised. No pues was obamed but the pubic rumus was found to be uncorered of periosteum and the bone was frablc A specimen of the bone s removed and submitted for pathological exmination By one labore ton the tissue 1135 reported as being a small cell sarcoma, by another as an osteochondaitis The second case was that of a child aged eleven who had been complainins of limp and pain in the nght groin for a period of ten months. There 1123 come limitation of hup motion and a tender selling in the rogron of the nghe pubic ramus. I may examination disclosed the spical swelling of the nghr schuopubic junction with a nornal appearance on the left side The mass at the schiopubic numus uus cxposed The ponosteum ww found clevated orer a cherry-speed tumor of bony hard consistency Section of the tumor “rescaled cartilage irregulark seeded with deep red otscous granula tion and bon islands. No pus granulacon cisne, or sequestra were found The may us considered to be an osteochondnths in thc zone of endochon- ·43 Ischlopubic Osteochondritls dral ossification and the carplage represents inflammaton lesions without ani specific character "11 Since Van Nechs carlier descnption, a number of larger reports by Voltancol, Asplund' Sanchus-Olmos, Heeren,' Haberler,' Zetlin *0 Dandson, Durham, Wolfing '' *3 nell as a number of shorter case histories by Inclan, Manfred," Mlcrsmer " and others40 11 11 harc appeared in the literature Debtalla o credited by Chiariello with haring discussed the condition before the Regional Congress of Orthopedics and Radiology at Vienna in 192? It seems, however that attention was directed to the con diaon not as a specific entity but rather as illustratng the retardation of closure m the uschopubic epiphyius in a case of coxa plana Fic 29 Epiphyreal dysploa. Bors of thirteen van with ayns of rulmple epiphyseal otrotrement in addition to wymptomatic delayed closure of the schopubic epiphysex, there a deturbance in osification of the apital femoral epiphyse. From a reading of these various contabutions, the impression is obtained that a number of varianos, if not indeed sereral different conditions, haic been grouped under the heading of ischiopubic Osteochondntis. As a consequence the onset of symptoms has been attributed to a varied ctiology infection, with tuberculosis specifically excluded, trauma, stress, and epiphyscal dysplasia (Fig 29 ) The possibility of stress as an cnological factor cannot be too lights dismissed cien in the more typical cases occumng at an carlier age. All students of the condition have called attention to the fact that the affection marufcsts itself at a ome of great ostcogenic activity and at a time of great Activity on the part of the child. The symptoms are clearly exacerbated by creesse actiun and are muogated and even cured by rest Voreover the location of the condizon at the cpiphyseal junction, where maximal muscle train takes place, where stress fractures occur in older patients, and where gracilis erostesses hare been noted, clearls indicates 1 rclagon to stress.

·injuries and Surgical Diseases of the Ischred Wiether the appenmncc of simipconus niust be predicred ca gourmet difference in strost or victlicr an additional factor such a je gran faction mac lic assuured is not at present evident. Despite the lack of unanimits is to ctiology the camal peru fairly well defined Tlc al crage age of onset o about seten vezes un months 17ıc youngere cluk in whom the condition has been diagnosed live Jaars old Since the epiphyss inually closes at about the age of e Innit may reunin on meil auclie to fourteen years of age the port of (Jinricllo. In a sitreen scar-nki patient most umusal sinpicton uras, Inclccal le citostained that this case belongs radier to froup of stress fracture than to the true osteochondnodes. I'yic ont may tre insiems uith gradually increasing pat, lump. Jos gimde ferrr It mi loncicr axtur abruptly with severe poin, fever, and printration ausgeving a sciese infection. The pans es localize Klic frin or clic parca cren toelate to the knoc, as in a clara katle hip forint for chanteur 13iks 1995 of course Ic erplanned bi the that thic obturator neric, along which tlic pain radiates, supplies Dot! thic lip but also the lulum and the lachrapubic junction. The Tinap, prevent is A typical lily limp Whillc all motions of the hup may be ne dicted in tlic sverc casc tlsc lulp is usually held in fenion and abduction Josusteol smotion us pxxsilole Pressure nier thic greater trochanter of the thigh wually challs no but there a invariably pain and renderest orcr thc eschlopabuc junct Suelling over the schopuvic junction along the inner aspect of the it and even occasionally in the region of the Isbuum, is a frequcor observe! On rectal crimination, condemness can be chiested over the lachjopubic ! gjon and , suelling can usually be detected. Exacerbation of the sympi on activity and their sulosidence on rest are highly significant. There duken in conjunction with a characteristic anal picture of a cherry hazelnut szed suelling with irregular osteoporosis lorted to the regio the cpiphysis suffices to establish a differential diagnosis between the col ton and a truc contas, ROENTGENOGRAMS NECESSARY FOR DIAGNOSIS Without roentgenographıc cridence diagnosis is impossible. The mr. appearance of sodular swellings in the region of the schiopubic epiphyte hou net not in itself sufficient jusufication for dugnose of the condit (Fig 10) Caffcy has called attention to the fact that the appearance o module may be nothing more than that in the normal closure of 1 epiphync Heeren' studied the pely tgenograms of ninety five chud in whom the epophysal line 87 lized. Of these turty three 1 ·45 lichlopubic Osteochondritis tten the ages of two and tuclic were found to present thic characteristic oroid snellings with irregulanties in ossification at the eschiopubic junction In the majority of the cases, the finding was purely accidental and borc no relationship to the condicion for which the patient was under treatment. On the basis of their x my appearance, Hecren believed that the cntire group should be divided into two subgroups, one of which presented symptoms, the other of which was completely symptom free In the former group consisting of nine patients, the oroid area of decalcification was surrounded by a somcu hat scleronc zone that was absent in the latter group (Fig 31) in i bov Fr. 30 Normal verbnt in closure of the schiopub,c epiphy's of nine yen on the right side the opphytos has closed with nodule forme tron. On the left dds, closure is still incomplete and osufication regular The patient symptom free. Because of this difference, Zertlintº expressed the opinion that this latter group could be classed is an osteochondrosis while the designation of osteochondritus should be reserved for the smaller group that presented symptoms of a cortis. In the more sei ere cases, which may eren present the appearance of a sepsis, the differentiation from a true osteomyelitis of the ramus of the ischium may be most difficult It is made more difficult by the use of antibiotics that may completely cloud the clinical manifestations of the disease. In such instances, the use of the aspıraong needle may be found indispensable In both the mild and the hyperacute cases, bed rest usually leads to gradual subadence of the symptoms. For uncontrollable pain, Sanchis-Olmos has recommended the local injection of 1 per cent procaine directly into

·46
Infuries and Surgical Disease of the Ischium
ܝܟ
Fac 31 Inchiopobic ogcochondrios, lo the upper picture, the left ade
present the upperruse of schropubic opteochondrits during the 100to
planx. In the lower picture, healong hos octuited three months later
(Reproduced from Dushem, H A kochlopubic osteochondora. / Bor
o lotet Swe 19 937 1931 )
he area of swelling Generally speaking surgery would not seem to be
ndicated since healing with complete restoration of the contouty of the
pone has been repeatedly reported.
REFERENCES
1 AMD, G A few cases of sschio-pubsc osteochondros. Actu cbe scat
dmt I 1930.
2 BEITOLA, V Osteochondrite sqmo-pubica. Prense med ograd 23 233&
1936.
3 CATFEY J In Pediatric Y ray Disgross Ind ed, Chucrgo lar Book Pub
lusher, 1956, P 94
+ CHIARELLO, AF L osteocondnte schuo-pubicu. Ama std dl chur 13 1222,
1944

·Ischiopubic Osteochondritis A7 5 DADO 11 Radiological appearance and clinical wgnificance of oscuchondotrs rschio-pubica. Acta pedir 11 233 1930. 6. DURH4>1 HA Ischio-pubic Osteochondnis. ) Bone Joint Surg 19937 1937 7 HABERLE, G Dic gutartige verlaufende unspezifische nictastausche S1- chondritus ischro-pubica im Kindesalter als tupesches hrankheitshild Arcb kim Cbr 13 625 1933 8. HEEREX J Roentgenologische nachuesbare reranderungen der Scham Sitzben Epaphusce und ihre Llmische Bedeutung Röntgenprurls 5 12 1933 9 HIS, A. Osteochondrms whio-pubic hmderal Praris + 458 1933 10. IXOAN A. Osteocondrosis de la Rama isquio-pubiana del coral Bol Societat Cabana de Pediatris 12 223 190. Il Lonan, L. Sulla osteocondate ischio-pubica. Arcb ortop 57 119 1942 12. ALANTHEDL M Alcuni Cap di osteocondate schro-pubica. Arcb. ortop +9 781 1933 13 Mirastun, h. Osteochondrus ischuo-pubicu. Tuberkuloseart 57 390 1951 14 OUTLAND, T. and HAVLOY CR. Osteochondntos ischio-pubice. Gurbrie Clin Bull ! 14 1938 15 SANCH-OLMOS, V Diesepifisplasia isquo-pubica Cor ap locom 2 350 1945 16. VAN VECK, MI Osteochondnte du pubis Arcbles provinciales (Franco- Belges) de chirurgie 27 238 1924 and J.AMA 13 155 1942 17 VOLTANCOU, G Osteochondrite sschio-pubica. Cbr og wormiento 9 281 1952 18 VILKEX W Osteochondritus sschio-pabuca. Ztscbr Kinderb 61 127 1938. 19 tuntxa, A Uber Osteochondnts chio-pubiu. Deutscbe ZuscbT Cbir 199 413 1926. 20 ZEITLI A A. Osteochondrons-osteochondnu Eschuo-pubica. Radiologo 77 722 1936.

·CHAPTER 6 Fractures of the Ischium be | THE OLDER Literaturs, fractures of the ischium were considered nrc. Whule exact figures are not owulable, some da of their incidence may gathered from the fact that in a series of 13 041 fractures collected from eight different hospitals, Gurltfound only 108 fractures of the pelvis. In another series of 14,556 fractures collected by Sonson' at the New Work Hospital during the years 1894 to 1905 only 75 involved the pelvis. In a study of 104 cases of fractures of the pelvis, Michaelis found 51 fractures of the pubs, 20 of the schium, 18 of the illum, 10 of the acetabulum, and 4 of the sacrum These opinions as to mcidence are not shared by more recent students. hey and Conuelle note that fractures of the pelvts are not rare may be gathered from the fact that Noland and Conwell report a sense of 185 cms seen over a penod of 12 years. They note further thac fractures of the acetabulum are really fructures of the pelvis formerly considered a fire injury but uith increasing use of the tray the lesson is being dugnosed more frequendı Probably as a result of the more antemanie use of the Tray and undoubtedly in consequence of increasing high-speed travel, the dragtrases of fractures of the pelvis is becoming not rare bot widesirably common. This is specially true of the acetabulum, of which the schu form the largest port. In 500 cases of fracture of the polsxs reported in 1928 I Vesterbom found of fractures of the acetabulum. In the same year Romani' reported on 139 cases of central fracture of the acetabulum. While fructures of the acetabulum appar to be by all means the most common of the aschiel fractures, inctures of the body the namus, and even of the schral piac have been reported ·Fractures of the lachium 49 FRACTURES OF THE ISCHIAL BODY Exclusic of the adolescent avulsion fractures of the apophysis of the ischial tulicrosity, fractures of the body are more common in middle age than in children or the aged. They occur more frequently in men than in women Excluding gunshot wounds, which are notonously unsclective as to incidence and completely uninformatire as to pathomechanics, fractures of the body of the Ischium hare usually been attributed to thc cffects of direct traumi Because of its protected position under the mass of gluteal muscles the traumia is usually due to falls or blow's directly against the ischium. Of SLt cases reported by Alalgaigne threr resulted from a fall on the buttock, onc from a gunshot wound, one from an csplosion and one dunng the course of an instrumental delivery in this last case, the fracture resulted from the intrapelvic forcc ctcrted by the forceps in a woman who had suffered a double vertical pelvic fracture (Alalgaigne type) sone two years previously In 1881 Bennett illustrated the findings in a fracture of the whole 1schium discovered in the dissecung room. In 1909 Sharpe" presented the findings in a patient who whilc fishing in 1893 had fallen on his buttock. Disability was minimal but exacerbation of symptoms occurred in 1902 It was not, however until 1909 after the introduction of the Y ray that a dcfini mic diagnosis of fracture of the ischium could be made with objective demonstration of the fracture site In 1920 Haines' reported the case of a thirty three var-old male, who suffered a bilateral fracture of the ischil cuberosities after falling from a wagon. The displacement was reduced per rectum with satisfactor healing In 1921 Hodge described a similar injury in 1 fifty scien-car-old male who fell forty feet from a trec, lending on his buttocks. Transiton paresis of the bowel and bladder ensued but se covery was complete in seven weeks. Ehalt* has described a case where, following a fall on the buttochs u hile shating fracture of the ischiopubic junction ertending into the acetabulum was observed There was definite Jimitation of hip motion and the position of the fractured fragment had to be corrected bi lateral traction. After three months immobilization good union with retum of function occurred Despite the strength of the muscles attaching to the schium, arulsion fractures of the body or the tuberosity seem to occur but rarely in the adult levertheless, in 1778 Varet's reported the occurrence in a pregnant woman of an "intrapartem fracture of the tuber ischi duning the course of a simong labor pain." Belli reported an interesting case in which fracture of the ischial tulcrosit 13 atributed to muscular arulion. The patient a fifty-seven year-old male fell on hrs night side but complained of imn cdiare pain on the left side There 1135 limitation of motion in the left hip and ·50 Injuries and Surgical Diseases of the lichtum ecchymosis has confined to the left side where the fracture had occurred. Gilbert" described a stul more startling case of fracture by muscular iyulslon The patient unes cranling his automobile, which beckfired. Though he had not been struck by the crank hondle, he immediately complained of pain in the perineum and along the inner aspect of the nghe thigh. He uns ablc to walk home and the following day drove his car to 1 medical consultation where a diagnosis of bilateral fracture of the eschrum was made With respect to the pathology Alalgaigne has nored that the actum may "sometimes be separated almost entirely in front of the descending FIG. 32 Avulsion fructure of the bchal tuberov Only a small fagment of bone at the Insertion of the hamstring muscle has been deached ramus of the pubs and postenorly from the cony loid cavity which retums mtect, while someames it u only the tuberosity which is detached from the bone" (Figs 32 and 33) Displacement of the fragrant s minimal and is usually inward following the direction of the fracturing force Doutward desplacernent a prevented bị the attachment of the sacrotuberous bigament. Downward displacement would occur only of all the fibres were ruptured as in Joberts case (gunshot wound)" Depending on the scients of the injury there may be sssociated visceral injunes, such as injun to the scrotum, the urethra, or even the kidney These are, howerer uncommon in umple froctures of the body Tim tory retention of the unne ou ing to hematoma from injury to the pudendal ressels or to reflex inhibition following mjur to the pudendal serves inay ·Fractures of the Ischium 51 occur Scratic radiation of pain and con sciatic nenc paralysis is not un common after these fractures Directly after the injun these patients complain of pain in the perineum, along the affected thigh, and occasionalls along the distribution of the sciatic neric Because of the weight beaning function of the schium, sitting 15 excruciating! painful Rectal palpation clicits sharply localized pain and Occasionally crepitus can be clicited upon rectal palpacion (D&Valz) A localized arta of contusion and later ecchymogis olcr the buttoch and down the thugh are almost invariably present. FX 33 Complete facture of the body of the ischtum. Antenarly separation has occurred u the schropubic junction. Posteriorly the body has been fnctured just below the acetabulum, which remains mtact While the diagnosis will probably not be overlooked on those patients who present the characteristic symptoms, the condition may crist with a minimal symptomatology Cotton," who expressed the opiruon that the diagnosis was not justified in the majority of instances, noted "at last in 1912 I have seen a case resulting from a sitting fall in a woman sare for local soreness, no symproms." In such instances, the x ray will definitely establish the diagnosis. Houcier it must be admitted that in cases with little duplacement the custence of a fissure fracture may well be overlooked despite the high degree of diagnostic accuracy the pray malos possible Active surgical intervention is not indicated. After simple bed rest and the subsidence of the acute symptons, these patients are able to resume their normal activities with but little difficult Healing occurs in about eight ·52 injuries and Surgical Diseases of the Ischlum wecks. Downw and displacement of the fragient seldom occurs and, as in the cases of ischial apophysiolyses, does not warrant any effort at replace ment. On the other hand crcessive medial desplacement of the fragment 10 a woman of childbearing age nay justfy attempts at outward displacement of the fragment, since nartowing of the pelnic outlet may prove to be a serious cause for dystocra. Such efforts should be made with the grcatest gentleness and with conscious recognition of the fact that force sufficient to damage the wall of the rectum or vagina might serre to conrert 1 simple into a compound fracture. FRACTURE OF THE ISCHIAL SPINE Fracture of the ischual spine appears to be of the greatest nunty Indeed, except for the report of Burman and Sinberge no other reports of thus leson Fm 34 Fructure of the achu pine associated with fructure of the scrUOL (Reproduced from Burman, AL, md Sinberg S, Tear of the ucrusplooo liga ment. BuL Hosp Joint Dis 1 69 1947 ) could be found in the literature. Their paaent was injured when the truck that he was daving w'us struch from the rear As a result of this impact, the patient was throun forward, striking his chest against the steering wheel and his knees against the instrument panel . When seen more than a month after his injury the patient still complained of pain in the loner back and along the outer side of hos left hip He walked with a definite hip and knee ·Fracturor of the ischium 53 Imp Votions of the lack and left lup were nurhals restricted Therc uts definitc tendemais ouer the left sidle of thic scrum and along tlic course of the sacrospinous liganent A rentgenogram made on the sanıc day disclosed a comminured linear fmcture of the left ischial spine crtending into the pelvis, and a fracture of the left side of the sacrum at the point of ongin of the sacrospinous liganient A later v ras disclosed detachnient of a bloch of the sacrum in this area The patient was treated conservatively and three months after injun was able to retum in light wash though still complainmg of pain in the left groin (Fig 1+) In a later conimunication Burman' reported a second case in which in 3ssociaton with other injuncs-fracture of the eleventh thoracic vertebra, FK 35 Fncture of the rumus of the schrum attributed to creestre pull of the HicroCuberon ligiment. (Reproduced from Burman, L. Tar of the sacrospmous and microtuberous bgamente'] Bone Joint Surx HA 331 1952.) laceration of the urethra, fracture of both ramı of the left pubus, and a fracture of the superior ramus of the nght pubis—there was a fracture of the lower left side of the sacrum and an avulsion of the ischial spine Roentgenogram of the pelve made one hundred nmety two days after the injury was reported is showing "nonunuon of the avulsed sschial spine and the distalli rotated fragment of the sacrum” This patient also was treated consen atveli but contnued to complain of pain and limitation of motion almost a var after his injury While it does not seem likely that arulsion of the ischial spine would in itself establish a definite indicaton for surgical interi ention, Associated injun cither to the nearby inferior gluteal anten or to the pudendal artery wtuch winds amund the base of the sschusspine to re-enter the pelvic ·54 Injuries and Surgical Diseases of the Ischium crity mught make necessary an urgent operation for the control hemorrhagc. FRACTURE OF THE ISCHIAL RAMUS Fracture of the schial ramus occurs not infrequently in conjunction more complicated fractures insolsing other parts of the pelvis. Isola fracture of the rinnus secins to be more common than fractures of the box or tuberosity and usually resulas from direct trauma. The ate of fract is at the sschuopubic junction. In a series of cighty pelvic fractures, Jense noted aghc ischial fractures, of which seitn occurred at the schopu junction Earlier reports on this subject had been made by Le Gros Carl in 1859 by Peters" in 1903 and Jones in 1943 Disturbance in unnagon appears to be a not uncommon complication the fractures by direct forcc. Rapture of the bladder and of the aret have been described. Unnan retention may be due to reflex inhubicon to retroperitoneol hemorrhage The diagnosis may be establshed by the history of a direct blow localo tenderness made worse on extension and abduction of the thigh, Lumitat of motion of the hip, ecchymosis in the penincun, hup limp, and locala tenderness both on ertemal and rectal cwmnation. Conhisson with od condiaons that may present a simular symptornatology an be aroided or by means of x ray examination Deplacement is slight and except for the treatment of complicat nothing more than bed rest is required to insure healing of the fracture. While fractures of the remos result most frequently from direct violen It has been reported as a result of indirect stress. Durmen' described a a that he attributed to excessive pull of the sacrotuberous ligament (Fig 3: Stress fractures of the schial namus lave appeared in the literature and the designation of "stress" or "march" fracture of the descending rooms the publs or of the schiopubic juncton (Fig 16) The earliest such repo the exact details of which could not be renfied, seems to have been mm by Cappelletu in 1847 Another case was reported by Marches " m 191 Forcher Alaser considered the condition as a typical sport mjury fencers. It appears to have been seen often among soldier rocnints by heltre? and Brandt,' and has recently been igun described by Jones Vicherson," and Selal orich and Lore" Wachsmuthe expressed the opinion that the pathogenesis of the conc non 135 to be sought in the antagonistic action of the addoctor magou which tends to entend the pelis, ind the addoctor brevis, longus, and it gracilis, which tend to flex the pelvis. Herrschen" considered the condic 15 manifesting the same signs of fatigue os are to be seen in steel and othe ·55 Fractures of the lichlum . FK 36. Stress fracture of the schal nimus. Top u the tme of onset of symptoms, there wo mure of ndiolocency wah penorcal reaction at the junction of the descendog rimus of the pobic and the numb of the schrim. Bottom one year later when all symptoms had disappeared the radrolucent tra had been reconstituted by new bone formation. (Courtesy of Dr A Fradman) structural muatenals. He described four different stages in the course of the affection ponoseal neuralgia, ossifying penostitis, rarefying osteitis, and finally fracturc. Under excessive stress, weakening of the bonc occurred as the roult of a reonentation with a gliding away of the bone crystals at the ste of sets Where the stresses were not crcessite or where the crercises ·56 Injuries and Surgical Discoses of the Ischium were properly conducted, neu borc crystals were deposited in accordance with Rours lau of artophy and hypertrophy Where the stress es sufficiently reduced or where the penostcal reaction was sufficiently great, frec ture did not occur Corresponding with this concept histolograal sections through the area of stress fracture revealed lacunar resorption of the bonc trubeculac, local rzed arcas of necrosis, penosteal thickening and scattered bone trubeculac surrounded by newly deposited ostcold tissue. In many respect, it pre sented the picture of bone formadon seen in normal endochondral ossifict ton It is interesting to note that these phenomena atur precisely at the ischiopubic junction and that ther yras presentation may be idenacal with that seen o schiopubic osteochoodhtis of children. Charecteristically the condition develops in persons who having previously led a sedentary lfc, are suddenly required to engage in prolonged and strenuous activities. This has been observed in overzealous training for Athletic activity and more particularly among young military recruits. The first simptom, pain in the perineal, sschial, inguinal or medal femoral regions, is noted some weeks or months after the onset of the actuut The pun ts progressive and s made worse by persbtence in walk ing ninning or combat erercise. A stelling may develop in the schropubic region but is not usually associated with any furtation of motion m the hup Emmungon discloses tenderness on palpadon in the perineum over the ischiopubic junction. The roentgenogram is characterzed by hazziness at the eschiopubic junction, later perzostcal proliferation, and ultimately fracture at this site. Trestnent is directed touurd bed rest during the acute phose. Haling invariabls takes place without any rendual disability The appearance of the condition may be avoided bi wong and carefully selecung the cm ercises to which the recruit is subject. FRACTURES OF THE ACETABULUM Fractures of the ischial portion of the acetabular aunty hare been the subject of many studies and here appeared in the literature under various headings, wch as intrapelac luution of the femoral head, central disloca trons of the femur "dashboard injuries" of the acetabulum, and ischio ucetabular fractures. Though they are said to have been recognced by Paul Acgmetus and Ambrose Paré, Callusen B credited with having made thic first report of such a case in 1778 He described the cract extent of the fracture and called attention to the value of rectal palpation in localong the site of the lozon. A dor considerable part of the confusion that surrounds the subject ·Fractures of the Ischlum 57 has arisen from attempts at classification of the various fractures on the basis of the almost innunxrable combination of fracturc lines that may be present. In the interest of breits it seems justifiable to divde fractures of the acetabulum into three different types (1) fractures of the rim, the so-called dashboard fracture (2) central fractures of the acetabular floor and (3) Ischioscetabular fractures FRACTURES OF THE ACETABULAR RIM Fractures of the nm, actually fractures of the rim with dislocation of the femoral head, are usually the result of direct impact, and have Fr. 3 Fructure of the stubular rm with potenor dolocation of the femoral had, so-alicu dashboard fracture. become noticeably more frequent since the adient of high speed locomotion. Formerls fractures of the superior nm, the result of landing on the extended legs after a fall nere more common. At present, fractures of the posterior rm that would result from backuard propulsion of the flexed femora against the ischual portion of the nm are more preralent (Fig 37) lo e in consequence of the frequency with which this mechanism operares in patients whose legs, in the seated posidon, stric the automobile dash board (instrument panel) that the fracture has received the designation of dashboard fracture. The diagnosis may be suspected from the nature of the injun If not ·58 Injurles and Surgical Diseases of the Ischlum unconscious the patient complans of severe pain and complete func incompetence of the affected limb In contradistinction to the px assumed after fracture of the femoral nech, the lumb Bustalh b flerion, adduction, and internal rotation (Rarch the lumb mai b ternally rotated.) Corresponding with the upuard dislocation, the trochanter lies above Nelatons Jine, and the distance from the an superior spine to the homolateral internal malleolus is less on the af then on the normal side. Acthc motion of the thigh and passire abdi ertension and external rotation are impossible. Definite diagnosis can be establshed only by means of the may this is not, however aluais simple and a small fragtient hidden bebro femoral head may be asily overlooked. Wherever there is serious os to the actual condition, toys should be made with different espx and preferably stereoscopically Treatment is directed toward carls reduction of the dislocation delay of eren a few day's marhedli increases the difficulty of redo Delay of as much as six wecky mi render reduction impossible and if possible, useless, because of the damage to the head as a result of cu tory impairment. All those ti ho hait audied these cases are in com agreement that early reduction is of the utmost importance Steann Alilford" eren go so far is to state manipulative reduction should take precedence ortr the treatment other skeleul mjuries There is a common misconception that a patremu o suffcnog from xrere inson and shock s in too critical condmon fo administration of muesthet. A short scting anaesthesia w noc contradict the paucit s ur passages are open and if reduction can be accomplished 101 mmurex However the reduction of 1 dislocated hip ulazit tends to refiere a und often the key to recoven Open reduction of the seabulum be delaved provided the dislocation of the farmoral herd has been reduced. Reduction depends upon relatation of the y-shaped ligament of Big by fienon and internal rotation It is stated that this procple was empl 25 arly o 1670 and to the routine practice of Smith as early as Bigelowhurself admits the prority of Smith in respect to the use of fc and all the currently employed methods of reduction, trat of Alles Bigelon and of Stinson" depend upon this proran maneuver Wich hup in flesion, the femoral head as then pushed or pulled back into acetabalır quit Once the reduction has been accomplished, funher procedure wil pend upon the conditon of the rim and the condition of the patien there is little displacement, the tugh mas be uunobilized in abduction pluster of Paris spice for 1 mmimum of su atchs, or until there is Assurance that wilt union hos talen place. Excessive inmobilization i ·59 Fractures of the Ischium be avoided as tending to produce stiffness in the hup or flattening of the head Equally satisfactory results may be obtained by immobilizing the limb in balanced traction to os crcome the pull of the pelvitrochanteric muscles. Motion without scight bearing should be encouraged ininiediately but under no arcunstances should u cight bearing bc pemitted beforc firmi union can be demonstrated. This may take as long as four to sit months ra. 38 Sertx fittion of fractured acetabular rim (Courtesy of Dr O hertler ) but is a restriction well wonhu hilc, if the possibility of a severe traumaac anhints of the hip can be minimized If there is am) displacement of the num fragment so that the stability of the reduction is thereb: brought into question, operative fixabon of the fragment by means of screus is indicated (Fig 38) Where the fragnient is of the superior margin, it may be approached by the antenor iliofenoral INCI:10n.. Where the fragment involves primanlı the posterior margin apposch as best made through the postenor iliofemoral incision. If the margin As so fragmented that the possibility of screu fixation is excluded, it is probably trest to forego ant attempt ar reconstruction of the glenoidal nim ·60 Injuries and Surgical Diseases of the Ischlum "fur" or poor fair or poor and to treat the condition as an old congetual delocation by means of pelvic support osteotomy of the type described by Schanz Indeed, it may be questioned whether this may not be the best form of therapy in all such cases. Despite Campbells staterneat to the contrary cren stisfactory reduction of the head and replacement of the fractured fragment does not insure complete functional rehabilitation. Simplc dos location of the head without fructure of the icetabulum atil s smpc fracture without dislocation may lead to a destreasingly high percentage of late traumatic arthritis of the hip In a series of twenty-two stach cases studied by Thompson and Epstein there were no "excellent" raults (1. those in which there was normal restoration of function) Sixteen of these twenty two cases were treated by closed reductions. Of thes, "good" rcsults were obsen ed in only seren u hile in the other nine the results were In all sercn cases, the dislocations were reduced within the first twenty four hours, the average time of weight beanng was four months. The results in the six cases treated by open reduction were either Though these figures would seem to contraindicate attempts at open operation, the authors express the opinion that while thus senes does not prove that open operation is contramdicated, it does demonstrate the relaove effects eness of early closed reduction, and that of performed at all, operation should be carried out promptly Similar conclusions though with some hat better results were reported by Stewart and Alulford, i ho attempted to evaluate their results with respect to the severity of the injury and the time elapsed before reduction Of 77 cases in which there were rim fractures, 5 died following marupadetion. In 69 posterior rum fractures with postenor dislocation in which closed manipulative reduction 1195 used, 25 were Grade 1 (simple dislocation with no fracture) 33 were Grade 2 (comminuted nm fracture with mild dołoct tion) 9 were Grade 3 (communuted rim fracture with marked intrapelux protrusion) and 2 were of Grade 4 (associated fracture of the femoral head or neck) Nineteen cases of the 25 Grade 1 group gare cruellent or good resulos (76 per cent) Fourteen cases of the 33 Grade 2 group gave ercellent or good results (42 4 per cent) Two cases of the 9 Grade 3 group garo crccllent or good results (223 per cent) One of the Grade 4 group grure crccllent or good results (50 per cent) of the 67 posterior dulocations 29 coses belonging to Grades 1 2 and 3 were reduced within the first 12 hours with 26 excellent or good resulo (896 per cent) Thirteen cases of Grades 1 2 and 3 were reduced bettiecn the thirteenth and tirtnty fourth hours with 10 cxcellent or good results (17 per cent) All those reduced more than 24 hour after injun goit four or poor results, Of 33 parients in u hom operation was undertaken 5 were submitted to primry recorructure measures and 27 stre submitted to open reduction ·Fractures of the fichium 61 Only 7 of these gauc cxcellent or gond resulo (255 per cent) Though thes would seem to be conclusucli against open operation congderwuon must be given to the fact that these cases were operated upon at an average of 33 days after mun and were obviously of the more serious group This would seem to be substandsted by the fact that in 5 postenor dislocations, of which 4 were reduced by open operation within 24 hours and i by closed reduction followed by open fixation onc wech later 2 crcellent and 3 good results were obtained In summan it would appear that the entent of the injury is not simportant in the ulomate outcome of the case as is the time that has elapsed before reduction of the head is obtained. If reduced within the first 24 hours, the rosults appear to be fairly satisfactory If unreduced for more than 24 hours, the results appear to be at best only fair regardless of the treatment or the secon of the lesion. It is this which justifies the opinion that reduction is of pnme consideration eren in the face of concomitant injunes. CENTRAL FRACTURES OF THE ACETABULUM Central perforating or floor fractures of the acetabulum appear to be definitely less common than either rm fractures or the ischioscctabular fractures from which they should be carefully differentiated. There is con siderable confusion as to the exact definition of "centralfractures. Wester born“ reported a series of 500 pelvic fractures in which the acetabular floor was fractured in 67 in which there was intrapelvic protruson of the head in 21 Similarli Romani" collected 135 such cases from the literature and added 4 cases of hos out. In both instances, it appears that it was the intra pelvic protruson of the head rather than the nature of the fracture clut Has emphasized Vaughan" insisted that only those be called "central" in which the head actualls penetrated the floor of the acetabulum withour min fracture and much the edges of the acetabular fragments surrounded the femoral nech like a collar He particularly called attention to the fact that neither intrapelvic protrusion of the femoral head nor medial displacement of the mediał wall of the peliis could be considered as true central or perforating fractures of the ecetabulum There can be no quarrel with Vaughans definipon as regards the most severe cases of central fracture but it would appear to be too erclusivt of the milder cases in which undoubted fracture of the eceabular floor without or with but slight penetration of the pelums has occurred On the other hand, since intrapelure protrusion is possible in cases of ischioacetabular fracturc, It must be admitted that the merc intrapeluze protrusion of the femoral head does not establish the existence of a central floor fracture IVhile the trse of the term "central doslocation" s useful in differentiatng fractures of ·62 Injuries and Surgical Disease of the Ischium the acetabular floor from those in which there is posterior or superior des location as a result of the rim fracture it is somentat confusing when it is desired to distinguish between truc fractures of the floor alone and those that involve the acetabulum and other parts of the pelvic tall Heroche attempted to clanfy the issue by referring to those intrapelvic protrusionS DO which the femoral head actually penetrated the floor of the acetabulum os central while referring to those in which the femoral hand followed the medially dislocated inner wall of the pelo es "Eccentric" dulocations, Fonton observed that fracture of the base of the acetabulum is more frequent than is suspected especially the mild forms often pass onrecognized and are commonly misapprchended os contusions of the hip." lo support of this thesis Dapont" reported to coses seen in Brocas clinic one complained of muld pain on pressure orer the trochanter and maintfested the symptoms of a mild plastic arthros for a period of five months The other a young soldier was hicked by a mulc. With the exception of localised pain over thc honzontal ramus of the pubis, on rectal canunion, all signs and symptoms were mojmal. The xrej in both revealed . fracture of the acctabulum Kontorowitch" reported the case of a man of seventy who after a fall on his side was unable to rise There was some ecchymosus of the scrotum. Though the trochanter was depressed there was no tenderness on pescuisson over the trochanter Except for abduction and adduction, motions of the hip were normal and rectal cramination was negative. The X-ray never theless disclosed a fragment of bone from the acetabulum projecting rato che pelvic cality Central fractures may occur at all ages. Therenoth states, frtc ture of the acetabulum may castls occur in the infant. The ferrore) peck Ls strong and when the trochanter is struch, the head is driven into the acctabolum and enforces a yielding of the cory loid cont The y-shaped cartilage acts as a sort of buffer and pennits some play between the different parts of the pelvis. It yields gradually and becomes progresovely none, especially in its lower vertical segtient." Dupuytren" is quoted to the effect that in youth the force w huch is directed against the center of the con loid carity may separate the parts of which thic imoredute bones composed and whose point of union is the center of the cavity” Trumatic fractures of the ecetabulum are seen more frequendy in men than I women. In 53 cases reported by Delannoy 1 41 were found m males and only 12 mn fanala. Acetabular fractures are usually the result of external traume. They hart been described as occurring after falls on the feet or knees, falls on the opposite shoulder falls on the actum, the prochanter or the sschion, or of talls or blows against the antenor curve of the pubs arch This type ·63 Fractures of the lichlum Cisc is usually unilateral but recentls Camera reported a bilateral casc rc sulting from a street fall Bilateral cases, the consequences of conruisic theraps have been reported by Ligas." Lingle and Rolbing " Haincs, s haundirsky and Hoch" and others. halinowski notes that this ordenrise are type of fracture is not infrequently seen in electroshock therapy It an be crplained only by the sudden contracture of muscles which pull the had of the femur towards the pelvis. The mechanism of this fructure seems to be the same u that of factures of the neck of the four The impact of certam adductor musclos cither compresses the femur to that a frac turc occur or of the acetabulum DOT #rong nough to resist, it us fractured and the head of the femur s drven into the pelete canti A great many cxperimental studies have been undertaken in the cffort to explain the pathomechanics of these fractures. In sixteen cadaver experi ments performed by Vireviures the trochanter ves struck by a fire kilo gram hammer but acctabular fractures resulted in only a few instances and of those only one was central Féré lct cadavera fall on their schn with the thughs flexed Honzontal fractures of the type described by Walther but no central fractures of the acetabuluni were obtained Thei enor failed to produce central fractures of the acetabulum until thc bony femoral nech was replaced by an artificial wooden prosthesis and then only when the legs were in extension. When the legs were in fleuon bloux agamst the trochanter vielded horizontal fractures of the ischroacetabular cype. It may well be that the failure to achieve consistent results experimentally Hus due to the madequacy of the force employed, king and Richardsstate that the tremendous force with which a person may be thrown against the instrument panel (or against the back of the front seat if he is siding in the rear seat) is well illustrated as follows the linenc cnergy of a 150 pound body moving at 45 miles per hour is 10 200 foot pounds. In bringing this moving body to rest the same anrount of cnergy must be expended (10 700 foot pounds is equivalent to five tons falling one foot.)" Because of the magnitude of the force required to produce central frac tures of the acctabulum, serious injury to the pelvic viscers are not infrequentlı sociated with this fracture Unnar retendon is an almost con stant complication, but actual rupture of the urethra, the bladder the hid ne 4s well as mjur to the rectum, obturator vasels, nenes, and cien the SCHICHC nome have been reported. These injunes may be senous though to jonparuoc life and their emergency treatment pre-empts an attendon to the fracture itself In che chce of a true trusl fracturc of the acetabulum with intrapelvic protein of the femoral head, the dragnosis is usually made without too much difficules The patients complain of severe pain, inability to bear ·64 Infuries and Surgical Diseases of the lectura veght and marhed limitation of motion, especially of abduction. Thus due to the abutment of the great trochanter against the acetabular nim Large ecchymosis in the regun of the inguinal ligament (Losseit's sgo) od Occasionally a nummular occhymosis at the base of the scrorum (Dedors sign) may be seen. There s tendemess on percussion over the great trochanter thar is definitel closer to the pubic spine on the affected side tham on the unaffected ade (Rours sign) (Fig 39) Though the leg moty lie to Fx 39 Rours su The dogance from the cp of the tro chanter to the modhime of the bodr ble on the side of fracture than as the corny and Intemal rotation 1 zoglun found outernal rotation most compon, so that # fint sight the condition resembles that seen m fractures of the femoral nech. There is apparent shortering of the affected lanb. On rectal crimeston crepitus and the nued projection of the femoral head (Esries sogn) may be felt In the edunced coses the roentgenogram affords a raads and dependable means of dugnosis. The femoral head incorcred by bont projects into the pelvic causty In an unusual case reported br 1 acquez arcular portion of the acetabulas floor was desplaced into the pelsts but without ans dolock tion of the femoral had ·65 Fractures of the Ischlum In the nuld case, the r ray may show only indistinct lincar fracturc lines without any evidence of inward projection of the femoral licad Such cases mai present onls nnnunal signs localized pain over the trochanter, localized pam on rectal canination, acrisonal ccchymosis in the scrotal or ingenal region and sonxe limitation of monon. These are the so-called "silent cases that may justifiably be mustahen for contigons Houter the inability or ܢܝܐ FIG. 40 Healed central fncture of the acetabohum The entire floor of the sectabulum has been desplaced krito the peltes by the femoral hend, which protrudes beyond the arcuate ime. the impossibility of definitely establishing the diagnosis does not preclude its exotice. Henschen reported the case of a noman aged tuenty five months pregnant, who fell a dostance of four feet off 2 wagon landing on her right side. She complained of great pain, inability to wall, and had difficulty on urina tion for e pernd of three davs. All other signs mcluding rectal and rray cumminon were negable and after six s cehs hospitalizagon the patient 1195 permitted to retum honx Because of limp and progressive pain, the pabent returned to the hospital and at this time a large bony mass project ing from the inner wall of the pelvis was felt both on rectal and vaginal ·68 Injuries and Surgical Diseases of the Ischium eumnation. The I ray disclosed the femoral head protruding to the pelvis and covered by a large mass of callus. Thus lcd to definite difficuln m de livery and the child uss bom with a cranial depression correspondmg to the bons mass on the mner pelic wall Henschen atributed the protrusion to the fact thac the patient had been permitted to well before firm unson had occurred with resulaant gradual vielding of the pelux wall and progressett deposition of excess callus. Treatment will vary with the severn of the lesion. In the mid cuse where there is fracture without centnal deslocation of the femoral head, bed rest with friction to orercome the force of the pelez trochanteric musclos 4711 suffice. Waght beaning should be interdicted for at least four months or until there is seasonable sur DCT that firin union has occurred. In women of childbearing agt, r B particularly important to prevent the possibility of grid- Darrowing of the pehric out let bi muud protrusion of the fesoral head (Figs. 40 and 41) In cases where there o mund protrusion of the pelvic wall without actual penetration of Lorrapeire protrusion of the seal the floor lateral traction may be ulom (Oros pelro) follow my belong of 1 central incture. The tip of the greut tro applied to the great trochanter clander oopmges gunst the sertabalar margin (Camens) or the perc almas and there i red fedaction m the mirs tubcruity distance be pulled out by the turbockle method described by Johast and recommended bs Dudgeon's (Figs. 45 and 46) In cases in which the sceabolar om has remained unbroken, Whitinans method of impinging trochanter agunst the ribs and then leting the head out of the metabolom has been successfully performed by Kleinbergh and Cokey" The most severe cases where the head penetrates the floor of the acetabulum and the fractured fragments encircle the deck bateral to the apital enlargement are not upenable to the more consentire closed methods of treatment In such cases, I aughan adresed prompt resort to open operation. The operation is completed and shocking Lo one such case aughan reported 1 stosfacton outcome despite uafection of the sound The progressus in such cases is serious. In 26 poents utth unquestioned central fracture of the metabulum tut Vaughan collected from the Intesa Fi +1 ·67 Fractures of the Ischium turc & died. In the other 18 patients who ined the functional result was good m onls 3 The rest presented endence of pain and limitation of motion oping to osteoarthritic changes in the hip in an analysus of central fracture of the acetabulum Stewart and Alilford noted that 8 of 10 patients reduced by closed methods within the first 12 hours shoued good or crcellent re sults. Onc patient, Grade 2 reduced within the first 24 hours, had an ex cellent result while another Grade 3 had a poor result Six patients treated after 48 hours all showed poor resulos. Of 4 treated surgically only 1 showed a good resul, 1 11a fair and 2 were poor Five of the 18 patients des cloped a vascular necrosts with later osteoarthritic manifestobons Where sererc osteoarthritis is the final outcome therapy must be directed toward its relief As in other forms of arthritis, treatment as possible by means of arthrodosis, by prothetic replacement of the femoral head by tallum cup arthroplasti or by the resection angulation operation. ISCHIOACETABULAR FRACTURES In 1891 Walthers who had been attempting experimentally to reproduce central fractures of the acctabulum described a fracture that has been alled "schioacetabular "In tho condition, the schium as a whole is pushed and ulted inward us a result of a fracturc line which passes through the ischio-pubic junction, the acetabular cave and the ischial spine (Fig 42) Though not co mon, it occurs more frequently than is suspected and has been frequench erroncously included in statistical studies of central fractures of the acetabulum" of the six cases reported by Westerborn 23 "central dislocation of the femoral head," five are clearly of the type that must be described as ischioacttabular G1012, Leinaa, * Milch," and others have reported cases under the more specific designation of ischioacerabular fractura Thos fracture, like other ertensie pelvic fractures, may be associated 17th injuries to the neighboring soft tissues, the bladder the urethra or the bouel Injunes to the obturator norte and paralitc phenomena from in fun to the sciatic nere are not uncommon Tither the peroncal or the cabul or both portions of thus nerre may be molied. The nerve may actually be partially or completeh severed but most frequently the paralytic phenomena are due to traction on the nent at the time of injur Recover may be parul or complete Usually the diagnosis of this secre tipe of pelix injury is apparent but it may appear m such mild guise is to be mistaken for a contusion of the hip Typicalls the picture that of a marked disability following a chanc teristic histon of mon The leg is usuallı held in fledon, abduction, and ·68 Injuries and Surgical Disease of the Itchlum cxternal rotagon. Active motion is completely inhibited and pesure option of markedly limited There is tendemoss on percussion and palpation orer the trochanter Within a short time of the injury swelling resulang from hemorrhage may be noted in the region of the crural canal (Loessee's aga) at the base of the scrotum (Destots sign) or along the pubxc ramitas Fra 42 Lachroacetabular (1 Albert) fncture The fracture loco tends from the schropub jonction through the floor of the treesbulon to the schwarpme The entire ner wall of tho pelro has been deplaced medwlly lading to a cruc acham rerum (Delummoy s sign) Corresponding to the degree of hemorrhage, there mar be a sense of fullness in the Iliac foss. Depending on the degree to which there is intrapelvic protruwon of the femoral head, the fascia betuten the iltumn and the great trochanter will be related ( Wis' sign) and the distance from the great trochanter to the pubic spine will be dmunsshed os com pared with the opposite ade (Roules egn) Rectal emmuration for the de termination of crepitus or intrapelvic protruson of the medial wall of the ·69 Fracture of the Ischium pelios (Eales sign) should never be neglected. Though the trochanter may lic above Nelatons Ime, this has no pathognomonic significance (Fig 7) It is a purch geometrical relationship and merely indicates some abnormality in the region between the trochanter and thc pelne wall. The court of last and possibly of first resort is the ray The treatment of these cases is most unsatisfactory The prognosis is not í Fra 43 Old, healed schiocetabular fracture, wuh production of Orto npe of petits, TICTC utre no signos of hip jont insoliteat, but the patient presented signs of permanent mic nerve parahis good In 16 cases reizeued by Rahman only 1 case had a complete func tronal secouen while in the other 13 functional loss of 15 per cent to 50 per cent was recorded. Cortalorda" estimated the orer all loss of function at between 30 and 40 per cent. Of 139 cases studied by Romani there are onli 29 cura. Twenty one parents died and 77 had marhed functional loss. On the other hand, Stewart and Vfilford reported that of 18 central fracture deslocations of all grades treated by closed reduction 2 u ere excellent, 7 were good, 1 495 fair and I was poor Of the 4 central fracture dolocanons

·70
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·71 fractures of the Ischlum treated surgically I was good, 1 fair and 2 were poor Where there is no mashed inward displacement of the medial pelvic urall prolonged bed rose without utight beaning until there is evidencc of finn bony union is essential (Figs. 43 and H) Where there is nicdial displacenient of the peluc well, efforts must be made to reduce the fragincnts to niinimize the tendency toward ostcoarthritis and, in the case of females of childbeaning age, to avoid the possibility of narrowing the pelvic outlet In individual cases, reduction FK. 46. Method of applying the Jahas tombuchle cest has been accomplished by a variety of methods, all of which employ the principle of lateral traction on the femur As in central fractures of the acetabolum, lateral traction may be crerted by a sling around the upper end of the thigh or by adducting the legs olc a luister placed between the upper ends of the thigh (Oller and Varemmur) Thos principle was employed bi Jahren u hen he incorporated double turn bruchlos in leg casts. Bs Cicending the upper turnbuckle and closing the Inu er tumluchle, the upper ends of the thigh were forced outward and ciented a lateral force on the fracture through the pelvfemoral ligameno ·72 Injuries and Surgical Diseases of the Ischium (Figs 45 and 46) Where such methods are unsuccessful, lateral traction may be exerted through the insertion of wzres, screws, or bands coro che great trochanter Replacement of the fractured fragineats by manipulitoa through the rectum is seductively simple and has been accomplished success fully It is, however a highly dangerous method since puncture of the rectal mucosa may lead to infection of the hematom, of the parietal issues, and of the fracture itself It is for safer cien if more trying on the patient, to enter the petros retropentoncally through an inguinal incision as suggested by Long The method must, of course be followed by continuous Lateral traction to eliminate the medial dore imported to the femoral head by the pelratou chanteric muscles. In one rastance reported by Levine actual plaang of the fractured frogments uns successfully accomplished Unprotected papter bearing should be avoided unul firm healmg has tahen place but both actitt pasire mouon should be encouraged early In sıx instances, in which the extent of the acetabular injury educared the impossibility of a satisfactory functional return, Westerbom perforond phman vitallium cup arthroplasty "Yn five of the sex patients the results have been encouraging" In other instances primary arthrodests, primary arthroplastic procedures, or reconstruction operacions may have to be considered. REFERENCES and I ALLI, OH Difficulties encountered in reduction of dislocations of the hup Gross prize cu Donan, Philadelphia, 1896. 2 Bai H h Fractures of the ischium Tr Brooklyn Sarg Some in Long Island AI I 15 24 1921 3 BENNETT EH Facture of the schium Tr Acad Med Ireland 302, 1891 4 BULLIT H) The Mechanism of Dislocation and Fructure of the Hips. Philadelphus, H Clas, 1869 5 BRANDT G Schleschende Frakturen. Ergebenpisse der Chirage and Ontba pedie 33 1 1910 6. BOZMAN A1, 20d SNIQ S. Ter of the actospudou ligament Ball. Hosp. Jom Dus : 69 1947 7 BURMAN A1 Tear of the secrosperous and secrotuberous bguments | Bome Joint Surg 144 331 1992 B. CAMIDU, R. Un cuo di fratrure bilaterale dell acetabulo con penetrant della teste femorue nel bacino. ALIRITTY ortop. 2 #6, 1951 9 CAMPBDLI, W C Postenor delocigon of the hip with fracture of the pretabulwn. ) Bone Joint Surg 18 842 1936 1C4 CAPPELETTL G Interno une frattun delle bruncte uscendente dell'ictoo e descendente del pabe cautat de retragove moscolare Giornado Proges JAX Oxologis, Verede, lod xr. 12 482, 1847 11 CUAL LE Grof Fracture of the mos of the schium with rupture of the urethre Lancet 2 137 1859 ·73 Fracture of the lichium 12. Corey B. Central fracture of the acetalmulum / Bone Joint Surg 7 458 1925 13 COTTALONDA, J Recherche experimentelle tur les fracturas par enfoncement de la cavité cory kode Thesc de Alontpelier Lyon cbr 20 32, 1923 14 COTTON F Fractures and Dislocations 2nd ed. Philadelphia, IV B Saunders Co. 1924 466. 15 DELAYYOY E. Fracture de la ante con loide et luxation centrale du fertur Rou cbrr $9 317 1921 16. DETAL, H Simple fracture de l'ischum Signe pathognomonique. Union med de la Gironde, Rordcou 11 62 1866 abo Presse med Belge , 30, 1867 17 DUDAEON H Peluxe fractures and dislocations reduced by turnbuckle (Jahss) Bone & Joint Surg 24 354 1942 18 Durort J Fructura du fond du cotile. Presse med 29 135 1921 19 DUPUYTREN G Lccons onles de clinique chururgical futos i l'Hôtel Dicu de Paris Paris, Germer Bailliers, 1832 2 110 1832 20 EAALT Bruch des Sitzbuns be Pagetscher Erkrankung Röntgenpraris 8 233 1936. 21 FAXTO* Reference br Dupont. 22. FfREG. Etudes etpenmentelles et clinique sur quelques fractures du bassin Progt med : 325 403 421 1880 23 Fonchen MAYFR, 0 Trunungs Veranderungen bei Sponfechten Wien klin IV conscbr 63 331 1951 24 GILDERT 1xt A case of double facture of the chiom. Soub African M Rec 24 232 1926 25 Giol, T Excepcional tinedad de fracture Equicacetabular (Walther) Semans med 36 725 1929 26. Gualt E Beitrage zur hugurth der Frakturen. Arcb klin Cbh 3 394 1862. 27 Harits H H Unusual complications of conrulare therapy Psycblaric Quart 18 273 124 28 HANES, N D Double fructure of the schiadic tuberostics. Ann Surg 71 190 1920 29 Hrvur h. Die traumatische Locatio centralis femoris. Bruns Belst ka. CITY 62 294 1909 30 Hopot, E. B. Isolated fracture of the tuberosity of the pctuum. Am Surg 73 117 1921 31 Jair, S. Injuries molning the pelvis. Am J Surg 43 394 1939 12. Iris J Bechenbrüche Arch klm Cbr 101 305 1913 33 Joxen DFA B. Varch fracture of the inferor pubic ramis. Radiology +1 586, 1943 34 KALNAI LB., und Hool PH Sbock Trestment Psycbonitgery Ven York, Grune und Stratton, 1952, p. 131 35 hrs JA. ind CovwLHE Fractures Dislocations md Sprors 4th ed. St Lours, C. Vosbi 1946 36 hig, und RKJA, V Fructure deslocation of the hip. J Bone + John Suntg 3 533 1941 37 hinir, S. I'ractures of the ecerahalum with luation of the hip. Am Sury "5 SX 1923 ·74 Injuries and Surgical Disease of the Ischlum 38. hovro OIFITUL, DAA Fracture da bassin. Fracture simple et limite de la crite cotz lodc. Tbèse de Lyon 1903 39 LENAT F Una rama vincta di fratture ischio-cetabuler Arcb od and Soc #al di cbr #905 1937 abco Cbir or] TOFTHERIO 1 6 197 21 416, 1938, 40. LEYNL A1 Centrul fracture of the acetabulu, treatment of 1 Bond Joint Surg 25 902 1943 41 Laas, a Lustizione centrale bilaterale del femore de contrazione morcolare Cbir org motthiento ' 171 1979 42 LINOLEY J R., und ROBBINS, LL. Fracturos following electroshock therapy Radiology + 124 1847 43 MALOANE, J F Trahté des Fractites Paris, J B Balisere, 1847 H ALARCHEN, C frattura della branca chio-pubia per eccesso di Indon moscolau Radiol med 2 244 1915 45 MARET Obsertions sur les fractures du begynn Mr. Acad de Dion 1 85 1778 46. AIKOILLIS, G Ober Beckerfrituren, Alonchenet undrinische Albundangen Munich, J F Lehmanns Verleg 1891 +7 Viral H Ischio-ucetubular (Il alther ) fructure. Boll Hosp John Db. 167 1955 48 Nruxasov S. March fracture. Am J Surg 62 154 1943 49 Pertas, L. Fracture of the sched-pobuc namus and rupore of the bladder An lled, Plubidelphu, 5 837 1903 50. RAIKAN H Uber die Zeitral Luation des Scheokelkopfes Brons Beste tant, Cir 123 38 1921 51 ROMAN, A La fruguri per affondamente traumatico dello ante con borde con lussazione in pelrina della teste femorale. Chto ory Mortimento 12 360 1928 52 Roux arm and OMLANJANIAN A Étude sur renforcement de lecetabulum per la tête du femor Ret med Suisse Rom 22 211 1902 53 SELAKOVIC, W., and Love, L. Stres fractures of the pobic ruzu.) Bom Jomt Sorg 364 573 1954 54 SHARPE, 11 Trenserse fracture of the body of the ischium Bath lobors Hopklas Hosp 22 57 1911 55 STEWART MI J. and Minoan, L. W Fructure dslocations of the bup / Bow Jobur Smg 364 315 1954 56 Shimov L Fire cases of dislocation of the hip. New York ] Ved 10 118, 1889 57 Srusan L. Fractares and Dulocation 7th ed., New York and Philadelphia, La uod Febiger 1912 58 Tucesor L. Les fractures dmples et imaccos de la ante contoide. Ret dortbop 5 763 Ind Act, 1901 59 TOMMON V P, and EMTE H C Traumatic dislocation of the hep J Bone Joma Sung 334 746, 1951 60 VACotez Fructure comminuto de los leque. Bull. Soc ont de Pos 1 101 Sth ser, 1887 61 Vavaux GT Cemal deslocidion of the femur Sartt Gynee + Ober IS 249 1912 42 VIETALL, VI ] These de Lyon 1999

·Fractures of the Ischium
75
63 WAARVUTII Reference by Brandt
64 Waltura, C Recherches ceperimentelles sur certains fractures de la cavite
con loide. Bull Sac anat de Paris S 561 1891
65 ll ESTADORX A. Beitrage zur Kenntnis der Bechenbrüche und Beckenlura
001. Acta cbir scandinst 63 (Supp. A) 1928
66 11 ESTEBORY A Central dislocation of the formoral head treated by mold
urthroplast J Bone Joint Surg 36A 307 1954
67 IVILIELM R. Die "Schleschende Fraltus Warsch Froktur Deutscbe Zuscbr
Cbir 25+ 11 1910.

·CHAPTER 7 Ischial Apophysiolysis ISCIAL APOPHYTIOLY315 is an avuksion fracture of the apophysis of the ischial tuberosity It occurs in adolescents before the age of eighteen to menty five years, at which ume closure of the epiphyscal le normally takes place. The condition is so charactersuc as regards modes of onset, symptomatolog, roentgenographic appearance, and clinical course that it must be considered as constituting a specific clmıcal syndrome. INCIDENCE Though this condition must have occurred before its earliest description m all probability it was ther, cien as nou all too frequently cesually dismused as being a mild muscle tear of the type commonly called "charles horse. Historically it is interesting to note that in his treatise on frectares and dislocapons, Afalgaigne' observed that the ischium may cornictimes be separated almost entirely in front of the descending namus of the pubxc and posteriorly from the cotyloid cavity which rerums intact, wtuk sometimes it is only the tuberosity which is detached from the bone." Although hc failed to make any conclusive statement as to the enstence of adolescent apophysiolysı, he noted that after fracture in adolos “it might be presumed that the por erful muscles inserted into the tuberosity would drow down the detached portion of all the fibres were ruptured es in Joberts casse. From the literature at present available, Poland" seems to have been the first to call specific attention to the fact that apophyseal separation of the chial tuberosity could occur In 1898 he noted 1 RV Parker hus observed a separation of the epiphysis in th with support tion following a back and the author has seen i ble the result of direct violence. 1 76 ·Ischial Apophysiolysis 77 lather of these oliserers, hou cer can be credited with having de scribed the typical picture of adolescent apophysiolysos resulting from in direct violence As accurateli us can be established at the present anc, Bert' was the first to report such a case Hus patient was a malc of tu enty three who at the age of nients while running in a foot race, suddenly felt "something snap" in his buttock and fell to the ground. He complained of severe and progresslic pam thar rendered standing walking sitang in a hard chair or forward bending impossible Roentgenogrphic examination disclosed that the large nass that could be felt below the eschual tuberosity TUTTE FIG. 47 The crescentic shades of the completely aruised schal apophytes as seen li ng just below the femoral neck. (Rc produced from lich, H Aruluon fracture of the tuberosity of the schim) Bone Joint Surg 1:832, 1996.) HB an unumted portion of the schium. This was remored with great relief to the patient In 1996 Vilch' reported the second ase This was the first instance in which the symptomatology of the acute phase of the condition was obsened, and in which attendon was particularlı directed to the characteristic sal appearance The patient a young girl of elei en, had suffered an mun to the night buttoch while doing a split during practice for a dance. In attempting to regain the upnght position, she "felt something slip in this region fell bach, and was unable to anse. The prin radiated along the course of the hamnstnng muscles and both sitong and standing here painful. 4 dugtsas of mucie sprain was made and bed rest was advised. After Sieral days the pain subsided, but on leaving her bed, limp and an apparents lengthenmg of the affected limb brought her for consultann ·78 Injuries and Surgical Diseoses of the Ischiura Examination disclosed a mild limp slight unsteadiness in gat, uod a marked limitation in motion of the right hup Adduction, maternal rotation and extension of the nght hip #cre painful Agarst resistance, estetision of the right hip was definitely diminshed as compared with the left, unaffected hip With the hnec flered the hip could be normalls flered, but with the Inec cxtended there was definite increase m pain and limitation of fleron Direct pressure orer the tuberosity was painless, but rectal palpation of the tuberosity and secrotuberous ligament clicited complaints of sharp porn Fram 49 Incorupletely atuked Ischlal apophyt's appears • peor-bchial shadow.lyng just below the body of the schium on the right side. The roentgenogram revealed the pathognomonic crescentic shadow of the avulsed sschul apophysis (Figs 47 od 48) Voder purple bed rest, there was complete abatement of pain so that the patient did not return for follow up x ray cxamination. Because of the inability to follow the case to its definitive eod result, the clinical picture of the acute phase in de scribed along with signs that must be conndered os pathognomone of the condition. In the vean thar followed this earlier presentanon other cases have appeared m the English and Continental Intersture with increasing frequency These in conjunction with two additional cases in which it was possible to follow the patients roentgenographically up to the time of coat plete healing permitted a definitive description of the syndrome (Afich") Charcteristically the condition occurs in patients below the of ·79 Ischial Apophysiolysis Tann five the upper agc linut for complete ossification of the schjal apophysis. It has been described as rare though this is open to question. It is difficult to draw any conclusions as to its eract incidence. AlcLaughlin noted that in the files of the Presbytenan Hospital, cu York City only three cases of arulsion by muscle action could be found At the samic ume Caffe, stated that he had seen three similar cases that were not reported. Though this would seem to document the relatiic mnty of the condition as indicated by the pauatı of cases reported in the literature, the increasing number of such reports suggests that many more such instances could be Fr. 49 Bilateral schal apophysiolyes. On the nght side there some etidence of attempted halms on the left side the apophyxs clearly ununited (Reproduced from Gorkhanh, t Case of bilateral arubuon fracture of the schal tuberosity Arcb Ortbop Unfall-Cuir 33 236, 1933) found in the unreported files of other roentgenologists. Alany more undoubtedly will be found as soon as the possībility of its OccurTence is recog nued and all cases of "muscle sprains in the gluteal region are routinely submitted to my examination. The condition is seen predominantly in males and only tho female cases hare been reported m the literature (\lılch-) In both of these in dividuals, apophysiolysis de cloped under circumstances of strenuous activity analogous to those known to have precipitated the symptoms in the males. It seens, therefore, reasonable to attribute the higher incidence m males to their greater participation in sport or other physical activity and not in any genetically determined factor With the crception of the case reported by Gutschank all the instances thus far reported haic been unilateral Gutschanh s patent was a male who ·80 Injuries and Surgical Disease of the Ischluma presented all the signs of a nght sided aiulson of the schel spophys The rochigenogram, however unerpectedly rei caled the carstence of 10 identicel lesion on the left side (Fig 49) In the absence of mus bussion of recent trauma or any locelizing symptoms, it was presumed that the repre sented an antecedent previously gorecognized evulsion In the great majonn of males the left side has been involved, while m females the right side was affected Thes, foo would seem to bespeak soene pecularity in the use of the left louer extremuty by nght handed males rather than any predilection for the right side in the females. In all cates, the influence of trauma and speciallı of cIcsse tengon on the hair string muscles has been reported. All the cases were preceded by strenos activity such as football playing running jumping or acrobatic dancing It is unfortunate that jo Gutschanh s case there was an assochured cartier separation of the upper humeral cpiphyos that led to the tentative suggestion of an underlying endocrine pathology in two other cases, one reported by AlcA laster and another by Scott," the designauon cpuphustus" vs bred. Mellaster how crer was affimore in denying an endocrine basis and Scott, whose patient showed a basal metabolic rate of muntes 24 per cent stated "There were no outstanding symptoms or ngra to suboruotste a diagnosis of frank hypothyroidism other than sparse hair distribution md a consistently slow pulse The assumpoon and even the suggettion of an anderlying endocrine disturbance as the basis of the condition would seem totally wwarned. The lavolvement of only one other epiphysis, the absence of any of the roent genographic evidence typical of generalzed epophy sors or cpaphyscal dist turbance, and its nonappearance in all the other cases would not justify my senous consideration of this as an etiological factor By and large, it may be stated ategorically thar the condition as of traumauc ongin and results from muscular volence within the age limuts of closure of die schaal Apophysis. DYNAMICS The pathomechanics of the condition that appear characteristic of the crect bipedal stance of the human may be explained on an analysis of the structural dengn of the pelvis . For the purpose of analyse, the adult peltas may be considered as consisting of tio arched Her er anns united terrort at the symphysis pubes and aruculating postenorls with the sectum Exch heripelves acts u 1 lever of the first class with the femoral head as the fulerum The amenor pompon of the bony lerer es formed by the descendiog smus of the pubis and the antenor porgon of the ischual ramus. The posterior portion of the lever us formed by the body of the schem and the posterior part of the ischual remis After closure of the schul spophyssa ·Ischlol Apophysiolysis 81 dynamic balance of the pelvis over the femoral fulcnim mas be issualized as maintained by one force couplc acting upon the anterior extremity of the lever and by another acting oppositelt at its posterior end (Fig 50) The anterior force couple is represented bi (1) the pubofemoral and iliopsoas muscles, which tend to d]t the pelins downward, and (2) the muscles of the antenor abdonunal wall, which tend to tilt the pelvis upliard The postcnor force couple consists of (3) the lumbar and oblique abdominal muscles, which act to tile the pelvis downward, and (+) the glutci and the hamstring muscles, which assist the anterior extensors in tilong the pelizs upward under the age of apophyseal closure the dynamic analysis is entirely different The mere interposition of the apophyseal plate converts In patient Extension Forcm Sacro-cathc Ugonente bachtal Lover Ara Pubte larte Art Fecord For Externton Forces Foulon Forca Fra 50. Dynamic balance in the adult pelvis. Errenslos forces that tit the pelos upaard are the mascles of the abdominal wall (anteriody) and the ploteal and hamseng mascla (postenor) Fledes forces that tilt the pelra dommard or proient corre entendon are the pubofemoral and Hopsoas muscles (anterior) and the scrotuberous boonont (postenoty) (Repro duced from Vict, H, Ischial apophysioliis-Anew modronx, Ciha Onb z 189 1953) the postenor part of the lever arm mto a lever of the third class, in whuch the force is applied berliecn the fulcrum and the resistance to be overcome The combined mterior and posterior forces that tend to alt the pelvis downward may be considered os concentrated just antenor to the apophyseal plate while the upward tilning force of the hamstrings is applied posterior to the plate At this point, a sheanng strain is set up that can result in separa tion of the apophysis of the ischial tuberosini (Fig 51) Although no actual measurements of the tensile strength of the apophyseal cartilage or its attachment to the bonc arc at present available, it must s priori be considered as sufficient to withstand normal stresses. It must, howc1 cr act as a locus minoris resistentiae under the stress of the forces that are suddenly applied durng the course of strenuous physical and sport activity This mechanim precisely analogous to that which des clops in so-called Ospond Schlatter s disease m calcaneal apophysiolyss, and in upper ferporal priphuolisk, where the normally competent capital epiphysis as sheared ·82 Injuries and Surgical Diseases of the Ischia off bi ourhard rotation of the excessreli stressed femoral shaft staz agams the rosistance offered by the tour iliopsoas muscle. Of all the muscles wtoch, uctug posteriorly send to or the pelrs up ward into attension, the hamstrings that are stuched direct to the schmal tuberosity are the most important. This is of especial significance or under stunding the pathomechanics of apophishise. is has alread been need the attachment of the human biceps fermoros muscle differs from the more generalized attachement found m louer forms on that the sacrotuberoos rendmous portion of the human sacroperoncas complex aqures m addtronal point of insertion and ultimately recognized as the sacrotuberous or great sucrosciate ligament (Surton) The consequence of this is that ibe Fladon forces Schatic Ugoments Genoa Force bebito puble Low AIR Toberosity Syoptyle Record lots Extension Ferats Fredon Forons Fc 51 Dimanx balance o adolescent spophrvolts. The monar end porn error fexo forces are greater than the attemon forces od sveld 2 reaker forte that promoured to the region of the spophyseal plate. The stabilistes I share force couple concentrated at the spopbiscal plite pad leads to a porsalitas (Reprodored from Wochen H. Ischial popote wahss- DET 8Ddronx. Ce Orit ? 189 1943) toodious pornon of the human sacroperontalis complar acts preaseh to oppose che donna ard mobon that the misculer portion of thus complex mitustes. This sertos to for the spophews and thos to locations and accentom the counterbalancing action of the muscular forces that tend to clerate the Ischun bi gomg the pelvis dorinin ard (filemon) Excessive desplacement of the oralsed fragment prespali dos nos ustali ocetur in consequence of the restrumng action of the sacrotuberous or grort SecTUSCETIC ligament. The fibers of this stroctare directed opsard od muud. sre idealls utinged to commerct the forces of the artiseto wached to the tuberosits of the schon The gernelos mimor the postenor fibers of the addoctor Dagnis, and the quadratus femonts muscles tend to doplace the fregant donduud and ourrud file the hornstrang Imuscles tend to pull the fragment directs doutnud. The resultant sector force duu award and outuard is drametalh opposed to the direction of the fibers of the secrotuberous lgiment which courses ophard 28d muid ·Ischial Apophylolysis 83 (Fig 5") [xcessic desplacenxent of the avulsed apophy sus as accordingly only possible in the cient that the attachment of tlic sacrotuberous ligament ether to the apophysis or to tlic sacrum itself has been disrupted From the cases that have appeared in the literature, it is possible to rc construct the clinical course of the conditon and to correlate its symptomatology with the characteristic roentgen appearance. In the acute stage directly after injun the patient complains of sciere pain, limp and limuna tion of motion Sitting standing or any motion that tends to put thc hanstring niuscles under teision and thus pull on the avulsed fragment clicits crquesite pam An acutely tender mass may be felt or seen in the injured buttoch and, on rectal examination, pam is sharply localized to the region Sacro-slatke 1kg Gomallus Interior Quadratus for morts Adductor mognut Bicept Semitandmows Semimembranows FRO 52. Forces actmg on the schaal ruberouty The direction of action of the different mumerated forces is indicated by the arton (Reproduced from Ililch, H., Aroldon fracture of the schaal tuberosity ) Bone + Joint SNT8 832 1926 ) of the ischial tuberosity. The roentgenogram rcicals an irregularity of the tulerosit 15 compared with the opposite unaffected side, or a characteristcally crescente-shaped shadou In pauents in whom complete separation of the apophyos has not occurred the roentgenogram may present them appearance of perischial calcificanon such as may be seen in tuberculous mrection or tuniors of the schium The pathology is that of an acute fracturc in many instances. Operative intervention will disclose the avulsed took shaped apophus and the attached hamstring muscles lying in a font hematom (Helmer) HEAUNG At a later stage endence of early healing may be found in a form operated upon by harfiol fine months after injury because of pain. The apophyseal fragment with its attached hammering mer ·84 Injuries and Surgical Dhooses of the Ischlum found to be movable but attached to the body of the schom by dense fibrous connectic tissue On removal, the fragment is found to be thick ened by irregular masses of callus unbedded in a large mass of cotoxectare assue. This is clearly representatric of the healing stage that is resunlaed on the roentgenogram by the irregular thickening and apparent fragmentation of the lunate shadow (Fig 13) es Fra 53 ischal pophy polyte Fragmented shadow clarecerits of the healing saugt. FG st Heled Ruge of bichiel apophysalyas The idated only by the fact that the tuberontı ippar to pror erostence of apophylates on the right tode* be porch but thicker than on the noona) left side In the event that healing proceeds uninterruptedly unvon of the apophis seal fragment with the tuberosen may be expected Eren under estrena stress the symptoms 117l disappear and the site of the fracture will be recog nozable on the roentgenogram only by the appearance of a thickened or irregular outline as compared with the opposite, unaffected ade (Fig 54) If healing is interrupted, hon ever the patient may continue to complaw of disability Olting ather to pain or to the persistence of ions in the buttoch. In that event, as in the case reported by Winhler and Rapp," prenez-five ·Ischlal Apophyslolysis 85 scars after the onginal injun thc cicised mass was described as “nomial osscous matter with normal marrou elements, thc cxtcnor ixcing partially lined by hu alınc cartilage and tense tendinous tissuc Therapeutic indications ore best determined by the correlation of the roentgenographic with the clinical course Since the condition is a fracture through the apophyscal plate as a result of musclar action, complctc healing can be apected to occur provided the parts are put at relative rest This does not muolre plaster inmobilization, but mcrcly avoidance of hamstring tengon. Complete bed rost unul bony union has occurred is ideal but dous not appear to be imperative Bed rest during the acute stags and until all pain has disappeared is unquestionably necessary and will be readily acceded Fra 55 Ischal pophutrolyt. Left, aruked apophys before operadon nabt after open operation and routure. The apophyss has undergone nepoc pectors (Reproduced from Hellmer H. Cose of numate sepan Don of the epiphyss of the schrum Arcb Orrbop Unfall-Cbt # 45 1933) to by the patient. Thereafter limited activity such as does not precipitate the reappearance of pain seems to have to deterrent effect on the normal process of healing In general , a conservative approach to the treatment of this conditon as indicated. If the separation is minimal, bony union may be confidently expected provided rest during the acute stage is enforced. Where the separation is crcessie, fibrous rather than bony union will eventuate and recurrent episodes of pain may subsequently arisc. In the acute phase, surgical inter ention es contraindicated and skillful neglect is the treatment of choc. Plam neglect, hou ever such as is manifested by failure to recognize the condition or permission to participate in strenous activities, must be implicated as the cause of sonunion The nxere determination of nonunion does not in itself constitute an indication for treatment. \ormal function as possible am in the presence ·86 Injuries and Surgical Diseases of the Ischlum of nonunion. The patient described by Labuz 128 not considered suffi ciently disabled seven years after onset of symptoms to require any treat ment other than physiotherapy Scott's patient seen four years after his onginal injury 123 completely 251mptomatu. It must be admitted, how ever that nonunuon docs expose thc praent to the possibility of recurreace of symptoms as a result of stretching or teanng of the surrounding muscles and the scar tissue in which the fractured fragment is imbedded. Where pin recurs or perusts or where the detached fragment of bone mechanicalh interferes with normal activity surgical intervention would appear to be justificd. The problem then is whether to attempt replacement of the frac tured fragment or to excise the offending mass entirely FHSS Resection of aiaked schmel apophys. Let, the appearance of tho aruked spophyse before opeaton; righ, after resecton of the naked pophrys (Courtesy of Dr H 'McLaughlin.) Through reposition and direct suture may appear to be the most deal solution it is clearly not the most expedient Surgical replaccineat is it all times difficult of technique and uncertain in outcome la cases of established nonunion, the excess fibrous tissue encountered at operation so omulupties the difficulties as to render resuture unjustifiable. Hellmer performed opku reduction with suture of the aruked fragment. Though the result has reported to be satisfactory the roentgenogram (Fig 55) clearly indicates that asepuc decrosis occurred and that ultimate healing would require a long penod of creeping substitution. In a smlar atuation, Darrach b seported to have met failure after attempted resuture. Where simptoms pereist beyond the time n hen healing may be expected to take place, excision of the mass with reartachorent of the banestring muscles offers probably the best hope for speedy symptomatic rebef Berry ·Ischial Apophysiolysis 87 hanol, and Winkler and Rapp' cxcrsed the nonunited apophysis without any apparent residual disability to the patient (Fig 56A D) and this is undoubtedly to be preferred to nusguided cfforts at resuturc. REFERENCES 1 BERRY J MI Imcturc of the tuberosity of the ischium duc to muscular 1c tron JALA 59 145, 191 2. CAFFEY J M Discussion of "Ischul apophysiolysis” at Miceting of Ortho pedic section of Academ Medicine March 20 1953 3 GUTIOLANT, A Case of bilateral avulsion fracture of the schial tuberosity Arch ontbop u Unfall-Cbr 33 256 1933 4 HELMER, H A case of traumatic separation of the epiphyus of the ischian Arcb ortbop 11 Unfall-Cber 34 45 1933 S hARFOL CAvulson fracture of the Ischial tuberosit Zentralbl Сbir 57 2466, 1930. 6. LAOLZ, EF Arukion of the schnl tuberositi J Bone Joint Surg 28 388 1916. 7 MAIGAKVE, JF Treatise on Fractures md Dislocations Pans, Billicre, 1847 Vol. 1 P 648 8. MCLALGIIN H Discussion of Ischul Apophysiolyses at Meeting of Orthopedic section of VI Academy of Vledicinc, Varch 20 1953 9 VALASTER, P E Epiphysis of the sschul tuberosity | Bone & Johne Surg 27 193 1945 10 Viral H Arulsion fracture of the tuberosity of the ischium. J Bonec Joint Surg 8 832 1926. 11 Milan, H Ischial apophıxınly A neu syndrome. Clin Onb 3 184 1953 12 POLAND, J Trannatic Separations of tbe Epipbyses London, Snoth and Elder 1898 p. 614 13 Scort 1 \o-union of the schial tuberosity associated with epiphysis of the vertebrae. } Bone & Joint Surg 28 862, 1946 14 SUTTOY Sox Joris BLAYD Lugonents 3rd cd, London, H h. Lewis, 1902 15 HITLEL, H. and Rype 1 H L'nuited cpaphyw of the schrum. ) Bonet Joint Surg "9 234 1947 ·CHAPTER 8 Periosteitis of the Ischium, Gracilis Exostosis, Osteitis of the Ischium PERIOSTETIS PERIOSTFAL REACTIOV8 ALONG the inferior aspect of the tuberosity of the Escluum may be seen in a variety of different conditions. They are CONTADO duning the development of progenic or tuberculous Osttomelits, may occur danng the course of mfections else here in the pełnos (Fig 57) and arc mountably a stage in the life huston of aschal decubitus ulcert. Thes may appear hou ever in conditions in which no question of infection an arise. Periosteal changes without any lytic leven in the body of the schoum hart been described by hrebs. This observer who m 1934 first called * tention to the arthnic marufestations in the sacroilac joint probably the earliest sign of ank losing spondilitis, noted that a "rescutar perrosteus of the ischial tuberosity was a common roentgenographic finding in the cont dition He observed that, though not alu ays present, it was a more contaton cerky finding than the typical changes in the apophiscal points of the sport. Hc conadered these changes to be of an inflammatory mature and probably due to invasion of the periosteum by vascular connective tissue found in rheumatoid conditions in mild cases, a relatn els benign periostitus ** presenç, but in the more sucre cases crtense crosion of the bodr of the icbruin had been obseried Iller * ho corroborated this opinion, 1179 led to a studi of the condwan 13 ·89 Perlosteitis of the Ischlum Gracilis Exostosis Ostellis FKG 57 Bilateral periosters of the schul tuberunities follos ing septic abortion. (Courtoi of the \ational Institutos of Halth.) by the observation of a patient with anky losing spondylitis. This pacient complained of pain in the right groin and thigh. I ray cxamination disclosed an uregular periostitis of the tuberosity with anki loss of the symphysis (Fig 58) In seventeen other cases that Ilier collected, she nored anky loss of the symphysis in nine cases and varying degrees of penostinis of the ischual tuberosity in nine cases. She observed that crosions of the tuberosity might be extensive and might sumulate the findings in definite ischial tuberculosis, and particularly called attention to the differengation between this con dition and the so-called gracilis Crostosus noted by ion Bacy er is characteristic of arthritis defor mans. Fic. $8 Peryostoite of the schrum. Irreg GRACIUS EXOSTOSIS obar penostal proliferations with beginmg anks foss of the symphytos pubs in patient waf anbiz bosing sponds lats. (Reproduced In certain padenos, the person from Iller 11 Changes in the symphyss and steal changes that have been de the schium i Bechicerc* dacuse Ronetepramu 11 541, 1939) scribed as occurring in the region of the schial tuberosit seem to be concentrated near the ongm of the gracilis moscle and have therefore been called "gracilis cxostosis." Von Raever who had noticed this along with other changes in the dnphysis of the long bones, believed its appearance klas pathognomonic of arthrids dcformans of the hup Schiff undertook a study of the condmon at the suggestion of on Bacier and found it present only in those patients with enthnos defomans of the hip in whom there was an associated dorsal Lyphesis. Aat pelis, md flat foot with a crted gat. To crplain this peculiar concatenation of signs, Schuff claborated in ingenuous thcon based on the ·Injuries and Surgical Diseases of the Ischium Assumption that the dorsal lyphosis necessarily enforced a compensatory lumbar lordosis. Since the degree of compensation possible in the lumbar spine unas less than the degree of kyphosis possible in the dorsal spine, the deficit necessary to re-establish stable cqulibrum was compensated by upward alung of the pels. This displaced the center of gravity backuud over the lower extremities but at the expense of erotssive strain on the Y shaped ligament of Bigelow and the muscles, especially the gracilis, attached to the anterior leier arm of the pelvas. As a consequence, and in accord with Wolf's law of bone transformation, the exostosis developed of the site of Cresc gracilis strain Without in any manner deamg the possible relidir; of gracilo era in the development of the crostors, its pathognomonic sigmficuoct 10 Fre 89 Bilateral gracils costoso a female nnb osteoarthrubs of the neght hip. There are oo ngas of itphoss and no fanening of the pels o. arthritu defomans may be seriously doubted. Eren Schiff admitted thar It tres not found in all cases of arthrits deforming, bor only in those 1.500- ciated with dorsal kyphosts, flat pelvis, and Art cverted feet. This secured to bespaah a particularlı determining role to elements other than the arth ritus deformans. Strangli cnough, it vas pot constantly found even in those patients with kyphotic spines, fiat pelres, or flat everted feet me u hom, bet for the arthrus, the associated conditions postulated for the appearance of the gracilis exostosTS \nete present. From the evidence adduced by Schiff it appeared that nerther the anthintis itself nor the kyphoso offered sufficient explanation for the geniesos of the gracilis croSTOSIS. This became more obrious when the pelvic roent genogrun of patients under treatment for other condrions were examined with special reference to the presence of the esostoses. It was soon found that (1) parietits with arthritis of the hup but without dorsal kyphosis (Fig 59) (2) patients without arthritis but with lyphous (Fig 6) and (3) ·91 Perlosteitis of the Ischlum Gradlis Exostosis Osteitis FK 60 Persosteitis of the schlam on the right side and gracilos costons on the left adem a fernale with marked dorul lyphoses resultmg from tuberculosis of the spre Theres no anthrits and the pelo s fiat. TK 01 Bilatenl gracilis gostoso ni male with Paget s disease There is no anhias, no byphosis, and no flattering of the pelro. patients without ather anthritis or by phosis (Fig 61) might present may evidence of the gracilis costosis. While the exostosis undoubtedly developed in response to some forces, presumably strain at the insertion of the gracilis muscle, the conclusion that it could be looked upon as a pathognomonic sign of arthritis dcfomnians appeared to be entrels unsupported ISCHIAL OSTEITIS Under the title, "Some Crocs of Destruction of the Ischium of Doubtful Enology" Odelberg' described four cases that he believed represented a "non-specific inflammation of the schuum. Two bous aged eleien, one aged fifteen, and a girl aged thirteen presented the sanie clinical and roentgenographic picturc (Fig 6?) Without any antecedent horon of injun those children began to complain of pain along the inner aspect of the thigh with ·92 Injuries and Surgical Discost of the luchtung ndiation to the knec. Prolonged walking or any movements that pute strain on the affected umb resulted in a painful lomp In the ady phases of the condition, des viis accompanied by a low-grade fever Clinical cramuniaon revealed no atrophy of the thigh or gluteal muscula turc, but all showed signis suggestive of hup joint disease. In all, the x my disclosed evidence of a tarefying osteits with decalafication and even widespread destruction suggestire of tuberculosis of the schial tuberosty The serology and tuberculin tests were nogavic. All were operated upon In the first case, microscopic T amination revealed "a farly cellular tissue with considerable cel division and markedly mfiltrated with plastoma and round cells Here and there poly morphonuclar leucocytes Inflanttony changes of a non-specific maturt. Case 2 showed "profuse infiltration of pus cells." Case 3 disclosed "1 Tiscular augue rich in cells made up prin cipally of rouod cells, part of which were polymorphoduclear leucocytes or cells akin to these. Here and there Fig. 62 Destruction of the Ischlum typical plasma cells. In addition, there The tre of nodoloceneT o dimilar to that won in tuberculos. (Reproduced were even more oral cell closels from Odeberg A, Sorrectes of de pached together and among them struction m che ichrund of douboral et ology Act: cbir 56.273 ietoser taking place frecly No tuber 1942 ) cles or grant celk." No bactenological gronth could be obtuned from the pus or the tissue either on culture inedia or by guines pig inoculation in any of the cases. In the first three sex, the foci were completely exentemted wich prompt subsidence of symptoms. In the fourth cast, the crenteration was incomplete and symptoms continued for a number of yean The absence of more precise data precludes the possibility of other establishing or ercluding any definite caiological agent From the locaçon of the lenon and the age of onset, the lichihood of schopobtc Osteochondnious of the type described by Van Necka aould seem to be slight Wulfing hos inclined to consider the lesson in the nature of 10 apophysis. This possibuirs annot be dismissed entirely because the schel apophytes develops cracdi within the age period dunng which the conditioning noted On the other hand, the citeat of the ini olitment and is priman localizenon soncu hat entenor to the actual site of the apophy sus costos sonic doubt upon the explanation ·93 Parlosteitis of the Ischlum Gratis Exortorls Osteltis In 1936 Fitte descnlcd tuo cases occumng in children about the age of elcren, which crccpt for the alisence of feier appeor clinicalls and roentgenographically to be identical with those described by Odelberg As in those cases, both the scrolog and the tuberculin tests scrc ncgatic. Unfortunately the histology in these cases could not be determined be cuse under conservative therap! the condition resoli cd with completo bony regeneration Fitte especially emphasized his belief that the condition he described was simuar to that described by Voltancolic cycept for the fact that the lesson was located in the tubcrosity and not in thc eschiopubic junction. The conditions described aborc seem to be similar clinically and rocnt genographicalls with achial osteitis occurring at a làsecage. In 1952 Golden' reported the case of a twenty -51% year-old woman vi ho to w ceks after an abomon, developed pain in the perineum and nght louer ortrenut The pam in the per neum especially on Aenon of the thugth, persisted and roentgenogram rciealed an osteitis of the schium thar subsided under conservative therapy Golden ways of the opinion that the condition might arise either from inflammatory or neurotrophic causes and was sumular to if not identical with, thc pubic osteitas described by Beer' after opera Fra 63 Ostents of the schium. Rocntgen tions in which the unnary blad endence of schaal deuruction dereloped four der had been opened weeks after progatectomm and subsided under symptomat trtiment. (Reproduced from The same opinion was expres hlonger Al. En und LeTine, Iseblad ostrils New York | Ved 53 1579 1953 ) sed by hlinger and lerine u ho reported the case of a fifty five scr-old man in hom a one-stage prosto tectomy had been performed four wechs before the onset of left scratc pain. Ermination disclosed tendemoss over the ruberosity of the uschium and ray showed an area of rarefaction in the left schrum below the acetabulum" (Fig 63) Under rest, analgeni, and physotherapy the symptoms subsidech There was gradual resumption of normal locomotion. A follow up a rei study of the pelize bones efter a nonth had clapsed showed osseous regencranion in the affected area of the eschium. To subsequent symptomatic or objective sequelae resulted Without specificalls mentioning the possible role of the vertebral system of rets, the authors shroudh suggested as an explanation some relation ·224 Infuries and Surgical Diseases of the Ischlum ship to the long standing infection in the prostate. It may be that e shouldering thrombophlebitis involving a group of small renous radicals in the peltis 1125 present In communicating with lems draining the pelize bones, an extension of the process to them ius permaed and finally caused an occlusion of these venous channels resulang in the local changes noted in the bone OSTEITIS DEFORMANS Pagets diseases, osteitis deformans or Osteins hyperplastica, es a disease characterized by cnlargement and deformoon of bones (Fig 64) Ids onset FRO 64 Pagets disease of the pelves. Longitudmal gradons ad cym like areas are seen throughout the petra boost 13 Usually after the fortieth year and it most commonly mrolves the skull, the vertebres, the sacrun, the pelvis, the fators, and the abrac. Its etiology is unknown and Pagets ongmal theory of mitortory ongm bas bern discarded. The disease omsidrous in onset and is frequently discovered tudencally during the course of cramination for other suspected condi nons, Patents often complain of pain long before the diagnosis is establshed. Currng of the long bones of the leg or difficulty in fitong = bat to the increasing size of the had is frequently the first symptom that the patient notices. Jorolvement of the vertebral column leads to pain in the back and I gradual loss of height so thac, with the curred femora and there, the arms appear relatively too long and the patient assumes matoude that hos been described us san.

·Periosteitis of the Ischlum Gradis Exostosis Ostaltls 95 Usually the disease is poly ostotic but it may appear in monostotc form that may occasionally come on after trauma. In its fulls des eloped form the diagnosis is most readily made on the basis of the roentgenographic appearance of the involved bones. The pelvis na present the typical "cotton udol" appearance or there may be coarse fibrillar striations with areas of astlike resorption Isolated insolvement of the ischium is rarc. Histologicalls Paget bone presents cridence of increased bone destructon and reformation. As a consequence of these rapid changes the normal regular appearance of the bone is disturbed and on section presents an irregular mosaic pattern. The bone trabeculae are coarse and thick In areas of activity they are lined both with multinucleared osteoclastic giant cells and osteoblasts. The bone marron as of a fibrous nature. In resting areas these cells arc absent and the bone marrou Is Sually fatti The bone recon struction appears to progress at a more rapid pace than the destruction and sa result, the diameter of the bone increases. The bone formation, hon ever occurs so rapidly that complete calcification does not tahe place and a large part of the neul formed bone remains in an osteoid state. The consequence of this is that though the bones arc thicker their calcium content as loner than in normal bones. Despite the apparent disruption of the normal vascular pattern in Paget s bone, there is a marhed increase m blood for that is estimated to be as much as twenty times that seen m normal bones. This has been explamed as being due to the formation of numerous small artenorcrous shunts similar in their effect to that seen in arterios enous aneurysms. This accounts for the "hy peremma" seen in Pagets bons, the increased skin temperature over areas of Pagets bone, as well as for the signs and symptoms of cardiovascular dis turbance often found in cases of advanced Paget s disease While the serum calcium and morganic phosphorus arc within normal limits, the serum phosphatase is notably increased in actie Pagets discase. Where the disease is not actic, or in the beginning of a monostotic inrolement, thc phosphatase may not be cleated. Its determination is not of pa thognomonic sigruficance and is nierely indicative of osteoblastic activity Pathologic fractures are not uncommon in Paget s disease Often it is the appearance of such fractures after relatively slight trauma that leads to the uccidental discover of the custence of the disease. These fructures occur mainly in the long bones and are unusual in that they are transverse in their trajecton Healing occurs in these cases without any difficult and often with excess callus. Sarcomatous transformation has been noted in a considerable number of these cases. Vlost frequentls these sarcomata are of the osteogenic vaniti but chondrosarcomas and fibrosarcomas have also been reported. It is sometimes en difficult to determine the cristence of a malignant degeneration

·96
Injurius and Surgkal Dkseases of the Ischlum
FC 65 Isolated Pages disease of the schrum. Longitudmal ATATOM
with cvrlike urtas localized onds to the schoon.
FK 6. Isolated Pages dsense of the schoon HacTokopke xection
of tissue retrosed from the parent of Figure 65 The bort trabecube
are thrlmed and regular ind prosent the Apial monex uppermet
of Pagets dosex. The martor fibroas

·Perlosteitis of the Ischlum Gradiis Exostosis Outoltis 97 or to be certain of the absence of malignancy particularly in monostotic fornis of Paget s disease This is illustrated in the following case E S, female, aged forts four gasc a luston of sonu ginecological operanon fourteen voor before the onset of pain following an mjury to the hip. Y ray of che hup (Fig 65) was reported as showing "coarse anations involving the acctabulum and the schium Diagnosis adranced Pagct s disease." Despite this, the history of loss of anteca pounds dunng the prerious six months without any of fort at dictmng and the histon of an earlier ginecologic operation suggested the possibility of malignant incolicment of the schium Bropor pus performed. The microscopic report pronounced bone destruction Bith moderate bonc production" completely sustained the radiologist s opinion of Paget s dosesse (Fig 66) REFERENCES i Bez, E. Peroxitos of the symphy as and descending ramus of the pubu fol lowing suprapubic operations Imernst ved 17 244 1924 2 FITTE, M1 Osteocondntas del esquion Bol y trab, Soc de chr de Buenos Atres 20 248 1936 3 GOLDEX A Losions of the schium and pubis in pregnancy resembling Ostertus J Urol 67 370 1952 4 ILLEL, MARIE Veränderung an der Symphyse und Sitzbein bei der Bech teren'schen Erkrankung Röntgenprans 11 342 1939 5 hurata, AL E, and LAINE, J Ischlal ostertis. New I ork | Ned 53 1579 1953 6. hen W Roentgenbild des Beckens bei der Bechtercuzchen koolheit. Fortscbr Geb Rontgenstrahlen 50 537 1912 7 ODELDERG, AIEL Some cases of destruction in the ischium of doubtful etiol og Acta cbr scmmdiru 56 273 1924 & SCIFF A. Veränderung um Rammus inferior ossos achu bei Arthats Defor mant. Zuscbr Ortbop Cbrf7 500, 1926. 9 Vax NECE, A1 Osteochondrite du pults. Arcbives provinciales (Franco- Belges) de chirurgie 27 238 1924 10 VOLTANCOLI, G Osteochondrite ischro-pubice Chroff movinento 9 281 1925 11 II ELFTY, M Uber Osteochondnus ischio-pubici. Deutscbe Ztscbr cblr 199 413 1926 ·CHAPTER ? Pyogenic Osteomyelitis of the Ischium INFECTION OF TIE ISCHIVY may occur as the result of many different organ isms. Infections by actinomyces" cclunococcus,a' Fracnlcl s diplococcus , Eberts bacillus, Pfaffer s bacillus, piocyaneus, as well as by the more commonly known organistis such as staphylococcus, streptococcus, and the tubercle bacillus have been reported. Though a number of cases of progenic osteomyelitis hare been reported, the incidence of isolated progenic infection of the Ischium must be con sidered as low In 1949 cases of osteomyelitis collected from the biterature, Kletrom found involvement of the pelvic bones in only 35 cases, with bchaal involvement in nonc. In 385 instances of osteomyelitis seen in 320 of his own patients, 36 involved the pelves and only 2 the ischium (0.005 per cent) A somen hat similar incidence was reported by Oreto who in 100 cases of osteomyelitis, observed at the surgical clinic of Alesana, found 11 involv ing the pelvis and only 2 involve the ischium (00125 per cent) of those I was isolated in the uschium and I in the schium and the femmir On the other hand, in 71 cases of childhood Osteomyelits, Doran and Brown' found 3 in the ischium (0.04 per cent) Thus incidence is aght cornes greater than that reported by hlemm and more than three times greater than that reported by Oreto This nould seem to indicate that the incidence of ichual osteomyelitis a greater m children than in adults. This may be at plained by the presence of epiphyseal crolage plates with Detaphyseal darteries both at the ischiopubic junction and at de tuberosity Localzation of the infection to the region of the schiopubic junction apo pears to be more common than to the tuberosary Such cases here been dean ·Pyogenic Osteomyelitis of the Ischium 99 scribed by Bilhaut, Inglemons," Le Fort' Ottolenghi," Alc\Vhorter,10 Col rin' Söderlund " Zaffagninn," Valks" Ligas and others Cases in which the nfection onginated in or was localized to the tubcrosity harc been re ported by Pohomy " Geist, and others. The following case is interesting both with respect to its pathogenesis and bactenology 11 R., male, age suti fiss, was admitted to another hospital with a diagnos of hypertrophued prostate. Suprapubic drainage wus instituted but shortly thereafter the patient began to run a septic tenperature up to 104° Fahrenheit, and compain in the right hup and perineal region One month later a perineal plamed of FL. 67 Subucate outomyelitis of the schial tuberosity Thert # 1 perrosten reaction with cescentic shadow somewhat mogemuse of that been in achibal pophysioly. There showeier n addition, evidence of destruction of bone n the rutis and m the menor espect of the tuberosty con sus made exposing the prostate but no pas could be located. The patent left the hospital with a suprapubic tube 10 place. When first been, he was call complaining of pain m the schial region and naus disclosed evidence of irregu lar destruction in the region of the nght ischaal tuberonty smilar to that seed in Founger adults with tschual apophynolysis. The left ixchal tuberosty revealed only slight penosteal proliferation (Fig 67) Incisions aere made ofer both schral tuberosities on the left ade, no pus was found even after elerioog the periosttum. On the nght ade, a small amount of pus was found in m abscess aut around the ischil tuberoan ahich catended toward the pobus along the pubic runus. Culture of this "pes" retailed staphylococcus and bacillus pyocy inct. The found druned for 4 to 5 day's had then closed (Fig 18) The infection may be blood-borne and may be primary in the ischuum or It may be secondan to infection in the hup joint or the femur In one of the Cases seported by diclVhorter the infection followed a "cold" and in others ·100 Injurles and Surgkal Diseases of the Ischlum was secondary to infection of the femur In Pouzet she case, the ofection followed a fall end in the case reported by Le Font capte on after a blow on the thigh of the affected side The onset may be gradual and in several cases reported by Geet the de velopment of fistulow openings gure the first indicraon of the underlying condidon. Usually how cyer the onset is sudden with a high fever and other signs of sepsi Thc patient complams of pain about the hip or in the pert neum and there is limitation of mopon in the hip that may suggest hip joint involvement. In contrast to true hip joint infections, not all the mobons of the hup are concentcally limited. This is a diagnostic point of great in Fra 64. Subscure teoriy elin's of the schlal tuberosity Following damages of the wchhl abeces, there slight irregularny of the bone 'ut the site of surgical inter vention. portance and selecare limination of some of the hip motions indicates the need for further investigation of the case. Probably the most valuable cutdence may be obtained by rectal examunsaon The presence of localzed tenderness or melling along the remus or the tuberosity is of the varnost significance. This is well ilustrated in the following case A third-par-old child wu then with chills and high fever screra] darz oftet "cold." The right thigh was held m abduction and external rotation, and the chuld ** dmitted to the Hospital aich e sonore diagnosis of epophyatus of the hup. Though the child rested any attempt at mternal rotation and edduction, the thigh could be passively flared and extended slightly without undue pase Recal examination revealed pomt tendemoss klong the ischal mu with a boggy suelle ing at the lower margin of the obtuntor forunen Vith the rectal finger # 1 guide, this is wa upirated through long nedke inserted across the rocha rectal foam. A fes drops of pas from which staphylococcus aus grown were recovered. A small incision in the penneum peruutted epictation of the sbocess ·Pyogenic Osteomyelitis of the Ischlum 101 uith prompt aldence of all symptoms. The u ray disclosed no evidence of bone destruction, and the wound closed within a short time without any residual disability In the proantibiotic period AlcWVhorter reported a mortality of 10 per cent in these cases. Unless promptly drained, the subperiosteal abscess may perforate into the hip joint and lead to a septic arthnts, es has been reported by AlclVhorter Pouzet, Le Fort Guilleminct and others In the case of the sur y car-old boy descnbed by Ottolenghu the abscess spread along the rschiopubic ramus and probably by pressure on the cavem Osus musclc, led to a distressing priapism that subsided only after incision and dramage. Fistulization of the perosseous abscess into the schiorectal fossa has occurred leading to a mistahen diagnosis of a primary ischiorectal abscess with persistent drainage, until the bone focus was recognized and treated. Where the abscess points in the perineum, its presence is quickly betrayed bs swelling If the pus spreads along the planc of the pelvfemoral mascles, it may lead to secondary mfcction of the postenor or medial foscul compartments of the thigh and necessitate extensnc drainage of the thigh before the infection can be controlled As in other infectious processes, the widespread use of antibiotics has re sulted in a profound change in the clmıcal picture these coses present. The septic symptoms are quickly brought under control and what would carlier have been immediately recognized as an infection not infrequently raises the Suspicion of a malignant process. The same is truc of those cases in which the onset is not as explosive as in the acute cases. This is seen in the follow ing cose treated by Dr S Klenberg J Sm a male aged fifty-tad begun to complain of a "pinching pain and a farmg" sensation in the nght buttoch, nduating to the night thigh and nght bree. The pain was not constant and appeared to be improving my made ser eral weeks previously had been reported as showing a neoplasm but biops hus reported to be negative. The patient, nevertheless, was not pusfied and came for further study The Mazzini and Bence-Joncs tests were negative. The urine, blood count, and blood chemistry were wittun normal limits. Im we reported as showing patchy Oferts of the night schium. Arcus of resorption are present in the lower thurd of the body of the pubre bone. At the junction of the descending namus of the pubis and the ascendmg rumus of the aschium there is indicaton of a partly united frac ture (biopa ) There is no cortical thxheniog no penosats und no regional man. The original films were inspected. They shou what appears to be an osteolytic lesson in the body and descending nimus of the night schrum with a patho- Logic fracture. While an atypical tumor must be considered the radiographic find mp at the present ume suggest fracture at the level described followed by a traumatic extenporosis. The pre-cassang urex of resorption notable in the pubic Lone appear to be healiog* (Fig 69) Вкт H2S performed through a mell perineal incision. The pathologut re ·102 tafuries and Surgicol Diseases of the Ischium ported "thickening of the osseous trubeculac. Exccagno scarsong of the ute trobecular martOTY and ed@ce of chronic inflamaraton nducted by the presence of numcrow lymphocytes and other inflammatory celke Dagooch. bora grade chrome Ostcony clites of the schium. No indiation of tumor formation While it may be hoped that the use of pobrobic has climmated the cuter type of fulminating sepuc infections, the probability of a lou grede of chronic osteomyelices of the Ischium must aln ays be kept in mod in cantos the present atypical symptoms of hip joint infection or even infection of the ischiorectal fossa. Any doubtful lesson in the schum an be easily 11- vesogared through a relatively sorrall incision over the subcutaneous portios of the schrum in the perineum. FIG. 69 Chronic osteomyelitk of the bachaun Tho pertence of regular arep of Oiation on the ruberoam and mou ruksed the dispuchon of neoplastic moltement. (Courtesy of Dr S Kleinberg) Traincnt of acute Osteomyelitus of the ischium is by incision and drunage. The sound should be pached open until healing has occurred from the depths of the viound No imunobilizagon is necessary in chronic coses, re section of the involved portion of the bone is to be preferred to simple son cerization of the affected area Adequate doses of appropriate antibiotics arc of value in the treament of scure coses, but, in instances of chronic ostes myeloc uofection, resection under the coverage of antibiotic therapy as the tregunent of choice. REFERENCES I BAHAUT AL Osterte de la brunche montante de luctum ct descendant de pubu Amiles de chirurgie et de l'ortbopedie 13 65 1900 2 Coun AR Osteomyelite of the remot of the schuu. Aivacsous lind 16 50; 1933 ·Pyogenic Osteomyelitis of the lichlum 103 3 Dow4x 11 T. and BronL llenatogenoar inconi clitis. Surg Clyno Obst 10 658 1925 4 GusT E Osrcom clitus of the pelvic bones. J.AJIA 77 1939 1921 (Dec. 17) 5 GUILLEMINET M Ostconn élite grise du laun et de la hinchic. I you chir 32 452 1935 6. IKLIAMS, P L Ostcom élitc olgue du publs. Rer ortbop 18 297 1931 7 LLENI P Dic akute osteomyelitos dos Becken und Krcurbcins Brus Beirt klin Cbir S01 1912 8. LaFont R, and PKCQUET J Deur cos dinthnic ugue de la hinchc consecu tive a me osteomyélite de l'ischion Bull et mêm Soc Nar de Cblr S5 +53 1929 9 LEGAL A. Rilen clinia sull osteomy clite primitiva del pule ed ischiopubiana. Cbir org motnnemo 26 45 1941 10. Nicll HORTER, GJ Oscomielitis of the uschium and the pubis. Surg Gyn Ć Obst +9 205 1929 11 Alunoz I. VACCARO, H, FOIXADL L., and FCUDOA, S. Actinomycosis inquiá tia. Rot inéd Cbile 77 211 1919 12. Oneto, P Sopra un caso di osteomyelite acuta dell'ischio Rassegna iniemi clm c tetap 17 729 1936. 13 OTTOLENGIL, CE. Osteomyelitis de la ruma txulo-pubrant Rer orlop y traumatol 3 325 1933 14 Pokorxy L Osteomyelitis jm Sitzbein. Rontgenprarls 10 16R 1938 15 POULET AF Osteomy clitus dc l'ischion Lyon cbir 32 463 1935 16. SORLUXD G Uber dic septische osteomy clitus in publs Acta cbir sco dmat 67 850 1930. 17 TILLAAXYS, H Die Verletzungen und Cirurgiscbe kreukbeitou des Beckens Stuttgart, F Enke, 1905 18. VALEX S. DET Recent case of acute ontcomyelitis of the ischium Now Albany Aled Herald (N.S.) 34 76 1925 19 ZAFFAGYINI A. l'Osteomyelte acuta del pule Cbir org movimento 13 333 1929 ·CHAPTER 10 Tuberculous Osteomyelitis of the Ischium THE ISCHIUV IS one of the more unusual stes of localization of osseous toberculous infection. Magnusson" nored that of all the cases of bone tuberculosis seen bett cen the jars of 1928 and 1936 only 0 2 per cent involved the ischium. Soularly in a series of 5 384 cases of skeletal tuberculosis, Rebaudi fond 100 sacolving che pelso und 16 incolvag dhe schsum. Pror to 1910, reference to tuberculosis of the ischium sier sent in the literature. Get reported a angle case, Zellmci ero collected nx cases from the literature, Blankoff and Powellle eech reported another cast, and Mazzar" reported three coses, in which the clinical diagnosis uw nade bor so which tuberculosis was not prored. Isolated reports were mudc by Volancolia Mazzon" Goyot,' and others. After 1930 houcrer the condition appears to bene been diagnosed more often and a number of reports of individual cases have been made by Serran," Grunert,' Tapman, " Clavel" Kaplan, and Alicht Inglerans and his co-workersdescribed su cises and, in decussang their it port, Sorrel and Sortel-Dejenoes reported 14 cases, 7 in adults and 7 m children. Tnvellia 10 a xudy of 579 cases of skeletal tuberculosis found 100 involviog the pelvis with 12 in the ischuum, an inadence almost teo ames o great as that reported either by Rebaudi or Alagnusson. Tuberculosis is less frequently encountered in the schw than 10 any of the other pelvic bones, with the exception of the sacrum. Zellmeyer Raf land, ** Ludloff " and others have called attendon to the fact that tuberculosks of the schium is unlile tuberculosis of the long bones and the discase commonly resembles that seen in tuberculous epiphyseal and apophyseal infections 104 ·Tuberculous Osteomyelitis of the Ischium 105 Terrillon is quoted by Zellmci er to the effect that tuberculosis occurs by preference near cpiphyscal lines and that therefore, at the outset tuberculosis of the pelvis appears as an "ostcits of the inner aspect of the pubis, the sichual tulicrosity thc iliac crest thc ischial spine and the posterior superior spose of the illum." With the exception of Tornillon, isolated cuberculosis of the spine is not mentioned by any other author and it may be accepted that the ruberositi s tvpically the arca in which ischial tuberculosis is localized. In deed, the fact that the apophysas of the ischial tuberosity does not develop until after the age of cleren has been suggested as the explanation of the fact that the majority of cases have been diagnosed in young adults. This may not be a valid argument, howerer since the time of recognioon may not represent thc age of onset of the infection This is indicated by Sorrels re ports of tuberculosis in children and more specifically by the report of Scrrati u ho described an infantile type of schial tuberculosis. Moreover this does not account for the fact that tuberculosis of the ischiopubic junction is seldom found as the site of ongin of tuberculosis of the ischiun. The mfection is blood-bornc and localnes primarily in the spongiosa. In Its carly stages, tuberculosis of the ischium presents the appearance of grired granulation tissue m which, microscopically mulunucleated giant cclts and thickened bone trabeculae are found At this time the xray usually gives little clue to the existence of any pathological process. Later when crtensive destruction has occurred, the x ray discloses the presence of the asteolytic lesion in which sequestrae may be seen. The extent of inrolemicnt, hontrer as neter revealed by roentgen appearance and typical tuberculosis Aith tuberclc bacıllı can be demonstrated throughout the bone in the pres erice of an apparently normal roentgenogram. In fact, the development of fistulae may be the first indication of the presence of a tuberculous infection Canes sicca s rare, and abscess formation u most common The onset os insidious with but little elevation of temperature. Its erolutron is slou Pain is minimal until the tuberculous abscess in the bone approaches the surface when it may become severe and resemble sciatica or : hup joint infection. At this time, the ischium may be tender and is usually en larged Fistulae may appear in the gluteal region or in the perineum. In one case reported by Lorthoir 11 2 urethral fistula, which was mistaken for a urinary tract abscess, could not be brought to healing until thorough curet tage of the eschium had been accomplished These fistulac spread along the muscle planes and especially those that open in the buttoch are often mistahen for simple aschrorectal infections. Text to actual demonstration of the organism by aspiration the rent genogram is the nost valuable and frequently the only available diagnostic medrum. \ras eridence does not appear until a vonable time after the in fection has been established Depending on the sevent and extent of the in ·106 Injuries and Surgkal Dhouses of the Ischlum volvement, the roentgenogron may disclose a small area of dextron on the posterior or inferior border of the tuberosity (Fig 70 ) In more ad vanced cases, it may present a crescentic shadon ren suggestive of that sex in ischual apophy solysis. It » holiever to be differentiated from the latter condition by the fact that there is irregularity and osteoporoses on both ades of the epiphyseal plate instead of a smooth separation At a later stuga more or less extensive destruction of the tuberosity with the forma con of sequestrse is characteristic of the condition Tnvelli nored that sequestrum formation occurred in 20 per cent of the cases of apophyscal tuberculosis FIC O Endly tuberculosis of the bachium. There wall are of destruction on the posterior spect of the cuberosty Tubercle becil were recorered og opinition of the area. Attention. and could almost be considered as pathognomonic of the condiaon Berkers attribured ches to the regenerative capacity of the nisure in the vicinty of the cpiphyseal plate. It may well be that this is also the cuplanation of the cystic appearance of the jura apophyseal tissue to which hicaböck called Second only in importance to the densonstration of characterste x my lesions, is the appearance of fistulous discharge from qwert abscesses Tuberculous ischial abscesses may remain relaarely symptom free for long periods of time and their arliest manitostaton sony be e fistulos decharge following a posttraumatic or spontaneous rupture of the orreloping bony wall It has been stated that a tuberculous abscess located in the posterior pect of the schium tends to track do172 wasd and discharge beneath the free border of the gluteus maximus Abscess of the escending rumus may ds- ·Tuberculous Osteomyelitis of the Ischlum 107 charge higher through the sciatic foramion, whilc abscess of the descending rimus forming between tlic bone and the obturator internus may cither trach along that muscle and open on the outer side of the femur or may 25 m Lorthoirs case, trach along the ischiocarcinosus niuscle and drain into the Urethra. Abscesses forming between the bone and thc obturator externus may drain through the perineal region the inner aspect of the thigh or as m Ferriers casc into the space of Retzius. In Gant s case, there was an associated ischiorectal abscess and in the case reported by Rosc, to tu o fistu lous openings, one in the ischiorcctal space and another in the perineal regron titre described Despite the diversity of pathways by which discharge from a perischial abscess has been described, rupture into the hup joint seems to be unhnown. Indeed, it appears to be the rule that while a septic arthntis of the hup sec ondary to progenic ostcomyelias as common infection of the hip secondin to tuberculous infection of the ischium docs not occur This is more remarkable in that sections of the Ischium remoi ed for cuberculosis have been shown to harbor tubercles in areas close to acetabulum where there was absolutely no roentgenographuc evidence of bone involvement. On the other hand, intrapelvic perforation of a periischual tuberculous abscess is not unusual. All observers are agreed that bone tuberculosis is mereli a local manifestagon of a disseminated disease and that urcatment of the condition involves tud separate considerations (1) care of the patients health in general and (2) care of the local lesion. In the prechemotherapeutic era reliance for improning the general condition of the patient was placed on bed rest diet, and helrotherapy Since the des clopment of chemotherapeutic agents, how cer the necessity or value of these ancillary measures has been senously questioned. Indeed, Selihoff and Selikoff and Rabına have expressed the opmion that “further experience will confirm that bed rest, cxcept for acute disease or m the presence of constitutional symptoms, adds little to chemotherapy Should chernotherapy not be available, honeer because of toricity bacternl drug resistance, etc. bed rest might be uolazed advanta geously Fire progress in the modern chemotherapy of tuberculosis came with the development of streptomycin, but it was later found that streptomycin in combination with other antituberculosis drugs, such as para-aminosalicy lic acid and, more recently isoniazid or iproniazid, gare better results than Gither drug when girer individually Optimal effects appear to denie from the simultaneous trse of three antı tuberculosis agents, dih drostreptomycin, para-aminosalıcı lic acid, and ssoniazid, grien for a minimum period of at least one year Iproniazid appears to be more desirable than soruszad when there are systemic cffects, but ·08 Injuries and Surgical Disouses of the Ischium should be disconunued as soon as construtional symptoms have disappeared Thus regimed by itself appears to be of value only in synorul tuberculoss or minually involved bone tuberculosis. Where there are definite areas of cascous necrosis and abscess formedon, chemotherapy alone is insufficient and must be combined with operative surgical interpention Surgery must be such as to crenterite the accrotic focus, but an be per formed more safely under the cover afforded by a chessotherapeut regnmcn. Despite surgery chemotherapy should be conunued for a period of at least three months and prefenbly for a period of about one to one and a half year. Barring the development of allergies or drug sengsaviy chemotherapy should consist of para amunosalicylic acid, 10 to 15 Gm. daly by mouth, dihydrostreptomy an, 1 Gm daily inttumuscular)}, and songazd, 1 mg per hg of body weight, daily In tuberculosis of the ischium, the most expeditious method of remonng the focus of the infection, and thus avoiding the possibility of complication, is by resection of the entire ischium Saucenzation of the local area alone is imdequire and examination of rugues removed et operation has sepertedly demonstrated the existence of histological tubercles m apparently nonaffected areas far removed from the area of destruction grossly demonstrated by roentgenographic examinador. The inadequacy of less catenare intervenaan 13 seen in the following case which is reported through the courtesy of Dc. L. May er Thu padieni, O F. was originally admitted to the hospital in 1933 at the age of sur, for the release of a shoulder contracture resulting from Erb s paby In 1936, he nas radmitted for iDainon od drunage of an abecess resulting from tuberculow cervical adensis. In May 1939 be wo redouted because of pajo in the night hup regtore that raduated to the knee. Flexion of the hip wu powible only to eghity degrees and the thigh was held in wight erternal roation. There w'u for tenderness on palpation of the nght sschul muberosury and the cemperaturt rost to 102 Fahrenhas. Yray disclosed soone regulancy in the coaroar of the sschral tubercasy arthe poorly developed wmpbois pubb Though the poster bility of tuberculosu wu entertained, it was felt that conservative treatment was indicated and the patient was sent to the comuy bon. While on the country home 2 Anu appeared over the outer end of the aght clerick and three ausses developed in the rigtic buttock. There was e foron contratost of the hup u odc hundred fifty degrees and flexion was possible to only ninety degrees or et du time showed sequestritoa of the porenor pordion of the schul cuberosity (Fig 71) The tuberosty w resected m Jumann 1970 (Fig 12) The pancats pomoperuove course was storms and he continued to run temperatures. This ittributed to the tuberculous infection of the chance that we resected The did not give more than componen relief in Februan o abscess developed in the perineum at the base of the scrarum This su incised and drained in Afarch, an infection of the posterior fuscul space of the thigh dereloped that noctuated inctaon and drainage. The pudet subarquent developed endence of amyloid discore of the liver 20d the hoogo red teg du grangt's posture. He ulumately developed ugns of peritoneal corolvement und died. It is questionable ·Tuberculous Osteomyelitis of the lichlum 109 whether earlier surgery would have saved this childs life but there is no doubt that resection of the ischium at the time of the first diagnous vould have spared the child the additional distress of aliscos formation, with multiple incisions and dramage. On the other hand, the bencficcnt cffect of wide and carly resection of the schrum is shown in the following cases. I Fm male, aged fuenti cyght was fine seen in Februn 1940 unha histon of swelling of the nghe thigh that developed fourteen months previously follow mg erercise on a mechanical horse. Four months before admission to the hospital, Fra 71 Case O F The posterior portion of the schnum hos sequestrated and a separated from the bods of the book. There Tidence of mrolit ment of the pubaceabalar bone but without insa son of the hip joint. The roentgenogrun some what wegeurse of the appearuxe men in schlal apophavioli's . mam wys noticed below the nght gluteal fold and four weeks before adminon the mass became pamful Under hot bath treatment a fistulous opening appeared. A small incision was made with the evacuation of much grumou material and the wound nos pached. The patent later ran a temperature up to 102 Fahrenheit and was admitted to the hospital where adequate nanon and drunage instrated Culture of the pus obtained was sterile, but guinea pig inoculation was sabsequently reported to be posure for tuberculosis Yn studies made several dans after the incution here reported as showing “irregular necrosis of the sschal tuberosunt u well us the ascending rumus of bone. Several abscesses are present Within the bone. Diagnosis tuberculous ostcoms elitis of the Ischium" Three wechs later pubperiostcal resection of the Ischium from the level of the sschul spine to the bodi of the pulss uus performed. The wound, houerer did not heal and sereral months later the pauent des eloped a large abscess of the might thigh that requred incision and drunage. The wound in the permeum sull remained unhealed ind, in June, 1942, the patient was radmitted unth a teht schrorectal fossa abscess The abscos no incased and druned \o tuber ·110 Injuries and Surgical Diseases of the lichtum culos we found in the wall of the airty Thereafter all wounds bezbed and the patent has remuned symptom-free since. The follow mg case is presented through the courtesy of Dr J Bochuren R. R., mele, age twenty-one, was admitted to the hospital in October 1944 with a horory of a fili injung the aght dep three van previously Zberafter the poet lund difficules in running and had slighe limitation of motion is the nght hup. Two years before admision, the potent ## seen by another physica who had x rays made. These were reported as showing an era of bone destro tion of the body and ramus of the schuun with speciales of bone in the moft DAY Fra 7 Core.OF After Operation. The ruits of the Dictorum ad all the tuberosity heie been resected and personeel clevision along the lower border of the deck of the foorus segrest Ing 1 lou grade osteomyellos" nothing w done at this one. Ta April, 1944 13 abscess developed on the lateral espect of the right femar This was opened with the evacuation of a large amount of por By Sprember the dous seened dry but did not heal The patient suddenly sto i tanperrure op to 103 Fahrenheit, but this subsided as soon as the shares in the thigh on opened On his admouen to the hospital, the patient walked with a nghit hip hmp, 20d had limutation of hup flexom as ninety degrees The alan oper the right school tuberosity wu red with increase in local temperature. The art of the schom ww wodurated and factuant Y ni dosclosed "an irregular uren of necrose volving the cores and a portion of the marrow cerity of the tuberosty of the nght Bchtun. Adjacent to the area there are irregular alafic deposits probably tuberculou o curicter la the soft copies ore the posterior and maer especta of the right femur et die juoction of the middle ad opper thirds of the shaft . there are onell culcific deposio dotinet from those Doted in the salural roberosuya (Fig 73) ·Tuberculous Osteomyelitis of the lichium 111 Fire days after adhuron the ischium was roxected subperiostcally Microscoprcalls tipal tuberculosis was found Two wecks after operation tfic round healed by poimen union and the patient was permitted to letic thc hospital With the present des clopment of antirulxcrculosis drugs, such as isoniazid, para aminosalıcı lic acid and streptomycin, the whole problem of tuberculous ostats, es of tuberculosis in general is cntering a new phase in vluch a biological approach is possible. A new drug cicloserine has but recently been described and doubtless others will be des cloped Final eralpation of K Fr. 73 Cose R. R. There B a mall sa of accros's on the posterior aspect of the tuberos with a mild perrosteal raction (Courten of Dr J Buchman.) these drugs must swart their more mature appraisal. Even though the ulti mate verdkt will unquestionably be favorable, the need for surgical assist ance in the evacuation of abscesses and the removal of such sequestra as may form will persist. The earlier it is performed (and certainly before fistuliza tion of the abscess has occurred) the better will be the result REFERENCES 1 BLAXTOFT B Osterte tuberculeuse primase de la tuberosité de rischion. Arcbres proticisles (Franco-Belges) de cbiringie 30 895 1927 2. Bean, S. hlinische und experimentelle Untersuchungen über an besonderes Regenerationsvermogen m der Epiphusenmarbenzonen Linger RohreoLnochen Deutsche Zuscbr cbr 25+ 488 1941 ·112 Injuries and Surgkal Diseases of the Ischium 3 CLAVEL, AI Contnbución a custstig de la tuberculos del ap locomo # 149 1947 non 4 FE, C Onete tuberculeuse de la branche tschuko-pobicans, abces cand consécuaf de la avné prti scale. Pents Arcbloes de nedute et pharer scie millores 25 392, 1893 5 GANT M Tuberculoss of the Ischiam Lancet 2 461 1959 & GRUNDT A. Tuberkulose de Beckengürtel. Rontgepraris 4 237 1932. 7 Gutor Tuberculoso de l'inchron Pans, Tomsaction de Congres DETAITOR ale de la tuberculose 2 174 1905 8 INGELINS, R, VENDEUVIE, A, and GrouLT P So observations de tubercu losc de l'ischon. Aeta ortbopédica Belgica 13 27 1947 LAPLAN A1 Tuberculows of the tuberosity of the schrum. Am J Roent genol 35 490, 1936, 10. LATZ, J F Skeletal tuberculosis. Mt Sina Hosp. 23 574, 1956 11 LOKTTKOD Reference by logelnas 12. LUDLOTT h In Loge's Lebrbucb der Ortbopedie Ird ed. Jer, G Fbcher 1938 p. 106 13 ALAOVUTON R. Tuberculous artates of the schnm.) Bone & Jobs Sony 20 23 1938 14 ALAZZONE Cane della tuberoan destra dell sschro, Cloica Chirurgica della R Unterste di Row 1888 15 AIAZZARL A. Carle seca del pobe e della branca uchia pubica Arab. Ortop. H 354 1928 16 MILCL H Partul resection of the cluarn. Opentie procedure ) Bon Jotut Surg 16 186 1935 17 Mina, H Tuberculous of the schlal tuberosty Ball. Hosp. Jorm Dis. 19 1940 18. POTELL SD Tuberculosis of the schrum. The Post Graduate 17 3617, 1903 19 REAAUDY Tuberculose del buccino Arcbroro di wediere e chirurgie 2 91 1933 20 ROITLAND, F Die Tuberkulose des os ische als typ der epophyses tuberko lose. Bei Klx Tuberk 101 660, 1949 21 Rose Reference by Zellmeyer 22 SAAT I) The chemotherapy of tuberculosis ] U Simdi Hosp. 23 331 1956 23 Suore ) I. ad RADIN CB The management of pulmonary tuberculow I ft Siagi Hosp 3 +01 1956. 24 SETRATI, I Por La tuberculos del sqaloo ka nfancte. Rer opport pediat 6 25 1950. 25 SORREL En and Sorre. DeJERNE, AIME. Tuberculose essende at ontlasti colaire Paris, Alaston et Cie, 1932, Vol. 1 p. 76. 26 Tuvalu, L. Pincoulgu wchranice. Cbir ot] THODPRTO 24 317 1938. 27 Turvan, GS Tuberculosis of the schium. Bore & Joint Surg 318 490, 1936 28 VOLTAXCOLL G Osteochondrite schiopubice Cb 078 novimento 281 1925 29 Zozaya Ende climque de le tuberculose do Dischiar Reute beter Patronale de la tuberculose IS 101 1909 ·CHAPTER 11 Periischial Soft Tissue Injury Exaus('E OF INJURIES to the pelvic viscera which are usually associated with extensive damage to the ischium, njunes of the more immedurc peni Ischial soft tissues have been descnbed Chief among these are those to the glurcal arteries and the sciatic nerie." Because of their relatarely protected position beneath the mass of the gluteus maximus muscle hou crer such lesvons are uncommon. They have been more frequently encountered as a result of penetrating injunes sustained under war condigons, but have also been observed to occur in avl life in consequence of stab wounds or even after apparently simple blous on the buttocks. than INJURIES TO VESSELS Injury to the superior gluteal artery is three to four times more frequent mjon to the mfenior gluteal ressel because of the addigonal protection afforded by the sacrotuberous ligament and the bony pelvis. Injury to the mfcrror gluteal artery does occur hou ever and may occasionally be confused with pathological processes occurring within the ischiorectal fossa. Tillaux" reported a case in which a supposed schuorectal fossa abscess occurred tho weeks after a fracture of the femur This was incised and found to be a hematoma caused by a bone spicule that had perforated the menor gluteal artery Battle described a case that resulted from a fall on the nght buttoch. The patient complained of pain and was hospitalized be cause of the appearance of a pulsating mass in the buttoch. Operation disclosed a hematoma caused by rupture of the infenor gluteal arter A some what similar case, caused by a crushing injury was reported by Servier' 113 ·Injuries and Surglcal Diseases of the Ischlumo On the other hand, bleeding from either of the gluteal resxebs has beco reported following infections within the ischuorectal fosse hocage reported a case in which crosion of the supenor gluteal artery followed upon the formation of a cold abscess" in the left gluteal region Apart from actual injury to the vessel wall, cases of ancurn of the gluteal retsels have been described 22,4 Willet" described in aneurysm of the gluteal vessels following embolization in a patient with heart disease. In three other cases, in which the inferior glatcal artery was copanuous with the popliteal (ischiopopliteal artery) the ancurysmal dilatuon tu noted to extend down to the level of the linee jolot. Guillaumete reported a case that dercloped eight months after the patient had fallen a distance of about sur feer. The appearance of pain and swelling in the night buttoch led to aspaus tion of the mass, operation, and later death Depending upon the nature and extent of the arterial injury hemontage from either of the gluteal vessels mas be profuse and sufficiency severe to threaren life immediately or it may occur gradually and give rise to a slowly increasing mass in the gluteal region The hematoma thus formed maty give rise to pain owing to compression of the scratic nerte und me if wecondarily infected, lead to a serere sepsis. Eren in the absence of extemal bleeding the possability of damage to the gluteal arteries must always be kept on mind so any injury to the gluteal region Where brish bleedmg from a penetraung wound m the neighborhood of the gluteal arteries is present, it is unquestionably safest to enlarge rive exter nal wound for the purpose of secunng adequate hemostasis. This is not al ways a simple procedure, especially if the main branch of other arter os involved. Normal retraction of the artery do nithin the pelvas may sender it inaccessible through the external round The difficulty arises meses which there is no external bleeding but in uluch the developrent of a pal- Saung swelling suggests the possibility of an aneurysm The possibility of an ancorysm or abnormal arterorenous communicato must be contemplated in all cases where stelling has followed an mjury to the buttock. In mall incaremal sacs or in those with thich walls the char acteristic sagtrata of aneurysis may be absent. The presence of a pulserang mass or the existence of e systolic murmur that doappears on compression the ihec artery is, of course, suggestire bur not parfiognomonic These 5mptoms may be present in other pulsating tumors or in terise abscesses that transmit paluation Similarly pain or pressure paralysis of the serve perrt may appear as signs of both solid tumors and aneun sal dilatations. The treatment consists of complete croston after careful limon of all uterial communications. This is not a simple procedure and is accompared by a high operaore mortality Battle' and Dennis' n ho reported on such cases, call particular attention to the necessity of controllmg hernorrtage boy of ·Peritschial Soft Tissue Injury 115 prelminan comprosion of the shac arterythmugh a transperitoncal inci son. After the iliac arter has been ticd complete cxcision of the ancurysm may be undertaken Direct surgical approach to the glutcal arteries may be made through muscle splitting incisions in the direction of the fibers of the gluteus matimus musclc The superior glutcal artery is to be sought aboic the level of the pyrifornuis muscle and the infonor gluteal artery below the louer border of this muscle (Fig 7) INJURIES TO NERVES Merve injuries resulting from affecaons of the ischium invoke pnmanly che scratic nene. Pam m the distribution of the obtuntor neno B usually of a referred nature and has been described in lesions of the obturator fora men and in conditions localized to the ischiopubic juncaon. Symptoms referable to the pudendal nerves are ertremely rare, though they hare been de scribed in fractures of the eschiopubic region and in the so-called ischiopubic osteochondnades. In at least onc case of ischiopubic abscess, priapism *** the most destressing symptom. Whether this is to be attributed to a nerte mtition or to tension within the sheath of the ischiocai cmosus muscle is not clear In all instances where the symptoms are of a referred nature, they usually subside with cure of the underlying pathology In the sciatic nerve, perma Dent peroneal palsy may persist cren after healing of the fracture that precipitated its appearance. Although the abrupt onset of symptoms may sug gest actual severance of the continuity of the nere exploration of the Scratic nerve at a later time may reial no such cvidence. Where the signs of peronal palsy persist, treatment must be directed toward the relief of a paralytic dropped foot by operative orthopedic inter ention. Where pun the predominant symptom, relief may occasionally be obtained by stretching of the sciatic perre or by cpidural injections of local anesthetic agents. INJURIES TO MUSCULATURE All affections of the eschium are associated with some degree of involrcment of the perischial musculature. Hemorrhage is frequently profuse and may be followed by organzation or calcification producing a tumor mass that may resemble a neoplasm (Hancock") Infection of hematomata in this region may present complicated problems because of the anatomical arrange ment of the fascta, nhich crtends into the thugh. It is not uncommon for mfection of the ischium to be complicated by involvement of the postenor compartment of the thugh with the derelopment of a secondary abscess at tendmg es lou down as the knee In such event, the onginal source of infec-

·116
Injuries and Surgical Diseases of the Ischium
tion of the schium must be evacuated as well as the secondary abscess on the
thugh
REFERENCES
I BATTI, W B. a case of treate gluteal Levni Brit An I 2 1415
1998
2. DENNIS, F S Treatment of spontaneous gluteal aneurysm led Nets +
565 1886.
3 Dura, L A. Aneurysm of the schatic artery Soorb 11 I 15 651 1859
4 FOCHER, G Die Ilunden und Ancorwhen der Artena Gluta und Ischiar
dian. Arcb bra. Cbyt II 762 1869
$ GURLAL VET Reference by Tülozanns, H
6 HANCOCX Ossafic tour in the schial region. Loncet 1 420 1850.
7 LADL E Ancarimu der Arterta Ischiadica. St Partsburgo Ved storbent
scbrift 1 38 1876
8. honi Reference by Tilmanns, H
9 CALE Reference by Tillmanns, H
TO SET AL. De l'aneurisme de lartere forskere. Ga bebd de med 5 176
1868, P )
11 TILALI, PJ Ancunse diffuse consécuuf de l'artère ilaque cuerne Bad2
et tér Soc cbir Poris 16 473 1890
12. TILLMANNS, H Drie Verler ongen med Cirrurgiscben Aronkbenen des
Beckers Stuttgart, F Enke, 1905
13 WALET EDC Embolic aneurysms of the gluteal artery Potbolognal Trat
Actions 1900

·CHAPTER 12 Ischial Bursitis SOVE STUDENTS Hur questioned the possibility of mechanical irritation to the regton of the schral tuberosity because of the cushioning cffcct of the gluteus maximus muscle In the crect position this muscle docs indeed corer the ischual tuberosit On the other hand, it must be recalled that in the seated position the front of the pelvis is alted upuard and, as a consequence, the rschil tuberosit mores dou ouard becomes uncovered by the gluteurs maumus muscle, and comes into immediats, almost subcutancous contact with the seat Direct pressure is so great that in certain monkeys es has been prerrously mentioned, it leads to a broadening and fattening of the ischual tuberosity Precisely the same obseration has been made in humans con denned to prolonged assumption of the sitting position. Regnault" noted that although the ischium is not usually flattened in humans, it may under cerrain circumstances acquire the same conformagon *s characterizes the ischa of monkeys. He reported three cases in point. (1) m old lady both of u bose hips had become anh, losed in Acnon as a result of mfectious arthritis, and whose ischta "presented a flattened surface 26 millimeters nude, n huch entended beyond the ischial body and was continu BUS UTth the ascending ramus hich us itself flattened so that it presented a superior and inferior surface rather than an antenor and posterior surface which is normal" (") a case that followed tuberculous ankylosis of both hips and (3) a similar deformy seen by Dr Alaric following ank; losis of both hips. While the significance of direct pressure cannot be denied, it seems po cular that relatively so feu cases of bursitis have come to attention in the literature Heinche,' who suas particularly interested in this, communicated with llenge von Gruber about it The famous St. Petersburg anatomist er pressed the opinion that the relative infrequence of clinicalls obsened bur 117 ·118 Injuries and Surgical Diseases of the Ischlum 10 situs was to be found in the relative incorrency of the ischial burse. He noted that in all his dissections he had encountered the schial bursa onls once in children under the age of ten years. Domay on the other hand, categorically disagreed with von Gruber and expressed the opinion that deep bursae arc not aduentuous but are laid down embryologicalls In the face of these mutually exclusive opinions, no satisfacton explanation of the relative infrequence of the condition has been offered. Information of the bursal tissues about the schial tuberosity has been reported in the literature under the atle of "hygroma * Though relzarely rare, such cases as have been studied are well documented with respect to etiology hostological appearance and crcaunent. On the other hand, there is a second form of ischial bursitis that appears formerly to have been common and to have appeared so comunonly in association with specific occupations as to have acquired the familiar designation of "weavers bottom, "" Lighter man s disease, or lathe tumers bottom. It appears that tuo types of ischual barstis may be recognized (1) the cystic hygroma and (2) occupational bursitides Hugromata of the ischil bursa have been the subject of larger communt cations by Bungner Dupont, Friend, Heineke' kister' Alauersberg Alüller 11 Nicarse, "' Chassaignes,' and Schuchardt." Up to 1896 Mlauersberg was able to collect only ten cases of ischial hygroman from the literature and only a few cases have been added since that ame In hus 1930 report of fifty five cases of cystic hygrometa, Jones' does not mention a single case involving the eschnal burra. He notes, however that "trauma, both acute and long continued plays e significant part in the coology whercus infection has a doubtful place. This in conformity with the hostones obtained by other observers in cases of ischual bı gromate. In all, there is a histon of a folle a blou on the schnun, prolonged horseback nding or the inntation of a leg prosthesis following amputation The onset of pain, especially on atting followed at a variable time after trauma. It was invariably the appearance of tumefaction, either unilateral or bilateral that led to uldmate clinical recognition and surgical intervention In some instances, the tumor s relatncly amall and attached directly to the Ischial tuberosity In one case, the cystic mass extended down the back of the thugh almost to the knec. Aspiraton of the mass yielded a fibrinous, sanguinolent flud. In those cases in which the mass tras carpated, the gross and histologtc appearance of the wall of the cix was identical with that described by Jones for hygronata of other anatomical derivagon The cyx wall contisted of Kicral lavers the outermost of which was firm connective tissue. The inner ninst lining will presented varying appearances of accrouc trsue rice bodies and villous proliferations ·Ischlal Bursitis 119 Though vanous fonin of treatment basc len suggested in the past, cici sion is unquestionably the procedurc of choicc The follow up studies made of higromata subnutted to ctcision have shown no tendency toward recurrence. The clinical picture of the cystic higromnata differs cntirely from that which has been designated as weiers botton.." Beyond casual reference to this second form of ischial bursitis, no accurate description of the condition has been found in thic literature. As in many other instances of crcessic familant there is an almost contemptuous disregard of tlic condition. This may be explicable on the ground that these patients seldomi presented cler- Fr. 74 A famt shadou is seen just postenor to the schal tuberosty The is characteristic of school burntb mnd must be differentiated from the shadon enn ischial apophysiolyss. cut surgical mdıcations and the opportunity of exploring the condigon has thus been orerloolcd. Sutton' in discussing ucarers bottom stated that “when a subcutancous bursa attains an abnormal size it is invariably due to pressure associated with particular occupations valers and lighter men from prolonged situng on hard seats suffer from bursae over their schial tuberosities." Hein in a reference that could not be senfied, is reported to have described a similar condition as common among lathe vorhers. While uovers bortom has Largely disappeared with the disappearance of hand wearing there are still many nonlightermen or lathe workers who in the arduous pursuit of sport have been forced to spend painful hours on the hard seat of a rou boat and can attest to the reality of the condition They do not disparage the impor fance of their schualgia nor deny themseho the comfort of a cushioned seat.

·120 Injuries and Surgical Dheoses of the Ischlum This affection is characterized by pain and localized tendemes on pres. sure orer the schial tuberosity The paio is typically present on atting part from this symptom the only diagnostic sign is the appeanoce of a radiopaque shadow in the region of the ischal tuberosity (Fig 74) It vndoubtedly the lack of this diagnostic medjun in the past that accounts for the recognition of the clinical syndrome without any indication for surgical intervention. It is unfortunate that the significance of the shadow is Mil L 11 Fic 75 Circumsnbed rentgen opacmcs that overlap the shadow of the bachial tuberosity are aligned in the direction of the harstag muscles urming from the tuberosity ton misapprehended under the noncommuttal dragnosis of "pensschial alcifica dos in the following cose. S S male, aged my-three, had been struck in the left buttock when in qutomobile backed into him. There was no ecchymous but the patient coolplamed of pain in the buttoch. This pain was made work on sitting and radiated down the back of the left thigh to the knee Elevation of the log putting on the shoes, or making 1 quick step caused an encerbation of parn. The patient had been trated by duatherm for a perod of about three veel thout any imelonton of the symptoms Examination disclosed tendemes localized orer the uchual tuberosity with a defimte spation of the hamstag musclos on this side. X nay (Fig 75) eraled a shador that su dugnosed 11 "perschul alefico 000 Operation is adored bat refused by the patient Desthermu sus con tinued by hu local physician for penod of about 1 months after a bach the paun disappeared H ·Ischial Bursitis 121 The opportunit of cramining the pathology in these cases nas afforded by a case seen by Dr S Kleinberg through whose courtesy the case is reported . B. Com female, aged fifty-cight, gave hrston of Intermittent pain in the region of the left schial tuberosit Over a period of mo years. The pain, made Horse when seated with the left thigh flered, mdiated down the log to the calf Apart from tendemess on deep pressure over thc tuberosity of the ischium, all clmscal findings were negatic The rray (Fig 76) was reported as showing alcareous deposits within the ischial burse on the left side and CICision was decided upon FK 76. Radiopacity s seen in the characteristickoatod for in fchal burua. At operation, this wu found to be due to the presence of creamy alartou material m the deep Bctul buco (Courter of Dr S Kleinberg) Operation was performed in the lithotomy position An oblique 10c1ion wrs made and on cutting through the fascia and the gluteal aponeurosis a bursal cality m the region of the attachment of the hamstring muscle close to the ischium **s entered a moderate amount of creamy akarcous matenol extruded. The sac mis acued und the wound closed in leiers with a pressure dressing Culture of the material #reported to be bactenologically senile Postoperative rray disclosed complete absence of the radiopaque shadon The panicot was relieved of ber simptoms. The findings in this instance suggest that the patholog m anses of weaters bottom is entirely different from that of the higromata and is similar to that seen about other tendon insertions, peritrochanteric bursitis subacromial bursitis, radiohumeral bursius. It may well be that the reason for the porcm of reports on this condition in the literature is that the condigon may be transiton in nature. Il here there is no evidence of radiopacını ischialgia es ·122 Infurlos ond Surgical Diseases of the Ischium the main symptom. Where the pain perusts, I may should be made to deter munc the existence of a perischial calcification. Though excision may give complete relief of symptoms, surgery would seem to the court of last resort Protection of the unitated area, cushioning of hard scats, local heat, and injections of a local anesthou are suggested methods of treatment pror to surgery It is important to be anne of the condition in the differential dragnosis of conditions characterized by schaac mediapon of pain REFERENCES 1 BCGVEZ, O V Uber an enormes Hygroma des Schlumbeutels suf dem Tuber osss schit Berl klin IV conscbr 26 485 1889 2. CLASAIVAS, E. Boursos da Glassetrict de la région trochantenienne et de La duque postericurc. Arcb gén de med sth ser 2 53 1853 3 DOVENY Ú Earnichong und Bau der burwo mucose. Arcb Anst Pbystol. 295 1897 (Anatomische Abteilung ) 4 Durant ) kynte de la Bourse Aluqueuse de la tuberonté Ischudque. Ball. soc med de la Suisse Ronlande 9 302 1875 5 FRIEND E Higroma and fibrosis of the tuber ischu burse. Ann. Sog 37 303 1903 & GRUDER, VI Reference by Heinche. 7 HEINEKE, WV Anatomie imd Patbologle der Scblembendel und Sebner scberdea Erlangen, ET Jacob, 1867 8 JONES, H T Croc bural hygrotas ) Bone + Jonat Sors 12 48 1910. 9 hin, E Hygromu burde tubers schn. Medemiscbe Chirurgisebe Crn tralblatt 1V100 17 532 1892 10 MAUDSBERG, P Schlembeutel-Hygrome in der Beckengegend Invogural Doskertizon, Berlin, 1896 11 A1CO, A Bursitis ischudica Inaugural Dissertation Freiberg 1895 12. MACABE, POULET and VAILLARD Nature tuberculerke des hygromes et des Storita tendincusou Rot cbir 5609 1885 13 RFARACLT F Morphogenue des Ischions Bull Soc mat de Pos 76 639 1901 14 SOTLQLARDT h Uber die Enstehung der subkutanen Hugroma. Areb kliv Cbr 11 609, 1890 15 SUTTON Sn John BLAND Tuniors London Cassel und Co., 1894 p. 42 16. Lericon of Vedicine mod Allied Science Mev Sydenhamn Society 1899 ·CHAPTER 13 Ischial Decubitus Ulcers Despite VOST VIFTICULOUS nursing carc, thc de clopment of decubitus ulcers s frequenchs unavoidablc in patients long confined to bed or the wheel chair Although they may de clop at any point of prolonged pressure, they are usually found over bons prominences, particularly the sacrum the trochanters, the ischial tuberosity, the anterior iliac spines, and the ruberosity of the os calcis While pressure against unyielding bony prominences is the underlying mechanism in the development of decubitus ulcers, a number of other known factors plas a part in their appearance Chief among these are the loss of tissue resistance that results from the parolyac vasodilatacion associated with spinal shock and interruption of spinal vysomotor control the loss of sensa tion thar normally leads to change in position when prolonged pressure threatenis ischemes, and morsture that leads to maceration and ulamate bresh dogn of the shin Ischial decubitus ulcers may develop carly in the course of a paraplegra or late, after the patient is ambulant on braces or in a wheel chair At the out set, the shin over the schual tuberosity becomes reddened Later there is a shelling over the tuberosit, the bursa beconies thickened and inflamed, and can be readily palpated. If pressure continues the skin may become necrout, leaving a granulating area over the intact bursa. If how are the bursa) tall s ruptured a sinus tract des elops and the bursa almost invariably becomes Secondarlı mfected. As a result of the bursal infection, the underlying tone involved. This response os at first limited to the periostcal covenog but later leads to a true osteomyelias of the schium (Fig 77) Though the superficzal ulcer may be releasels small, widespread necrosis and infection mai exist in the deeper tissues. Guttman has noted that infec ton mai spread in three different directions ·122 Injurici and Surgical Dkogsas of the Ischiura the man symptom. Where the pain persists, r ray should be made to deter mune the custence of a perischial calcification. Though crcision ma gire complete relief of symptoms, surgery would seem to the court of last resort. Protection of the unitated ares, cushioning of hard seats, local heas, and injections of a local anesthesia are suggested o methods of treatnent prior to surgen It is important to be aware of the condition in the differential diagnosis of conditions characterized by suitic reducion of pain REFERENCES 1 Btxa, O V Uber en enormes Hygroma des Schleonbeutels auf dem Tuber osse schi. Berl um I'cbnscbr 16 485 1889 2 CHABAIGNAC, E Bourses du Glissement de la région trochantericane et de la ile que postérieure. Arcb gen. de méd 5th ser 2 93 1853 3 DOVEXT Estaschlong md Bon der bursae mocosae. Arcb Anu Pbystol 295 1897 (Anatomische Abteilung ) 4 Dupont ) hinge de la Bourse Moqueuse de la tuberosité ochutique. Bull. SOC med de la Suisse Ronumde 9 302 1875 S FRIEND E Hygron and fibrosis of the tuber ischi burse. Am Sw8 17 393 1903 6 Gxuma, Reference bı Heinckc. 7 HEVERE, I Anatomie und Patbologie der Scblennbeutel und Sebnemscheiden. Erlangen, E. T Jacob 1867 8 Jove, HT Cutic bursal higrons. J Bone & Jorm Surg 12 48 1930 9 KOSTEX, E Hygrome burne tubers schil Aledriniscbe Cbururgische cer Talbot, I sen 17 532, 1882 10 ALAVERSBERG, P Schleimbeutel-Hygrome in der Beckengegend. Inaugural Dasertation, Berlin, 1896. 11 Altun, A. Bursitis ischiadicu. Inaugural Dosertinon, Freiberg 1895 12 NICAINE, POCLET und VARIARD Nature tuberculeuse des hygromes et des Sinovits tendencases. Rocbir s 609 1885 13 RDOVAULT F Alorphogenue des Ischioas. Bull Soc mon de Paris 76 639 1901 14 SCACCHARDT h Ober die Erstehung der subkutanen Hygrane Arch. Hus. Cbir 11 606, 1890. 15 SUTTON, St Jor BLAYD Txomots London, Consel and Co, 1894 p. 442. 16 Lencor of Medicine md Allied Sciences Men Sidenham Society 1899 ·smolied. This response is at first limited to the periostcal covering but later leads to 1 truc asteomyelitis of the schium (Fig 77) CHAPTER 13 Ischial Decubilus Ulcers DEMIE VOST V TICLIAMS nurung care the desclopment of decubitis ulcers os freguesith marodablc in patients long contined to lxed or the wheel chair Although the nias dc clop at any point of prolonged pressure, they fre usually found ouer bons prominences, particularly the sacrum, the trochanters, the schial tulcroon the anterior sliac spines, and the tuberority of the os calcis. While pressure against uns ielding lons prominences is the underlying Gechantsm in the dei clopnient of decubitus ulcers a number of other known factors play a part in their appearance. Chief among these are the loss of Boule resistance that results froin the paralvuc sasodilatation associated with spinal shock and incorruption of spinal rasomotor control the loss of sensin bom that normally leads to change in posicon when prolonged pressure threatens achetnia, and moisture that leads to maceration and ultimate break dos n of the shirt Iscbal decubitus ulcers may develop carly in the course of a paraplegia or hate , after the patient is ambulant on braces or in a wheel chair At the out set the shin over the schval ruberosity becomes reddened. Later there is a stelling over the tuberosics the bursa becomes thickened and inflamed, and cm be readily palpated, If pressure continues the skin may become necrosc, eres over the intact bursa If howtzer the borsal wall se ruptured, a sunus tract desclops and the bure almost invariably becomes Secondaris infected. As a result of the bursal snfection, the underlying bone Leannag a granulating Thorogh the superficial ulcer may be relatively small, widespread necrosis and mfertur ·124 Injuries and Surgical Disease of the Ischlum (a) wong the ischial rimus, the infection spreading us & mule mbi direction towards the hip joint, although it may rery rarely also sprad med toards the pobu, (b) down along the postcnor fiscal compartment of thigh, sometimes us far as the knee, in walking coses, (c) forward into region of the groin. This direction of sprad os associated with prolonged continuous nursing in the prone position. The padent will develop sellin the groun, which will either perforate spontaneously or reveal puis on tspurit This of spread of infection is particularly dangerous as it u most obou to therapeutic measures. type B D E Fre 77 Stages on the formation of bctual promure sores A Inoce baon kto accross orerlyng otac buns, C uomo deselopakete pith moct skin D nos trat, necrock skin and farolvement of the under lyng bone E osteomyelitis of stuum with runifying trucos( Repro duced from Tocman, ÁL P and Hardy A. G, Pathology and certment of pot sore in paraplegi, Bm / Plast Surg 7 179 1954) of temperature. As one would expect, sepac mrolvement of the bone naturelle hos lo rep cumuons on the hemopoietic mechanisms, rerulang o more or less sucre anen The tragedy in these cases is tut un rule the separc complicadons follout pressure sores progress alenty--- Ingering or crecping type of sepsis without r. There is hardly any need to mention that disastrous effc Huis septic condition hos on the nitrogen balance of the patient In fact, we ha admutted paraplegios with pressure sores in ech u extreme sute of malautam that it could be compared only with that of the inmates of the Beken Camp Once they have developed, those ulcers are chronic, may assume cateTISI propinions, and usually resist all forms of conservatore themp (Fig 78 They invariably necessitate arduous and painful surgraal dressings that I doscouraging both to the patient and to the surgeon in the degree to whic ·Ischial Decubitus Ulcers 125 they are unsuccessful Apart from the discomfort of the patient the ulcerat mg arcas act as portals of infection through which scrum proteins are lost so that these patients go into profound negatic nitrogen balance become cmacuated and ancinic This establishes a dilcnuma fost difficult to resolve On the one hand, it is alınmost impossble to restore nitrogen balance in such patients unol the wound lias been closed On tlic other hand, the plastic surgen necessary to effect such closure is not readily tolerated by these pa nents until they can be brought into better preoperatic condition by high calorie and high protein fecuing and by blood transfusions. An effort may bc made to facilitate nitrogen retention by the administration of testosteronc or synthetic androgenlilc honnoncs along with this regimen. ܚܬ Fr. 78. Typical appearince of bilateral sschul presure pore. There is citesine undermining of the sore on the sght ade. (Reproduced from Blochana, R. hostrubele, J G, and Grocky P11. Surgical repair in decubitus ulcers pan plegko. Plast Reconstruct Surg + 123 1919) By all means, the best treatment is prophylaxis. The paraplegic patient should be turned even to hours so as to avoid the possibility of prolonged pressure. If evidence of skin pressure appears, the patient should be placed in other positions until the skin regains its normal circulation. If necrosis with out involvement of the underlying burss has occurred, the necrotic arca should be excused, the skin should be approumated, and direct suture at tempted If however the bursa has been opened complete cxcision of all necrotic tissue including the entire bursa must be accomplished Failure completely to excise the infected bursa ineiitablı icads to recurrence of the ulcer In the absence of any bone ini olement, wide cicision follou ed by skin flap corerage of the defect frequently leads to priman closure of the wound (Fig 79) Experience houcier has established the fact that when subject to ·126 Injuries and Surgical Diseases of the Ischium trauma or renewed pressure, the new shin ulcerates in emctly the same mana ner as had the old with re-establishment of the onginal condition. It was as a result of the knowledge ganed in the treatment of relatrely large numbers of var liounded paraplegues that attention was directed to the importance of the underly ing bone. Even in the absence of evident roentgenographic signs, Blocksma, hostrubala, and Greely state that m almost all decubitus ulcers of several months duration, the underlying bone is definitely diseased whereas in the more recent ulcers there may be little or no bone involvement Our pathology reports shou degeneration and/or fibrosis of bonc 518 percent, osteitts and/or osteomy clits 24 1 percent. No Ft 79 Lschal rore before operation. There we no mrohement of the tad acmon of the ulcer with clasore by means of a fuatio flap wo powible. (Reprodaced from Icoman, Al, and Hardy A. G Pathology and treatment of presure words in paraplegxa. Brkt / Plost. Surg 7 179 1954 ) disease of bonc reported 24 1 percent" (Fig 80) In those in whom re cumbency in bed was maintained the ulcerations occurred predominandy over the sacrum, the femoral trochanters, or the anterior iliac spines, depend ing upon whether the patient was supine or prone. With the de clopment of the rchabilitation program and the assumption of the seated position a sharp rise in the inadence of ischial ulcers was noted. Because of the satsfactory results obtained by resection of the femoral trochanter and the underlying sacrum, the dovrebility of removing the bony prominence of the eschium appeared clarly indicated and was undertaken by kostrubala and Greely 4. In the begroning they "begin by amputabing portion of the schial tuberosity and then covenng the defect with gluteal and biceps muscle flaps and a local rotation flap from the posterior surface of the thigh corering the donor ares unth a split thickness shin graft. The re sults were not satisfactory in all cases, howerer because (1) . bons prom nence remained as a potential hazard in the production of a nen ulcer and ·Ischial Decubitus Ulcers 127 (') incomplete ctcision of dressed lone led to the recurrence of sinus tracts." In general the results in what has been called old cupc ischal closure may be judged from the fact that in operations performied on fortycight ulcers, 62.5 per cent showed healing after onc opcration an additional 18 7 per cent closure after the operations an additional 1' 5 per cent after three operations, and 6,3 per cent after the fourth operation Because of this they were led to complete cscision of the schium Fre 80. Ostcornyelius of the schrum m bilateral school decubitu (Reproduced from Blocksms, R., hostrubale ) Gand Greeley P W Surf al repar in decubitus ulcers in paraplegres. Part # Reconstruct Surg 123 19 19 ) A now and more radical method of treating the ischral decubit has prored sempler and more satisfacton After ctcision of the ulcer Gigli sus are passed through the obturator foremen and a complete ostectomy of the schial tuberosity performed. The schial nami are commed further with & Sauerbruch rongeur the lateral cxcmon conunung until the bony fulcrum supporting the internus muscles has been removed The obtantor internus muscle is then fanned out und then sotured over the lateral rumus to the obturator enternus and to the cut ongin of the luceps ferons muscle. It then usually possible to close the wound bn sumple pronari closure usang local tissue to fill in the entre defect uithout the use of any flaps Though the emet steps in the procedure are not described, it appears that these authors employed essentially the same technic as was reported by the present water in 1935 The method of resection of the bone as well as the ·128 Injuries and Surgical Diseases of the Ischiuma area resected are evidendy identical. The only difference would seer in the approach to the bone through the already existing defect in the ated skm rather then through the standard skin incision Becrue of t ther bone tres exposed through an infected ares, preoperative prepara means of Sulfasuxidine, 3 Gm cicry six hours, peniallin, etc. employed. Following operation, the atting patient is not able to any bus body on bony prominences which are covered with very implo padding of fac and skin and the necessity for the use of compliated muscle flaps sal The patients who are sble to walk on brices have shown no evidence of mstability Complications have been few and not serious Healing a materally decreased. Of this group only 14 percent required 10 additio to cffect i comfortable closure, Tho uleen in this group have recurte repair The results reported by these authors in 97 operations on 85 ulcer 882 per cent closed after the first operation, 106 per cent closed af second operaaon, and an additional 12 per cent after three or operations. REFERENCES 1 BLOCKIVA, R, KOSTRURALA, J G ad GILBY PW Surgical re decubitus ulcers in paraplegic Plast Reconstruct Sweg * 123 2. GUTTWAY L. The problem of treatment of pressure sora m sprog plegia. Br J Pla Sorg / 19, 1955 3 KOSTRUBALA, J G und GREELEY P W The problem of decubitus o paraplegica Plast Reconstruct Surg 2 403 1947 4 Ana H Partial resection of shrum. ) Bone Joint Surg 17 18 and Bull Hosp Joint Dis 1 19 1940. 5 Y DOVAN AL P, ad HARDY A. G Pathology and treatment of pressur in paraplegios. Brk | Plast Surg 7 179 1954 ·CHAPTER 14 Tumors of the Ischium IT IS DIFFICULT to estimate the cract incidence of isolated tumors of the schium. While tumors of the pelvic girdle cannot be considered as rarc, tumors of the ischrum alonc arc relatnici unusual and appear in the literature largely as individual case records. In a sencs of fortione cases of pelric girdle tumors collected from the five year records of two hospitals, Bickt noted only one as arising in the aschium. Braunstein collected ten cases of pelic fibroma of which three were located in or near the ischium. Up to 1905 Tilloranns' found the reports of ninety-eight cases of chondroma or Osteora in the literature. Only four cases were located in the ischium and, m 10 addrtional three cases, the tumor was found involving both the ischuum and the pubis with probable site of origin in the ischiopubic junction In one hundred sixteen cases of pelvic sarcoma, nonc was found in the uschium alone, Isolated tumors of the schrum may be either primary or secondary The prman tumors are of mesodermal ongin and may be either benign or mabgnant. The secondary tumors are usually metastatic and of ectodermal onigm. Among the more mmportant contributions on this subject in the Irterature there are reports of benign lipomas, fibromas, chondromas, ostcomes, ossifying hematoma erostoses, osteoclastomas, malignant sarcomas of varying cellular types, Ewings tumor my eloma, and metastatic car CINOM, BENIGN TUMORS Hancoch" described an unusual ossifying tumor in a woman of forty abo, as she fell to the ground in a sitting positon noted 2 snapping sensa region of the schium Shortly thereafter she perceived a swelling the seze of a marble in the schul region. Within six weeks , thus had cnlarged to the see of an orange , caused pain on standing and made sitting impossible tion in the ·130 Injuries and Surgical Diseases of the Ischium without the interposition of a cushion At operation, a large mass of ossific tisste internal to the biceps and postenor to the triceps was found otar the Ischial tuberosity This was attributed by Hancock to organzation of a hematom following rupture of the biceps muscle. Bihaut reported the case of a seven year-old female in whom a soft, almost fluctuating lipoma in the ischial region had been noted since birth Fra 81 Congenital Lipoma, nght behul region. (Reproduced from Bilhan, ALLupote congtar tale de la région ochotique drorte Anwes de Cbtrarle orthopédiqus 205 1909 ) The tumor had groun slowly and hed gradually become painful so that the child had difficulty in sitting It was reproved without difficulty and with complete subsidence of symptoms (Fig 81) kurnisont reported the case of a twenty three month-old infant in whom a small tumor had been noted in the left gluteal region at the age of fire months. Because of its rapid growth, this was remored and found to be a u ell encapsulated and regularly lobulated tumor As m Bilhaut s case this lipoma was removed without trouble and with complete cure. Fibromas in the region of the schium have been reported by Braun, Nicaise, 4 Fayrer * Tansin, to Tillaus, ' and others. These may anse either ·Tumors of the Ischium 131 from the cambium or the fibrous layers of thc penostcum In the case descridxd by Gould " the tunior vos attributed to a fall down stairs and cristoned pain radiating down the left leg for a period of two years. When first seen, it crtended from the postenor aspect of the great trochanter around the hup to project along the inner side of the hip Thc mass was fim rounded and freclı movablc on the hip At operation it was found to be attached to the ischium and 105 oked the sciatic ricric a portion of which had to be sacrificed to rcmovc tlic tumor Under the term crostoscs there have been grouped a number of different cases that might specifically be designated as chondronus, ostconns, and 1 FEG 82 Exostosis of posterolateral aspect of right schaal tuberosty (Reproduced from Feorel, EX Ecostoses de rischion these de Pons 1997) Osteochondromas. Fauvel," who has made a special study of these tumors, noted that they are usually covered by bursae and may be divided into two tipes, the osteogenic and the nonosteogenic. The osteogenic type arc usually mulapis, develop on the diaphyscal side of an epiphyss during the growth of a child, and cease growing when the chud stops growing They ire to be differentiated from the nonosteogenic exostoses, which are usually olitan and frequently posttraumauc or postinfectious. They may appear ut any age and may arise cither in the diaphyseal or epiphyseal regions. These tumors occur in the ischium less often than anywhere else in the peless and are almost nei er found on the outer wall of the pelves (Fig 82) They frequently give an antecedent histon of injun but in one case re ported by Lenormant apparently followed an attack of typhoid fever ·132 Injuries and Surgical Diseases of the Ischlum 1 Regnol," Delbean, " Djørup · Ferrano " Billroth,' and Tillmanns" reported cases in which the tumor was located in the body of the ischium (Fig 83) Lenormants case involved the inner aspect of the schium. Three additional Cases reported by Aicrols, Gillette, Marcuse, to and Wilms involved both the ischuom and pubs and probably arose from the schiopubic junction. In a similar case reported by Damourette,'' annary tract symptoms nere nored. Two cases of schral crostosis reported by Sandfelt" are said to have re sulted in dystociae, though the major cause of this complication appears to anse as a consequence of tumors located clscu here th: in the schium. West" reported the cause of 2 twenty fire year-old Pars Ilm u hom a herd, punless lamp had been present in the vagina for 1 penod of about two years. Thes mass completely obstructed the pelvic outlet and had to be re moued before normal dehvery w possible. The pathologist reported istmple Osteome. Tuo months efter delivery pemination disclosed a fira, fibrous band attend ing from the pubs to the tuberost of the schom. There was no cidence of recurrence and no mm- F10 83 Osteochondrum of Echtal ru partment of function, berdoty (Reprodoced from Didrup, Fr. The main symptomatology erok Om to Tilaalde of tralteros schil Hospitalet 75 167 191.1 ed by these tumors o pann, either localized to the site of the tuor or radisung along the course of the scape nerve. The local paso has been attributed to inflammation of the bursa thar frequently covers the top of these tumors The radnong pam has been attributed to direct pressure upon the sciotic nerve. The occurrence of scade para o probably the most common of the presenting symptoms of tumor of the Eschium and may be mistaken for pain onginating in a prolapsed lumbar intervertebral disc. In the schium the pain is most often due to compression or actual involvement of the scuoc narre Faurel has called attention to the fact that a differentiation may be made between the pain and that due to deal or low back injuries Pain resulting from conditions in the lumbar spine e ndicular mature and as accentuated by couglung or seczing es contrasted with staba" of tron- ·Tumors of the Ischium 133 cular ongin, which is not usually associated with paresthesias but may shon sagns of peripheral ncnc involcment The treatment is by crcusion, including all the base of the tumor No cases of metastases have been reported of tumors situated in this location, though such metastases have been noted in other pelvic tumors of this type. Benign osteoclastoina of the iscbunn has been descobed by Nissen" and by Brandsma. Nessen s casc appeared in a fenalc of thirty scien who had complained of pain for a penod of about clcien months. The whole of the f Fig. 84 Ostcoctaigoms of kchium (Reprodaced from Brand me, A. G, Destruction of the schrum b grant cell tumor Neder Nr Gresk IS 1460 1941 ) schiun from the spine to the pubis was involved The patient was treated by means of medium and was able to resume her full duties as a househ ceper uithin four months of the beginning of treatment Brandsmas casc ut as that of a man of forty who also presented symptoms of pain and limitation of motion in the hip The r ray rerealed complete disappearance of the ischium from the spine to the pubis . Treatment was by resection with complete subsidence of symptoms (Figs 84 85) Osteoid osteomia of the ischiom does not appear as such in the Literature. In 1937 Raspeia reported a case history that he described as a rare change mn the schium resulting from sport" Though the facts are not entirely clear they more closely conform to the clinical picture of osteoid osteoma

·134
Injuries and Surgkol Diseases of the Ischium
Ik 85 Vicroscopic section of tumor on Figure 81
FO H. Ortcold ogcon of the schium (Courtesy of Dr J
Vin)

·Tumors of the Ischlum 135 thun any other condition A completely mypical case is presented herc through the courtesy of Dr J Mootz The patient a woman of thirti three complained of persigent disconfort in the perncum that was naadc wore on walking Apart from slight limitation of internal rotation of the left hip and the rocntgenogram (Fig 86) no objectic findings could be clicttal The lesson was cuentrated some two months after onset of the symptoms. Unfortunatch tlic specinin 1195 badly macerated during the surgical procedurt so that the pathologist could only report that in "one ossue fragment a small zone of osscous tissue recongruction may represent the outer most penipheral border of an nicoid oscoma " Despite this, the clinical picture and particularly the rral of the lemon arc so ti pical of the condition as originally FIC. 87 Cyx of schium. (Reproduced from New England 11 ) 245 379 1951 ) described by Alilch" and subsequently by Jaffee that the diagnosis of osteoid ostcoma may be accepted. The patient made a complete and uneventful recovery following removal of the lacon The only case of a cyst of tbe iscbrm thus far reported appeared in the case records of the Plassachusetts General Hospital." The patient, 2 young man of screnteen, had turned somersault when he lost his nght shi u hulc water shimg He complained of increasing pain in the left thigh and had difficulty in walking Flexion, internal rotation and abduction uere linuted In pain that radiated into the inguinal and gluteal regions. There was no tenderness on external palpation but rectal exanunation disclosed a slightls tender bulge on the left side. I ray (Fig 87) revealed a cystic arca about 7 cm long and 45 cm wide lying in the ischium and extending up to ·136 Injurles and Surgical Diseases of the Ischium the lower margin of the acetabulum The bone was greatly cspanded, thim ned, and was the site of a fracture linc that extended from its superior pole to the lateral aspect of the cyst. There was no trabeculation, no appreciable zaralıement of neighboring bons, or significant penosteal new bone formaaon Though there was a montled alcification in the soft aissues about the bonc, there is no cuideacc of tumor formadon At operation the cust aus found filled with flud An unusual benign chondroblastome of the ischium was reported by hunkel, Dahlın, and loung IT MAUGNANT TUMORS Primary malignant tumors of the uschnum are genencally sarcoms of var jous cell types and vamous degrees of malignancı bat Ermg's timoris and solitary myeloma' have been reported Fr. $ Ewlogs tumor of the schium. (Coastery of the Armed Forces Institute of Pathology) Enings tumor usually occurs in individuals below the of twenty and may be associated with fever chills, and an elevared leucocyte count dujulat ing an acute infectious process. The rocntgenogrum cun casily be mistakeo for that of an acute ostcomyelitis (Fig 88) Vyelons tually occurs after the fourth decade of life and may be angle or mulople. Cotiera and his co-workert emphaseze the fact that the solan aype of myeloma s to be differencuated from the more common mulaple type. They note that the solitari fom may be further subduded into cuo clinical types one 10 which the primarily solitary tumor later becomes generalized, and a second, ·Tumors of the hchlum 137 Fra 89 Solman myelonta of the schrum. (Reproduced from Blum, S. D. Soltan myckoma of bone. Ani. I Rocatgenol 57 239 1947 ) Ti 90 Alicroscopic sction of mm cloma seen m Figure 89 m which the tumor remains localized for longer penods of time (four to twelve years) Thus concept is extremely important since, in certain cases at least, it holds out the hope of cure by radical removal of the mrolied arta. Blum' states that, up to 1947 the case he reported was the only one of isolated my cloma of the ischiom in the literature The patient was a man of ·138 Injuries and Surgical Diseases of the Ischium HT fifty who complained of sciatic radiacon of pain Yray involved a destruc tivc osteolytic lesion involving practically thc churc nght schuum" (Fig 89) This patient was treated by radiation therapy in che belief that the tumor was an osteogenic sarcoma. Biopsy was not performed unal after the mduaon therapy had been started (Fig 90) Alicroscopic section showed "large masses of plasma cells, fairly lange in size and round and omi in shape The nuclei are eccentric and the cytoplasm was light blue and grindular Thc noclci contamed one to to ouclei and the chromatın 11 arranged in spokelike fashion" Hemipelvectomy was performed but the patient subsequendy died as a result of a postoperative infection. Periosteal ser cons of the iscbrina has been described by Zachartac," round cell sarcomm by Alachell." Fra 91 Fibrosarcoma of the bachion. fibrosarcoms by Belot and Naban (Reproduced from Bclot, Lund Valen, (Fig 91), Weir" and Brooh, na fibro- Lolummeux fibro-wrcome jout myrocbondra SATCOMIA by Crunt de départ ischiatique Preise med H 851 1936.) osteogetuc by Ticozzj *Nogier and Dorrell and Thomas Reticult cell sarcoma is probably the most uncommon of all the sarcomas but does occasionally occur as the following case illustrates WSmale, aged surty complained of pain in the right hup for three and . half months. These was no history of troma The pain became progressisch worse and there was slight hmation of motion in the hup. Ynys of the hip pelvis, and back taken after admisston to the hospital were onginally reported to be negauve bat subsequent x ray films taken about one month later were reported to show in Oosteolytic lesion in the sechrum (Fig 92) A btopor sec ton, taken from the schlum, ats reported to show " network of reticulum cell which are actively laying down reticulum in varying degree" (Tig 93) Following the biopsy the pedent experienced some relief of pain bat despite large doses of my he gradually went down hill and died pacher" SIT CONS In the case of fibrosari07111 reported by Brooh, the tumor consisted of orgumized fibrous tissue with areas of fibrosarcoma especially in relation to the bony tissue-order of malignancy low This pagent was reported to be elive and symptom free three years after operation, which consisted sumph of curettage and radium treatment. There may be some question whether this case should be included noong the frankli malignant cases. If 50 it

·Tumors of the lichlum
139
FK 9
Reaculum cell sarcoma of the schrum.
Fra 93
Alicroscopic section of tumor geen in Figure 97

·140 Injuries and Surgical Disease of the Ischlum appears that with this exception, the outlool is poor for all these cases re gardless of the histological appearance of the tumor or of the treatment that instituted. Many of these cases, whether benign or malignant, present some boton that resses the question of relationshup of trauma to the appearance of the tumor Because of the biscological simulanty that may exist between osufy ing hematoma, osteoma, and sarcom2, some have maintained that trauma the etiologic factor responsible for the appearance of the tumor Others are of the opinion that the trauma mai act to stimulate a pre-custing nidas to grouth, may accelerate the rate of growth of a previously existing tumor or may merely serve to direct attention to a tumor already present. In many instances, there appears to be a well authenticated relationship between injury and the appearance of either benign or malignant tumor The determination of the matter is not infreqeuntly the basis for legal action and instances are on record where the courts hare affirmatively indicated their belief in the relationshup It would seem, hon ever that the presump are basis for such an affirmation should be on the satisfacuon of Segonds postulares (1) that the rumor anise within a reasonable time after the alleged injur (2) that it appear at the site of the alleged mjury and (3) that it be progressive from the time of the mjun The question of the relatonship of trauma does not arise in the case of secondary metastatic involvement of the ischium by 1 malignant tumor While they may be mesodermal in ongin, the majority would seem to be cctodermal and anse in malignant growths of the breast, the kidney the thyroid, lung or prostate. Of fo three lesions of the ischium in the files of the Armed Forces Iosutute of Pathology one wes loted as being a seconden fibrosarcoma, oncos a secondary adenocarcinoma, and fire us secondary carcinomas. Two cases of solated metastass of arcinoma to the achium hore been found in the literature. The first is described by Berg that of 1 renal arcinome with isolated metastasis to the ischiom the second vous ther of an endometrial carcinoma of the uterine fundus described by H Alilch and R A. Vilch" In this later is the presenoog symptom 1133 that of scaoc pan and the patient uns traared for almost a year under the mostalen diagnosis of "scratice" resulting from a lou back syndrome. The padent s lou back syndrome was cridently atypical and my of the pelris disclosed the true cause of her symptoms (Fig 94) As soon as the tumor was erposed it was evident that it ras maligrant and a wide resection of the ischium was undertahen. Vicroscopic section rorealed a metastatic adenocarcinoma (Fig95) Despite careful crimination, no primary site could be determined until sur months after operation when vaginal bleeding ak curred. Curettage led to the dagnosis of a corpus aronoma and a radical

·Tumors of the Ischlum
FIG. 04 Vietsstatke uterine adetrocarcinoma of the schrom
Endometrial carcinoma nxtastick to the schual tuberosity (Rc
produced from Vilch, H. and Wilch, R. A, AHA Arcb Surg
66 686 1953)
FK 95
Microscopic section of tumor m Figart 41

·142
Injuries and Surgical Diseases of the Ischlum
Fia 16 Microscopac section of utenne corrus carcinoma
produced Wilct, H and Alich, R. A, op cit)
(RC
Fra 97 Recurrent denourcmon fter resection of
schium in patient whoun in Figure 41
Ini sterectomy was performed. Alicroscopic section confirmed the idcoury of
the tumor with that of the metastatc schral tumor (Fig 16) The pract
remainded
symptom
frce for about three years after the scho) resection
when she began to complain of pain in the pelva \ mus at this omere
calcd recurrence in the pubs and the ilium (Fig 97)

·Tumors of the Ischlum 143 REFERENCES 1 Aicion R Einstose solitana cpifisifomic del pube ed ischio Arcb ortop 20 338 1903 2. BELOT L and NANAN L Volumıncur fibro-wrcon a point de départ Ischiatquc, Otesse mied H83 1936 3 BERG, A A Malignant hyperncphroma of the kidney Surg Gyn & Obstet 17 +63 1915 4 Bra, En. Tunsors of the pelvic girdle J Bone & Joint Surg 19 +02 1937 5 BAUT 11 Lipome congénitale de la région ischratique droite. Amales de Chirurgie ortbopedique 2' 63 1909 & BILLKOTL TH Sarhom der Bechenhohlc Cbinirgiscbe kimik Wien 1871 Berlm 1879 p. +00 7 BLL SD Soliton nn cloma of Lonc. Am ) Roentgenol 57 239 1947 8. BRANDSAIA, A G Destruction of the nchiom bi guant cell tumor Nederl tijdscbr geneesk $5 3460 1941 9 BRAC G Uber seltenc nicht verschiebare Bechentumore. Il len.. tued Il conscbr 31+ 1863 10. BRALYSTEIN La Uber Bechergeschwulsten Inaugural Dissertation, Bonn, 1888 11 Broom, WF Fibrosarcom of the ischium treated with radium, Brit led 1 1951 1929 12. CarVIPAKER, LE. Lesions of the ischium Proc Staff lect Alayo Cim 1 454 1939 13 Cotur, 11. Bosong F., and CANTRI, S. T Course of single myeloma of bone Surg Gynt Obstet 62 918 1936. 14 Cyst of ischium, Case record of Massachusetts General Hospital. New Eng land II 245 379 1951 15 DAVOLRETTE Reference by Faurel, E. 16. DELDEAU Mémoires sur les tumeurs carthagineuses ou enchondroties du bastoin. Jour du Progrès des Sciences fédicales Nos. 15–18 21 and 22 1859 No 2 1860 17 DJORUP Fr. Om to Tilfelde of svulster 11 os Ischu Hospitalstid 73 467 1932. 18. DOURELL, E IV, and THOMAS, A R. Ostcogenic sarcoma of the ischium. ) Roy Not Al Seru 27 393 1941 19 FALTEL, E. Enostoses de l'Ischion Thèse de Paris 1927 20. Faner, J Interesting surgical cases. 11 Tones Go 14 1869 21 ForAkio G Sopra un caso di condroma dell'ischio Bollettino delle spec Aled Cb, 3 62 1979 22. GULETTE Fibrome fessier Union méd 20 849 1875 3rd ser 23 GOCLD, A. P Fibroma growing from the ischrum Tr ub Soc London 38 225 1877 27 HAXCOCK Ossific tumor in the sschatic region Lancet 1 420 1850 25 JAFFEL, H L Osteoid Osteom. Arcb Surg 31 709 1935 Lipome péniosaque implante sur l'ischion. Ball et meni Soc cbr Paris 37 869 1911 27 hukmei, M1 G, DAHLIN D Cound Young HH Benign chondroblagona | Bone Jomt Surg 38A 817 1956 26. houTISSON M ·144 Inſurlas and Surgical Dkeases of the Ischlum 28 LENORMANT Oi Los troubles de crosance dans les croROSES Osteogeouque et les chondromas. Rec d'onbop 6 193 1905 19 MACHELL, H T Round cell sarcoma of the ischiom Card. 11 ) 7 13 1882 30 MARCUSL ) Enchondrome de Beclens. Deutsche Zuscbr cbrr 7 546, 1876 31 MILCH, H Osteoid tree forming tumor smukung anular sequestrum Bone Jomt Surg 11 681 1934 32. Anar H, and AluguRA Endometrial arctoom meresat to the schmal tuberosty A.M.A Arcb Surg 66 686 1953 33 NICALL, E Fibromo du Basm adhereat be tuberoucé ischiatique. Ret mont de inéd et de cbh 2 761 1878 34 Nisan hI Oscoclestons of the schium and pubu. Proc Roy Soc Ved London, orthopedic section, 32 823 1938 35 Noola, T Oreosarcome de l ischioo traité comme scroque. Ball et TAI Soc electroradiologique méd 24 381 1896 and 26 112 1938 36. Rasph, R. Über eine seltene Verinderung am Tuberoste ischi durch Sport. Röntgenpranis 9 124 1937 37 Reoroli Ostermazione chirurgiche. Clinica e Pratica 1836. Reference by Tillmanns, H 38 SECOND, P Le Cancer et les accideno da tril. Ason Française de Chirurgie 20 745 1207 39 STADIELT Reference by Tillmanns, H 40 TANANI Fibroma colossale della pelvi Gior di Roy Acad di Med 2 79 1881 41 TrCozzi, E Sarcoma ostcogeriecico primitve dell'ischuo. Ospedale dlaggiore di filmo 21 215 1933 42 TILLAUX, PJ Tuneur pénosuque de l schion Tribune pred 77 1047 1896. 43 TOLLALANNS, H "Die Lehre von Geschaukeen," in Lebrbacb der Allge INCRON Chirurgie 8th ed. p 737 1904 14 len, R. F Fibro com of the uschrum. Modice Record N.Y 21 302, 1882 45 Wert J AI Osteoms, etc., obstructing the pelvic outlet. Tr Ann. A. Obst et Gynec 10 346, 1917 46. ILUS, A1 Entferoung eines groszen Beckenchondrons. Verband deutsch Gesellscb Cbr 29th hoogte#, 1900 47 ZACHARLAL V Ein Fall von Sarcom, ausgegingen von Perrost des rechten Sitzknorrens, hiel, 1865 ·CHAPTER 15 Surgery of the Ischium THE VFCESSITY FOR surgical approach to all or a part of thc eschipm for diagnosis or definitive ticament arises in a number of different conditions Strangely enough, practically no guidance on this subject is to be found in mi of the standard surgical tests. Depending on the objective a janety of different approaches to the winous parts of the schium may be employed LOCAUZED AREAS For simple surgical procedures confined to localized areas, direct intra muscular incisions have been used They are best undertaken with the motion FK 98 The tramite made directly in the glutal fold. patient in the prone position and with the lower extremidos pendant over the edge of the table. The simplest is a small cun ed incision following the 143 ·146 Injuries and Surgical Diseases of the Ischlum injury to the lower margin of the gluteus maximus muscle (Fig 98) Lateral extension of this incision must be carefully gauged so as to avoid posterior femoral curanсous nerve, which lies between the ischial tuberosity and the grat trochanter to the inferior gluteal artery which lies at a somewhat decper level and especially to the scuoc nerve, which lies still deeper and runs at nghe angles to the line of the incision EXTENDED AREAS Where the condition under treatment may be expected to extend down the leg a longitudinal incision beginning at the upper edge of the schel Fra 09 The longhudmal incision Fra 100 The oblique insekron for a made midt better the kchial tu posure of the web spine medo bcrouty and the great trochenter of the through the fibro of the gluteus mit fertur It parallels the count of the sch mw muscle ut 1 slighter louer mangle tx nerve und citepdo downwurd froen than Langenbechs neaion for eposthe level of the gluteal fold. ure of the anterior glateal artery tuberosity and extending downward along the course of the humstring muscle us preferable (Fig 99) No important vascular structures will be cncountered in this approach and the scratic nerve lies safely lateral to the skin inciOD To expose the acrospinous ligament, the ischial spine, the gluteal or the pudendal vessels and nerves, the parent is placed on the unaffected side and an oblique muscle-splitting incision (Fig 100) of the type originally sug gested by Langenbech is made . It will be recalled that the superior gluteal arten and the suprapyriform fossa are to be located at the junction of the inner and middle curds of a line drawn from the postenor superior spine of the ihium to the tip of the great trochanter while the hup joint lies at the ·Surgery of the lschlum 147 junction of the nuddle and outer thirds of this linc (lig 7) For exposure of the infcror glutcal arter the infcrior pudendal vessels and nenos, and the base of the achial spinc an incision parallel to Langenbech s but slightly more caudalli placed should be indc Since all these structures lie at the level of the ind point of a linc dmun betucen the posterior superior spine of the iliun and the tuberosity of the schium, the upper limit of these in ctions should be continued doutward and outward parallel to the line joining the trochanter and the iliac spine. The fibers of the gluteus maximus muscle are separated bluntly csposing the desired structures. When the necessiti anses for reconstructiic approach to the glcriodal margin, four different incisions may be employed (Fig 101) Tor ctposure of the anterior A FK 101 Foar incssions for approach to the acetabulum A the antenor illofemoral (Sonxh-Petersen) B the lateral Nofemoral (1 tson-Jones) C the posterior illo femoral (Gibson) D the U or goblet-thuaped in chron (Alorphy) and superior margin the antenor iliofemoral incision (Fig 101A) the socalled Smith Petersen incision, is useful - This incision is an admitted modi fication of the incision originally described by Largi and subsequently modi fied by Langenbech, later by Sprengel. It is hockey-suck shaped, runs along the anterior thurd of the iliac crest to the interior superior iliac spinc, and us then angled downward between the antenor border of the tensor fasciae femoris and the posterior border of the sartonus muscles The muscle flap including if necessary the anterior fibers of the gluteus medius muscle, as turned outward erposing the reflected had of the rectus fertioris muscle Thich is divided and tumed downward. This cxposes the capsule of the hup jome particularly along its superor and anterior margins and affords easy access to the mednal or peluc surface of the os innominatum. The lateral iliofemoral (Fig 101B) so-called Watson Jones incision is a modification of an incision or ginally descnbed by Richet " Beginning at or just below and behind the anterior supenor spine of the illum, the incision us carried down to the base of the great trochanter and is continued down ·148 Injuries and Surgical Disease of the Ischium along the lateral aspect of the fenur The fascia is incised in the same lunc, cxposing the upper fibers of the vastus lateralis muscle. At the upper border of this muscle a small triangular space between the anterior edge of the glateus medius muscle and the posterior fibers of the tensor fasciae femoris Is opened and enlarged upward The gluteus medius and minimus muscles are retracted backward and the tenisor fasciac femons as retracted forward, exposing thc superior and to a lesser degree, parts of the anterior and posterior margins of the acetabulum. Additional mdth can be obtained by freeing the attachment of the gluteus medius or the tensor fasciac femons from the lisc crest. For exposure of the posterior margin of the glenoid the postenor ilso femoral, incision (Fig 101C) populanzed by Gibson' has been described. This incision differs from the incision onginally described by hochere in that exposure is made at the anterior margin of the gluteus maamus muscle rather than through its fibers. The incision is made from the posterior superior iliac spine to the base of the great trochanter and then down along the lateral aspect of the thigh. The fascia is incised in the same line the antenor border of the gluteus magumus muscle is defined, and the whole muscle es retracted backtrard. The gluteus medius and minimus muscles are retracted forord, if necessary after division of their attachment to the great trochanter This exposes the external rotators of the thigh-the pyriforrors, the gemell, and the obturator muscles hich are divided and retracted. The hip joint capsule and the posterior margin of the ecetabulum can be readily visualized For exposure of the entire glenoidal margin, the U-shaped incison onginally described by Lexer is superior to either of the others (Fig 101D) The incision begins at the posterior iliac spine, care doamuurd and for wurd around the base of the trochanter and then upkurd and forward to thic anterior spine of the ilum. After retraction of the skin and incision of the fascia, the borders of the gluteus medius musclc arc outlined and the muscle is bluntly freed. The trochanter is then osteotomized at its base and the bone--with the attachment of the gluteus medius muscle-is elevated as a single flap corposing the capsule and the glenoidal margin throughout 133 entire crteat Thu inchion was modified by Afurpby' by the addition of a femoral entengon coarerong the U into a goblet shaped incision. Nather of the incisions thus far axentioned permits ready access to the scending ramus of the schuum \ic\Vhorter' found it necessary to derise such an approach for the treatment of an osteomy clics in this ares With the patient in the Lithotomy position . traverse incision is made through the skin in the thigh extending from the middle of the grocles to the middle of the adductor muscle. The adductor munonus muscle is split at about the middle of the distance between the gracils and the adductor magnus muscle, ·Surgery of the fichlum 149 thers cuposing the roof of thic obturator fonu that couers a large part of the rions of the pulers and thic rschium. Though VicWl'horter apparently contemplatel the pasibility of a perineal oppmach, he avoided it is to dangerous, On the contran this approach M. ADOUCTOR MAG. SALVIS AD MIN NULLO CAYIRMWM ILCHIO CAYLAMOSUM TRANSVERSUM PERIRE TULATY ILMU SPHINCTER ANI --NPERINEI -- PUDENDA LEVATON ARE GLUTALUS MAX FK 10 Pernical inession for resection of the schrum (Wilch) on the left the shim ncruon with the parent on the Inthotomy B shown. On the right, the underlying octures are idenafied (Reproduced from Wsch, H. Partal resection of the schium. Bon & Joint Surg 17 166 1935) appears to be the safest and most expeditious not only for exposure of the Tinh but also for more extensile procedures involving resection of almost all the schium and the ramus of the pubis . It permits , additionally access to the mtrapelvic as well as cxtrapelvic extension of the disease for which surger as indicated When performed subpenostcalls it permits operation a nhout danger to the numerous anatomic structures in the region.

·1.50 Injuries and Surgical Discosus of the Ischium The operare technic first descnbed by the writer in 1935" seems to be amular in principle if not ja detail to an operation subsequently discovered to have been described by Bottini' in 1871 and by Allonilo in 1888 It is to be noted that Bottini refers to earlier work by other authors, namely Regnol Enchsen, Velpeau (1836) and before him to Maunoir (1769) TRACTION ON DAUCTOR MAG. ANLYIS MIN AND OBTURATOR BULBO CAYEDYOSURY FORAMIN OD TURATORIA MEMBRAXA OOTUAATOA RATUS TNT 05 BSCHII ILCHIO CAYERX0UM TENDOM OF IMTENDINOS DKIM TERLARIS CUT TUBEROSITY ISCH11 TRANSVERSUM PURINEI INCTER ANI LEVATOR AND EN PIRINET -A PUDENDA - U16. SACRO TUBROLUM BUTACUS MAX. CUT KELLNER FX 10) The structures on the outer side of the schwim uro frted subperostally coposing the bone and the obturator membrane (Reproduced from Bone Joir Sur op. cit) The operanon is most advantageously performed with the patient in the lithotomy podton and with the buttocks clernted. If the lithotoms position is impossible, horreser because of fusion of the hups, the lateral position may be employed, with only slighdy greater difficulty The tuber ischil, the ·Surgery of the Ischlum 151 mferor border of the body of the pulsis, and the inten ening rami arc palpated An incision is then nade along this sulcumneous boni ndge and s conmued for almout three or four inches posteriorly in the shin corening the gluteus matmus musele (Fig 102) The lower edge of the glutcus is ASSUR MAL LINS AKO MIR TENDON SCUE stru dus extricitat BULEO CAYENGUM TOMAMLN OBTURATOAIR MEMBAHA OBTURATORI TRACTION ON ETURATOR AT TACTION ON ISCHIO CAVEANODUM MOTRANSYUTSUM PIRIALI RAMUS INFOS IXHIT TWEETEST 16txt TRACTION ON A. PUDERDA M- COTAVLUSI TIMIS SPHINCTER AND LEVATOR AXE w PLRINET M HAIMA ROTO Quts LUTAEUS MAX CUT Sunt |CRUnea Erca SACROTUBEROSUNCOT Fic 10+ The mirapeluxe structures are freed Rubperiosteally etposing the obturytor membrane and the aner ide of the bone from the symphyss pobrs to post belor the ischal spre. (Reproduced from BORE Joint Sumky op defined and elevated with the finger so that the fibers that orerhang the tuber schu may be cut across , exposing the tuberosit of the ischium, with the attachment of the hamstring muscles and the sacrotuberous ligastest along its inner border At this margin berri een the two lase mendoned Structures, the periosteum over the tuber ischu is mcised By a subpenosteal ·152 Injuries and Surgical Diseases of the Ischlum desection, the hamstring muscles are detached and displaed baterally The periosteal incision is then amed forward along the rim of the schium and pubes in the line of separation betri een the adductor muscle laterally and the perineal aructures medially As the procedure is carried foruurd, the adductor magnus is separated and displaced laterally until the lower external portion of the bone is exposed Proceeding deeper into the wound, the adductors, quadratus, brevis and longus and, finally the obturitor a terus are separated exposing the loner na of the obturator forumen, and ! FIG. 105 The Tent of Lone then may be rexcted is indicated (Reproduced from J Bone Jorut Sett op st.) doplaced outward in one large flap that contains the sciatic nerve (Fig 103) Dunng the course of this dissection no important structures are met and no senous hemorrhage need be feared The cyposure of the medal wall a rendered only slightly more hazardous by the presence of the internal pudendal vessek. However if after separating superficial structure the ischiocrvemosus and transversus perineal thuscles, the dissection is kept strictly subpenostcal , the pudendal nerve and ressels will be elevated without any danger and the lower fibers of the obturator intemus will be exposed in the depths of the wound (Fig 104) These can now be raised freeing the whole of the lower margin of the ·Surgery of the Ischlum 153 obturator foremen. In the postcnor part of the mcision, the attachment of the sacrotuberous liganient us then sharply cut away and the lesser sacrosciatic foranın is openied Here care must be exercised to avoid injun to the pudendal vessels as they wind around the spine of the ischium With cution, they may be subperiostcally freed and displaced off the spre so that the resection may be caried out to or above the level of the spine (Fig 105) The area to be resected is then clearly coposed A Gigli sau es passed through the obturator foran en and the pubic mmus as cut across. With the FK 106. Roentgen appearance of the night half of the pelro after resection of the schrum for toberculoses sau or an osteotome the descending ramus is cut All the uschium below the level of the spmous process as well as the descending ramus of the pubis mas casily be removed through the incision (Fig 106) For the resection of less than the whole bone an aliquot portion of the mersion may be used. Despite the fact that the incision is made through the potentially mfected region of the perineum healing by primanı intention Bually occurs. In clean cases, laver closure should be made. In infected cases, dependent drainage is available through the postenor part of the in Osim. This type of resection, modified only in the respect that the approach to the bone is made through the grossly ulcerated area, B emplosed in the modern treatment of sschul pressure sores priman malignant tumors of the schium, hempelrectomi! that For 1 ·154 Injuries and Surgical Diseases of the Ischlum permits of much wider CACISION B to be preferred to radical resection of the Ischium, which us thoroughly satisfactory for most other conditions requir ing ischiectomy REFERENCES 1 BANKA, S. W. and COLEMAN & Hemipelvectomy surgical technique. ] Bone Jom Surg 384 1147 1956. 2 BOTTIxRostction of the ischial tuberosity A de runh de Med di Milano 215 470 1871 3 GDY A Posterior exposure of the hip. ] Bone Joint Swer32B 183 1950 4 GOMDON TAYLOR, G, und MONROE, R. Technique and management of hind quarter amputation. Brit J Surg 39 516 1952 5 KOCH, T Chirurgiscbe Operationslebte Sth ed. Jene, G Fischer 1905 p. 142 6. v LANGENDECT, B Concerning bullet woonds of the hip joint Arcb kim. Cbir 16 263 1874 7 Acll HORTEX, J G Osteomyelias of the sschiom and pobis. Surg Gyno Obst 49 205 1929 8 MILCL H Partal resection of the schium ) Bone & Jotar Surg 17 166, 1935 9 Mua, H Tuberculosis of the sschul tuberosity partial resection of schiam Bul Hosp Jofrt Dis 19 1910 10. Milovi Resection of the ischiom Am del circ med Arges 11 62 1898. 11 Mowy J B. Ankylosus of the Hip. Surgical Clmics 2 BO2, 1913 12 Pack, G T, and EHLICH H E. Exarticulation of the lower extremidles far malignant tumon hup joint diarticulation (with and without deep llinc dissection) and secro-iliac diarticulation (hemipelrectomy) Ann. Sorry 124 1 12-16 13 ROOLT A. Operitons applicable to ankylores Tbèse de Concours de Paris 1850, p. 81 14 SumH PETEHT AN A new suprurtcubr subpenontcal approach to the hup joint. Am. ) Ontb Surg 15 592 1917 15 Watson Jones, R. Fracture of the nech of the femor Brit | Surg 23 787 1935 ·INDEXES

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·Author Index Acrol, R., 13? ALA, O H., 58 Astand, G, 43 Clarke, Le Gros, St Qarel, V. 104 Coler B. 66 Colrm, R 99 Conwell, H EX 48 Cottalorda, J., 69 Cotton, F ), 51 Crumpacker L EX 138 Coder vi, 136 Bacson, 0,11 Battle B. 113 114 Beer E 93 Bell, HK, +9 Belor, L. 138 Benda, R. 37 39 Bennett, E. H. 49 Berg A, 140 Bern J V 77 86 Bich, E., 129 Bigelow H J 58 Bihaut, IL,99 130 Billroth, T 132 Blanko, B 10+ Blockana, R 16 Bluon, S D 137 BOCIO, L 26 Bottinų 150 Brandon, A. G, 133 Boundt, G, 54 Braun, G 130 Banten, I 129 Brachet, G, 10 Brook, 11 F 138 Brown, L 98 Bochman, J 110 Bunner 01, 118 Borman, 11, 52, 53 54 Duhla, D C 136 Dumoarette, 132 Darcon, 143 Delannoy E 37 62 Delbed 132 Denna, F S., 114 Del alz, H., 31 Dørup, Fr, 132 Domeny P. 118 Donn,11 1,98 Dorrell, E., 138 Dudgeon, H, 66 Dupont, j, 02, 118 Dupaytren, G, 39 62 Durtum, HA. 43 Ehal, 11, 19 Eppinger H, 32, 39 Epster, H C 60 Egn, P, 13 36 Caffey J 44 79 Calor, F, 'S Canet R63 66 Compbell, il Conso Cappeletah, G St Chaugas, E, 118 Chan, H 39 Chanello AF, +) 4 Foton, 39 Q2 Faurel, E., 131 Foré, C63 Ferring, G, 132 Fet C, 107 Fritte, 11,93 Forcher layer 34 Freud, E, 118 Froehlsch, 11.36 157 ·15B Injuries and Surgical Diseases of the Ischlum Gut, 11., 104 Gep, E,99 Gibson, 148 Gilbert, W, 50 Gilette, 132 Gion, T. 67 Golden, A., 9 Gould, A.P., 130 Greeley Pl, 126 Gruber 11. 117 Grunert, A., 101 Guillaumet, 114 Guilleminet, 101 Gurt, E., 48 Gutschenis, A., 79 Guttman, L., 123 Goryoc, 101 Laboz, E. F. 86 Lum 18 Langenbeck, B, 140 Le Dumaday F 25 LeFort, R. 99 Letrat, F, 67 Lenormant, C. 131 Leyme ) 93 Lerio, A1, 72 Low, P. 37 Liga, A 63 99 Lingley J R, 63 Lobel, R38 Lorrhoir 105 Love, L 4 Ludloff L 104 Haberler G 43 Hanner, H H 38, 63 Hainas, D. 49 Hancock, 113 129 Heeren, J., 43 44 Heineke, WV 117 118 Hellmer HA. 4 83 Henschen, h, 36, 39 54 65 Hertzler A. E36 Hoch, P H. 63 Holge, E. B 49 Iller 1.89 Inchan, A 43 Ingelns, P, 99 104 Alachell, HT, 138 AlcLaugtılın, H 79 MICN Laster, P E_, 80 A1cVhorter G J., 99 101 148 Vlaggaskan, R., 207 Malgaigne, J F, 49 76 Alanfredl, 11 43 Alurches, C. 54 Alarcure, J 132 Varet, 49 \ldersberg, P., 118 Alryer L108 Alimen, A 101 Alagonl, 104 Alcbrner k, 43 Aixchaels, G, 49 Allch, H. 67 77 78, 79 107 127 135 140 150 Milch, R A., 26, 140 Wilford L 58 60, 67 69 Villonl, 150 Alonte, ) 135 Afaller A, 118 Valker H. 36 Morphy 148 Naran, L. 138 Nian, E., 118, 130 Nickorxoa, S 54 Ninen, K L 133 Noguer T, 138 Jaffec, H L 135 Jaha, S 66, 71 Jumsen, Alurk, 25 Jensen, J., 54 Jona, DB 54 Jona, HT 118 Odelberg 91 hulingas, LB 63 haplan, A1 104 karfiol, C. 83 67 hei J A 48 henbock, R. 33 hog D 63 hurtoisson, AL, 130 Lemberg 66, 101 121 Klemen, Þ 08 Kloger AL E9 kocher T 148 hoeng 114 hohler 14 hontorowitch, D 62 hosttubule, J G 126 hrebs, 1 18 hunhel, 11 G 136 huster E. 118 Otta, 32 Ottolenghi, CE,99 101 Patent, L. 54 Persol, G 1,7 Pohomy L Pabend, J, 3 76 POCTITE, VI 33 Pouzet, AL F, 100 101 Powell,SD 104 ·Author Index 159 Rahn, CB 107 Rahman 1 69 Ropp 1 11 84 87 Rozd, R 133 Rebaud, 104 Renault 117 Reynol 132 Reiflund, F., 104 Richard, 1,63 Rochet A 147 Robbins, L. L. 63 Romani, 48, 61 69 Roret LS 1 Rose 107 Tunsing, 130 Tl1c cnot Im 39 62 Thorus, AR, 13B Thompson, V P. 60 Tleoz, r. 138 Tillaus P J. 113 130 Tillmann, H 129 132 Trelli, L. 101 Tupman, GS, 104 Vacquez, ut Valentine B36 Valls, S, 99 Ian Vech, A1 42 92 Vars, I D. 34 1 han, G T, 61 Vincent, J. 18 Vireria, VI J.63 Volancoli, G., 42, 43 93 101 Sancho Olmos, 143 Sarpd r. 36 Schaap C. 36 Schutz, F. 33 Schiff A., 69 Schlingenlufer F, 36 Schoolheli, B L 30 Schuchardt, h. 118 Scotr, 11.00 Selalonch, l. Sell off J L 107 Serrat, J 104 Scrirer 11. 113 Sharps, 11, 49 Sinberg S5? Sloane, D. 36 Sloane, VIF, 36 Siderlund, G 99 Sorrel E. 104 Sorrel Dejerine, Alme. 104 Sadfelt, 132 Stewart, VLJ., 58, 60 67 69 Scorson, L. 48, 58 Sutton, B., 9 9 B2 119 Wachomuth 54 11 aldey er 11, 10 Valtter C 67 11 cir RF. 138 Il est, J 11 132 I crterbom, A, 48, 61 67 72 Wilhelm, RS4 Illet, E, 114 Wilms, 11, 132 Vinkler H., 84 87 1 alfing 41 43 92 Taumg H H, 136 Zecharas, V, 138 Zaffagnini, A, 99 Zeitlm, ad 43 45 Zelever 101 Zwicker 36

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·Subject Index Acetabulum, 1 fractured, 18 56-57 See also Fractures, of acetabulum mensions for approach to, 147 otropelnac protrusion of 29 '-40 66 Adenocarciom, metastatic, 110 Adokexet apophysiolovys, 76–87 Alls en 08 Anatomi 1-11 Aneurysm, gluteal, 114 Anomalocs of hip pathogenesis of 25 Apophytolyta, 76-87 dynamics of 80-83 healmg of 84-87 Enchienet of 76-80 Apophystrs, 92 Artener, 2-10 injun to, 113 Arthrits, with fractures of acetabulum, 67 with Ottos pelias, 33 Arulsion factures, of schial spme 53 of schul tuberosty +9 76-87 Cyrt of schrum, 135 Chic hygroma, 118 Dashboard facture of acctabular ron, 37- 61 Decubitus ulcers, 123-198 Delannoy ssdlgn., 68 Dostot s sign 67 68 Dynamic balance in adult pelaks, 81 Dysplou, epiphyseal, 43 Dyrtoch, auses of 25 39 5? Earles sige, 61 69 Echinocactus, Ottos peltis after 36 Endocrmc disorders, ind apophysołysa, 80 Epiphyseal dysplus12, 43 Epphuis of schal tuberosity 3 Epiphysis, 80 Ei olution of pelv. girdle 1-2 Evmga tumor 136 Examination, physical, 12-16 roentgenogriphis, 16-23 Esostoses, 131 Bed sores, 123-128 Blood vessels, 9-10 mjanes to 113-115 Bodi of rchum, +6 fnctured, +252 Bn at strangle, 13 15 Baruco Bursus, 117-122 Fake dongnosis of acetabulur fructures, 18 30 Fake schuin vuru, 18 Fail hip intrauterine prepare affecting hap Calification, peruschbl, 120 Cartnoma, metestaus, 170 Childhood, deformitios m, 29 schropubsc oacochondrra m, 42-46 schium in, } 19 piogli osteomelits n, 98 Chondroblastoma, 136 Chondromas 131 Chrobach pela, 32 Fibrome, 130 Fibrosarcoma, 13B Formen, laser acroscutk, ? Fructures, of acetabulum, 56-57 central, 37 61-67 fake dragnosis of 18,30 and Ottos pelra, 37 of rim, 57-61 irulson, of schaal spmc 5} of schaal tuberosity +916-87 schioscctabolar 67-72 161 ·162 infuries and Surgical Diseases of the Ischlum Lightermana disease, 118 Lipotus, congenital, 130 Lomi i ngt, 67 68 Factures, (Comd) of mchum, 48-72 body 49-52 DUMA, 5+36 ping, 52-54 narch fructure of schul muros, 54 preudofncture of Schmur, 28 Kress fructure of schul numas, 54 Fupon, in Ottos pelvis, 40 Victthonter incalon, 148 Varch fructure of schbal mur, H llettatus of tumor, 140 Varphy incoron, 148 Alascles, attachments to airfaces of to pum, 4 itukson fractura, of sschlal sobre, of schbal tuberosity 49 76-87 mjunes to 115 Vlychana, 136 Gibron lactoon, 148 Gluteal arterios, mjurv to, 113 Gonococcus infection, Ortos petri after Gncils Togtoos, 89-91 Nekenan mfection, Oxtos pelis ifte Nelaton i lone, 13 14 Neng, 11 mjuna to 115 Hanipestctomm 133 Hip pathogenesis of momales of 25 Hygroma, cystic, 118 Inom, fractured, 48 JACKSOT, interior llofcron), 147 Gibson, 148 gobla-shaped, 143 Langenbeck, 140 lateral irafcmon), 147 Laer 148 longitudmal, 146 AlclVhorter 1.18 Vurphy 148 oblique, 146 perinci, 149 posterior Nofemoral, 147 Sunith Petersen, 147 transversa, 145 Ushaped, 148 Witoo-Jona, 147 lajane. Ser Fractura and Toure Intrautermo presure on fetal hip effects of 25 Iechal body +6 factured, 49-52 Lechul nou, 6 fructured, 54–56 local pare, 6 fructured, 52-54 kchal rubcronity 6-7 aruldon fructure of 49 76-87 cpiphyes of 3 Ischrectomy 150-154 Ischuocetubular fractures, 67-72 Lochopubsc cortcochondrots, 42-46 Lochrom UUT, 24-40 fake, 18 25 28 trove, 7+23 Obturator urter 9 Obmarator nerve, 11 Obeurtor vem, 10 Occupacional burstades, 118 Ossification of mommare bone, Ostetta, 91-94 deforpeans, 91-97 hyperplasice, 94-97 perngcitis, 88-89 Osccroarthrit, after fracture of toetat l, 67 Osteochondrits, chropubk 41-46 Osteochondrom, 131 Osteoclastoon, 133 Osteogenic crores, 131 Ortcold artcort, 133 Osteornes, 131 orcold, 133 Osteomyelit, Ottos pelro after 36 Plagerk, 19-10 ruberculous, 10+111 Ontos pelvt, 19 37-40 60 etiology of 36-40 was study of 34-36 Puget e decare, 01-97 Pubry peronteal, 115 Paraplegres, decubitus uken in, 123 Pathogeness of anomalies of hup, 25 Pers, natomy of 1-11 dynamic balance in B1 Purtriting mun, 113 Perlaci! Incision, 149 Permasters of baturum, 68-99 Perposal paly 115 Perche diens, fube wctum rum in, 27-29 Phytal mindor, 12-16 Prosure mora, 123-128 heudofracture of Bettiom28 Lam , lpx 21 Langenbeck mcmon, 146 Lache turnen bottom 118 Leer mcdon, 148 Ligunt, 7-9 ·Subject Index 163 Pubis, facturca, 48 nachropubic osteochondt, 12-46 Pubofanonl line of Shenton, 'I Pubo-rchade plate, 1 Progenxc oscomments, 98-10 Ratus of ischtum, 6 fructure, st-56 Rectal cumination, 11 Resection, 150-154 Resection-angulation operation, m Ottos pelit, +0 Roentgenographic cumination, 16-23 intcrror oblique 22 interoposterior 17-22 lateral, 23 of Ortos pelva, 37-36 posterior obliquc, 22 Roussign, Gt 68 Soft toue injuries, penschial 113-116 Spme of chrum, 6 fracture, 52-54 Stub Houck, 113 Stress, and factures of schtal rumus, St ind ichropubic ostcochondrk, 43-44 Subgluteal tungic, 13 Sorgen 145-157 m atended aren, 146-154 hemspelrectomt 153 Incasions for See Incisions m loalred arm, 145-146 in Otros pelis, +0 Itactan, 150–154 rotection angulation openton in Ottos pelras, 40 Trum, ind Ottos peluts, 36–37 of soft tispores, 113-116 tumors after 140 Tuberculous couto, Otto a pels after 36 Tuberculous osteomyelit, 107-111 Tuberosity of schrum, 6-7 irulsion fracturt of +9 76-87 epiphvus of 3 Tumor, 129-14 benign, 129-136 malignant, 136-142 1fter trauma 1-10 Sucroscate formen, losser 6 Sacroscan ligmeties, 7 SacTopmous ligament, & Sacrotuberon ligament, 7 Sucrum, fractured, 48 Sarcom 136 Scan nene, injunes to 115 pun, wrth tons of uschrum 132 1+0 Shentons pubofemonl lunc, 21 Shock theropi acetabular fncture after 38 Sign, Als 68 Brints, 13 15 Delannos, 68 Destots, 67 68 Earle ,, 64 69 Lamy s Inc, 21 Loden 67 68 \clatons Ime, 13 14 Roat , 67 68 Shenton ilme, 1 Smith-Petersen inersion 147 Ulcers, decubitus, 123-128 Vaginal commation, 12 I eins, 10 Icock, mora to 113-115 Il tron Jonds mcmion 147 Wavers bottom, 118 In cummatron, 16-23 of Ortos pelvu, 14-16

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