De Medicina

20 Since I have described the above, I can be held also to have described displacements in the legs: for in this kind of accident also there is some similarity between the thigh and upper arm, between the tibia and ulna, between the foot and the hand. But there are also some special points to note about the legs.

The thigh-bone may be moved out of place in all four directions, oftenest inwards, next outwards, very rarely forwards or backwards. If it has been dislocated inwards, the leg is longer than the other, and is bowed; for the point of the foot looks outwards;

if outwards, the leg becomes shorter and knock-need, and the foot is inclined inwards; the heel in walking does not touch the ground, but only the extreme end of the sole; the leg in this case supports the rest of the body better and more uprightly than in the other and there is less need for a stick. If forwards, the leg is extended and cannot be bent; as far as the heel the injured leg is the length of the other one, but the extremity of the sole is less bent forward; and in this case there is marked pain, and very often the urine is suppressed. When the inflammation and pain have subsided, the patients walk fairly and the whole of their foot touches the ground. If backwards, the leg cannot be stretched out, and is shorter; when the patient is standing the heel in these cases too cannot touch the ground. But the great danger with regard to the thigh is that it is difficult to replace, or, after replacement, slips again out of position. Some hold that it always does so; but such renowned authorities as Hippocrates and Diocles and Phylotimus and Nileus and Heracles of Tarentum have related that they had completely restored such cases; nor would Hippocrates, Andreas, Nileus, Nymphodorus, Protarchus, Heraclides, and a certain smith as well, have invented so many sorts of instruments for making extension on the thigh after this accident, if it had been all of no use. But although that opinion is a false one, there is this truth in it: since the ligaments and muscles there are very strong, if they retain their strength they scarcely allow of replacement; if not, they do not keep in place afterwards. Replacement, then, is to be attempted; and if the limb is weak it is sufficient to stretch it by straps, one from the groin, another from the knee; if stronger, the assistants will have more purchase if they have knotted the straps around long poles; and if after pressing the lower ends of the poles against firm supports, they have drawn the upper ends towards themselves with both hands. Even more forcible pressure can be exerted by stretching the limb over a bench, at either end of which is a windlass to which the straps are attached; when these are rotated as in a winepress, it is possible, by continuing to do this, even to rupture the ligaments and muscles, and not merely to stretch them. Now the patient is to be laid upon this bench, on his face or back or side, so that that part is always the higher into which the bone has slipped, and that from which it has receded the lower. When the sinews have been stretched, if the bone comes forwards, some round object is placed over the groin and the patient's knee must be pulled back over it with a jerk, in the same way and for the same reason for which this was done in the case of the forearm; as soon as the thigh can be bent up, the bone is in place. In the other cases, when the bones under extension have receded a little from each other, the surgeon should force the projecting part back, whilst an assistant presses the hip in the opposite direction. When the bone is replaced nothing further need be done, but the patient must be kept in bed for a rather long time or the thigh may become displaced again on moving while the sinews are still relaxed.

21 It is very well known that the knee is put out externally and internally and backwards. Many have written that it does not slip out forwards; and this may be very near the truth, for the knee-cap

is there right in front and holds the head of the tibia in place. Meges, however, has recorded a case in which he replaced a knee which had slipped forwards. In cases affecting the knee-joint the sinews can be extended by the same means as I have described for the thigh. And when it has slipped out backwards, as described above, a round ball of some kind is placed on the ham, and when the leg is bent up over it, the knee slips back again. In the other cases it is to be replaced by the surgeon's hands while the bones are being drawn apart in opposite directions.