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Name: Class: Date:

Chapter 06: Refrigerant System Components/Servicing System Components

1. The compressor separates the low side from the high side of the system.
a. True
b. False
ANSWER: True
POINTS: 1

2. An H valve is often referred to as a block valve.

a. True
b. False
ANSWER: True
POINTS: 1

3. If the evaporator is starved, superheat is very high.

a. True
b. False
ANSWER: True
POINTS: 1

4. Tubing with a nylon lining can be used with R-12 (CFC-12), R-134a (HFC-134a), and R-1234yf (HFO-
1234yf) refrigerants.
a. True
b. False
ANSWER: True
POINTS: 1

5. Removing spring lock fittings on refrigerant lines requires a special tool.

a. True
b. False
ANSWER: True
POINTS: 1

6. O-rings will not usually leak if they are reused.

a. True
b. False
ANSWER: False
POINTS: 1

7. The correct oil for use with R-134a is mineral oil.

a. True
b. False
ANSWER: False
POINTS: 1

8. Most early R-12 hoses were not barrier hoses.

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Chapter 06: Refrigerant System Components/Servicing System Components

a. True
b. False
ANSWER: True
POINTS: 1

9. The EPA requires the replacement of hoses or seals during the retrofit of a vehicle from R-12 to R-134a.
a. True
b. False
ANSWER: False
POINTS: 1

10. The expansion valve regulates the evaporator temperature based on the thermal heat load it detects.
a. True
b. False
ANSWER: True
POINTS: 1

11. Sub-cooling or super-cooling condensers can be found on some R-134a systems.

a. True
b. False
ANSWER: True
POINTS: 1

12. If R-1234yf refrigerant recovery/recycling/recharge (R/R/R) equipment detects the refrigerant in a system is less than
90% pure it will not allow recovery to proceed.
a. True
b. False
ANSWER: False
POINTS: 1

13. Refrigerant enters the compressor as a

a. high-pressure vapor. b. low-pressure vapor.
c. low-pressure liquid. d. high-pressure liquid.
ANSWER: b
POINTS: 1

14. Technician A says a receiver-drier is used in systems with a fixed orifice tube. Technician B says the receiver-drier
stores reserve refrigerant. Who is correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: b
POINTS: 1

15. Before installation: Technician A says that refrigerant system O-rings should be coated with new refrigerant oil.
Technician B says refrigerant system O-rings can be coated with a gasket sealant. Who is correct?
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Chapter 06: Refrigerant System Components/Servicing System Components

a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: a
POINTS: 1

16. Technician A says the amount of refrigerant flowing through an orifice tube is controlled by a remote sensing bulb.
Technician B says the orifice tube is located in the liquid line between the condenser outlet and evaporator inlet. Who is
correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: b
POINTS: 1

17. Technician A says that the thermostatic expansion valve may be located anywhere between the evaporator outlet and
the compressor inlet. Technician B says that fixed orifice tubes sizes are interchangeable in order to tailor system
performance. Who is correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: d
POINTS: 1

18. If a system has a thermostatic expansion valve, it will also have all of the following parts, EXCEPT:
a. accumulator. b. compressor.
c. condenser. d. receiver-drier.
ANSWER: a
POINTS: 1

19. The term purge an air-conditioning system in general terms means to:
a. Add sealant to the refrigerant system
b. Recharge the refrigerant system
c. Flush the refrigerant system.
d. Remove the refrigerant from the system.
ANSWER: d
POINTS: 1

20. All of the following are reasons why a flooded evaporator will not cool well, EXCEPT:
a. High pressure in the evaporator prevents refrigerant vaporization.
b. There is no space for expansion.
c. The refrigerant vaporizes too quickly.
d. The refrigerant cannot take on much heat.
ANSWER: c
POINTS: 1

21. Before attempting to service an automotive air-conditioning system consider all of the following Except:

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Chapter 06: Refrigerant System Components/Servicing System Components

a. Can customer afford the repair?
b. Do you have the proper tools and equipment to service the system?
c. Listen to customer complaint.
d. Does your diagnosis make sense based on customer complaint.
ANSWER: a
POINTS: 1

22. Most vendors will not honor the warranty on a new or rebuilt compressor unless the ____ is replaced at the time of
service.
a. accumulator b. receiver-drier
c. expansion valve d. a or b
ANSWER: d
POINTS: 1

23. On an expansion valve system the valve opens and closes in relation to ______ temperature and pressure.
a. compressor
b. evaporator
c. accumuator
d. any of the above, depending on the manufacturer
ANSWER: b
POINTS: 1

24. Refrigerant leaves the evaporator as a

a. high-pressure vapor. b. low-pressure vapor.
c. low-pressure liquid. d. high-pressure liquid.
ANSWER: b
POINTS: 1

25. A flooded evaporator can cause damage to the

a. compressor. b. condenser.
c. expansion valve. d. receiver-drier.
ANSWER: a
POINTS: 1

26. Once the refrigerant from the air conditioning system has been recovered, which of the following should the
technician do?
a. Check the purity of the refrigerant in the recovery tank.
b. Change the recovery unit fiters.
c. Record the amount of refrigerant oil removed from the system.
d. Change the receiver-drier.
ANSWER: c
POINTS: 1

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Chapter 06: Refrigerant System Components/Servicing System Components

27.

Technician A says the illustration above shows an orifice tube being removed. Technician B says the illustration above
shows an expansion valve screen being removed. Who is correct?
a. Technician A only
b. Technician B only
c. Both A and B
d. Neither A nor B
ANSWER: a
POINTS: 1

28.

Technician A says the valve at "A" is internally equalized. Technician B says the valve “B” is externally equalized. Who is
correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: c
POINTS: 1

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Chapter 06: Refrigerant System Components/Servicing System Components

29.

Technician A says the tool shown is used to unlock spring-lock coupling air conditioning lines. Technician B says the tool
can also be used to lock the coupling together. Who is correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: a
POINTS: 1

30. Technician A says in an H-block valve the temperature sensing sleeve (bulb) is internally located in the outlet port of
the valve. Technician B says the operation and function of the H-valve, or block valve, are essentially the same as the
thermostatic expansion valve (TXV). Who is correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: c
POINTS: 1

31. The refrigerant from a vehicles A/C system is being recovered into a recovery unit. Technician A says that both the
vapor and liquid tank valves on the recovery unit should be OPEN. Technician B says that both the high-side and low-side
gauge valves on the manifold and gauge set should be OPEN. Who is correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: c
POINTS: 1

32. Technician A says there are several condenser designs and flow paths in use today. Technician B says the only flow
paths for refrigerant through the condenser’s tubing is the multi-pass flat tube parallel cross flow. Who is correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: a
POINTS: 1

33. Desiccant is being discussed. Technician A says all three manufacturer-approved refrigerants use the same desiccant.
Technician B says the desiccant in an accumulator can be replaced without replacing the accumulator. Who is correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: d
POINTS: 1

34. A leaking evaporator is being replaced. Technician A says the new o-rings should be coated with clean refrigerant oil.
Copyright Cengage Learning. Powered by Cognero. Page 6
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Chapter 06: Refrigerant System Components/Servicing System Components

Technician B says the some refrigerant oil should be added to the system prior to recharging the system. Who is correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: c
POINTS: 1

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Chapter 06: Refrigerant System Components/Servicing System Components

35.

Refer to the figure above. Technician A says that the component identified by A is an expansion valve. Technician B says
that the component identified by D is an evaporator. Who is correct?
a. A only b. B only
c. Both A and B d. Neither A nor B
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ANSWER: a
POINTS: 1

36.

Refer to the figure above. Technician A says that the component identified by B is the condenser. Technician B says that
Copyright Cengage Learning. Powered by Cognero. Page 9
Name: Class: Date:

Chapter 06: Refrigerant System Components/Servicing System Components

the component identified by C is the accumulator. Who is correct?
a. A only b. B only
c. Both A and B d. Neither A nor B
ANSWER: d
POINTS: 1

Copyright Cengage Learning. Powered by Cognero. Page 10

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Chapter 06: Refrigerant System Components/Servicing System Components

37.

Refer to the figure above. Technician A says that the refrigerant at point 1 is a high pressure liquid. Technician B says that
the refrigerant at point 2 is a high pressure liquid. Who is correct?
a. A only b. B only
c. Both A and B d. Neither A nor B
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Chapter 06: Refrigerant System Components/Servicing System Components

ANSWER: b
POINTS: 1

38.

Refer to the figure above. Technician A says that the refrigerant at point 5 is a low pressure vapor. Technician B says that
Copyright Cengage Learning. Powered by Cognero. Page 12
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Chapter 06: Refrigerant System Components/Servicing System Components

the refrigerant at point 4 is a high pressure vapor. Who is correct?
a. A only b. B only
c. Both A and B d. Neither A nor B
ANSWER: c
POINTS: 1

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Chapter 06: Refrigerant System Components/Servicing System Components

39.

Refer to the figure above. Technician A says that the refrigerant at point 6 is a low pressure vapor. Technician B says that
the refrigerant at point 3 is a high pressure vapor. Who is correct?
a. A only b. B only
c. Both A and B d. Neither A nor B
Copyright Cengage Learning. Powered by Cognero. Page 14
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Chapter 06: Refrigerant System Components/Servicing System Components

ANSWER: d
POINTS: 1

40. Desiccant is being discussed. Technician A says the desiccant is integral to the condenser on some systems.
Technician B says that if the desiccant is of the non-serviceable type the entire condenser has to be replaced during a
system flush. Who is correct?
a. Technician A only b. Technician B only
c. Both A and B d. Neither A nor B
ANSWER: c
POINTS: 1

41. If the refrigerant system is suspected of being contaminated with moisture what component should also be replaced?
ANSWER: If the refrigerant system is suspected of being contaminated with moisture it is recommended that the
accumulator/receiver dryer be replaced
POINTS: 1

42. Why must the condenser outlet be at the bottom?

ANSWER: To ensure that only liquid refrigerant leaves the condenser
POINTS: 1

43. Why is the remote bulb of a thermostatic expansion valve attached with insulated tape to the refrigerant line?
ANSWER: To keep it from sensing the ambient air
POINTS: 1

44. Define desiccant.

ANSWER: Desiccant is a chemical drying agent that can absorb and hold moisture.
POINTS: 1

45. Define heat load.

ANSWER: Heat load is the amount of heat, in Btus, to be removed.
POINTS: 1

46. Describe the two major functions of the air conditioning system compressor.
ANSWER: To pressurize the refrigerant for condensation; to circulate the refrigerant throughout the system
POINTS: 1

47. What effect will bent cooling fins on the condenser have on the refrigerant system?
ANSWER: The efficiency of the condenser affects the overall performance of the refrigerant system.
POINTS: 1

48. What type of desiccants are acceptable for use on R-134a systems?
ANSWER: Only XH7 and XH9 desiccants are acceptable for use on R-134a systems.
POINTS: 1

49. What is the purpose of the evaporator?

ANSWER: The purpose of the evaporator is to cool and dehumidify the incoming air when the air conditioning system is
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Chapter 06: Refrigerant System Components/Servicing System Components

operating.
POINTS: 1

50. What is meant by the term starved evaporator?

ANSWER: A starved evaporator is the result of too little refrigerant being metered to the evaporator, resulting in poor
cooling.
POINTS: 1

51. What component is generally used on R-1234yf systems but can also be used on R-134a systems to improve
efficiency of smaller systems?
ANSWER: IHX-The internal heat exchanger
POINTS: 1

52. Describe what happens to the refrigerant within the evaporator.

ANSWER: Heat from the air flowing over the evaporator is transferred to the refrigerant. The liquid refrigerant is under
low pressure at the entrance to the evaporator. The heat causes the refrigerant to evaporate, changing the
refrigerant to a low-pressure vapor.
POINTS: 1

53. What is a barrier hose and when must one be used?

ANSWER: Hoses are usually made of synthetic rubber covered with nylon braid for strength and have an inner lining of
nylon to ensure integrity and to form a barrier wall to prevent refrigerant leakage. This hose design is
classified as a barrier hose and is found on all R-134a refrigerant systems.
POINTS: 1

54. What is the function of the orifice tube?

ANSWER: The orifice tube establishes a pressure differential at the restriction, with the high-pressure liquid line and
condenser on one side and the low-pressure liquid line and evaporator on the other side.
POINTS: 1

55. What is the function of the evaporator case drain vent?

ANSWER: During normal system operation, moisture collects on the surface of the evaporator and collects in the HVAC
housing. This moisture then drains out a vent in the bottom of the case assembly. It is normal to see a puddle
of water forming under a vehicle while the air conditioning is operating; the puddle indicates that the drain
vent is not blocked. A blocked vent can lead to moisture building up in the case, causing bacterial growth and
odor as well as water dripping into the passenger compartment.
POINTS: 1

56. What is a flooded evaporator and how does it occur? What are the results of this condition?
ANSWER: A flooded evaporator is the result of too much refrigerant being metered to the evaporator by the metering
device. As a result, the flooded evaporator will not cool well because of higher pressure in the evaporator
preventing the rapid boiling of the refrigerant. A flooded evaporator can also cause compressor damage if
liquid refrigerant enters the compressor assembly. A faulty metering device or an overcharge of refrigerant are
the general causes of a flooded evaporator.
POINTS: 1

57. What is the function of the modulator used on some air conditioning systems?
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Chapter 06: Refrigerant System Components/Servicing System Components

ANSWER: It separates the refrigerant in the middle of the cycle after the first pass that is still in the gaseous state and
recirculates it with liquid refrigerant to cool it again which enables almost 100% liquid refrigerant too pass on
to the metering device.
POINTS: 1

58. What is the difference in the evaporator design used on R-1234yf air conditioning systems?
ANSWER:
Evaporators on R-1234yf systems must meet more stringent SAE J2842 which imposes sever durability
testing due to the fact that the refrigerant is mildly flammable. If an evaporator is removed on an R-fa system
it must be replaced. No used or repaired evaporators should be used on a R-fa system.

POINTS: 1

Copyright Cengage Learning. Powered by Cognero. Page 17

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 Fig. 264

Talipes valgus.

There are tender points over the astragaloscaphoid joints, at the

base of the first and fifth metatarsals, in front of the internal
malleolus, as well as often beneath the heel. Patients who thus
suffer find that the feet perspire very easily. In walking the feet are
everted, and when tenderness is very great it is because too much
weight is borne on the inner borders of such everted feet. Inspection
of the shoes will also show wearing of the inner border and over the
inner malleolus.
Spontaneous cure of such cases does not occur, except perhaps
after long confinement in bed from other causes, but patients
occasionally become tolerant after a time, though many of them
grow steadily worse and avoid using the feet more than is absolutely
necessary.
Treatment.—Mild cases will be benefited, often practically cured, by
simply raising the inner border of the sole and heel of the shoe. This
causes more weight to be borne on the outer border than in the
natural attitude of the foot. It will be sufficient usually to make from ³⁄₈
inch to ⁵⁄₈ inch difference in the level between the inner and the outer
borders of the sole and heel. Shoes may be so constructed that this
difference is made invisible, or suitably bevelled narrow strips of
leather may be sewed beneath the sole along the inner side, or laid
in between its upper and lower layers.
While this suffices for the milder cases it is not sufficient for the
more severe cases, which require forcible correction, and often
under an anesthetic. The best way to accomplish this, after having
patients thoroughly relaxed with chloroform, is to make a thorough
manipulation of the foot, trying especially to so loosen its outer
ligaments that it may be more easily put in proper position and finally
overcorrected. The foot is then put up in plaster of Paris in this much
overcorrected position. Such splints are worn for five or six weeks,
after which suitable shoes should be provided, either with their inner
borders elevated or with metal flat-foot plates inserted, or both.
These plates are now in general use, and may be procured from
instrument dealers and in shoe stores. In particular cases it is
advisable to make a mold of the lower aspect of each foot, to have
this cast in iron, and then over the iron model to have a suitable
metal plate hammered so that it shall exactly fit the individual for
whom it is intended.
Only in extreme cases, rebellious to other treatment, has it been
shown necessary to resort to such treatment as division, by
osteotomy, of the neck of the calcis or of the astragalus.
 Most of these cases may be benefited subsequently by
gymnastics and massage, i. e., by stretching the contracted
gastrocnemius, if necessary, with some mechanical device, and
improving the general condition of the leg muscles by suitable
massage.
Metatarsalgia; Morton’s Disease.—Under this name has been
described a peculiar painful
affection of the third and fourth or the fourth and fifth toes, which
gives rise to constant sensitiveness and sometimes attacks of acute
pain, especially when the foot is shod, and which is often only
relieved by immediately removing the boot or shoe. These affection’s
are more common in the upper walks of society, especially among
women who are disposed to cramp their feet in shoes which are too
small for them. Aside from the location of the pain there will often be
found a tender spot at the point of greatest complaint. As these
cases become worse pain radiates farther and farther up the leg,
and may even assume the type of a sciatica.
Careful inspection usually reveals either a mild degree of flat-foot,
or of distortion by which the anterior part of the foot is broadened
and held in a depressed position—or else the dorsal part of the foot
is depressed behind the anterior part; there is also usually limitation
of dorsal flexion of the foot and plantar flexion of the toes.
Morton, who first described the affection as having a peculiar type
of its own, thought it due to entanglement of the external plantar
nerve between the heads of the fourth and fifth metatarsal bones,
and recommended for its relief excision of the head of the fourth of
these. The etiology of the affection is not always apparent, but it is
sometimes due to what has been described as a non-deforming type
of club-foot, while in practically all other instances it is in some way
connected with the use of badly fitting footwear.
—Without proper treatment it does not subside. A really weak and
pronated foot should be supported with a proper plate and elevation
of its inner border, while a short gastrocnemius should be stretched.
Only in extreme cases or when these milder measures have failed
need resort be had to Morton’s suggestion and excise the head of
the fourth metatarsal.
 Fig. 265 Treatment. —In this
3. Talipes Equinus.condition
the equinus position is simulated,
and the patient walks upon the
anterior part of the foot only,
perhaps even upon the ends of
the metatarsal bones. While the
congenital form is extremely
uncommon the acquired form is
that which commonly occurs.
Appearing thus in all possible
degrees it may in mild cases
cause merely a slight limp, while
the extreme cases cause a
pronounced deformity and
alteration in gait. The actual
condition is one of shortening of
the tendo Achillis through
contraction of its component
muscles, with corresponding
change in shape of the bones of
the foot. There is also more or
less shortening of the plantar
aponeurosis, and depression of
the astragalus, which is drawn
down upon the calcis (Fig. 265).
Causes.—Perhaps the most
common cause is paralysis,
either of infantile or cerebral and
Talipes equinus.
spastic type, of the anterior
muscles of the leg, the condition
being simulated sometimes in hysteria. The spasm which follows
disease of the ankle-joint may also produce it. It may be the result of
muscle contraction after fractures or even after certain fevers, the
foot dropping naturally into this position and remaining there
altogether too long. Hence may be seen the necessity for putting the
foot in the right-angle position whenever the lower limb is dressed in
plaster or other rigid dressings after fracture. Talipes equinus may
also be due to injury to and loss of power in the anterior muscles of
the leg, or it may be compensatory, as when one leg is longer than
the other. In any of these events the body weight is borne on the ball
of the foot, and some degree of arching of the foot, which may be
excessive, is sure to occur.
Treatment.—In the milder cases, when seen early, it may be
sufficient to thoroughly and repeatedly stretch the sural muscles, but,
in the more severe forms, tenotomy of the tendo Achillis, with
subcutaneous or perhaps open division of the plantar structures, will
be needed. In paralytic cases tendon grafting (q. v.) will be required,
probably with one or more of the measures mentioned above. In
some instances nerve grafting might be profitably employed. After
recovery from operation, braces adapted to each particular case will
in all probability be required, at least for a time.
4. Talipes Calcaneus.—In this deformity the anterior part of the
foot is drawn upward by its anterior flexors
and a little to the outer side, while the sural muscles are relaxed;
thus the patient walks upon the heel. The condition is often more or
less combined with talipes valgus. It is rarely of congenital origin, but
is generally due to paralysis of the distal muscles following injury or
poliomyelitis. It is sometimes of hysterical origin, and it may occur as
the result of muscle spasm following bone or joint disease (Fig. 266).
 Fig. 266 Fig. 267

Talipes calcaneus. Pes cavus, hollow clawfoot.

Those forms due to infantile paralysis are to be treated mainly by

tendon grafting or some similar expedient, and this to be followed by
a suitable shoe containing a sole plate with an upright attachment
and a joint opposite the ankle. Other forms must be treated, each on
its own merits, but according to general principles already
enunciated.
Pes Cavus.—Here the anterior part of the foot is drawn backward
and the plantar arch made much more prominent. It
may even be converted into a Gothic arch. Extremes of this type are
seen in the feet of Chinese women. One form is due to contraction of
the peroneus longus, owing to paralysis of the sural muscles, by
which the long flexors are permitted to work to extra advantage; and
yet another form is often of congenital origin, having its explanation
in paralysis of the interossei and other small intrinsic muscles of the
foot (Fig. 267).
When an ordinary metal sole plate fails to give relief a
subcutaneous or open division of the contracted structures may be
practised.
 CONGENITAL MISPLACEMENT (DISLOCATION) OF THE HIP.
Perhaps a more proper name for this congenital deformity would
be “misplacement” rather than dislocation. It is seen much oftener in
females than in males. It may be either unilateral or bilateral. The
displacement is usually upward and backward upon the dorsum of
the ilium. In rarer instances it is anterior and sometimes the head of
the femur lies not far away from the anterior superior spine of the
ilium.
Regarding its cause absolutely nothing is known. It represents
defective development rather than arrest, and is a condition of intra-
uterine life. The acetabulum is usually found incomplete, but whether
this is the cause of the misplacement or whether it fails to develop
because of the absence of the head of the femur from this cavity it is
not easy to decide. The influence of heredity in these cases is
undeniable, for it is known to have prevailed in certain families. Thirty
years ago but little was known in regard to the affection, and nothing
could be done to atone for it. Of late years it has been the subject of
special study by numerous investigators (Figs. 268 and 269).
 Fig. 268

Double congenital displacement of the hip. Buffalo Clinic. (Skiagram by Dr.

Plummer.)
 Fig. 269

Skiagram of coxa vara; deformity most marked at the epiphyseal junction. This
illustrates the mechanical limitation of abduction caused by the deformity, and the
compensatory tilting of the pelvis. (Whitman.)

Pathological changes are noted in the capsule itself, as well as in

the bony components of the joint. Thus the capsule is usually
elongated and stretched out of shape, while its lower portion may be
adherent to the margin of the acetabulum or may be shut off into a
small cavity by itself, this cavity having but a small connection with
the balance of the capsule and affording irresistible obstacles to
reduction. With changed joint relations the muscular arrangements
are also changed, some being lengthened, others shortened, as
would naturally follow from the approximation or separation of their
points of origin and insertion. Fig. 270
Conspicuous change is seen in
the upper end of the femur,
which is often atrophied, while
the neck is shorter than normal,
its angle lessened, and the head
of the bone often altered in
shape. A secondary acetabulum
is in time formed and is usually
found upon the side of the ilium.
This is shallow and insufficient to
ensure firm support for the head
of the femur, even were this well
developed. Aside from these
changes the pelvis is usually
poorly developed on the affected
side, its inclination increased, the
sacrum forced forward and
downward, the pelvic outlet
widened, while a considerable
degree of lumbar lordosis is
present (Fig. 270).
The condition is rarely noted
until a growing infant begins to
learn to walk. The condition is
one which has no symptoms,
only signs, and these do not at
first attract attention. Sometimes
it will have been noted that there
is an abnormality about the hip,
with too free play, or a snapping
sound about the joint. When the
condition is unilateral there is a
marked limp which increases
with the age of the child. With
each step the femoral head is
Congenital misplacement, with
pushed upward on the side of
consequent atrophy and shortening.
the ilium, and, in consequence, (Calot.)
the pelvis is tilted toward the
outside, as well as twisted downward and forward. The limb being
thus actually shortened, the limp or waddling gait is easily accounted
for. Along with it there is usually flattening of the tibia, while the
trochanter may be felt and often seen on a level considerably above
that where it properly belongs. Motility in the joint is abnormally free,
and with a child on its back, by alternately pulling and pushing, the
abnormally free play of the upper end of the femur may be easily
demonstrated, either with the limb in its extended or the flexed
position.
When the misplacement is bilateral the individual is more
symmetrically deformed. The lordosis is increased, the abdomen
protrudes, the thighs are separated more widely than is normal,
leaving perhaps a considerable space in the perineum; the gait is of
a peculiar waddling character, which makes locomotion apparently
difficult, although it is free from pain. In these cases abnormal
mobility of the hip may be demonstrated on each side.
As these patients grow through adolescence into maturity they
sometimes improve, but usually suffer more and more difficulty in
locomotion, while the abdominal protrusion and the lordosis become
more and more pronounced.
Three varieties of congenital misplacement are described as
backward, upward, and forward. It is in those instances where the
head of the bone rests well back or well forward upon the ilium that
the gait is most pronounced, but in all instances the great trochanter
will be found above Nélaton’s line.
Diagnosis.—The diagnosis offers few difficulties. The peculiar
waddling gait may be seen in extreme cases of bow-
legs, but then the hip-joints will be normal. Extreme lordosis may be
seen in cases of lumbar spinal caries, but here again the hip-joints
will be normal, while the spinal muscles will be rigid and the patient
disinclined to walk. Traumatic dislocations and the results of hip-joint
disease will be indicated by a history to correspond, as will also early
acute joint affections following the exanthems. The diagnosis is to be
made principally from coxa vara, considered below, and the various
defects following infantile palsy. In coxa vara there is no
corresponding abnormality of motion, while in the paralytic cases
there will often be failure in muscle power, which is not present in
cases of congenital misplacement. Finally in instances which offer
difficulties the Röntgen rays now afford a method of diagnosis.
Treatment.—For a long time after this condition was recognized
its treatment was unsatisfactory, and it was not until
Hoffa, about fifteen years ago, advanced his operative method of
relief that surgeons felt at all like advising operation in well-marked
cases. Then came Paci and Lorenz, first with improvements on the
Hoffa operation, and then with a method of so-called “bloodless”
reposition, which has been under severe test and testimony. Last of
all come Bradford and Sherman with their improved methods of
operation, which seem to me the most promising of all as well as the
most scientific.

Fig. 271

A plaster bandage applied by Lorenz, illustrating the extreme thickness of the

pelvic portion and discoloration of the adductor region. (Whitman.)
 Lorenz was doubtless correct when he stated that the principal
obstruction to reduction is the narrowed part of the capsule, just at
the upper part of the acetabulum, and that if this could be torn here
sufficiently to permit the passage of the head, reduction could be
accomplished by manipulation alone, and maintained if the
acetabulum were sufficiently deep. An almost insuperable difficulty in
most cases is, however, this narrowed capsule, and the number of
accidents, including not only fractures of the femur and the pelvis,
but various other injuries which have resulted from too great
violence, is altogether too large and too disturbing to justify the use
of such force as has often been used. Of more than one hundred
children upon whom Lorenz operated when making a tour through
the United States, but little over 10 per cent. have given anything like
ideal results; while the danger from fracture and laceration of
muscles and nerves, as well as of bloodvessels, is fully as great as
that pertaining to any open operation. It may therefore be maintained
that the percentage of success from the use of manual force without
incision does not justify the risks of the method. Sherman argues
that if we may open a knee-joint without hesitation to take out a small
piece of cartilage, we need not fear to open a hip-joint in order to
clear away a small obstacle. The patient is thereby saved from many
dangers and exposed to so few that it seems more humane and
desirable in every respect.
Sherman’s method is to make traction upon the limb, drawing the
femoral head down to a point just below the anterior superior crest,
where it can easily be felt, and to here make an incision over it in the
direction of muscular fibers so that they are not divided. After division
of the capsule the head of the bone is exposed and retractors
substituted by long loops of suture, put in on either side of the
opening in the capsules. In many cases a tenotomy of the adductor
tendons close to the pubis will also be of advantage. The leg is next
released from traction and the head of the bone allowed to glide
upward, while the finger is slipped into the capsule and down toward
the acetabulum. Upon this finger as a guide a long, straight, probe-
pointed bistoury is passed, and with it the narrower portion of the
capsule is cut through, down to the bone, taking care to not cut off
the ileopsoas tendon. The incision must be large enough to give free
access to the acetabulum. Traction is then again made with sufficient
manipulation so that the femoral head may be forced into its proper
cavity. When the head is in the acetabulum the retracting sutures are
tied together so as to close the upper part of the capsule, and other
sutures are introduced, as needed, to close the wound, leaving
space for a cigarette drain. The limb is then put into a position of
abduction of from 50 to 90 degrees, rotated in or not, as needed, and
a comprehensive plaster-of-Paris spica applied. In this both limbs or
only one may be included. The drain should be removed in two days
and the dressing left otherwise undisturbed for three months.
Bradford has added somewhat to our methods by showing not
only the arrangement of the capsule, but the fact that the acetabulum
is often filled with dense fibrous tissue which sometimes obliterates
it, and that this tissue can be curetted out, but that if it could be
utilized to aid in retaining the reduced head of the femur it would be
a great benefit. He operates as follows: The hip is subjected to
preliminary forcible stretching of all soft parts which can be stretched
by manual or mechanical force. A posterior incision is then made,
which, without dividing muscles, permits free opening into the
capsule and affords a channel to the deepest portion of the
acetabulum. The posterior wall of the capsule is then split, after
which all constricting and other obstacles at any point are carefully
divided. These may be detected by the finger, and can also be seen
by a small electric light passed down inside of a sterilized glass test
tube. The capsular wound is then retracted by deep retaining silk
sutures, placed at the lower rim of the acetabulum, thus affording a
pathway for the reduction of the head. After this has been
accomplished as described above, the sutures are tied closely
around the femoral neck, and these retain it in position. The other
portions of the split capsule are then sewed around the head and
neck, to the trochanter and fascia, in such a way as to retain the
bone where it has been placed.[37]
 [37] American Journal of Orthopedic Surgery, October, 1905.

The earlier the operation is done the better. It is necessary to

always maintain the limb in a position of well-marked abduction, and
for a long time, nor can patients be released from this at the
expiration of the first dressing period, usually twelve to fifteen weeks,
although the abduction can usually be reduced with each dressing
until at last the limbs are permitted to come together after the
expiration of nine to eighteen months. Even after the lapse of this
length of time it may be necessary to provide some form of
apparatus by which too much rotation in either direction may be
prevented, or by which pressure may still be made over the
trochanter, in order that it may be kept constantly pushed into the
acetabulum (Figs. 271 and 272).
Fig. 272
 Unilateral congenital dislocation, showing the fixation
bandage. A shoe with a cork sole about two inches in height
should be worn on the operated side, while the attitude of
exaggerated abduction is maintained. (Whitman.)

COXA VARA AND VALGA.

This term is applied to an abnormality in the shape of the neck of
the femur, consisting of a downward curvature or bending of the
femoral neck, which is thus displaced until it stands almost at a right
angle with the shaft instead of at the normal obtuse angle. At the
same time there is often posterior curvature, or sometimes an
anterior curve, of the neck, which causes a corresponding rotation of
the axis of the whole limb. The pelvic side of the hip-joint is
unaffected, the change occurring usually solely in the upper end of
the femur, the joint not being involved. It may appear in congenital
form and then may be attributed either to intra-uterine pressure or to
antenatal rickets or osteomalacia. The acquired form is usually due
to a non-inflammatory softening, or to structural changes which
permit of yielding, as above described. Doubtless different cases
have different causes, and they are not to be included in one brief
sentence. The condition corresponds to those abnormalities at the
knee which produce knock-knee and bow-leg. Were the bone as
easily examined at the upper end of the femur as at the knee the
condition would be more easily recognized. Therefore the term has
reference not so much to the results of active disease as to
deformities of congenital or acquired character. Fully three-fourths of
the cases are met with in male subjects, and the majority of these
occur only on one side. Thus of 190 quoted by Whitman, 85 were
unilateral, while only 26 occurred in females.
The more nearly the angle of fixation of the neck of the femur
approaches a right angle the further above Nélaton’s line will the
trochanter appear, and the more conspicuous this change the
greater the difficulty in abduction. Moreover, to shortening may be
added internal or external rotation, with consequent tilting of the
pelvis and compensatory alteration of the spinal curves.
Fig. 273 The disease is by no means
often of traumatic origin,
although traumatisms may
produce an arthritis deformans,
even in juvenile cases, and that
this may simulate a non-
symptomatic coxa valga is now
well established (Fig. 273).
Symptoms.—Coxa vara
produces certain
symptoms, among them pain in
the joint, radiating down the front
and inside of the thigh. If the
deformity be very marked, joint
function is impaired. Tenderness
is rarely present. When pain or
tenderness occur they may lead
to the mistaken diagnosis of
rheumatism or neuralgia. The
condition may arise as the result
of an acute ostitis, in which case
patients will be confined to bed
for some time. Actual shortening
may vary from one to one and a
half inches, while the limb will be
found adducted, the gluteal
region flattened, with a deep
curve between the trochanter
and the gluteal muscles.
Diagnosis.—The diagnosis is
to be made mainly
between this condition and hip-
joint disease or misplacement.
When abnormalities in the shape
or position of the limbs in the
young occur in a comparatively
short time, coxa vara may be
 suspected, especially in the
absence of that disability which
Coxa valga, with defective development coxitis usually produces. The
of the right femur. (Albert.) patient should be examined in
both the upright and horizontal
position. Coxa vara may have an abrupt onset, but it never produces
abscess. It is practically self-limited and will be followed, sooner or
later, by spontaneous cessation of all acute features, while coxitis is
progressive, with a destructive tendency. In coxa vara we do not
have the starting pains nor muscle spasms of coxitis, while the
actual shortening is much more marked. In doubtful cases the
cathode rays may be employed and will often greatly facilitate
diagnosis. The condition may be bilateral, but will still fail to show the
muscle atrophy so significant of tuberculous disease.
As between coxa vara and that senile form of coxitis already
described in the chapter on Joints as arthritis deformans, it should be
remembered that the latter is a disease of advanced life, while the
former occurs rather in its earlier periods. Moreover, in the former
there is no tendency to change in the femorocervical angle, no
matter what changes may occur in other respects about the joint.
When in the senile disease shortening really occurs it results from
actual absorption of bone.
Coxa vara tends usually to spontaneous cessation, which may be
considered recovery. Acute symptoms after a time subside, and
function is regained to the full extent permitted by whatever changes
have occurred in the shape of the bone. If symptoms are at all
severe they demand physiological rest in bed, with traction, and the
limb should not be used until pain has entirely subsided.
Conspicuous deformity may call for correction by subcutaneous
osteotomy made just below the trochanter. Only in exceedingly
serious cases is exsection of the joint necessary.

DEFORMITIES CAUSED BY INFANTILE PALSIES.

Deformities induced by more or less acute affections of the cord
and brain, or by hemorrhages, have assumed an ever-increasing
importance in orthopedic work. Most of them resolve themselves into
those due to acute anterior poliomyelitis and those due to cerebral
hemorrhages.

Fig. 274

Anterior poliomyelitis. Extreme flexion deformity at the hips, inducing quadrupedal

locomotion. (Gibney.)

Anterior Poliomyelitis.—Anterior poliomyelitis is an acute

inflammation manifested especially in the