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In the Tress, and nearly ready, Fifth Edition, Fcp. 8w.,
THE DUBLIN DISSECTOR,
OE
MANUAL OF ANATOMY;
COMPKISING
A CONCISE DESCRIPTION OF THE BONES, MUSCLES, VESSELS, NERVES, AND VISCERA ;
ALSO,
'Eiiz wlatibc Unatomg of tj^c liiffctcnt i^cgiong of t^c l^timan 23olig :
FOR THE USE OF STUDENTS IN THE DISSECTING-ROOM.
By ROBERT HARRISON, M. D.
New Edition, illustrated by upwards of 150 Engravings.
PART L^ANATOMY OF THE MUSCULAR SYSTEM.
Chap. I. — Dissection of the external Parts op the Head and Face External
Parts of the Head ; Dissection of the external Parts of the Face ; Vessels and Nerves of the Face.
Chap. II — Dissection of the Neck — Of the Muscles ; Dissection of the Vessels and Nerves of the Neck; of the Mouth, Pharynx, and Larynx; of the Pharynx; of the Palate and its Muscles ; of the Larynx ; of the deep Muscles of the Neck.
Chap. Ill Dissection of the Thorax — Of the Muscles on the anterior and lateral
Parts of the Thorax ; Dissection of the AxiUa ; of the Cavity of the Thorax.
Chap, IV. — Muscles of the Back.
Chap. V Dissection of the upper Extremity Dissection of the Muscles of the
Shoulder and Arm ; of the Fore-arm and Hand.
Chap. VI Dissection of the Abdomen Of the Muscles on the anterior and la- teral Parts of the Abdomen; Dissection of the Viscera of the Abdomen; of the Vessels and Nerves of the Abdomen ; Dissection of the Kidney and Ureters ; of the deep Muscles of the Abdomen; of the Perinaeum in the Male ; of the Pelvis ; of the Organs of Generation in the Male.
Chap. VII. — Dissection of the Female Organs of Generation.
Chap. VIII. — Dissection of the inferior Extremities Dissection of the Muscles
of the Thigh ; Muscles on the Forepart and Sides of the Thigh ; Dissection of the posterior Part of the Thigh ; of the Muscles of the Hip ; on the back Part of the Thigh ; of the Leg ; of the Muscles on the anterior and external Part of the Leg ; of the Muscles on the Back of the Leg ; of the Muscles of the Foot.
PART II.— ANATOMY OF THE VASCULAR SYSTEM.
Chap. I Anatomy of the Arteries Anatomy of the venous System ; of the foetal
Circulation ; of the Thymus Body ; of the lymphatic or absorbent System.
PART IIL— ANATOMY OF THE NERVOUS SYSTEM.
Chap. I — Dissection of the Brain — Membranes of the Brain ; Dissection of the
Cerebrum; of the Cerebellum or Lesser Brain; of the Medulla Oblongata. Chap. II — Dissection of the. Medulla Spinalis, or Spinal Cord. — Dissection of
the Membranes of the Spinal Cord ; of the Spinal Cord ; Origin of the Spinal Nerves ;
Dissection of the Brain from below ; Vessels of the Brain ; Origin of the cerebral
Nerves.
Chap III. — Dissection of the Nerves. Chap. IV Organs of Sense.
PART IV.—ANATOMY OF THE OSSEOUS SYSTEM.
DUBLIN: HODGES AND SMITH, GRAFTON-STREET.
LONDON: LONGMAN AND CO., AND SIMPKIN AND MARSHALL.
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On.ojj'
^ ' - -^
A
TKEATISE ON FRACTURES
IN
THE VICINITY OF JOINTS,
AND
ON CERTAIN FORMS
OP
ACCIDENTAL AND CONGENITAL
DISLOCATIONS.
ROBERT WILLIAM SMITH, M. D., M. R. L A,
FELLOW OF THE ROTAl COLLEGE OF StlKGEONS IN mELAUD ;
LECTDBEE ON SURGERY AT THE RICHMOND HOSPITAL SCHOOL OF MEDICME; SURGEON TO THE TALBOT
DISPENSARY, AND TO THE LUNATIC ASYLUM, ISLAND-BRIDGE ;
SECRETARY TO THE PATHOLOGICAL SOCIETY OF DUBLIN ; FELLOW OF THE ROYAL MEDICO-CHIEURGICAL
SOCIETY OP LONDON.
DUBLIN:
HODGES AND SMITH, aRAFTON-STREET.
1847.
/'T.J^ ^
DUBLIN :
PRINTED AT THE UNIVEESITY PKESS,
BY M. n. GIIiLi.
PREFACE.
" On ne saurrait assez insister sur le diagnostic des fractures et des luxa- tions, car on rencontre a chaque instant dans les hopitaux beaucoup des cas qui ont echappe a la sagacite et a I'observation des grands maitres. C'est ainsi que les affections de I'articulation coxo-femorale, les luxations scapulo-hum^rales, les fractures de I'extremite inferieur du radius, et en general toutes les solutions de continuite au voisinage des articles, sont les sources de nombreuses erreurs."
DupoYTBEN, Legons Orales, t. iii. p. 393.
The object which I have had in view in submitting the following pages to the consideration of the Profession, has not been to present a systematic treatise upon the ex- tensive subject of fractures and dislocations (which the valuable work of Sir Astley Cooper renders unnecessary), but to direct attention to that most difficult portion of it — fractures in the vicinity of joints; and even here I have, for the present, limited myself to the consideration of those of which I had most experience, the differential diagnosis of which I found to be attended with the great- est difficulty, and whose anatomical characters I have had the most frequent opportunities of investigating.
The elaborate researches of Breschet, Dupuytren, Bouvier, Guerin, and others, have done much towards elucidating the subject of congenital luxations ; it must still, however, be considered as being in its infancy, and,
IV PREFACE.
therefore, any addition to our knowledge of it cannot be deemed unimportant, the more especially as congenital and accidental luxations are frequently confounded.
It has been my endeavour to make the style of the work as familiar and perspicuous as possible. Whatever deficiencies may exist in the descriptions of the various injuries alluded to, will, I trust, be found amply compen- sated for by the illustrations, for the accuracy of which I pledge myself They have, with the exception of a few copied from other works, been drawn from nature under my own immediate inspection, by that distinguished artist, Mr. Connolly, whose name is a sufficient guarantee for their fidelity. They have been, with the exception of those contained in the fourth, seventh, and eighth chap- ters, engraved by Mr. George Hanlon, whose abilities are too well known to require any eulogium upon my part.
To the Publishers, Messrs. Hodges and Smith, my best thanks are due, for the readiness with which they ac- ceded to all my wishes with regard to the work.
Dublin, 63, Eccles-sreet, April, 1847.
CONTENTS.
-♦-
CHAPTER I.
PAGE.
On the Diagnosis and Pathology of Fractures of the Neck of the Femur, 1
CHAPTEE 11.
On Chronic Rheumatic Arthritis OF THE Hip-joint, 113
CHAPTEE III.
On Fractures of the Bones of the Fore- arm, in the vicinity of the Wrist-joint, 129
CHAPTEE IV.
On Fractures of the Humerus, in the vicinity of the Shoulder- joint, 176
CHAPTEE V. On Fractures of the Acromial Extremity of the Clavicle, . . 209
CHAPTEE VL On Dislocations of the Bones of the Foot, 224
CONTENTS.
CHAPTER VIL
PAGE.
On congenital Luxations of the Wrist-joint, 238
CHAPTER VIII. On congenital Dislocations of the Shoulder, 256
CHAPTER IX. On Dislocations of the Lower Jaw, 273
CHAPTER X.
Additional Observations on Fractures of the Radius, Disloca- tions of the Bones of the Foot, and congenital Luxation of the Wrist-joint, 294
ANALYTICAL INDEX.
CHAPTER I.
DIAGNOSIS AND PATHOLOGY OP FRACTURES OF THE NECK OF THE
FEMUR.
PAGE.
General symptoms of fracture of the neck of the femur, 2
Appearances of limb, when the patient is supported in the erect position, . 4
Fracture without the previous occurrence of a fall upon the hip, .... 5
Diagnosis of the injury frequently very obscure, 5
Contradictory statements respecting the amount of shortening in fractures
within and external to the capsule, 6
Cervical ligament of the femur — " retinacula" of Weitbrecht, .... 7
Circumstances which influence the amount of shortening of the limb, . . 8
Different periods after the accident at which shortening may occur, . . 11
Sudden occurrence of shortening, some time after the receipt of the injury, 12
Erroneously ascribed by Dupuytren to the yielding of the provisional callus, 13
Opinion of Rodet as to its value, as a diagnostic sign of the seat of fracture, 14
Opinion of Rodet as to amount of shortening, in each variety of fracture, 15
Extracapsular fractures accompanied by fracture of the trochanters, . . 16
Causes from which the second lesion of the bone results, 17
Rodet's diagnostic sign of the seat of fracture with respect to the capsule, 20
General position of the foot in each variety of fracture, 22
Opinions entertained respecting the cause of inversion of the foot, ... 23
Mr. Guthrie's explanation inapplicable to cases of intracapsular fractures, 23
Dupuytren's opinion incorrectly stated by the editors of his lectures, . . 26
Symptoms of impacted fractures of the neck of the femur, 28
Difficulties which attend the diagnosis in these cases, 29
Impacted fracture and contusion of the hip frequently confounded, ... 30
Contusion in cases of chronic rheumatic arthritis, mistaken for fracture, 31
Usual anatomical characters of intracapsular impacted fractures, ... 33
Anatomical characters of extracapsular impacted fractures, 34
Rare variety of extracapsular impacted fracture, 33
Vlll ANALYTICAL INDEX.
PAGE.
Osseous deposits about the trochanters in extracapsular fractures, . . 36
Erroneous opinions generally entertained as to their use, 37
Object for the attainment of which they are formed, 40
Haemorrhage in cases of extracapsular fractures sometimes fatal, ... 41
Anatomical characters of fractures within the capsular ligament, ... 41
Partial fracture of the neck of the femur external to the capsular ligament, 44
Mr. Adams's opinions as to the mode of occurrence of partial fracture, . 46
Objections to the doctrine of partial fracture of the neck of the femur, . . 48
Mr. CoUes's cases of partial fracture within the capsular ligament, ... 50
Question of osseous union in intracapsular fractures briefly considered, . 52
Prognosis in cases of fracture within and external to the capsule, ... 64
Causes of death in cases of fracture of the neck of the femur, 65
Changes in the head and neck of the femur, consequent upon old age, . . 66
Illustrative cases, 69
General conclusions, 110
CHAPTER 11.
CHRONIC RHEUMATIC ARTHRITIS OF THE HIP-JOINT.
Authors who have particularly noticed the disease, 114
Causes and symptoms of the affection, 114
Difficulty of flexing the hip-joint, 115
External characters of the disease, . .- <^. .... 115
Case by Mr. Adams, 116
Case of the late Doctor Percival, 119
Anatomical characters of the disease, 119
Condition of the synovial membrane and ligaments, 120
Alterations in the acetubulum, 120
Alterations in the head of the femur, 122
Alterations in the neck of the femur, 124
Treatment of the disease, 127
CHAPTER m.
FRACTURES OF THE BONES OF THE FORE-ARM, IN THE VICmiTY OF THE WRIST-JOINT.
Mr. Colles's description of fracture of the lower end of the radius, ... 130
Causes and symptoms of the injm-y, 134
Position in which the hand is supported by the patient, 134
Difficulty of supinating the hand, ." ... 135
Alteration in the form of the lower extremity of the fore-arm, .... 136
Projection of the lower extremity of the ulna, 137
Usual situation of the fracture, 137
ANALYTICAL INDEX. IX
PAGE.
Diday's opinion respecting the direction of the fracture, 137
Shortening of the posterior surface of the radius, 138
State of the internal lateral ligament of the carpus, 138
Peculiar appearance of the wrist, 139
Sequelae of the injury, 139, 170
Anatomical characters of the injury, 140
Nature of the displacement of the lower fragment, 140
Overlapping of the fragments seldom occurs, 141
Direction of the fracture generally transversa, 142
Voillemier's doctrine of impaction, 143
Cases illustrative of the pathology of fractures of the lower end of the radius, 146
Voillemier's theory considered, 156
Fracture with displacement of the lower fragment forwards, 162
Differential diagnosis, 163
Fracture of the radius and ulna, close to the wrist-joint, 164
Differential diagnosis, 164
Treatment of fracture of the lower end of the radius, 167
General conclusions, 171
CHAPTER IV.
FRACTURES OF THE HUMERUS IN THE VICINITY OF THE SHOULDER- JOINT.
Fractures of the greater tuberosity of the humerus, 176
External characters of the injury, . , . 177
Anatomical characters, 178
Cases recorded by Mr. Guthrie, 181
Difficulty of maintaining the fragments in apposition, . , 183
Ligamentous union between the fragments, 183
Impacted fractures of the neck of the humerus, external to the capsule, . 185
Diagnosis obscure, 186
Ahatomical characters, 187
Intracapsular variety generally combined with fracture of the tubercles, 188
Differential diagnosis, 188
Osseous union of the intracapsular variety, 189
Permanent deformity, 191
Anatomical characters, 192, 194
Alterations in the aspect of the head of the bone, ....... 194, 196
Separation of the superior epiphysis of the humerus, 199
Projection beneath the eoracoid process, 200
Deformity likely to be permanent, 202
Osseous union, 202
Error of Vidal respecting the anatomy of the epiphysis, 202
Sir Astley Cooper's description of the injury, 204
General conclusions, 206
b .
X ANALYTICAL INDEX.
CHAPTER V.
FRACTURES OF THE ACROMIAL EXTREMITY OF THE CLAVICLE.
PAGE.
Opinions of authors respecting the displacement of the fragments, . . . 209 Anatomical characters of fractures external to the conoid ligament, 210, 218
Fractures between the conoid and trapezoid ligaments, 215
Fractures external to the trapezoid ligament, 215
Nature and causes of the displacement, 216
Diagnostic signs of fracture between the coraco-clavicular ligaments, . . 217
Symptoms of fracture external to the trapezoid ligament, 218
General conclusions, 222
CHAPTER VI.
DISLOCATIONS OF THE BONES OF THE FOOT.
Sources of security of the bones of the foot against displacement, . . . 224
Symptoms of luxation of the metatarsus and internal cuneiform bone, . . 225
Rotation of the foot upon its long axis, 225
Alteration in the form of the sole of the foot, 226
Anatomical relations of the displaced bones, 227, 231
Anatomical characters, when the luxation remains unreduced, . . 228, 232
Mode in which the injury is produced, 233
Internal cuneiform bone generally remains with the metatarsus, . . . 233
Sanson's account of Dupuytren's cases, 234
Case of luxation of the metatarsus recorded by Mazet, 235
Cases of luxation of the tarsal bones, by Mr. Liston and Sir A. Cooper, . 236
Importance of early reduction, 236
CHAPTER VII.
CONGENITAL LUXATIONS OF THE WRIST- JOINT.
Case recorded by Cruveilhier as an unreduced luxation, ....... 238
Opinion of Dupuytren respecting it, 240
Congenital luxation of the right carpus forwards, 241
Congenital luxation of the left carpus backwards, 245
Anatomical characters compared with those described by Cruveilhier, . . 250
Case of congenital luxation of the carpus forwards, 251
Proofs that the deformity was congenital, 253
Dislocation of the carpus from injury, 254
ANALYTICAL INDEX.
CHAPTER VIII.
CONGENITAL DISLOCATIONS OF THE SHOULDER,
PAGE.
Condition of the shoulder which may be mistaken for congenital luxation, 257 Congenital luxations frequently escape observation in the infant, . . . 257 Varieties of congenital luxation of the shoulder observed by Guerin, . . 258
Cases of congenital sub-coracoid luxations, 258-265
Sub-acromial congenital luxations, 266
Opinions as to the causes of congenital luxations, 271
CHAPTER IX.
DISLOCATIONS OF THE LOWER JAW.
Case of congenital luxation of one condyle, 273
Appearances of the face, 274
Condition of the temporo-maxillary articulation, 279, 280
Opinion of Ribes respecting the development of the glenoid cavity, . . 283 '
Glenoid cavity formed by the growth of the articular eminence, . . . 285
Symptoms of luxation of both condyles from accident, 286
Appearances when the luxation is left unreduced, 287
Ribes's description of the changes which take place, 287
Symptoms of luxation of one condyle from accident, 289
Deformity produced by chronic rheumatic arthritis of the jaw, .... 290
Anatomical characters of the disease, 291
Diiferential diagnosis of the congenital luxation, . 292
CHAPTER X.
ADDITIONAL OBSERVATIONS ON FRACTURES OF THE RADIUS, DISLOCA- TIONS OF THE BONES OF THE FOOT, AND CONGENITAL LUXATION OF THE WRIST-JOINT.
Cases of fracture of the lower end of the radius, 294
Gangrene from tight bandaging, in cases of fracture of the radius, . . 295
Fracture of the lower extremity of each radius, 297
Dupuytren's cases of luxation of the metatarsus, incorrectly described by
Sanson, 298
Translation of Dupuytren's Memoir upon the subject, 298
Analysis of Cruveilhier's case of luxation of the wrist, by Dupuytren, . 303
MAY 1 S 1917
TREATISE ON FRACTURES,
&c. &c.
CHAPTER I.
ON THE DIAGNOSIS AND PATHOLOGY OF FRACTURES OF THE NECK OF THE FEMUR.
" La science du diagnostic tient le premier range entre toutes les parties de I'art et en est la plus utile et la plus difficile ; sans un diagnostic exact et precis, la theorie est presque toiijours en defaut et la pratique souvent infidele." — Mem, de VAcadem. Roy. de Chi- rurg.^ t. v.
The words of tlie celebrated Louis, wliicli I have prefixed to tliis memoir, altliougli written with reference to the diagnosis of fun- gous tumours of the dura mater, apply with propriety to the sub- ject of which I am about to treat in the following pages. Many and valuable additions, it is true, have of late years been made to our knowledge of the subject of fractures of the neck of the femur, but there are still many points connected with its history which are involved in obscurity, and some upon which there still exists much variety of opinion. If I shall succeed in removing any of this uncertainty, if I shall be able to place the diagnosis of the various forms of fracture of the neck of the femur in a clearer light than has hitherto been done, I shall have accomplished fully the object which I proposed to myself, in bringing forward a subject upon which so much that is valuable has already been written, but the difficulties attendant upon which every practical surgeon will, I am sure, freely admit, and the importance of
B
Z FEACTURES OF THE NECK OF THE FEMUR.
whicli is sufficiently attested by tlie immber of tlie memoirs that have been devoted to its consideration.
In the majority of cases of fracture of the neck of the femur, the nature of the injury is announced by symptoms sufficiently striking, and equally remarkable, whether we examine the limb while the patient is in a recumbent posture, lying upon a hori- zontal plane, or while he is supported in the erect position, rest- ing the weight of his body upon the uninjured limb. When we make the examination as the patient lies in bed, we observe that the injured limb is shortened; that the heel corresponds to some part of the region between the tendo Achillis and the internal malleolus of the sound side ; that the foot is everted, and that the entire limb rests upon its external surface; the knee-joint is slightly flexed; an unnatural fulness is seen in the inguinal region, and the upper and outer part of the thigh presents an unusual convexity, and a certain amount of tension ; the patient complains of pain throughout the whole of the region of the hip- joint, and in the vicinity of the insertion of the psoas muscle: the pain in the latter situation is generally aggravated when the surgeon inverts the limb and flexes the thigh upon the pelvis ; the trochanter major does not stand out from the pelvis as promi- nently as upon the sound side ; it is approximated to the crest of the ilium, and the glutgeal region is flattened. When an extend- ing force is applied to the foot, and continued sufficiently long to overcome the contraction of the muscles which draw the lower fragment of the broken bone upwards, the limb is restored to its natural length, and most of the external signs of the fracture dis- appear; but if, while the extending force still continues in action, the surgeon communicate to the limb a movement of rotation, a grating of the fragments upon each other becomes manifest, the crepitus can be felt by the hand placed upon the trochanter major, and is frequently communicated to the hand of the assistant who is extending the limb from the foot : when, however, the extending force ceases to operate, this characteristic sign of the fracture dis- appears, and the limb, once more abandoned to the uncontrolled power of the muscles, is again shortened, and the foot becomes again everted. By rotating the limb we also ascertain that the trochanter major moves in the segment of a smaller circle than
FRACTURES OF THE NECK OF THE FEMUR. 6
natural, or revolves upon its own axis. If the patient be desired to raise tlie extended limb from the horizontal plane upon which it rests, he at once, and without even making the effort, expresses
his total inability to do so : if urged to make the trial, he attempts it by placing the toes of the uninjured limb behind the heel of the other, and thus contrives to raise the latter a little ; or else he
B 2
4 FRACTURES OF THE NECK OF THE FEMUR.
places his hands behind the broken femur, and by their assistance Ilexes the thigh slowly and with caution upon the pelvis, bends the knee-joint, and draws up the foot, but without raising the latter from the surface of the bed : he is able to extend the limb perfectly, and, to a certain extent, can flex the thigh upon the pelvis, provided the leg is, at the same time, flexed upon the thigh, and the foot supported : he is able to increase the rotation outwards of the foot, but cannot perform the opposite motion : the motions, such as flexion, which the patient can perform only in a limited degree, and that which he is almost totally unable to exe- cute, viz., rotation inwards, the surgeon can communicate to the limb, but not without causing considerable pain.
Having now carefully examined the appearances which the limb presents while the patient lies upon a horizontal plane, let the surgeon, in order to form a still more decided opinion as to the nature of the injury which the hip-joint has suffered, direct the patient to assume the erect posture, and, aided by the support of an assistant, to rest his weight upon the uninjured limb ; he will then have the characteristic symptoms of the accident pre- sented to him in a more striking point of view ; the shortening of the broken limb then becomes very manifest, for although the toes may touch the ground, the heel does not rest upon it ; the eversion of the foot and knee, the diminished prominence of the trochanter major, and the flattening of the corresponding side of the nates, are also rendered very evident when the patient assumes the erect position ; the posterior region of the thigh looks in- wards, and the head of the fibula is directed backwards; the patient possesses a kind of consciousness that he is unable to bear his weight upon the broken limb, and therefore attempts nothing of the kind. The injury is most likely to happen to those who have arrived at an advanced period of life, and is usually the residt of a fall upon the trochanter major. Sabatier has remarked : <'Elle est si communement la suite des chutes qui se font sur le grand trochanter, que c'est deja une forte presomption pour I'ex- istence de cette fracture, que de savoir que le blesse est tombe sur cette partie." I believe, however, with Sir Astley Cooper, that, under many circumstances, the fall is the result and not the cause of the fracture ; and in several instances which I have
FRACTURES OF THE NECK OF THE FEMUR. 0
seen, the neck of the femur has been broken, although the indi- vidual has not fallen at all, having supported himself by laying hold on some convenient object; and it should ever be remem- bered that the slightest and most trivial causes are sufficient to produce the injury in persons of advanced age; the foot being caught by some inequality in the ground, or becoming entangled in a hole in the carpet, are by no means uncommon sources of the fracture ; and Sir Astley Cooper has done well in cautioning the young surgeon to be upon his guard, as he might otherwise ima- gine that so serious an injury as fracture of the neck of the femur could not result from causes so trivial, and without the occurrence of a fall upon the trochanter. Such is a general outline of the symptoms which indicate the existence of a fracture of the neck of the thigh bone. These symptoms are each, however, liable to so many important varieties, and are so modified by the situation of the fracture, the relative position of the fragments, and the extent of injury done to the soft parts entering into the composi- tion of the articulation, or in its immediate vicinity, that it be- comes necessary to examine somewhat m detail the more impor- tant symptoms, and to consider attentively the circumstances which, in any given case, may modify the signs and obscure the nature of the injury which the hip-joint has sufifered. The sur- geon who supposes that the difiiculties attending the diagnosis of fracture of the neck of the femur are slight, and easily overcome, can have had but a very limited experience indeed of such inju- ries ; and I think that, in the course of this inquiry, it will be- come manifest that the majority of the symptoms of fracture may be present in cases in which the neck of the femur is uninjured ; and that, upon the other hand, the fracture may be unaccom- panied by the more important of the usual diagnostic signs.* We cannot, in investigating these injuries, form our opinion, guided by any particular symptom, for there is not one which, sepa- rately considered, can be looked upon as unequivocally indicating
* " Le diagnostic du fractiu-es du col (du femur) n'est pas sans d'assez grandes difficultes, et plus d'une fois des practiciens exerces ont ete incertains sur le jugement qu'ils devaient porter. L'on voit, par exemple, des invidus qui presentent lea signes rationnels de cette lesion sans etre atteints, et d'autres, au contraire, qui n'en offi-ent aucun quoi- qu'elle existe reellement." — Legons Oiales, t. Li. p. 95.
b FRACTURES OF THE NECK OF THE FEMUR.
the existence of a fracture of tlie neck of the femur ; it is by the union of all that we can alone hope to arrive at a correct diagnosis. There is no feature in the history of fractures of the neck of the thigh bone, which at first sight appears more extraordinary than the difference of opinion which has existed, and indeed still continues, as to the amount of shortening of the limb which oc- curs in the two varieties of this important lesion. Upon this question the most eminent surgeons of modern times are directly opposed to one another. Sir Astley Cooper, Amesbury, Chas- saignac, Vidal (De Cassis), and others, maintain that the shorten- ing is greater in the intracapsular fracture than in the extracap- sular. Upon the other hand, Desault, Boyer, Dupuytren, Cloquet, Earle, Stanley, &c., have stated, that the greatest amount of shortening accompanies the fracture external to the capsule. How are such conflicting statements to be reconciled ? Are we to agree with Rodet, who says : " Cette opposition formelle entre les opi- nions de ces grands chirurgiens vient sans doute de ce qu'il n'y a rien de constant dans le degre du raccourcissement, qui accom- pagne de ces deux especes des fractures ?" I do not think so, and I feel satisfied that the degree of shortening of the limb may, with certain precautions, be considered as diagnostic of the seat of the fracture, and that it is greater when the lesion of the bone is ex- ternal to, than when it is within the capsular ligament. In dis- cussing this question, I wish it to be understood, that I allude to the retraction of the limb which immediately succeeds the receipt of the injury ; this is the period at which it is most important to form a correct diagnosis ; for the surgeon is expected not only to give a decided opinion, almost at sight, as to the nature of the injury, but also to state his prognosis, and as this must be mate- rially influenced by the diagnosis which he may form, the impor- tance of being able to ascertain exactly the seat of the injury with respect to the capsule is apparent. The chief circumstances ac- cording to which the degree of shortening varies in cases of intra- capsular fractures are, the direction of the fracture and relative position of the fragments, and the amount of laceration suflered by the fibrous covering of the neck of the bone. With regard to the former, when the line of fracture is perpendicular to the axis of the neck of the bone, or when it has passed from the superior
FRACTURES OF THE NECK OF THE FEMUR. /
part of the corona of tlie liead obliquely downwards and inwards, there is nothing in either of these cases, so far as the relative position of the fragments is concerned, to prevent the inferior fragment from being drawn upwards ; but when the fracture runs from the inferior part of the corona of the head obliquely down- wards and outwards towards the summit of the trochanter major, then, provided there be no displacement as regards the diameter of the bone, the ascent of the lower or external fragment is op- posed by the superior, and the amount of shortening is less than in either of the other cases which I have supposed. This is only in accordance with an obvious and general principle, viz., that the direction of a fracture regulates to a certain extent the nature and amount of the displacement consequent upon the lesion, but I do not see that the knowledge of this general principle is of much use, when we endeavour to apply it to the case before us, for, notwithstanding what has lately been asserted to the contrary by Rodet, I am inclined to agree with Dupuytren, who has said : " II n'y a aucun moyen de reconnaitre dans quel sens a lievi cette obliquite." I shall, however, allude hereafter more particularly to the opinions of Rodet upon this point, and pass on at present to consider how far the shortening of the limb is influenced by the condition of the fibrous membrane which encircles the neck of the bone : this important investment constitutes a cylindrical sheath of great strength, extending from the inferior attachment of the capsular ligament to the circumference of the cartilage of the head of the femur ; it is derived from the deep fibres of the capsule, and here and there appears to be thrown into longitudinal folds or bands, which Weitbrecht has termed "retinacula;"* it is covered upon its external surface by synovial membrane, and numerous vessels pass along it to the head of the bone. It may, for convenience sake, and from the function which it fulfils in many cases of fracture within the capsule, be termed the " cervi- cal ligament of the femur." If the force which acts upon the neck of the femur be inconsiderable, and, as it were, exhausted, after producing the fracture, this ligament may escape uninjured, or nearly so. In such a case, the retraction of the limb will be very
* Syndesmologia, 1742.
8 FRACTURES OF THE NECK OF THE FEMUR
slight, and will be at its minimum when the fracture has traversed the bone obliquely from the inferior part of the head of the femur downwards and outwards. When the cervical ligament remains nearly entire, it not only limits the retraction of the limb, but it likewise becomes the sole medium through which a vascular commimication is maintained between the fragments ; it is, there- fore, very important to observe the utmost caution in examining the limb ; and if the existence of fracture of the neck of the femur is rendered evident by the presence of the other symptoms which characterize this lesion, we should, I think, abstain from institut- ing such an examination as is necessary to produce crepitus. In doubtful and obscure cases, this examination should of course be cautiously made, but I perfectly coincide with the opinion of Boyer, that, in the majority of cases of fracture of the neck of the femur within the capsule, the nature of the injury is sujffi- ciently indicated by other symptoms.* Mr. Stanley observes, that in several instances of recent fracture of the neck of the femur within the capsule, he has found a considerable portion of the synovial and fibrous covering of the bone entire, and the extent of its laceration has obviously infliienced the degree of displacement in the limb. This covering, remaining entire on either side of the neck of the bone, must counteract the shortening of the limb. Should it be preserved entire on the anterior side, the eversion may be wholly prevented ; and when, as in the fol- lowing instance, the membrane is uninjured, the fractured sur- faces in such case may be kept firmly together, and the limb secured from any change in its length or position. A man, aged sixty, was knocked down in the street, and on his admission into
* " Un assez grand nombre d'autres phenomenes la caracterisent suffisamenf, sans avoir recours a celui-la, que la situation profonde des fragmens et la grande epais- seur des parties moUes qui les entourent, doivent rendre au moins tres-difficile a distin- guer ; et quand bien meme ce signe serait facile a reconnaitre, les mouvemens propres a le mettre en evidence seraient-Us exempts de danger ? Nous ne parleront point de I'irri- tation des parties environantes, que nous croj^ons bien moins facile a produire et moins dangereuse qu'on ne I'a pense ; mais est il indifferent de s'exposer h. rompre completement le prolongement fibreux de la capsule que s'etend sur le col du femur, et qui lui sert de perioste ? Les mouvemens de rotation communiques au fragment inferieur ne sont-ils pas le moyen le plus propre a produire cet effet pernicieux ?" — Boyer : Traite des Maladies Chinirgicales, t. iii. pp. 268-9.
FRACTURES OF THE NECK OF THE FEMUR. \)
St. Bartholomew's Hospital, shortly after the injviry, he com- plained of pain in the hip, but there was neither shortening nor eversion of the limb, and its several motions could be executed with freedom and power. In this absence of all the usual indi- cations a fracture was not suspected ; the patient, therefore, was merely confined to his bed. At the end of a fortnight he had an attack of inflammation in the intestines, from which he recovered, but suffered a relapse, and died in the fifth week from the date of the accident. On examining the body, no trace of injury was found in the parts around the hip -joint, but, on opening the cap- sule, small effusions of blood, apparently not recent, were disco- vered beneath the synovial and fibrous membrane, covering the neck of the femur, also beneath the synovial membrane, covering the ligamentum teres. The head and neck of the bone were sawed through the middle, and in each portion a dark line, evidently occasioned by the effusion of blood, was seen extending through the bone at the basis of the neck. A fracture was discovered extending along this line, but the broken surfaces were in con- tact, and the synovial and fibrous membrane covering the neck of the bone was uninjured. In this case, Mr. Stanley remarks, if an attempt had been made to walk at the end of two or three weeks from the accident, a separation of the fractured surfaces, and consequent shortening of the limb, would have been the result. Hence, in cases where the nature of the injury is doubt- ful, we may infer the obvious propriety of imposing on the pa- tient a strict confinement to his bed for as great a length of time as if the fracture had been ascertained.* Cruveilhier likewise has alluded to the injurious consequences which may result from an over-anxiety upon the part of the surgeon to elicit crepitus. This distinguished pathologist remarks : " On con9oit combien il est peu rationel de vouloir a tout prix par des mouvemens de ro- tation imprimes aux membres, obtenir le bruit de crepitation, comme moyen de diagnostic ; il n'est pas besoin de dire que ces mouvemens peuvent avoir le grave inconvenient de completer la rupture du repli fibro-synovial, respecte in quelque sorte par la cause fracturante."f
* Medico- Chirurgical Transactions, vol. xiii. t Anatomie Pathologique, livraison xxvi.
10 FRACTUKES OF THE NECK OF THE FEMUR.
Among the causes whicli limit tlie retraction of the limb in cases of intracapsular fractures, we must not omit to mention the powerful capsular ligament, which so closely embraces the articu- lation. Sir Astley Cooper states that, when the bone is broken within the capsule, the leg becomes from one to two inches shorter than the other. So great a degree of shortening I have never witnessed as an immediate result of the fracture, nor do I think the capsule would admit of such an amount of displacement, unless it were extensively lacerated, an occurrence which is very rare indeed, " With respect to the shortening of the limb," says Mr. Earle, " to the extent of two inches, as I have never witnessed such an occurrence, I cannot but conceive that there must be some inac- curacy in the statement, more especially when the great strength and unyielding nature of the capsular ligament are considered." Boyer likewise expresses the same opinion ; he says : " Quand la fracture a lieu dans I'un des points de la longueur du col du femur qui correspondent a I'interieur de I'articulation, le ligament orbiculaire qui n'est jamais rompu, contre-balance les causes de displacement, et en resistant en haut et en bas a I'impulsion des deux fragmens, il borne quelquefois la raccourcissement du mem- bre a quelque lignes."* But when the fracture is external to the capsule, and not impacted, there is but little to prevent the full force of muscular action upon the lower fragment of the bone, while, at the same time, the upper is depressed by the weight of the body, so that, from these two causes, a degree of shortening may be produced equal to, or even greater than the entire length of the neck of the bone. In confirmation of his opinion of there being a comparatively slight degree of shortening in extracap- sular fractures, Sir Astley Cooper describes the case of a man who died in a fortnight after having sustained this injury. In the account of the post-mortem examination he mentions that all the limbs were rigid from the fixed contraction of the muscles, yet the broken limb was found to be not quite three-quarters of an inch shorter than the other ; the fracture was external to the capsule, and the neck of the bone was forced into the cancelli of the trochanter major. " Before writing this statement," Sir Astley
* Traite des Maladies Chirurgicales, t. iii. p. 262.
FEACTURES OF THE NECK OF THE FEMUR. 11
observes, " I again inquired of Mr. Key (with, whom he had attended the case) the degree of diminution in the length of the limb, and his answer was : " If you mention three-quarters of an inch, you will state rather more than its degree of retraction, even when all the muscles were contracted to their utmost rigi- dity." Sir Astley Cooper has here, however, entirely overlooked the influence which the circumstance of the fracture having been impacted exerted upon the shortening of the limb. In almost all such cases (as I shall afterwards endeavour to prove), the short- ening is less than in the more ordinary form of extracapsular fracture, in which the neck of the bone does not remain im- planted in the cancellated tissue between the trochanters. Between these two varieties of the extracapsular fracture, it appears to me, that, as respects the shortening of the limb, this distinguished surgeon has not made the necessary distinction ; had he done so, I do not think he would have maintained the opinion, that the greater amount of shortening accompanied the intracapsular frac- ture. It seems probable, that the difference of opinion which exists upon this point is also in some measure to be ascribed to a proper distinction not having been made between the shortening which occurs immediately after the occurrence of the fracture, and that which is noticed at a later period. Indeed, the period at which shortening occurs is subject to much variety; it may ma- nifest itself instantaneously upon the receipt of the injury, and that to a considerable degree. In such cases the injury will gene- rally be found to be a comminuted fracture external to the cap- sule, a fracture which has lacerated the whole of the fibrous structures which invest the trochanteric region of the femur.
Again, we meet with cases in which the shortening of the limb is not by any means decided or evident for several days after the receipt of the injury: in such instances it usually happens that the muscles have been, to a certain extent, paralyzed by con- tusion; but according as, under the influence of rest, &c., they regain their power of contracting, the limb becomes slowly and gradually shortened, and this independent of any process of ab- sorption. A third class of cases occur, in which the retraction of the limb, having been at first scarcely perceptible, at the expira- tion of a few weeks becomes very considerable, owing to the
12 FRACTURES OF THE NECK OF THE FEMUR.
rapid absorption of tlie neck of tlie bone. In the case of Marga- ret Myler (No. ix.), tbe amount of shortening was at first only a quarter of an incli, but at the end of six weeks amounted to one incli and a half Lastly, examples are sometimes seen in which the limb retains nearly its natural length for many weeks after the receipt of the injury, and then a very decided and, comparatively speaking, considerable degree of shortening occurs, not gradually, but suddenly. In these cases the diagnosis is somewhat obscure ; the cause which has produced the fracture is comparatively slight, and the patient has not made any attempt to use the limb after the receipt of the injury ; the eversion of the foot is by no means so well marked as when the retraction has occurred early ; the patient is, it is true, unable to raise the limb en masse, but this may be owing to the effects of contusion upon the muscles ; in fact, in cases such as those to which I allude, there may be at first neither shortening of the limb to any appreciable extent, eversion of the foot, nor any change in the position of the tro- chanter; and therefore, unless we can ascertain crepitus, it is most difficult to decide whether the neck of the bone be broken or not ; and if we fail to elicit crepitus, the more prudent course is to withhold our opinion until time shall more fully develope the nature of the injury. In these cases the surgeon is apt to allow greater freedom to the patient than is advisable, or, it may be that, in his anxiety to establish the nature of the injury by producing crepitation, he employs too much force in rotating the femur ; in either case it is highly probable that the sudden occurrence of shortening of the limb will establish the nature of the lesion which the joint has suffered; the eversion of the foot now becomes de- cided, and the trochanter altered in position. These phenomena may take place long after the occurrence of the accident. In these instances it is most probable that, at the time of the receipt of the injury, the cervical ligament, having escaped laceration, pre- vented the retraction of the limb, but that subsequently it was torn, either in consequence of some imprudent exertion upon the part of the patient, or too eager a desire upon that of the surgeon to produce crepitus by forcible extension and rotation of the limb ; the retraction then takes place as the immediate result of the laceration of this important membrane.
FRACTURES OF THE NECK OF THE FEMUR. 13
This subject has been fully considered by Amesbury, and the Baron Dupuytren, in the second volume of his Oral Lectures, remarks : " C'est ainsi que le deplacement des fragmens ne s'est fait qu'au bout de quelque heures, de deux, trois, cinque, dix, et memo trent jours, par suite de quelque mouvemens du malade, ou bien pendant que Ton faisait des recherches pour s'assurer de la nature de la maladie." I am of opinion, however, that this cele- brated surgeon has not given the correct explanation of a pheno- menon with which it is obvious he was familiar. He says: " Au bout de deux ou trois mois, le cat provisoire cede au poids du membre sur lequel les malades se soutiennent, et les fragmens ces- sant d'etre en rapport, une difFormite a lieu, un raccourcissement se produit." Now, if the opinion be correct, as I believe it to be, that the sudden occurrence of shortening, at a period more or less remote from the receipt of the injury, is diagnostic of the pre- sence of a fracture within the capsular ligament, I think I am justified in ascribing it to the more or less complete laceration of the cervical ligament, consequent upon some imprudence upon the part either of the surgeon or of the patient, and that it is in no in- stance to be referred to the yielding of the callus, when the patient attempts to bear the weight of his body upon the injured limb. It is, I conceive, highly probable that the shortening noticed by Du- puytren, at so distant a period as four months after the occurrence of the accident, did not take place suddenly, but was owing to the gradual process of absorption going on in the neck of the bone, though it may have escaped observation as long as the patient remained in bed, with the limb enclosed in an apparatus destined to maintain extension. Furthermore, if there be any one fact in surgical pathology more certain than another, it is this, that in cases of fracture of the neck of the femur within the capsular ligament^ there is scarcely any callus ever effused; it certainly is never formed in such quantity as to be at all capable of counteracting the causes which produce shortening of the limb : in extracapsular fractures, osseous matter is poured out in many cases most copioiisly, but wdien the lesion of the bone is entirely within the capsule, the absence of callus, either provisional or final (if there be any truth in such a distinction) , is most re- markable, even in those cases in which osseous union has occurred
14 FRACTURES OF THE NECK OF THE FEMUR.
between the fragments. If tlie plates representing tlie tinion by bone of the fracture within the capsule, which are appended to the cases published by Messrs. Langstaff, Adams, and Jones, be compared, the resemblance which they bear to each other will be found to be very striking : in all union has taken place without the deposition of osseous matter around the fragments; in all consolidation has been effected by the direct union of the two bony surfaces which were confronted to each other, and not by the effusion of callus. The opinion, therefore, which ascribes the phe- nomenon in question to the yielding of the callus, when the weight of the body is thrown upon the limb, must, I fear, be rejected as erroneous, although supported by the high authority of so distin- guished a surgeon as the late chief of the Hotel Dieu.
It has lately been asserted that the opinion which maintains that the sudden occurrence of shortening of the limb, sometime after the receipt of the injury, is diagnostic of a fracture within the capsule, is incorrect, and Monsieur Rodet believes it to be equally cha- racteristic of an extracapsular fracture : he correctly describes the whole of the trochanteric region of the femur as being invested with a dense fibrous covering, derived from the tendinous struc- tures attached to the trochanter ; he believes that this fibrous ex- pansion may escape uninjured at the time of the occurrence of the fracture, that it may be subsequently lacerated, either by for- cible rotation of the limb, or premature exertion on the patient's part, and that, under such circumstances, consecutive displace- ment will occur. I do not by any means wish to deny the pos- sibility of such an occurrence in extracapsular fractures, but I certainly cannot admit the assertion of Rodet, that it is as fre- quent in the one variety of the fracture as in the other. I have never witnessed consecutive displacement in cases of fracture ex- ternal to the capsule, nor have I ever seen an instance of this fracture, in which there was not shortening of the limb from the very moment of the occurrence of the accident. When, more- over, I consider that the extracapsular fracture is always accom- panied (as I shall afterwards endeavour to prove) by a fracture of one or both trochanters, and that this second lesion of the bone is the result of the impaction of the upper fragment into the can- cellated tissue of the trochanter, I think I am justified in main-
FRACTURES OF THE NECK OF THE FEMUR, 15
taining that there is, in every instance of fracture of the neck of the femur, external to the capsule, a primary and immediate shortening of the limb, and that the so-called consecutive dis- placement is merely an increase in the amount of shortening already existing.* It has been shewn that, in fractures within the capsule, the degree of shortening consequent upon the injury depends chiefly upon the condition of the cervical ligament ; and it is maintained by Rodet that the state of the fibrous structures which invest the trochanteric region will regulate the amount of retraction of the limb, when the lesion of the bone is external to the capsule ; and that, when these tissues remain uninjured, and the trochanter unbroken, there will be no shortening of the limb : but I shall quote the words of the author. " Si la fracture est extracapsulaire, les tissus fibreux de la region trochanterienne pourront aussi dechires a des degres differens, et le raccourcisse- ment qui I'accompagne devra varier dans la memo proportion, II y a cependant ici une autre condition dont il faut tenir compte, c'est I'etat dans lequel se trouve le grand trochanter. S'il est intact, ainsi que les tissus fibreux qui I'entourent, le raccourcisse- ment est nul." " Mais si le grand trochanter est brise en plusieurs fragments, ces fragments s'ecartent les uns des autres, et alors le raccourcissement se produit sous de faibles efforts, quoique les tissus fibreux ne soient pas dechires. Si le nombre de ces frag- mens est considerable, ou si les tissus fibreux sont largement di vises, le raccourcissement ne reconnait presque plus de limite, et peut etre porte jusqu'a 3, 4, 5 centimetres et au dela. De tout ce qui precede il est permis de conclure :
"1. Que le raccourcissement peut etre nul dans les fractures in- tra-articfolaires et extra-articulaires.
" 2. Que lorsqiiil ne depasse par 18 ou 20 millimetres, il peut appartenir egalement aux deux especes des fractures, et n^a par con- sequent rien de differentiel.
" 3. Enfin, que lorsqvOl depasse d'une maniere notable ce degre de 20 millimetres, il est a peu pres certain que la fracture est extra- articulaire."'\
* "Le deplacement est rarement ainsi consecutif; il s'opere presque toujours imme- diatement, surtout si la fracture est extra-capsulaire" — Sanson. f L'Experience, 14 Mars, 1844.
16 FRACTURES OF THE NECK OF THE FEMUR.
Now there is, in my opinion, one important objection to the first conclusion, i. e. it supposes a condition which I beheve never exists. M. Rodet says, that in extracapsular fractures there will be no shortening of the limb if the trochanter remains unbroken, and its fibrous coverings uninjured ; but, I would ask, does it ever happen that the neck of the femur is broken external to the cap- sule, without injury to the trochanter ? My own experience leads me to believe that it does not. I believe, as I have already stated, that all extracapsular fractures are, in the first instance, also impacted frac- tures, and that all impacted fractures are necessarily accompaniedby a fracture traversing some part of the trochanteric region. I have omitted no opportunity of investigating this point, and have now examined here and elsewhere upwards of one hundred specimens of the extracapsular fracture, and have found in all, without a single exception, a second fracture, traversing some portion of the intertrochanteric space: this space is somewhat of a semilunar shape, bounded above by the summit of the trochanter major, below by that of the trochanter minor ; its concavity corresponds to the posterior intertrochanteric ridge, and its convexity to a line drawn from the base of one trochanter to the other. Cru- veilhier has alluded to this second lesion of the bone ; this accu- rate observer remarks: " II est excessivement rare de voir une fracture extracapsulaire du col du femur parfaitement simple."* The second fracture usually begins near the centre of the summit of the trochanter major,t passes from thence downwards and inwards, following in general the convexity of the space I have mentioned, and either terminates before it reaches the lesser tro- chanter (Case No. lii.), or else it is continued through the cen- tre (Case No. xliv.), or below the base of that process (Case No. XXXV.). Sometimes it is a fissure, which splits either one or both trochanters (Case No. xlv.) without detaching any por- tion of either. Chaissaignac has alluded to a case of this description ; he observes : " Le grand trochanter offrait une fracture oblique incomplete, beante a la partie superieure, et s'efFacant peu a peu
* Livraison xxii.
f " Cette eminence (le grand trochanter) se brise, presque toujours en meme temps que la base du col, et la lieu de la brisure est generalement le point de re-union des deux tiers posterieurs avee le tiers anterieure." — Cruveilhieri loc. cit.
FRACTURES OF THE NECK OF THE FEMUR. 17
vers la partie inferieure, ou I'on voyait enfin cesse toute trace la solution de continuite." This second lesion of the bone is the necessary result of the forcible impaction of the broken cervix into the shaft of the femur, and it is, probably, the second frac- ture in order of time. What occurs appears in fact to be this : the neck of the femur is, in the first instance, broken by the fall upon the hip, and then driven into the cancellated tissue, between the trochanters, by the weight of the body, and the prolonged action of the first shock ; but as soon as the neck of the bone is broken, the femnr is rotated outwards, even before the action of the first impulse has ceased ; thus the posterior inter-trochanteric ridge being thrown forwards is forcibly driven against the back of the neck of the femur ; two forces, therefore, combine to pro- duce the fracture throvigh the inter-trochanteric space, one of which consists in the impaction of the cervix into the shaft, while the other is found in the collision which takes place be- tween the broken neck of the bone and the posterior inter-trochan- teric ridge. The impaction of the superior fragment is of itself, however, not only capable of producing the secfnd lesion of the bone, but is the chief cause of it, especially in those cases in which the neck of the bone is driven into the cancellated tissue between the trochanters, leaving the greater part of the inferior fragment in front (Case No. xlvi.) ; for in such cases the broken cervix is driven directly against the ridge connecting the trochanters posteriorly, which it breaks ofi" by its wedge-like action alone, and moreover, this second fracture is as constantly present in cases attended with rotation of the foot inwards.
It depends principally upon the violence with which the injury has been inflicted, whether the neck of the bone shall remain implanted between the trochanters, or whether these processes shall be so completely separated from the shaft of the femur as to allow of the escape of the cervix from the cavity which it had formed in the reticular tissue of the lower fragment ; if the force has not been very great, the neck of the femur remains wedged in between the trochanters, and one or both of these processes are split off from the shaft ; but if the fibrous structures before alluded to have not been injured, these broken portions of the trochan- ters are still held firmly in their places, and the impacted cervix
c
18 FRACTURES OF THE NECK OF THE FEMUR.
does not become loosened ; but if tlie force lias been considerable, the impulse prolonged, tbe bone in a state of senile atropliy, or if, as frequently happens, the patient, in endeavouring to rise, falls a second time, tlien, under these circumstances, the trochanters are not only broken from the shaft of the femur, but are so far displaced and separated from their connexion with the soft parts, that the cavity, or socket, as it were, into which the superior fragment has been received, is destroyed, the impacted cervix, thus set free, no longer opposes the ascent of the inferior frag- ment, and the case then presents the characters of the ordinary extracapsular fracture, with great shortening of the limb.
It appears to me that no other adequate explanation can be furnished to account for the constant and uniform occurrence of the second fracture, than that which has been suggested, namely, that in all cases of extracapsular fracture of the neck of the femur, the superior is driven into the inferior fragment ; if it were simply the result or consequence of the fall upon the trochan- ter, surely we should meet with it frequently in cases of frac- ture within the» capsular ligament ; but it does not occur in such cases, and must therefore be the result of a force which operates in the extracapsular, but not in the intracapsular frac- ture, and that force seems to be the impaction of the upper into the lower fragment, for although in fractures within the capsule we occasionally find impaction, it is always to a trifling ex- tent, can never influence the condition of the trochanter, and presents altogether phenomena totally different from those which accompany it when the neck of the bone is broken external to the capsule. From the opinion, therefore, of Rodet, that there may be no shortening of the limb in certain cases of fracture ex- ternal to the capsule, I must altogether dissent ; I can imagine a case of fracture within the capsule, without shortening of the limb, though it is difficult to be conceived, and rarely met ; and it is very probable that in the recorded cases of the absence of shortening of the limb, there has been inaccuracy of measure- ment; we cannot always be sure that we have measured from exactly corresponding points in the crests of the iha, and can- not therefore employ that degree of accuracy which it would be necessary to do, before the fact of the complete absence of shortening in any given case could be estabhshed. Still I am
FRACTURES OF THE NECK OF THE FEMUR. 19
not prepared to deny the possibility of the occurrence of frac- ture within the capsule, without shortening of the limb. But with respect to extracapsular fractures, the case is very different ; for in all such injuries there is impaction, and if so there must inevitably be shortening of the hmb, even though there may be no loss of obliqviity in the neck of the femur, no separation or displacement of the fractured trochanter, no laceration of the fibrous structures.
The second conclusion which M. Rodet has arrived at is the following: "Que lorsqu'il ne depasse pas 18 ou 20 millimetres, il pent appartenir egalement aux deux especes de fracture, et n'a pas rien differentiel." If we limit this conclusion to cases of intracapsular fractures and extracapsular impacted fractures, we must acknowledge it to be correct ; but it cannot be extended to those cases of extracapsular fractures (and they constitute the majority) in which, in consequence of the displacement of the broken trochanter, the neck of the femur does not remain im- pacted. In the impacted fracture it is true that the amount of shortening is frequently not greater than that consequent upon fracture within the capsule, so that from this symptom alone we cannot form a diagnosis as to the seat of the injury ; but when to the other symptoms which attend the impacted fracture we add the circumstance of there being a comparatively slight degree of shortening, the latter then becomes an important element in the differential diagnosis. With respect to the ordinary extracapsu- lar fracture, with fracture and displacement of the trochanter, the shortening is always greater than in cases of recent fracture within the capside ; I am not, therefore, disposed to agree with the opinion which maintains that the shortening of the limb is a symptom destitute of value, in determining the seat of the injury with respect to the capsule ; cases, it is true, frequently occur in which this symptom is not of itself sufficient to determine the ques- tion, but the well-informed and experienced surgeon does not ground his diagnosis of these obscure injuries either upon this or upon any other symptom separately considered, for he knows that the union of all can alone lead to the formation of a correct opinion. Suppose he meets with a case in which the shortening of the limb amounts to only half an inch, he knows that this may indicate a fracture either within or without the capsule, but will he there-
c2
20 FRACTURES OF THE NECK OF THE FEMUR.
fore reject the consideration of this symptom ? Surely not, for he learns from it that if the fracture be external to the capsule, it is, in all probability, an impacted fracture ; he then examines fur- ther, and if he finds it impossible, or extremely difficult to restore the limb to its natural length by extension, that he cannot elicit crepitus, that the loss of power is not as complete or absolute as in cases of fracture within the capsule, he at once connects these symptoms with the slight degree of shortening, and from their union he forms the diagnosis of extracapsular impacted fracture of the neck of the femur.
Having rejected the amount of shortening, as diagnostic of the seat of fracture with respect to the capsule, M. Rodet then endea- vours to prove that the direction in which the force has acted furnishes the only certain diagnostic sign, and that the fracture will be intra or extracapsular, oblique or transverse, according as the force has acted in a vertical, lateral, or transverse direction ; he maintains that when the force has been applied vertically, as in a fall upon the feet or knees, the fracture will be oblique and within the capsule ; and that if the anterior part of the trochanter strikes the ground, the fracture will be intracapsular and trans- verse ; that it will be mixed, or partly internal and partly exter- nal to the capsule, when the force acts chiefly upon the back of the trochanter ; but that in a directly lateral fall, the fracture will be completely external to the capsule. The statement may be arranged thus :
|
FORCE ACTING. |
FRACTURE. |
|
Vertically, Antero-laterally, Postero -laterally. Transversely, |
Oblique and Intracapsular. Transverse and Intracapsular. Mixed. Extracapsular. |
Now, in rejecting the amount of shortening, and substituting the direction of the force as a means of arriving at a differen- tial diagnosis, the author has not thrown much light upon the subject; on the contrary, it appears to me that he has abandoned the aid of a symptom which, if the proper precautions are taken, is not likely to lead to the formation of an incorrect opinion ; for if the surgeon is familiar with the causes which modify the shortening of
FRACTURES OF THE NECK OF THE FEMUR. 21
the limb, lie will know the exact amount of value that he is justi- fied in attaching to this symptom ; and if he connects it properly with the other symptoms present, he will find that it furnishes not only one of the most important indications as to the seat of the fracture, but also one that is available in the generality of cases.
With respect to Rodet's diagnostic sign, it will, of course, be admitted as a general principle, that the mode of applica- tion of the force, and the direction in which it acts, will deter- mine the situation and direction of a fracture ; but I contend that it is seldom available in practice in determining the seat of a frac- ture of the neck of the femur with respect to the capsule, for it would be extremely difficult, if not impossible, in the generality of cases, to obtain from patients a description of the direction in which the force was applied, as accurate as would be necessary before we could avail ourselves of it as a means of diagnosis ; it is not probable that a person of advanced age, who had just suffered so severe an injury as fracture of the neck of the thigh bone, would be able to inform us whether the shock was sustained by the ex- ternal surface of the trochanter, or whether there was a deviation, either anteriorly or posteriorly, from a directly lateral fall. Rodet seems to have been aware of this difficulty, for he observes that the direction in which the force acted is to be ascertained, not only from the account given by the patient, but also by examin- ing the hip, and ascertaining the precise situation of any contu- sion that may exist ; but in many cases, though there may be considerable swelling, there is no external ecchymosis, and in others, both contusion and tumefaction are so considerable and so extensive, that they lose all value as indications of the precise spot to which the force was applied, or of the direction in which it acted. In Case No. lix. there was a distinct abrasion of the skin over the most prominent and external part of the trochan- ter, shewing that the force was applied transversely, the direc- tion which, it is maintained, indicates an extracapsular fracture, and yet dissection proved that the fracture was completely within the capsular ligament. I could adduce other similar cases, but think it useless to do so, for even though we were to admit the correctness of the theory, we could not avail ourselves in practice of the proposed diagnostic sign.
22 FEACTURES OF THE NECK OF THE FEMUR.
The position of the foot, in cases of fracture of the neck of the femur, is not subject to as much variety as the shortening of the limb ; in general it is turned outwards. The degree of eversion, however, varies in different cases : sometimes the foot, as the pa- tient lies in bed, rests upon the heel, and the toes merely incline outwards, while in other instances the eversion is complete, both of the foot and of the entire limb, the patella being directed out- wards, and the head of the fibula backwards. This complete eversion may be present either in the intra or the extracapsular fracture, but in general is less marked in cases of impacted frac- ture : the patient is seldom able to invert the foot in the slightest degree, and when the motion of rotation inwards is communicated to it by the surgeon, severe pain is complained of. The number and strength of the muscles which rotate the limb outwards, and the natural tendency to eversion which exists in the foot, account for the limb assuming this position in almost all cases of fracture of the neck of the femur, but it is extremely difficult to offer a satisfactory explanation of those comparatively rare cases in which inversion is the posture which the foot assumes. I do not here speak of those instances in which the posture varies at different times, under the influence of external and accidental circum- stances, or of those in which the foot will remain turned either inwards or outwards, according as it may have been placed. Those examples of the injury are now alluded to in which the position of inversion is decided and permanent, the patient being unable to alter it, and where the surgeon, though employing much force, and causing considerable pain, can only communicate to the limb the motion of rotation outwards to a very limited extent.
My own experience woidd lead me to say that inversion of the foot is most frequently seen in cases of extracapsular frac- tures. I have seen seven examples in which the foot was turned inwards, in five of which the fracture was external to the cap- sular ligament. Such cases merit the closest attention, for they are especially liable to be confounded with luxations. I have seen this mistake committed more than once, and the patient submitted to a painful and injurious extension of the limb. Mr. Stanley has justly observed that, among the more com- plicated injuries to which the hip-joint is liable, that of frac-
FRACTURES OF THE NECK OF THE FEMUR. 23
ture of the trochanter major combined with fracture of the neck of the femur has, under certain circumstances, a strong resemblance to dislocation of the head of the bone. Whenever the fractured portions of the trochanter can be brought into contact, a crepitus can be produced, which may enable the surgeon to ascertain the precise nature of the injury. But when, from the direction of the fracture, one portion of the trochanter has been drawn by the ac- tion of the muscles towards the great ischiatic notch, no crepitus may then be discoverable ; a direct source of mistake will then arise, from the positive resemblance of the fractured portion of the trochanter to the head of the femur, the former occupying the same place which the latter would do in dislocation ; and if with these circumstances there should happen to be inversion of the injured limb, the difficulty of the diagnosis must be considerably increased. The case of Patrick Murphy (No. xxix.) furnishes a good illustration of the truth of the preceding observations, and several others of a similar nature might be adduced. They should teach us not to ground our diagnosis upon the presence or absence of one symptom merely, in cases of fracture of the neck of the femur. But what are the circumstances which prevent eversion of the foot, or what are the causes of its being occasionally turned inwards ? Mr. Guthrie is of opinion that when the fracture has taken place in such a manner as to be external to the insertion of the rotators outwards, yet sufficiently within the insertion of the glutseus medius and minimus, so as not to deprive them of their due action, the toe will be turned inwards, or else remain without any change of position. This explanation is not satisfactory, for it only applies to cases of fracture external to the capsule, and affords no solution of the occurrence of inversion of the foot in cases of intracapsular fracture ;* and, moreover, even though in any given case the fracture took the precise course which Mr. Guthrie has supposed, it does not follow that in- version of the foot should necessarily result ; for the adduc- tor muscles and the pectinaeus should still be more than suf- cient to counteract the tendency of the anterior portion of the glutaeus medius and of the tensor vaginae femoris to in-
* Mr. Guthrie states that inversion of the foot does not occur iu tlie intracapsuhir fracture. This is manifestly an error.
24 FRACTURES OF THE NECK OF THE FEMUR.
vert tlie foot. It may also be observed, tliat Mr. Guthrie's ex- planation fails to account for tlie occurrence of inversion of the foot in those cases of extracapsular impacted fractures in which the trochanter, though split, is not displaced — in which it still remains connected by its fibrous coverings to the shaft of the bone, every motion of which it follows ; in such cases, the attachments of the rotators outwards are not destroyed, and yet we occasionally find the foot inverted.
Without, therefore, rejecting Mr. Guthrie's explanation of the cause of this deviation from the usual symptoms of fracture of the neck of the femur, some other solution must be sought for, that will admit of more general application — one that will have reference to fractures within the capsule, as well as to those external to it, whether the latter are impacted or other- wise. The inversion of the foot has been attributed by Ekl to the circumstance of the neck of the bone being driven obliquely into the lower fragment.* This explanation, even though it were founded upon fact, only applies to one variety of the frac- ture ; it is, however, merely an hypothesis. In fractures external to the capsule, with comminuted fracture and displacement of the trochanters, the position of the foot is not subject to much variety. In the great majority of cases there is complete eversion, in consequence of the action of the adductor muscles, and the weight of the limb, naturally preponderating in this direction; and I am of opinion that we should ascribe the occasional occur- rence of inversion, in such instances, to the relative position of the shaft and of the neck of the femur, rather than to the action of the muscles which rotate inwards; for those rotators outwards, whose influence the fracture does not affect, still preponderate over their antagonists. At all events, in the cases to which I am alluding, the presence of inversion of the foot should never be permitted to embarrass our diagnosis : the facility with which the limb can be brought down to its natural length by extension, and the shortening removed, the recurrence of this shortening when the extending force ceases to act, and the possibility of flexing the thigh upon the abdomen, should be sufficient to enable
* Ergebmsse in clem Klinikum zu Laudshut. 1826.
FRACTURES OF THE NECK OF THE FEMUR. 25
US to form the diagnosis of fracture external to the capsule, with fracture and displacement of one or both trochanters.
There is one remarkable circumstance which appears to have escaped the observation of those who have described injuries such as those now alluded to, accompanied by inversion of the foot, and which appears to support the opinion that this symptom is to be ascribed to the relative position of the fragments, rather than to the influence of muscular action. I have observed it several times, and it is this : the deformity having been removed, and the limb restored to its natural length by extension, as soon as the ex- tending force ceases to act, though the limb is again shortened, the foot will be found to remain everted. Why should this be so, if muscular action had been the sole, or even the chief cause of the inversion in the first instance ? In other fractures, accompa- nied by deformity, the result of muscular action, if deformity recurs after having been removed by extension, it will be found to present the same features, or nearly so, as those which, in the first instance, characterized the injury. I know of no instance in which, under such circumstances, it will not only not present similar features, but exhibit actually opposite characters. Mus- cular action, therefore, is not of itself sufficient to explain the occurrence of inversion of the foot, in cases of fracture of the neck of the femur, no matter where situated; and it has been justly observed by Cruveilhier, in reference to this subject, " de- viation du pied devrait etre toujour la meme, si elle tenait a une cause identique. Taction musculaire."
Inversion of the foot may accompany fractures within the capsule, as well as those external to it ; of this I have myself seen two examples, and Stanley, Cruveilhier, &c., have mentioned similar cases. A middle-aged man fell in the street, and his hip struck the curb-stone. The immediate consequences were that the limb was inverted, and shortened to the extent of an inch, and no crepitus could be discovered. It was presumed that a dislocation had occurred, and accordingly an extension of the limb was made. The constitutional irritation occasioned by re- peated trials to reduce the supposed dislocation was such, that the man died five months from the time of the occurrence of the acci- dent. In the dissection of the hip, a fracture was found, ex-
26 FRACTURES OF THE NECK OF THE FEMUR.
tending obliquely tlirough the middle of the neck of the femur, but entirely within the capsiile. A portion of the fibrous and synovial membrane, on the anterior side of the neck of the bone, had escaped laceration.* With reference to this case, Mr. Ames- bury observes: " The causes which gave rise to the inversion of the limb in this instance are evident." This is certainly a simple method of disposing of the question, but it would have been more satisfactory had he specified the causes fo^ the information of others. I suppose he alludes to the fact of the cervical ligament having been uninjured on the anterior side of the neck of the bone ; but, as Mr. Stanley has justly observed, this circumstance might, probably, prevent the limb from being turned outwards, but it affords no explanation of the occurrence of inversion.
In every case of fracture of the neck of the femur, accompanied by inversion of the foot, which I have had an opportunity of examining after death, the inferior has been placed in front of the superior fragment; it was, therefore, with much surprise that I read the following passage in the Le9ons Orales : " Si le frag- ment interne se porte en arriere, et I'externe en avant, il y a alors deviation en dehors, si au contraire la fracture est oblique en sens inverse, la deviation aura lieu en dedans."f These remarks were so directly opposed to the result of my own observations, that I could only explain them upon the supposition that the opinion of Dupuytren had been incorrectly stated; and a confirmation of this conjecture occurs in the memoir of Mercier upon fractures of the neck of the femur, published in 1835, in the Gazette Me- dicale. In a note appended to this memoir it is asserted that, in the passage which has been quoted from the Le9ons, the opinions of Dupuytren have been erroneously stated by the editors of the Lectures; that, in fact, the words " en dehors" and " en dedans" should be transposed : and in the article upon fractures, published in the Dictionnaire de Medicine et de Chirurgie Pratiques, Sanson states it to have been the opinion of Dupuytren that inversion of the foot occurred when the lower fragment was placed in front of the superior. Cruveilhier also has recorded a case of fracture with inversion, in which, after death, this relative position of the frag-
* Medico- Chinirgical Transactions, vol. xiii. f Tome ii p. 109.
FRACTURES OF THE NECK OF THE FEMUR. 27
ments was found.* The difficulty, however, still remains to be solved, viz. how does the circumstance of the lower fragment being placed in front of the superior, favour the occurrence of in- version of the foot ? The rotation inwards, in such cases, is pro- bably to be ascribed to the change in the direction of the fibres of certain muscles, and consequent alteration in their action, re- sulting from the displacement forwards of the lower fragment. This position of the lower fragment would, probably, render the pectinasus and superior portion of the adductor magnus rotators inwards, while, at the same time, the position of the superior frag- ment behind the inferior presents a mechanical obstacle to rota- tion outwards, the tendency to which is further prevented by the diminution in the power of the small rotator muscles of the hip, consequent upon the fracture of the trochanter. If the lower fragment be so far displaced forwards as to bring the insertion of the pectinseus and upper portions of the adductors in front of their origin, these muscles would, probably, become rotators inwards, or, at all events, their power of rotating outwards would be lessened.
Whether this conjecture (for it is nothing more) be correct or otherwise, it still appears to me that the influence of the muscles, in producing inversion of the foot, is but secondary ; and that the lower fragment must first be thrown, by the violence which pro- duced the fracture, into a position favourable to their action as rotators inwards. I am conscious, however, of the insufficiency of these observations to explain the occurrence of the pheno- menon in question, in cases of intracapsular fractures ; for in such it is difficult to conceive how the lower fragment could be thrown so far forwards as to afiect the action of the muscles, by altering the direction of their fibres. The question is still open to inves- tigation.
There has been already mentioned a remarkable species of fracture of the neck of the femur, termed the impacted frac- ture, which is characterized by symptoms very different from those which accompany any other form of this lesion, and with which it is most important that the practical surgeon should be well acquainted. In many cases these symptoms are so obscure,
* Livraison xxvi.
28 FRACTUEES OF THE NECK OF THE FEMUR.
and so much, at variance witli those with which we are familiar, as denoting the existence of the more common forms of fracture of the neck of the thigh bone, that more than ordinary caution is requisite to enable us to avoid committing an error in diagnosis, and pronouncing that the injury which the joint has suiFered is merely a severe contusion, which will not be followed by any serious impairment of the functions of the limb ; whereas the truth is, that shortening and lameness are the inevitable and permanent results of even the slightest degree of impaction of the broken cervix into the shaft of the femur.
This peculiar form of fracture is the only one, the diagnosis of which is attended with difficulty, for it rarely happens that the limb is shortened to the same extent as in the ordinary exam- ples of extracapsular fractures ; in general the amount of retrac- tion is nearly the same as in cases of fracture within the capsule. Between these two forms of injury, therefore, the shortening of the limb is not available as a means of differential diag- nosis ; upon further examination, however, it will generally be found that crepitus cannot be elicited upon rotating the limb, because upon the one part the neck of the femur is so firmly wedged into the cancellated tissue of the shaft, that the fractured surfaces cannot be moved upon each other ; and upon the other the integrity of the strong fibrous and tendinous structure which invests the whole of the region traversed by the second fracture, which has been already alluded to as being always present, is such that the detached portion of the trochanter, whether large or otherwise, in general moves with the shaft of the bone, and it is only by submitting the patient to an examination unjustifiably severe, that we are occasionally enabled to produce this character- istic evidence of fracture. When we endeavour to extend the limb, we usually find that no force which it is safe to employ will restore it to its normal length, and in general the dislo- cated head of the femur will return into its socket more readily than the impacted cervix will leave the cavity between the tro- chanters, into which it has been driven.
More remarkable deviations than these, from the ordinary symptoms of fracture of the neck of the femur, sometimes attend this particular lesion ; and cases have occurred in which the patient
FRACTURES OF THE NECK OF THE FEMUR. 29
has not only raised liimself from tlie groimd after tlie fall which caused the fracture, but has even walked a considerable distance, bearing his weight upon the injured limb.*
In ordinary cases of fracture of the neck of the femur, when the limb is viewed as the patient lies upon his back, the ap- pearances are such that the surgeon has no difficulty in ascer- taining the nature of the injury which the joint has suffered; but in that particular form of fracture now alluded to, in which the broken cervix I'emains firmly implanted in the cancellated tissue between the trochanters, the whole expression of the limb is well calculated to deceive us: it does not present that completely powerless aspect which we notice in other cases of fracture of the neck of the thigh bone ; the patient has more com- mand over its motions, and I have seen cases, in which, after the lapse of a few days, he has been able to raise the extended limb by the unaided efforts of its own muscles: there is frequently no greater degree of shortening than a very slight inclination of the pelvis would account for ; and althoiigh the limb is usu- ally turned outwards, it does not lie everted in that prostrate, powerless state, which in its whole expression announces the ordinary fracture of the neck of the femur ; indeed in many instances the patient is seen to maintain the limb resting fairly on the heel, turned neither inwards nor outwards, and is able without much pain to flex the leg on the thigh, and the latter on the abdomen: the trochanter major, being still supported by the neck of the femur, firmly implanted in the lower fragment, does not fall back towards the ischium as it does in those cases in which there is no impaction; on the contrary, it frequently seems to stand oiit even more prominently upon the injured than upon the sound side, and when the patient is supported in the erect pos- ture, the prominent position of the injured hip becomes very apparent : add to these the impossibility of eliciting crepitus, and
* " Nous avons vu un homme qui a pevi marcher pendant plusieurs jours, avec le secours d'un baton, avant qui les fragmens d'une fracture du col du femur se fussent de- places. On ne pent concevoir un fait aussi extraordinaire qu'en consid^rant que la cas- sure de cette partie du femur est ordinairement inegale; que I'engrenure des inegalites des deux fragmens peut les soutenir ; que leur separation est moins facile qiiand I'une d'eux est taille en forme de coin, et engage dans une ecliancrure proportionnee de I'autre." — Boyer^ t. iii.
30 FRACTURES OF THE NECK OF THE FKMUR.
we have a group of symptoms by no means characteristic of frac- ture of the neck of the femur, but such as would rather induce us to arrive at the conclusion that the injury was merely a severe contusion, from which, under the influence of rest and treatment, the patient would recover, without any impairment of the func- tions of the limb.
These are truly embarrassing cases, for we are expected to pronounce at once our opinion as to whether the bone is broken or not ; the recollection of every surgeon will furnish him with instances in which he has experienced the utmost difiiculty in coming to a conclusion in his own mind, under the circum- stances which have been described; and it is certain, that not only have cases of impacted fracture of the neck of the femur been often mistaken for contusion of the hip, but also that numerous instances of the latter injury have been recorded as examples of fracture of the cervix femoris cured without lameness or defor- mity resulting. In the Gazette des Hopitaux* it is recorded that a woman, set 64, was treated for an intracapsular fracture of the neck of the femur, and that she was discharged from hospital at the expiration o£ one month, '■'■ parfaitement guerie et sans claudica- tion." It would indeed require a more than ordinary share of credulity to enable us to believe that in this case there had been a fracture of any part of the neck of the femur, much less an in- tracapsular fracture. The truth is, that when the muscles around the hip-joint have suffered a violent contusion, in consequence of a heavy faU upon the trochanter, and all the component parts of the joint have received a severe shock, when we examine the limb as the patient lies in bed, there is much in the appearances and symptoms calculated to mislead us ; the patient is, in general, unable to raise, by one voluntary effort, the extended limb from the bed; the inclination of the pelvis produces an apparent short- ening, and the foot lies everted ; there is swelling around the joint, and every motion is attended with pain.
These cases of contusion of the hip-joint, the result of a fall upon the trochanter, are not unfrequently followed (especially in old people), at a period remote from the receipt of the injury, by
* Tome ix.
FRACTURES OF THE NECK OF THE FEMUE. 31
a real shortening of the limb and eversion of the foot, circumstances well calculated to confirm the belief of a fracture of the neck of the femur having been the original injury, whereas the fact is, these subsequent changes are the result of a vital process, a slow and mild inflammatory action, excited by the contusion in the cancellated tissue of the head and neck of the femur : the delicate vascular structure of the interior of the bone suffers, as it were, a kind of concussion, by which the vessels are excited to increased action, and interstitial absorption of the neck of the bone results ; the limb becomes shortened, the foot everted, and not unfrequently we will find in such cases all the symptoms of chronic rheumatic arthritis established.*
We are, in general, enabled to ascertain the real nature of the injury by observing the relation which the trochanter major bears to the anterior superior iliac spine; this relation, being the same upon each side, is usually sufiicient evidence of there being no other injury than contusion ; but it is to be remembered that the normal relation of these two processes being altered does not always imply the existence of a fracture of the neck of the femur, and I can suppose a case in which the position of the trochanter major with respect to the iliac spine will not serve as a diagnostic mark between a contusion of the hip and the impacted fracture of the neck of the femur. For instance, a man of advanced age, who has long suffered from the effects of chronic rheumatic arthritis of the hip-joint, falls upon the trochanter and receives a severe con- tusion,— how are we to distinguish this case from one of impacted fracture of the neck of the femur ? In both there is shortening of the limb, eversion of the foot, and a change in the position and bearings of the trochanter major ; in neither can we elicit crepitus, or elongate the shortened limb ; in neither can the patient raise the limb en masse, or it may be, that in each he has supported his weight upon it, or even walked a little after the receipt of the injury. If we find, upon questioning the patient (and in such
* " Enfin je soupgonne que dans certains cas ou on a observe le raccourcissement chrouique du membre, dans ces circonstances ou les signes de la fracture avaient ete equivoques, il n'y point eu fracture du col, mais que la col a subi ime violence qui y a determine des alterations organiques de natui'e diverse par suite desquelles s'est operas une resorption ulterieure.'' — Chassaignac.
32 FRACTURES OF THE NECK OF THE FEMUR.
cases we should never omit to institute tliis inquiry), that he has been long subject to pain and stiffness in the joint, that he walked lame in consequence of a gradually increasing shortening of the limb, — if, in short, we find that he has been suffering from the symptoms of chronic rheumatism of the hip-joint, and if the powerless state induced by the recent injury wears off, under treatment, in a short time, we have, of course, grounds for believ- ing that there is no fracture of the neck of the femur; and upon the other hand, we are justified in supposing that some more serious injury than contusion has taken place, if after long con- finement to the horizontal posture, the patient still remains inca- pable of using the limb.
But although the previous history and the progress of the case may elucidate the nature of the lesion which the joint has suffered, the means of distinguishing between these two forms of injury of the hip at the time of their occurrence still remain to be supplied. The evidence of the existence of an impacted fracture of the cervix femoris is of a negative rather than of a positive cha- racter, and may be thus briefly stated. 1. Slight shortening of the limb. 2. Slight eversion of the foot. 3. Absence of crepitus. 4. Great difficulty in all cases, and in the majority of instances an impossi- bility, of removing the shortening of the limb by extension ; and lastly, less loss of power than in other forms of fracture of the neck of the femur.
With respect to the anatomical characters of the impacted fracture, we usually find that when the neck of the bone is broken transversely with respect to the direction of its axis, the superior fragment is simply implanted in the cancellated tissue of the in- ferior, without any interlocking of the broken surfaces ; but occa- sionally we meet with cases in which the irregularity of the line of fracture is such, that the fragments become interlocked, or, as it were, dovetailed together, as in Case No. XLi. The latter form of impaction may occur in cases both of extracapsular and of intra- capsular fractures, but the former can only happen when the frac- ture is external to the capsule ; for the relative size of the frag- ments in the intracapsular fracture is such, that the one could not be received into the other : hence, in these cases we find a dovetailing together of the fragments rather than impaction, the
FRACTURES OF THE NECK OF THE FEMUR. 33
broken surface of eacli fragment presenting eminences and de- pressions wliicli mutually accommodate one anotlier.*
In all tlie examples of impacted fractures of tlie neck of tlie femur witliin the capsule, which I have had opportunities of exa- mining, the anatomical characters of the injury, and the relative position of the fragments, have been strikingly similar ; the head of the bone sunk below its natural level ; its superior surface lying nearly in the same horizontal plane with the summit of the tro- chanter major; the inferior or internal portion of the upper over- lapping the lower fragment ; and the superior or external part of the latter rising above the level of the corona of the head of the bone, and frequently overlapping its cartilaginous surface (see case No. lviii.) Wlien a vertical section is made through the head and neck of the bone, and through the trochanters, the line of fracture is seen taking an undulating course, the broken surface of the upper fragment presenting, near its cen- tre, a kind of dentiform process, which buries itself, as it were, in the cancelli of the lower fragment, while the compact tissue of the arch of the latter penetrates the reticu- lar structure of the head of the bone.f I had an opportunity of ex- amining, in the " Musee Dupuy-
tren," the specimen illustrated by the annexed wood cut, but could not learn the history connected with it. It was an example of fracture within the capsule, at the line of junction of the head
* " L'engrenement des fragmens s'observe moins souvent peut-etre dans la fractiu-e intra-capstdaii-e, que dans la fracture extra-capsulaire. Cependant je I'ai observe plu- sieurs fois ; dans iin cas de fracture intra-capsulaire du col, observe sur un adulte tres vigoreux, j'ai trouve un engrfinement r^ciproque forme ainsi qu'il suite : le fragment superieure et le fragment inferieure presentaient chacmie une cavite et une avance osseuse : la cavite de I'un recevait I'avance de I'autre et reciproquement ; l'engrenement etait lei qu'il y ayait immobilite complete." — CruveiUiier, Liv. xxvi.
f Par suite de ce mouvement de descente de la tete, la partie inferieur de sa surface fi'actm'ee a cesse de correspondre au col du femur ; et reciproquement la partie superiem-e de la sm-face fracturee du col, abandonnee par la tete, est libre, et se presente a nu aux re- gards de I'observateur." — Musee Dupvytren : puhlie au Nom de la Faculte. Tome premier.
B
34 FRACTURES OF THE NECK OF THE FEMUR.
"witli tlie neck of tlie femur. The head of the bone had sunk below its natural level, its upper surface being in the same horizontal plane with the summit of the trochanter major; the line of fracture was undulating ; inferiorly the compact tissue of the lower fragment had penetrated the cancellated structure of the head of the bone, while, at the upper part, the lower fragment overlapped the superior. The fragments thus mutually supported each other. They were closely united by an exceedingly dense, fibrous tissue.
The distance to which the superior fragment, in cases of extracapsular fractiires, is driven into the oancelli of the shaft, varies considerably. In some cases (No. lii.) it does not exceed a few lines, while in other instances the broken surface of the upper fragment is in contact with the compact structure of the outer wall of the trochanter (No. xlvii.) ; and if the force applied be very great, this layer of compact tissue may itself be broken, and then the neck of the bone is found in contact with the ten- don of the glutseus maximus, or with the bursa which separates that muscle from the great trochanter (No. xlvi.) The same variety is to be noticed with respect to the angle which the broken cervix forms with the shaft of the femur. In some few cases it deviates but little from the natural angle (No. li.), and sometimes, although rarely, it forms an acute angle with the shaft (No. L.) ; but in the majority of instances the fragments are placed at right angles with each other (No. xlvii.) This deviation from the natural angle is not, however, the only displacement which the neck of the bone suiFers in cases of impacted fractiires ; for in numerous examples of this injury the neck forms with the shaft of the femur, an angle salient in front, the axis of the broken cervix being directed backwards instead of forwards: in some cases this displacement is carried to such an extent that the ante- rior surface of the neck of the bone, together with the anterior portion of its broken surface, is placed in front of the shaft, the posterior part of the fractured surface alone being imbedded in the cancellated tissue between the trochanters ; the back of the neck of the bone, in such cases, is found resting against the pos- terior intertrochanteric ridge. This alteration in the axis of the neck depends principally upon the direction in which the force
FRACTURES OF THE NECK OF THE FEMUR.
35
which has produced the fracture has been applied ; and in such instances the eversion of the foot will be greater than is usual in cases of impacted fracture ; while, upon the other hand, when the cotyloid fragment is implanted in the shaft in such a manner as to leave the greater part of the inferior fragment in front of it, the eversion of the foot will not only be less than usual, but may even be altogether absent, and inversion is the usual position of the foot in such cases.*
There is a very remarkable variety of the impacted fracture external to the capsule, of which I have seen but one example: in this the lower fragment penetrates a short distance into the cancellated tissue of the superior, the reverse of what generally happens. The shaft of the bone being drawn upwards when the fracture occurs, and the neck of the femur being driven down- wards, the angle formed where the inferior extremity of the broken surface of the lower fragment meets the internal margin of the shaft, penetrates the lower portion of the reticular tissue of
the upper fragment : this tissue is thus brought into contact with the external or superficial surface of the compact structure of the
See case xlyi. D 2
36 FRACTURES OF THE NECK OF THE FEMUR.
inner wall of tlie shaft of the femur, while the upper part of the broken surface of the cervix rests upon the lower portion of the surface of the lower fragment. An example of this singular form of impacted fracture has been delineated by Mr. King.* Its occur- rence must depend upon the direction in which the force which broke the bone was applied, but, unfortunately, I am not in pos- session of the history of the specimen represented in the pre- ceding wood-cuts. The fracture, in this instance, has been wholly united by bone, and a profusion of osseous matter has been de- posited around the fragments.
In alluding to the history of the extracapsular fracture of the neck of the femur, accompanied with invagination of the supe- rior fragment, it has been already mentioned that a second frac- ture traverses the posterior intertrochanteric space: in general, the existence of this second lesion of the bone is only revealed by post mortem examination, for the tendinous and fibrous struc- tures which invest the whole of the trochanteric region usually remain uninjured ; the detached portion of the trochanter, there- fore, moves with the shaft of the femur, and crepitus cannot be elicited : to use the words of Chassaignac : " Quelquefois, malgre la fracture du col du femur, avec separation du trochanter, ce dernier, conservant des connexions asses resistantes avec le corps de I'os au moyen dti perioste, que n'a pas ete dechire, se meut simultanement avec le femur, quand on exerce une traction sur la partie inferieure du membre."
When we have opportunities of examining anatomically spe- cimens of impacted fracture of the neck of the femur external to the capsule, some months after the occurrence of the injury, we usually find that irregular masses of bone have been depo- sited in the vicinity of the trochanters and their connecting lines : these bony growths are sometimes very exuberant. They encircle the neck of the femur to a variable extent, but are to be found in greatest quantity along the posterior intertrochanteric line, except, perhaps, in those cases in which the anterior part of the broken surface of the neck of the bone projects in front of the shaft, or when, as sometimes happens, the anterior part of the
* Cyclopaeclia of Surgery, article " Fractures."
FRACTURES OF THE NECK OF THE FEMUR.
37
lower fragment has been broken off from tbe shaft ; the bony ma- terial is then deposited freely along the anterior line.
These exostotic growths have not escaped the attention of pa- thologists, but it has appeared to me that the purpose which they are intended to serve, and the true object of their formation, have been altogether mistaken. They have been described as being simply additions made to the trochanters, and their con- necting lines, by which a species of socket is formed to receive the neck of the bone, the acetabulum supported, and the indivi- dual enabled to bear his weight upon the injured limb : they have been supposed to be merely provisions adopted by nature for the support of the weight of the body. " Quelquefois la nature dis- pose avec une sorte d'intelligence ces ossifications, de maniere a les rendre propres a consolider I'articulation accidentelle. Tels sont les cas oi\ des anneaux osseux completes ou incompletes, pro- venant de la base du col ou des trochanters, ou formant un sourcil avance a la partie superieure de la cavite cotyloide, invaginent pour ainsi dire la fausse articulation. Tel est encore ce cas com- munique par Powel a S. A. Cooper."* These observations of Vidal are, perhaps, correct, as far as they apply to cases of frac- ture within the capsular ligament ; but in the instance to which he has referred, as recorded by Sir Astley Cooper, the fracture was external to the capsule and impacted. " The neck of the femur
' Traite de Pathologie Externe. Par Aug. Yidal (De Cassis), t. ii.
38 FRACTURES OF THE NECK OF THE FEMUR.
had been broken at its junction with the body of the bone, and had been forced into the cancellated structure between the trochanter major and trochanter minor, where it had been united with the cancelli. But the most curious circumstance in this dissection was, that, in order to give the support which the body required for a limb in such a state, an addition had been made to the trochanter major and trochanter minor, by which means they rested against the acetabulum, and in every slight change of position would give an opportunity for the weight of the body being supported by these processes resting against the OS innominatumr* Mr. Adams also has observed, " The lesser trochanter, in most of the cases which we have observed, was greatly increased by bony depositions, and became a prop to s^^p- port the head ; and it is probable that, in these cases, the aceta- bulum is propped up by the growths of bone from the shaft of the femiir."t
After an attentive consideration of this subject, and a careful examination of a great number of specimens of the impacted extracapsular fracture, with a view to ascertain the truth or fal- lacy of this doctrine, it appears to me that the mechanical sup- port of the head and neck of the femur, and of the acetabulum, is neither the sole, nor even the principal object intended to be accomplished by the deposition of these irregular masses of bone ; in general they are less copiously deposited below the neck of the bone than elsewhere ; they are most luxuriant about the back of the trochanters and the posterior intertrochanteric space, and are usually proportionate in amount to the extent of the lesion which the trochanters have suffered : when the trochanter major is merely, as it were, split, or fissured, its fibrous coverings remaining entire, and the broken surfaces directly confronted to each other, the quantity of new bone is exceedingly small, while, upon the other hand, it is abundant when a large portion of the trochanter is broken ofi" and displaced, in consequence of the laceration of the fibrous tissues which invest this region ; and finally, these osseous depositions are most exuberant when the trochanters are comminuted, and the fragments displaced both from the
* Sir A. Cooper on Dislocations, &c., page 160, plate ii. fig. 1. f Todd's Cyclopaedia, page 810.
FRACTURES OF THE NECK OF THE FEMUR.
39
shaft and from each other. If to aiFord mechanical support to the pelvis were the true object of their formation, surely we
should expect to find them more frequently than we do in cases of fracture within the capsule, for it is in such cases that this mode of support is most necessary ; but although it is no doubt true that in many of these cases they are present, it is equally true that in the great majority of intracapsular fractures they are never formed, whereas in almost all cases of intracapsular impacted fractures, where the patient survives the accident a sufficient length of time, bony matter is deposited in greater or less quan- tity ; and yet, in these cases, the circumstance of the neck of the bone being impacted in the shaft, renders less necessary the me- chanical support which these adventitious growths have been sup- posed to afford ; and although I am willing to admit, that when very exuberant they may afford support to the neck of the bone
* Sandifort, IMuseum Anatomicum, vol. iv.
40 FRACTURES OF THE NECK OF THE FEMUR.
and to the pelvis, yet I feel convinced tliat sucli is not the object for the attainment of which they are deposited ; the final cause of their formation is the union of the fracture already described as traversing the intertrochanteric space, and the constant exist- ence of which, in cases of extracapsular impacted fractures, has been overlooked by the generality of writers.
When the patient survives the accident sufficiently long, bony consolidation takes place between the opposed surfaces of the im- pacted cervix and of the shaft, but this union is never accom- plished with so much facility, or at so early a period, as that of the fracture through the trochanter ; the latter I have frequently found united firmly by bone, while the neck of the femur has, upon being left for some time in water, become loose in the cavity which it had formed for itself between the trochanters : in these cases the bond of union between the cervix and the shaft is gene- rally a cartilaginous, or fibro-cartilaginous, structure of extreme density and great strength, and which, along with the mechani- cal support resulting from the impaction, enables the patient to bear his weight upon the limb before the osseous union of the cervix with the shaft has been accomplished.
When the neck of the femur is broken external to the capsule, the line of fracture is usually transverse with respect to the direc- tion of the axis of the neck, but in some instances the fracture passes downwards and outwards so obliquely that a portion of the great trochanter remains connected with the upper fragment, while in other cases the obliquity is in the reverse direction ; and Vidal mentions his having seen one instance in which the obliquity downwards and inwards was such, that the trochanter minor re- mained with the superior fragment ; such cases are, however, correctly speaking, examples of fracture through the trochanter, rather than of the neck of the bone. The extracapsular fracture is frequently accompanied by extensive ecchymosis, and upon post mortem examination we occasionally find that the eiFused blood has separated from each other the muscles of the thigh, even as low as the knee-joint; the surfaces of the fracture bleed freely, and in recent cases we find clots of blood occujDying the space or cavity circumscribed by the fragments of the shattered bone. The haemorrhage from the lacerated vessels of the cancel-
FRACTURES OF THE NECK OF THE FEMUR. 41
lated tissue is sometimes very profuse, causing great tumefaction and excessive pain ; and Cruveilhier has recorded an instance in whicli the patient sunk upon the fifth day after the receipt of the injury, apparently in consequence of the profuse bleeding which took place, from the source ju.st alluded to.
ANATOMICAL CHARACTERS OF FRACTURES OF THE NECK OF THE FEMUR, WITHIN THE CAPSULAR LIGAMENT.
In recent cases of intracapsular fractures of the neck of the femur, there are but few phenomena worthy of notice revealed by the anatomical examination of tlie joint ; indeed the only one which deserves more than a passing notice has reference to the condition of the cervical ligament, but this subject has already been alluded to at sufficient length. There is generally observed a preternatural amount of vascularity of the synovial membrane, and in some cases a small quantity of blood is found within the capsule, and sometimes coagulable lymph is seen adherent to the internal surface of the capsular ligament; the surfaces of the frac- ture are themselves sometimes covered by a layer of lymph, which can be drawn out into delicate bands by gently separating the fragments from one another.
In those cases, however, in which the injury has happened many years before the death of the patient, the morbid appear- ances are as remarkable as they are varied. The capsular liga- ment is usually greatly increased in thickness, and occasionally osseous matter is deposited in its structure. I have seen only one example in which it was extensively lacerated, but in several instances of oblique fracture have found it perforated by the sharp extremity of the upper fragment ; and the late Mr. Colles has recorded a case in which a sharp projecting splinter, belonging to the upper fragment, pierced the front of the capsule and the bursa, which is here placed, connected with the psoas muscle, the tendon of which appeared as if unravelled in its tex- ture, or split into a number of softened tendinous threads. The synovial membrane also is usually thicker than in the normal state, and lymph is deposited upon its surface, not only where it lines the interior of the capsule, but also where it is reflected upon
42 FRACTURES OF THE NECK OF THE FEMUR.
tlie neck of the femur ; in some cases the lymph, although formed into an organized membrane, does not constitute the medium of any adhesion, but hangs in fimbriated masses (No. xiii.), similar to those seen in this articulation in cases of chronic rheumatic arth- ritis ; but in numerous examples it forms adhesions of great strength between the opposed synovial structures, and also between these and the broken structure of the upper fragment, and sometimes both fragments are thus connected to the capsule and to each other (No. xxiii.).
The synovial membrane sometimes presents the anatomical characters of acute inflammation, but in general the lymph which we find effused is the product of chronic rather than acute syno- vitis ; nevertheless, it occasionally happens that not only the fibrous and synovial structures, which enter into the composi- tion of the joint, become the seat of acute inflammation, but even acute osteitis is established, and the capsule rapidly be- comes distended with lymph and purulent matter. These gene- rally fatal consequences are most likely to ensue, however, while the injury is recent, and their occurrence is most to be dreaded in those individuals whose constitution, either from intemperance or any other cause, is at the time favourable to the production of dif- fuse inflammation. In general the head of the femur preserves its globular form, and is moveable in its socket, but sometimes it becomes adherent to the acetabulum, and the opposed cartilaginous surfaces are found invested with a false membrane, which consti- tutes the bond of union, and beneath which the cartilage of the head of the bone is found differing but little from its normal state ; or else (in very old cases) the layer of cartilage being removed, the osseous surfaces of the head of the femur and of the acetabu- lum become closely joined to each other by a dense fibrous struc- ture, and a false anchylosis is established ; in some rare cases, an organized membrane covers the head of the femur, and also the acetabulum, and yet no union takes place between the two opposed vascular surfaces. The ligamentum teres generally remains unal- tered in its texture, but sometimes it appears, as it were, unra- velled, and resembles a cellular more than a ligamentous struc- ture.
The superior fragment of the broken cervix usually disappears
FRACTURES OF THE NECK OF THE FEMUR. 43
to tlie level of the brim of tlie acetabulum, either in consequence of the action of the absorbent vessels, or by the friction of the broken surfaces, or perhaps it is due to a combination of both these causes. The absorption, however, sometimes extends much further ; I have seen half of the globular head of the bone thus removed, and a case has been recorded in which the head of the bone was com- pletely absorbed. In some cases its lower surface becomes uni- formly concave, and a shallow socket, as it were, is formed, into which the upper end of the lower fragment is received ; or the upper fragment may present both a concavity and a convexity, which are adapted to a corresponding eminence and depression upon the surface of the lower fragment, and the relative position of which depends upon the original direction of the fracture. In a few rare examples the lower surface of the cotyloid fragment presents an uniform convexity, which is received into a very superficial and shallow socket, formed in the condensed cancel- lated structure between the trochanters, the femoral fragment having been absorbed. The case of Patrick Doolan (No. xi.) affords a good example of this condition of the fragments, the superior of which was united by membranous anchylosis to the acetabulun, while the lower surface of this fragment represented the half of a sphere ; the neck of the bone had entirely disap- peared, and a shallow cup was hollowed out in the space between the trochanters, to receive the convex surface of the upper frag- ment: both these surfaces possessed the hardness of ivoiy and the polish of enamel.
In old cases the femoral fragment is likewise absorbed to a greater or less extent ; sometimes it disappears entirely to its base, and the portion of the shaft, from which, in the normal state, it springs, presents a smooth and even surface, limited by the trochanters and their connecting lines (Nos. xix. and xx.) In general the two portions of the bone move freely upon each other, but in not a few instances they are united by a ligamentous or fibrous structure, the resxilt of the deposition of lymph : this dense tissue is sometimes formed over the entire surface of each fragment, maintaining them in close apposition, and preventing effectually the free motion of one upon the other ; but very frequently we find that the material of this union has been formed only at one
44 FRACTURES OF THE NECK OF THE SEMUR.
or two points ; in such cases tlie lower fragment enjoys a consider- able extent of motion, and the uniting medium becomes elongated into bands an inch or more in length. Occasionally the lower fragment suffers but little from absorption (although the fracture may have occurred many years before the death of the patient), its extremity merely becoming rounded, and presenting a smooth surface more or less convex. Portions of the compact structure along the posterior margin of one of the fragments, are frequently laid down upon the fractured surface and united to it ; it is comparatively xare to witness this phenomenon along the ante- rior margin of either fragment, and I believe that it takes place at the moment of the occurrence of the fracture, and that it is to be ascribed to the collision between the posterior margin of each fragment, consequent upon the rotation outwards of the in- ferior.
The absorption of the lower fragment is sometimes eiFected with extraordinary rapidity; in case No. ix. the shortening of the limb, which immediately followed the receipt of the injury, was only a quarter of an inch, but after the expiration of six weeks it amounted to one inch and a half; and in case No. xii. the removal of the greater part of the neck of the bone was accomplished in less than a month. According as the absorp- tion proceeds, the shortening of course increases, and the trochan- ters are gradually approximated to the level of the acetabulum. We usually find that the broken surfaces, and all the structvires which compose the false articulation, are lubricated by a viscous synovial fluid, in which flocculi of lymph are often seen, either free or attached to the synovial lining of the capsule, or of the neck of the bone : sometimes, but not frequently, we find what are usually termed foreign bodies, either free in the interior of the joint, or attached; they are analogous to the foreign bodies found in the articulations in cases of chronic rheumatic arthritis.
PARTIAL FRACTURE OF THE NECK OF THE FEMUR.
A peculiar form of injury of the neck of the femur, termed " Partial Fracture," has been described by the late Mr. Colles, and also by Mr. Adams. The former author has spoken of its
FRACTURES OF THE NECK OF THE FEMUR.
45
occurrence in cases of fractiire within tlie capsular ligament, and the latter lias described the symptoms and the morbid appear- ances supposed to characterize it in extracapsular fractures. In the article upon the "Abnormal Conditions of the Hip-joint," pub- lished in the Cyclopgedia of Anatomy, Mr. Adams, when speak- ing of the impacted fracture, remarks : " In general the fracture is complete of the compact and reticular tissue of the neck of the bone, and the upper fragment is wedged into the lower, as is the fang of a tooth into its alveolus; but cases, we believe, have occurred, in which the fracture of the cervix femoris was incom- plete, and had engaged merely the under stratum of the compact tissue of the neck of the femur. To comprehend well what occurs in the partial, as well as in the impacted fracture, we should attend a little to the normal anatomy of the interior of the cervix femoris, and the disposition of the compact and reti- cular tissue. Let us make a vertical section through the neck of
a healthy fenuu% in the direction of its long axis, and continue it down through the shaft of the dry bone, the section leaving
46 FRACTUEES OF THE NECK OF THE FEMUR.
one-half of tlie femur in front, and tlie other behind with the lesser trochanter, as has been done in the healthy femur of a well-formed adult man, from which the adjoining figure has been taken.
" This simple view shews us that the principal strength of the neck resides in the arch of compact tissue, which begins small where the globular head joins the under part of the neck, but which gradually enlarges downwards towards the lesser trochan- ter, and even so low as the middle of the femur, where it will be found to be nearly twice the breadth of the opposite wall of the shaft of the bone ; the compact structure which, scarcely thicker than a wafer, invests the entire head of the upper part of the neck and trochanter, seems to have little reference to any design of imparting strength or resistance to this part of the bone.
"When we fall, or leap from a height, on the feet or knees, the thin upper stratum of the neck, and the whole of the reticular tissue of the neck, will first receive, and probably yield somewhat to the weight, by which some of the force of the shock may be decomposed, but to the bony arch of compact tissue, to which we have alluded, must ultimately be referred any violence which the neck of the femur can receive from any impulse transmitted from above.
" We seldom hear of a fracture of the neck of the femur occur- ring to a healthy adult, when he falls with violence on his feet or knees, for the weight of the superincumbent body is thrown in the most favourable manner on the bony arch of compact tissue before alluded to, which, from its density and form, and strength derivable from both, it is almost always able to resist ; and even a fracture of the acetabulum, or rupture of the capsular ligament and dislocation, are accidents more likely to happen under such circumstances.
" But, on the other hand, let us suppose a person to fall on the trochanter major, which is resisted by the ground, while the weight of the pelvis, &c., acting obliquely on the under surface of the neck, will have a tendency to bring the neck of the femur into a straight line with the shaft of the femur, or, in other words, to efface its obliquity, hence the compact tissue, so often alluded to, cracks across, and if no more happens for the present, we have
FRACTURES OF THE NECK OF THE FEMUR. 47
the simplest form of partial fracture of the neck of the femur. The possibility of such an accident occurring implies that there is toughness and tenacity enough of the material composing the reticular part of the neck of the femur to yield without breaking, of which there can be now no doubt entertained,
" While circumstances are in this state, we can conceive the possibility of a patient being able to stand after such an accident, or even to walk for some distance ; and when examined by the surgeon, we can understand how the latter, as it has often hap- pened, might be deceived into the opinion that there was really no fracture.
"Again, we can easily imagine how, under such circumstances, an awkward movement or a fall may render the fracture complete, or how, from a severe secondary injury, or even the continued action of the first impulse, somewhat varied in its direction, the broken neck of the femur could be wedged into the cancelli of the shaft. When we remove the femur, which has been the sub- ject of this partial fracture of its neck, and examine it, we shall uniformly find that its natural obliquity is lost, and that the head and neck of the bone are directed simply horizontally inwards, at right angles with the shaft.
" Viewed posteriorly, the intertrochanteric line, in all the cases I have examined, seemed to have been the seat of osseous deposi- tions, and the interval between this and the head, which constitutes the back part of the neck, was diminished one-third. When we make a vertical section of the femur we observe that the compact structure at the upper part of the cervix, and the whole of the reticular tissue shew not a trace of fracture, or any alteration ex- cept that of loss of obliquity; but if we examine the compact arch of bony material which stretches from the lesser trochanter to the under part of the head, we find that this has been the seat of frac- ture, and that by a gradual, or sudden efibrt, it has been driven into the cancelli of the shaft of the femur, and with the compact tissue of the latter, forms a T-like disposition of these structures."
In the preceding observations it appears to me that the author has furnished us with a concise, but, as far as it extends, accurate description of the anatomical characters of those cases of impacted fracture of the neck of the femur, in which osseous union has
48 FRACTURES OF THE NECK OF THE FEMUR.
taken place ; but however ingenious tlie remarks may be consi- dered, they certainly afford no evidence of the occurrence of such an accident as partial fracture of the cervix femoris.
It would, in my opinion, be impossible to establish the doc- trine in question, except by the examination o? recent specimens ; for in the ordinary impacted fracture, when a vertical section is made through the head, neck, and upper part of the shaft of the femur, after bony union has been accomplished, the appearances are cer- tainly well calculated to mislead the judgment. The compact tissue of the concavity of the cervix forms, it is true, generally a right angle with that of the shaft ; bvit beyond this, as far as the interior of the bone is concerned, there is usually but little evidence of the upper portion of the bone having ever been the seat of fracture ; no line of callus indicates where the fracture traversed the reticu- lar tissue, nor does the compact structure which lines the upper part of the cervix exhibit any trace of fracture. But it is to be recollected that, in the impacted fracture, bony consolidation (when it does occur) takes place, not by the formation of callus, but by the direct union of the two osseous surfaces which are confronted to each other. It is, therefore, not to be wondered at that the reticular tissue, in such cases, should exhibit no trace of fracture, when the parts are examined after osseous union has been for some time accomplished; and it is still less surprising that no evidence of injury is to be found in the compact tissue of the upper part of the neck of the bone, for the fractmre in these cases is extracapsular, and altogether external to the commencement of the line of com,pact stimcture in question ; it traverses the bone exactly where the neck springs from the shaft of the femur.
But what appears to me to constitute incontestable proof that the cases upon which this eminent surgeon has founded his inge- nious theory should be looked upon as examples of the impacted and complete, rather than of the partial fracture of the neck of the femur, is to be found in the following passage : " Viewed 'postenorly, the intertrochanteric line, in all the cases I have ex- amined, seemed to have been the seat of osseous depositions." Now, I think sufficient evidence has been already adduced to prove that these osslfic deposits indicate that a fracture had traversed the posterior intertrochanteric space, and that such lesion is the
FRACTURES OF THE NECK OF THE FEMUR. 49
necessary result of an impacted fracture of tlie neck of the femur : of wliat use would tliese osseous depositions be in such a situation, if nothing but the concavity of the cervix had been broken? Or is it probable that the fracture through the tro- chanter (which the osseous deposits prove to have existed, which is the second fracture in order of time, and which is the result of the impaction of the neck of the femur into the shaft), is it likely that this second fracture would result, when the force ap- plied was not sufficiently great even to break the neck of the bone entirely through ?
It may also be remarked, that partial fracture is a form of injury to be looked for in the young subject, and most unlikely to occur at that period of life at Avhich fracture of the neck of the femur takes place, and of all parts of the skeleton, the neck of the thigh bone appears to me the least liable to such an injury. That the case of Sherlock (No. xlviii.) has been considered as an example of partial fracture, may be inferred from the following description given of it by Mr. Adams, in the paper already alluded to : " Alicia Sherlock, set. 64. Section of the head and neck of the femur, shewing fracture external to the capsule. The neck of the bone has sunk nearly to a right angle with the shaft. The compact structure which lines the conca- vity of the cervix has been hrohen, while the very thin stratum lohich invests the upper surface has yielded to the force without breaking ; but the cervix has sunk into the cancellated texture of the shaft at a right angle, and is now supported upon the lesser trochanter. There is no motion whatever between the broken surfaces, nor the slightest trace of fracture at the centred part of the neck of the bone. Exuberant growths of bone surrounded the seat of fracture, and con- tributed to form a kind of socket which received the superior fragment."
Having recently examined this specimen with much care, and left the bone for about two hours in boiling water, I found that it separated into three distinct portions, the shaft, the cervix, and the trochanter ; the fracture of the cervix was complete, and, as usual, a second fracture had detached the trochanter ; for the union of this second lesion of the bone, the osseous matter alluded to had been deposited, but perfect bony union had not taken
E
50 FRACTURES OF THE NECK OF THE FEMUR.
place, although the patient survived the accident for fifteen weeks.
Wlien it is considered that fracture of the neck of the femur oc- curs at a period of life when the bones are not likely to bend with- out breaking, and that in all the cases of supposed partial fracture, external to the capsule, there has been unequivocal testimony of the existence of a fracture of the trochanter ; bearing in recollec- tion, also, the fallacy of adducing, in support of the theory, the circumstance of there being no solution of continuity in the com- pact tissue of the upper portion of the neck of the femur ; and having found by actual examination of the specimens, in some of the cases adduced, that the fracture of the cervix was complete, and the trochanter likewise broken, we cannot avoid arriving at the conclusion, that the doctrine of partial fracture of the cervix femoris has not been established.
In the cases described as examples of partial fracture, by the late Mr. Colles, the injury, as already mentioned, was within the capsular ligament.* In case No. vii. the fracture was trans- verse, and close to the head of the femur. The fracture was incomplete, for the external bony coating of the neck of the fem.ur remained unbroken for nearly half the circumference of the bone at its posterior part, and was reduced to the softness and whiteness of cartilage. To the internal surface of this unbroken portion adhered many bony fragments of different sizes, which by the violence of the fracture appeared to have been torn away from the reticular substance of the bone. In case No. viii. the fracture was also transverse, and close to the head of the bone, but towards the posterior part of the neck the two pieces of bone remained con- nected with each other by a broad band of the external coating of the neck, which was unbroken ; this band was not less than an inch in breadth; it was palbably a continuation of the external coating of the bone ; its internal surface was as rough as a piece of coarse sand-paper, in consequence of small particles of the cancellated tissue of the bone remaining attached to it.
I have never seen an example of fracture of the neck of the femur, the anatomical characters of which exactly corresponded
FRACTURES OF THE NECK OF THE FEMUR. 51
with those described by Mr. Colles. I have, it is true, frequently found a considerable portion of the compact tissue which invests the posterior surface of the cervix torn from the cancellated struc- ture, and remaining adherent to the cervical ligament, which usually remains uninjured posteriorly, being, as already men- tioned, relaxed by the rotation outwards of the limb ; but in the majority of such cases, this lamina of compact tissue is itself broken into two or more fragments, in consequence also of the rotation outwards of the limb, for this motion, while it divari- cates the anterior margins of the fracture, crushes, as it were, the fragments together posteriorly, and hence it is that we so often find the intracapsular fracture, although simple in front, commi- nuted behind.
It would be very difficult to account satisfactorily either for the shortening of the limb or the rotation of the foot outwards, as long as we suppose the posterior part of the neck of the bone unbroken ; in my opinion, the presence of shortening necessarily implies, that if there be any fracture of the neck of the bone it must be complete : no one, surely, would be disposed to main- tain that the thin stratum of compact tissue which covers the pos- terior part of the cervix femoris is likely to bend, and thus to yield without breaking, in an old person, to a force which frac- tures the remainder of the neck of the bone ; and yet it is obvious that it must either bend or break, before retraction of the limb can occur. I have not been able to find in the Museum of the Royal College of Surgeons, the specimens which Mr. Colles has described as examples of partial fracture, nor is there any mention made of them in the printed Catalogue of the Museum, so that I cannot speak with confidence upon the subject ; but from having myself repeatedly seen appearances very similar to those which he has described, in cases in which the fracture was undoubtedly complete, I am disposed to believe that some mistake has been committed, the exact nature of which it is now, of course, impos- sible to ascertain.
It has been already mentioned that, in the great majority of cases of intracapsular fracture, the posterior portion of the cervical ligament remains uninjured, and that large fragments of the com- pact tissue of the corresponding part of the neck of the bone arc fre-
E 2
52 FRACTURES OF THE NECK OF THE FEMUR.
quently found adhering to it. In old cases, such as those de- scribed by Mr. Colles, this unbroken portion of the ligament ac- quires a great degree of strength, density, and thickness. In some cases it presents the characters rather of cartilage than of membrane ; and were it not for the high reputation of the author, and the general accuracy of his observations, I would almost be inclined to suppose that the structure or substance which he has described as bone " reduced to the softness and whiteness of cartilage,''' was merely the thickened, semi-cartilagi- nous, and unbroken portion of the cervical ligament, with frag- ments of the compact tissue of the bone adhering to it. Be this as it may, the theory of partial fracture of the neck of the femur is one that is interesting both to the pathologist and to the prac- tical surgeon, and it is of some importance that its truth or fal- lacy should be established. For my own part, although I may have failed to convince the judgment of others, I am satisfied that the doctrine has not yet been proved to be correct ; nor have I arrived at this conclusion hastily, but after having given to the subject that degree of consideration which is due to the opinions of the distinguished authors referred to, as the supporters of the theory.*
Does osseous union ever take place in cases of fracture of the neck of the femur within the capsular ligament f It is not my intention to enter at any considerable length into the investigation of this long agitated question, which, in my opinion, has been satisfac- torily replied to in the affirmative. We may, perhaps, for conve- nience sake, arrange the opinions at present held upon the sub- ject as follows : some maintain that the reparation by bone of the intracapsular fracture, although of very rare occurrence, yet has actu-
* There is no portion of the neck of the femur which has not been described as having been the seat of partial fracture. In Mr. Colles' cases the posterior surface is said to have remained uninjured ; in Mr. Adams', the superior. Mr. King, in Guy's Hospital Re- ports, October, 1844, describes a case in which less than one-third of the shell of the bone is said to have remained entire superiorly and anteriorly ; and in the Archives Ge- nerates de Medicine^ third series, second volume, Mons. Toumel has published a case in which the inferior surface of the neck of the bone remained entire. The patient was a man 3et. 85 ; he survived the occurrence of the accident three months and a half; the pre- paration is stated to be preserved in the museum of the Military Hospital at Ajaccio.
FRACTURES OF THE NECK OF THE FEMUR. 53
ally happened in several instances ; others, without denying the pos- sibility of such an event, are of opinion that its actual occurrence has not been demonstrated ; and, lastly, it has been asserted in the strongest possible language, not only that osseous union is altogether impossible, but that there are, in the hip-joint, "m old people, certain provisions for the prevention of such union, as if to avoid the ill consequences which, at this part of the hody, would necessarily arise from the usual mode of ossific reparation.''''
In the third volume of Guy's Hospital Reports (New Series), there is a paper by Mr.Bransby Cooper upon the causes of the non- union of these fractures, in which he dwells at some length upon the evil which he supposes would result, if osseous union were to occur : he remarks, " What would have been the residt if such union were admitted f That the provisional callus itself loould have filled up the acetabulum, and in every ivay have so interfered with the struc- ture of the joint as in itself to have proved destructive to the perfor- mance of every natural function of the limb. My object has been throughout to maintain, that it is ordained by nature that fracture of the neck of the femur, within the capsular ligament, is not to unite by ossific deposition^
Before making any observations upon the preceding state- ments, it will be more convenient to allude briefly to the opinion of Cruveilhier. This distingiiished pathologist believes that the bony union of the intracapsular fracture is impossible, because the fragments are not surrounded by any tissues capable of forming and depositing callus ; and he is of opinion that the ends of the broken bone, no matter how confronted to each other, never are directly united.
Now I believe that both the authors just alluded to are in error, in supposing that the effusion of callus around the frag- ments is necessary for the union of this fracture ; and must altogether dissent from the opinion which maintains that the ends of the broken bone take no part in accomplishing osse- ous union. How is bony union effected in cases of extracap- sular impacted fracture ? Surely it must be by the direct imion of the two bony surfaces which are confronted to each other : the surrounding soft parts cannot be in any way concerned in the process ; the osseous matter which we find effused along the pos-
54 FRACTURES OF THE NECK OF THE FEMUR.
terior Intertrochanteric space being intended for the union, not of the broken cervix, but of the fracture through the trochanter, as has been ah-eady explained ; and I believe that, whenever repara- tion by bone occurs in the intracapsular fracture, it is owing to the direct union of the broken surfaces, and that the effusion of callus around the fragments is by no means essential to the pro- cess.
This will become obvious to any unprejudiced person, who examines the plates representing the bony union of this frac- ture, which are appended to the memoirs of Langstaff, Adams, Jones, &c. All these cases have been examples of one or other form of impacted fracture ; either a portion of the lower frag- ment has penetrated the cancellated tissue of the head of the bone, or else the broken surfaces presented a series of convexi- ties and concavities which mutually accommodated each other, and, in consequence of which, the fragments remained, as it were, dovetailed together; and, moreover, in such cases, the in- jury which the cervical ligament sustains is comparatively slight, so that the broken surfaces remain confronted to each other, and consolidation takes place by the direct union of the sur- faces of the fracture. It is highly probable that, in the cases which have hitherto been published as undoubted specimens of the bony consolidation of the intracapsular fracture, there has been a mutual interlocking of the fragments, whereby they have been maintained in apposition : at all events, it is under such cir- cumstances that a firm bony union is most likely to occur ; for, as remarked by Desault, " it is a principle that will not admit of controversion, that, to effect consolidation, nature demands the fractured portions to be approximated, and, at the same time, to be in a state of absolute rest."
With respect to the statements and opinions of Mr. Bransby Cooper, which have been quoted, it is difficult to conceive how the provisional callus (supposing that it were formed) could ^^ fill up the acetabulum,'" already occupied by the head of the femur ; and it is equally difiicult to imagine how it could impair the structure of the joint, or prove more completely destructive to the natural functions of the limb than the fracture of the neck of the bone has already done. For my own part, were I so un- fortunate as to meet with this accident in my own person, I would
FRACTURES OF THE NECK OF THE FEMUR. 55
prefer running the risk of all the evils which Mr. Bransby Cooper supposes would arise from the union of the fracture by bone, to the necessity of carrying about with me, during the remainder of my days, so dangling and so useless an appendage as the limb usually is, in cases of disunited fracture of the neck of the femur within the capsular ligament.
In another place,* the same author remarks that callus is not formed in those situations where its presence would interfere with the motions of a joint ; and he asks, "what would be the effects of a mass of callus protruding on the inner surface of a fractured skull ? What degree of useful motion would remain in the knee or elbow, if both surfaces of a fractured patella or olecranon threw out a projecting callus?"
Now it is, of course, obvious enough, that such a mode of union would be injurious in the situations to which the author has referred, and, therefore, nature does not adopt it,, but has re- course to another mode, from which no consequences detrimental to the functions of the part can result. It is true that a mass of callus is not formed around the fragments in fractures of the skull or of the patella, but still the fracture of the cranium readily unites by bone, and so does that of the patella, when its direction is longitudinal. If, then, the effusion of calkis is not necessary in these instances, why should it be considered as indispensable that the fragments should be surrounded by it in cases of fracture of the neck of the femur within the capsular ligament? Nature is not limited to one and the same method of accomplishing her object in all cases ; and if the union of a fracture by external callus is either impossible, or likely to prove injiirious in any given case, bony consolidation, when it does happen, is effected by the direct union of the broken surfaces confronted to each other
After reflecting upon the cases that have been published as examples of osseous union of intracapsular fractures, I cannot by any means agree in the statement " that it is ordained by nature that fracture of the nech of the femur within the capsular ligament is not to unite hy ossifc deposition," for there is now certainly abun-
* Sir A. Cooper on Dislocations, edited by Mr. Bransby Cooper. Note by the Editor, page 144.
56 FRACTURES OF THE NECK OF THE FEMUR.
dant evidence to prove the actual occurrence of osseous union : those who deny its possibiHty must disbelieve the recorded facts, and what grounds have they for so doing, or how are we to form a judgment of the correctness or incorrectness of any statement? Surely we must, to a certain extent, be influenced by the charac- ter of the author of the statement, and his competence to form an opinion upon the subject, whatever it may be. " In the acquisi- tion of facts," as has been well remarked by that distinguished and enlightened physician, the late Dr. Abercrombie, " we de- pend partly upon our own observation, and partly upon the tes- timony of others. The former source is necessarily limited in extent, but it is that in which we have the greatest confidence ; for, in receiving facts upon the testimony of others, we require to be satisfied not only of the veracity of the narrators, but also of their habits as philosophical observers, and of the opportunities they have had of ascertaining the facts. In the degree of evi- dence which we require for new facts, we are also influenced by their probability, or their accordance with facts previously known to us ; and for facts which appear to us improbable, we require a higher amount of testimony than for those in accordance with our previous knowledge. Tliis necessary caution, however, while it preserves us from credulity, should not, on the other hand, he allowed to engender scepticism; for both these extremes are equally unworthy of a mind that devotes itself with candour to the discovery of truth."
If, then, we are satisfied of the veracity of the authors who have published examples of the osseous union of the intracapsu- lar fracture of the neck of the femur, if we believe them to have been competent judges, that they have had opportunities of ac- quiring correct information, and that they have not been superfi- cial observers, we must either believe their statements, or expose ourselves to the charge of scepticism, and render it obvious that our judgment has been so warped by theory and preconceived ideas, that no amount of evidence would be sufficient to alter our opinions.
It is not my intention to trespass upon the patience of my readers by entering into a consideration of all the causes which have been assigned to explain the infrequency of osseous union, nor woidd any advantage result from a tedious detail of the arguments that
FRACTURES OF THE NECK OF THE FEMUR.
57
have been adduced in support of each side of this long-disputed question; I shall, therefore, terminate this part of my subject with a concise summary of the cases which constitute the evidence by which the possibility of the occurrence of osseous union of the intracapsular fracture of the neck of the femur has, in my opinion, been established.
No. I. — Mr. Langstaff's Case- In this case the patient was a female, aged 50, when the fracture happened. She was confined
to bed for nearly twelve months after the occurrence of the acci- dent ; and during the remainder of her life, a period of ten years, walked with crutches. On dissection, it was found that the prin- cipal part of the neck of the bone was absorbed ; the head and remaining portion of the neck were united, principally by bone, and partly by a cartilaginous substance. On making a section of the bone, it was evident that there had been a fracture of the neck within the capsular ligament, and that union had taken place by osseous and cartilaginous media. With a view of ascer- taining whether there was real osseous union, the bone was boiled many hours, which, by destroying all the animal matter, satisfac- torily proved the extent and firmness of the osseous connexion,
58 FRACTURES OF THE NECK OF THE FEMUR.
and exhibited the spaces which had been occupied by cartilagi- nous matter.*
No. II. — Dr. Brulatours Case. — Dr. James, an English phy- sician (residing at Bourdeaux), aat. 47, was thrown from his horse on the 29th of March, 1826 ; he fell directly upon the great tro- chanter, but got up and walked a step or two, which occasioned such acute pain in the hip-joint, that he instantly fell again. On examination immediately after the accident, Dr. Brulatour ob- served the principal signs of fracture of the neck of the femur, such as shortening of the affected limb, eversion of the foot, and a feeling of crepitation in the joint when counter extension was made. Extension of the limb was kept up for two months, so as to preserve it of its natural length. Three months after the re- ceipt of the injury Dr. James was able to walk, with only the assistance of a cane, and subsequently recovered the full use of the limb. On the 20th of December, nine months after the acci- dent, he was attacked with hsematemesis, which proved fatal in two days.
The post-mortem examination of the right hip-joint shewed the capsule a little thickened, the cotyloid cavity and interarticu- lar ligament in a natural state ; the neck of the femur shortened, an irregular line surrounding the neck, denoting the direction of the fracture, and considerable bony deposit at the bottom of the head of the femur, and at the external and posterior part. A section of the head of the femur was made in a line drawn from its centre to the bottom of the great trochanter, so as perfectly to expose the callus. The line of union indicated by the callus was smooth, and polished as ivory. The line of callus denoted also that the bottom of the head of the femur had been broken at its superior and posterior part.f
No. III. — Mr. Stanley's Case. — A young man, get. 18, fell from the top of a loaded cart upon his right hip, the injury of which was attended with the following symptoms : he was wholly unable to move the limb, the thigh was bent to a right angle with the pelvis, and could not be extended ; abduction was difficult ; the limb was
* Medico- Chirurgical Transactions, vol. xiii. 1827. f Medico-Cliirurgical Transactions, vol. xiii. 1827.
FRACTURES OF THE NECK OF THE FEMUR. 59
everted, but there was no shortening, nor could crepitus be felt in any motion of the limb. This patient died of what was sup- posed to be small-pox, about three months after the occurrence of the accident. In the examination of the joint after death, the capsule was found thickened, the round ligament uninjured; a line of fracture extended obliquely through the neck of the femur, and entirely within the capsule ; the neck of the bone was short- ened, and its head approximated to the trochanter major. The fractured surfaces were in the closest apposition, and firmly imited nearly in their whole extent by bone. There was an irregular deposition of bone upon the neck of the femur, be- neath its synovial and periosteal covering, along the line of the fracture.*
No. IV. — Mr. Swan's Case. — Mrs. Powel, above eighty years of age, fell down, November 14, 1824. Sir Astley Cooper, who saw her soon after, believed that there was a fracture of the neck of the femur, although there was no appreciable shortening of the limb, and only a slight inclination of the toes outwards ; crepitus could not be perceived. The patient died about five weeks after the occurrence of the accident. Upon examination of the joint after death, the fracture was found to have been entirely within the capsular ligament, aud the greater part of it was firmly vmited. A section was made through the fractured part, and a faint white line was perceived in one portion of the union, biit the rest appeared to be entirely bone. The cervical ligament had not been inJLired.j
No. V. — Mr. Adams' Case. — " Owen Curran, set. 70, was for the last five years an inmate of the pauper department of the House of Industry ; he was very infirm on his limbs, and his mind was in a state of dotage. On the first of August, 1837, while walking across his ward, he fell on his right side ; he was finable to rise, and complained of pain in his right hip : he was carried to bed and immediately visited by the late Mr. William Johnstone (who was then acting for me as clinical pupil), who found the limb everted, and only half an inch shorter than the other. Mr. John-
* Medico- Chirurgical Transactions, vol. xviii. f Swan on Diseases of the Nerves, p. 304.
60 FRACTURES OF THE NECK OF THE FEMUR.
stone considered the case a fracture of the cervix femoris, which required no other surgical treatment than that of placing and pre- serving the limb in a semiflexed position over pillows. The old man suffered but little pain in the injured part: at all events he did not complain of it. In about five weeks after the accident he was raised out of his bed, and when placed standing he was able to put the heel of the injured limb to the ground. On the 30th of September, that is, about eight weeks after the accident, my friend, Mr. Smith, entered in his note-book the following memo- randum of this case : ' As the patient lies in bed he can elevate the injured limb by the unaided efforts of its own muscles. The e version is slight, and the degree of shortening amounts to one inch; no force can bring the limb down to the length of the other. From the history and symptoms, this seems to have been a case of impacted fracture.'
" This man survived the accident oneyear and nearly ten months, during which time he was contented to remain most of his time in his bed, but when placed on his feet could stand very well, and was able, but unwilling, to walk. On Tuesday, the 20th of May, 1839, he got an attack of bronchitis, which, the following Friday, terminated fatally. At twelve o'clock on Saturday, the 25th of May, assisted by Mr. Brabazon and some of the pupils of the hos- pital, I made an examination of the body.
" The right leg and thigh were much everted; the trochanter major was elevated and projected much outwards; the degree of shortening just amounted to one inch ; the muscles presented a healthy appearance ; the capsular ligament was of a yellowish colotir, and somewhat thickened. The femur was removed from the acetabulum ; this latter cavity presented a healthy appearance, except towards the margin of it, here the cartilage was softened. The round ligament was sound.
"The head and neck of the bone had lost their normal obliquity, and were directed nearly horizontally inwards ; the cervix pre- sented, both anteriorly and posteriorly, evidence of a transverse intracapsular fracture having occurred ; the globular shaped head of the femur was closely approximated behind and below to the posterior inter-trochanteric line, and to the lesser trochanter, so that the neck seemed altogether lost, except anteriorly, where a
FRACTURES OF THE NECK OF THE FEMUR.
61
very well-marked ridge of bone shewed tlie seat of tlie displace- ment, and of the union of the fragments. This ridge is evidently the upper extremity of the lower fragment of the cervix. The fracture of the neck posteriorly was found to have been closer to the corona of the head than anteriorly, and the fibro-syno- vial fold in the former situation was unbroken. A section has been made of the bone through the head, neck, and trochanter ; one portion has been subjected to maceration, and to boiling, and the bony union has been un- aJEFected by these tests. Scarcely any portion of the neck can be said to have been left. The section shews the compact line
which denotes the union of the fragments ; the head and shaft seem to be mutually impacted into each other, and almost the whole of the cervix has been absorbed; the line of rinion is serrated, solid, and immoveable, and the cells of the head, and substance of the shaft seem to communicate freely in all places, except where the thin line of compact tissue here and there points out the seat of the weld- ing together of the remaining portions of the head and neck of the femur.
" The bone was, in its recent state, on the 25th of May, 1839, laid before a meeting of the Pa- thological Society. It seemed to be the universal opinion of the members present that it was a
Q2 FKACTURES OF THE NECK OF THE FEMUR.
decided specimen of the intracapsular fracture of the cervix femo- ris, which had been solidly united by bony callus."
This case may be adduced in formal contradiction to the ob- servation and theories of that very eminent pathologist, Cruvelhier. It cannot be said to invalidate the more guarded opinion of Sir Astley Cooper, who, in his observations upon this subject, dis- tinctly states, that " he would not be understood to deny the possibility of union, when the bone was broken, without its peri- osteum and reflected ligament being torn, or when there was no separation of its fractured ends."*
No. VI. — Mr. Jones' Case. — "Jenkins Thomas slipped down as he was returning home one evening about the middle of October, 1838 ; he was seen on the following day by Mr. Cole, House Sur- geon to the Infirmary (Worcester), who detected what he con- sidered to be a fracture of the neck of the femur. He applied a splint to the ovitside of the limb, extending from the pelvis to the foot, and bound the legs together, making use of the left as an inner splint ; a bandage was applied around the pelvis. In about eight weeks the splints and bandages were removed, and he was allowed to get up soon afterwards.
" During the following spring and summer he was able to move about with the assistance of a stick, but with the limb shortened about an inch and a half, and considerably everted. He came under my care as an inmate of St. Oswald's Hospital, 13th January, 1840, and died on the 20th of April following, of chronic disease of the lungs. At the time of the accident he was more than eighty years of age, and he survived the injury one year and a half. On dissection the capsular ligament was found very much thickened, and the space between the trochanter major and the edge of the acetabulum greatly contracted ; the bone was macerated, and a vertical section made through the head, neck, and upper part of the shaft ; the neck of the bone was found to have been broken within the capsule : the fracture extended through the basis of the head of the bone, in the line of its j unction with the neck ; it was firmly united by osseous matter. The bone was first mace- rated, it was subsequently immersed for several days in a strong
* Todd's Cyclopsedia, p. 813.
FRACTURES OF THE NECK OF THE FEMUR.
63
solution of carbonate of potash, and one half of it was boiled in water for three hours without the slightest yielding perceptible in the line of fracture."* This specimen, which is preserved in the Museum of St. Bartholo- mew's Hospital, was sent to Sir Astley Cooper for examination. Sir Astlej was of opinion that the fracture was " in part with- in, and in part external to the capsular ligament ; in part unit- ed, and in part not, and the neck of the thigh bone ab- sorbed."!
No. VII. — Mr. ChorleysCase. Mr. K., aet. 72, fell against the curb-stone, and was at once ren- dered unable to move in conse-
quence of an injury of the hip. Upon examination the limb was found shortened and the foot everted. This patient, at the expi- ration of seven months, walked so well that some surgeons thought that no such injury as fracture of the neck of the femur had taken place. He died twelve months after the accident, from an attack of acute pneumonia, and on examining the hip it was found that the neck of the bone had been fractured obliquely within the cap- sule ; the fracture commenced above, close to the margin of the cartilage of the head of the bone, and extended downwards and outwards, terminating at a point in the lower surface of the neck, one inch from the cartilaginous covering of the head of the bone.
On making a longitudinal section of the head and neck of the bone, the line of fracture was distinctly marked by the callus, which now united the opposed surfaces ; the pelvic portion had been excavated, and had received the lower portion of the neck of the bone, near the middle of its fractured surface, where it was firmly united by an osseous deposit. A portion of the upper
* Medico -CMrurgical Transactions, vol. xxiv.
t Provincial Medical and Surgical Journal. 1841.
64 FRACTURES OF THE NECK OF THE FEMUR.
fragment extended in one situation a little external to the capsule ; this portion was not united.*
The preceding cases furnish ample evidence of the possibility of the occurrence of osseous union in cases of intracapsular frac- ture of the neck of the femur, and it is highly probable that they have all been examples of impacted fractures : certainly in all those, of which delineations have been given, there has been either penetration of one fragment by a portion of the other, or else the irregularity of the line of fracture has been such that the displacement of the fragments has been prevented ; they have been maintained in contact and at rest, and it is under such cir- cumstances alone that we are to hope for the occurrence of bony consolidation.
Our prognosis, in cases of fracture of the neck of the femur, must always be unfavourable ; in many instances the injury soon proves fatal, and in all the functions of the limb are for ever impaired ; no matter whether the fracture has taken place within or external to the capsule, whether it has united by ligament or bone, shortening of the limb and lameness are the inevitable results. In forming our prognosis, we must take into account principally the age of the patient, and the situation and nature of the fracture. The results of my own experience would lead me to say, that the form of fracture which is most rapidly and most frequently fatal, is the extracapsular fracture, when it is accompanied by a comminuted fracture with displacement of the trochanters ; but as regards the functions and utility of the limb during the remainder of the patient's life, the intracapsular fracture is the more serious acci- dent, for, independent of the difference which exists between these two varieties of the fracture, as regards the possibility of the occurrence of osseous union, there is likewise a remarkable dif- ference with respect to the ultimate shortening of the limb ; for in the extracapsular fracture the amount of shortening which took place when the injury occurred seldom subsequently undergoes any very material increase, but when the fracture is seated within the capsule, absorption of the neck of the bone slowly but steadily proceeds, and an amount of shortening of the limb is thus ulti-
* Amesbury on Fractiu'es, vol. i.
FRACTURES OF THE NECK OF THE FEMUR. 65
raately produced, equal to, or, in many cases, even greater than the entire length of the neck of the femur.
In fatal cases death may be owing to a variety of causes : some- times the patient dies in a few days from the effects of the shock upon a system already enfeebled by age ; very frequently bron- chitis sets in, and terminates fatally before ten days have elapsed ; in other cases the accident is followed by a severe irritative fever, the tongue becomes furred, the bowels constipated, the pulse quick and feeble, and the patient restless and thirsty ; he is unable to sleep, and complains much of pain about the joint; the tongue soon becomes more loaded, the countenance dejected, and expres- sive of distress and anxiety ; the patient begins to talk inco- herently, and raves at night, then the pulse fails, the tongue be- comes dry and brown, sordes collect about the lips and teeth, the anxiety of countenance and restlessness increase, the bronchial tubes become filled with mucus, a tendency to stupor, or coma, manifests itself, and then death terminates the scene. This form of fever is especially apt to be induced when the injured limb is kept firmly secured in splints and bandages, and maintained in a state of forcible extension.
In other instances a different, but equally fatal, form of fever is established : in these cases the swelling and tension about the joint and upper part of the thigh are considerable, and the pain, almost from the commencement, is of the most acute description : the patient is tortured by the slightest motion of the limb, and will not permit any examination of it to be made ; the constitu- tional symptoms at first resemble those of traumatic fever, but very soon their whole expression is altered, and the characters which they now present are those of a typhoid fever, analogous to those which accompany diffuse inflammation; severe rigors, accompanied and followed by an increase of local suffering, set in early ; all the structures which enter into the composition of the joint become the seat of an acute suppurative inflammation, and as the case draws near to its termination, pneumonia sometimes sets in, and the patient sinks under the combined effects of acute local inflammation and typhoid exhaustion.
Sometimes, as in the instance detailed by Cruveilhier, else- where alluded to, death is to be ascribed to the occurrence of pro-
F
66
FRACTURES OF THE NECK OF THE FEMUR.
fuse hffimorrliage into the substance of tlie limb ; in such cases the fracture is always external to the capsule, and accompanied by a comminuted fracture of the trochanter ; the blood is poured
out from the torn vessels of the cancellated structure, and occasion- ally also from some arterial branch of considerable size, that has been lacerated, or punctured, by a spieula of the broken bone : finally, in patients of very advanced age, and where proper precautions have not been adopted, sloughing of the integuments of the nates and trochanteric region occurs, and very soon places the patient beyond the possibility of recovery.
Among all the striking and varied changes which the human system suffers under the influence of that inevitable decline of organization, which is the attendantupon advanced age, there are few more remarkable than those which affect the osseous system. These strange modifications of structure are supposed to affect the skeleton of the aged female much more frequently than that of the male, and, along with the greater breadth of the pelvis, and projection of the trochanter major, to afford an explanation of the more frequent occurrence of fracture of the neck of the femur in the elderly female than in man. It is more especially in the bodies of those who have been bed-ridden for years before their death, that we notice these alterations, and they will generally be found even in the adult who has been, from any cause, for years
feactur.es of the neck of the femur. 67
confined to bed ; for long disuse produces atrophy and degenera- tion of the osseous system, without much respect to age, and the head and neck of the femur manifest more clearly, perhaps, than any other parts of the skeleton, the consequences of this remark- able lesion of nutrition: such is frequently the incapability of resistance, that the structure of the bone can be crushed by the slightest pressure of the finger.
This condition is owing not merely to the interstitial absorp- tion of the osseous fibres, but is also to be in part ascribed to the presence of a quantity of oil, which accumulates in, and becomes infiltrated throughout the entire of the tissue of the bone, the compact structure being, in many cases, reduced to a delicate lamina of bone, so thin as to be almost translucent, and the bony partitions, which separate from each other the areola of the reti- cular tissue, are here and there removed, in consequence of which large cavities are formed in the interior of the head and neck of the femur, and the strength of the bone, and its power of resist- ing external violence, are thus materially diminished. I have seen an instance in which a cavity capable of containing a mode- rate-sized marble was formed in the head of the femur. The cells of the reticular tissue thus enlarged, are filled, partly with oil and partly with a semifluid medullary matter, presenting great variety of colour, being in some places of a pale yellow, in others of a yellowish-grey ; and again, here and there are found patches of crimson of various shades, apparently produced by the admixture of effused blood with the morbid medullary matter ; the medulla in such cases becomes rapidly decomposed after death, and I have often found it presenting the green colour resulting from putre- faction, in less than twelve hours after the decease of the patient.
We also find that the arch of compact tissue which lines the concavity of the neck of the femur, and upon which the strength of this portion of the bone is mainly dependent, is in most instances reduced in thickness, and atrophied, in the aged subject; and although an example of fracture of the neck of the femur may occasionally be met with, in which this arch possesses its natural thickness (as in the case detailed by Mr. Porter*), yet this does
* Dublin Medical Journal, vol. x.
f2
68 FRACTURES OF THE NECK OF THE FEMUR.
not by any means invalidate the general truth of the assertion, that the atrophy of this arch, to a greater or less degree, is of com- mon occurrence in the advanced periods of life, and to be looked for in almost every instance of intracapsular fracture of the neck of the thigh bone : in a few instances I have found it reduced to such a degree of tenuity, and so totally altered in structure, as to permit of a section of the head and neck of the femur being made with a scissors.
The attenuation of the compact structure of the arch of the neck of the bone, the absorption of the partitions between the cells of the reticular tissue, and the consequent enlargement of these cells, together with the infiltration of the osseous structure with oil, — such are the chief local morbid changes which predispose the neck of the thigh bone to fracture from the most trivial causes ; under such circumstances, as has been justly observed by Mr. Adams, the fracture should, in many instances, be looked upon more as a stage of morbid alteration, from which no amend- ment is to be expected, than as an accidental lesion, which the efforts of nature and the aid of surgery can be deemed adequate to repair.
These remarkable local alterations have, however, a constitu- tional origin ; they are the effects of that decline of the vital powers which marks the approach, and attends the progress, of old age ; a decline, the effects of which are not confined to the osseous system, but are likewise to be seen in the muscles both of voluntary motion and of organic life. The fatty and atrophied condition of the heart, the analogous state of the voluntary mus- cles, and the oily degeneration of the bones, must be looked upon as indicating enfeebled powers of assimilation, and a dimi- nution in the energy of the circulation ; the arterial blood circu- lates slowly, is imperfectly oxygenated, and contains an undue quantity of carbon ; venous blood preponderates in the system, and to this latter circumstance especially we are to ascribe the morbid alterations in the muscles and the bones to which I have alluded. It would, however, be out of place to discuss this question, however interesting it may be to the physiolo- gist,* I shall, therefore, terminate this memoir with a brief ac-
* For a further consideration of the subject, see Dublin Joiuiial, vol. ix. p. 411.
FRACTURES OF THE NECK OF THE FEMUR.
69
count of the preparations contained in the Museums of the Rich- mond Hospital, and Richmond School of Medicine, accompanying the description with a concise history of the symptoms^ which each case presented during the life of the individual : the reader will then be able to judge how far they warrant the conclusions which have been deduced from them.
Case I. — Laurence Maguire, aet. 40. — Fracture of the neck of the femur within the capsular ligament, traversing the bone obliquely from above downwards and forwards ; posteriorly the fracture has passed through the investing cartilage of the head of the bone ; the anterior portion alone of the cervical ligament has been lacerated ; the synovial mem- brane of the articulation was ex- tremely vascular, but the joint con- tained scarcely any synovial fluid. A large abscess existed between the blad- der and the rectum, and the mucous membrane of the former organ was in- flamed.
In this case the patient had been violently thrown to the ground, and fell directly upon the external surface of the trochanter, foot was everted, and the limb shortened half an inch. Ten days after the occurrence of the accident severe febrile symptoms set in, and soon assumed a typhoid character: the tongue became dry and brown, the pulse feeble and rapid, and severe and fre- quent rigors, with retention of urine, and excessive irritability about the neck of the bladder indicated the formation of matter in the vicinity of that organ. The patient died upon the four- teenth day after the occurrence of the accident.
Case II. — William Collins, set. 36. — Fracture of the neck of the femur within the capsule, passing through the cervix trans- versely with respect to the direction of its axis ; the cervical liga- ment had been torn throughout its whole extent anteriorly, but posteriorly remained perfect ; the articulation contained only a small quantity of synovia, and its lining membrane was preterna- turally vascular. The injury was caiised by a fall upon the tro-
Th
70
FRACTURES OF THE NECK OF THE FEMUR.
chanter four days before the man was admitted into the hospital. The foot was everted, and the shortening of the limb amounted to three-qu^ters of an inch. In this case, firm pressure was made by means of a truss applied round the pelvis, and the pad of which was adapted to the trochanter : after two days, however, the patient com- plained of so much pain, that it wa necessary to remove the instrument irritative fever, nevertheless, set in the tongue became dry and coated with a brown fur; there was thirst and insomnia, and the patient gradu- ally became comatose, and died upon the seventeenth day after the receipt of the injury.
Case III. — Thomas Maguire, set. 84. — Fracture of the neck of the femur close to its junction with the head of the bone, a small portion of the compact structure of which has been broken oiFin front ; the cervical ligament has been torn in front, but internally and posteriorly is perfect, and holds the fragments i:i apposition ; blood was effused between the fragments, from the ruptured ves sels of the cancellated tissue. Th fracture was caused by the patient's having tripped over some slight ob- stacle while walking across his room : he did not fall to the ground. The foot was everted, and the limb short- ened exactly half an inch. The patient died of irritative fever a fortnight after the occurrence of the accident. Throughout the whole progress of the case the patient complained of severe pain in and around the articulation : there was complete insomnia. This case affords a good illustration of the occurrence of fracture of the neck of the femur from a cause the most trivial.
FRACTURES OF THE NECK OF THE FEMUR.
71
Case IV. — Dorah Campbell, aet. 75. — Fracture of tlie neck of the femur within the capsule, encroaching a little upon the head of the bone; the edges of the lower fragment have been rounded off, and its surface has become nodulated; the cervical ligament has been every where lacerated, except internally, cor- responding to the concavity of the neck of the femur; lymph was effused upon the fractured surfaces, and there was a little blood in the acetabulum. The injury resulted from a fall upon the hip ; the foot was everted,
and the limb shortened one inch. The woman died of suffocative catarrh two months after the occurrence of the fracture.
Case V.— Mary Gill, get. 80. — Fracture of the neck of the femur within the capsular liga ment, close to the head of th« bone. The broken surface of thi superior fragment is deeply ex cavated ; the cervical ligament has been ruptured throughout the whole extent of its ante- rior and superior surfaces, but is perfect internally and behind. The foot was everted, and the limb shortened half an inch.
Case VI. — Esther Christie, set. 60. — Fracture of the neck of the femur within the capsule. The upper fragment has been absorbed as far as the level of the acetabulum, and its surface has become smooth and dense, presenting a concavity anteriorly, and a convexity posteriorly ; the surface of the lower fragment is ex- tremely irregular, and covered with a fibrous structure ; a small portion of the compact tissue of the upper surface of the neck of the bone has been laid down upon the broken surface of the lower
72
FRACTURES OF THE NECK OF THE FEMUR.
fragment, and lias been united to it by the fibrous tissue already mentioned. The direction of the fracture was oblique from above downwards and back- wards ; the cervical ligament has been destroyed throughout its whole circumference ; the capsule was thickened, and its internal surface presented a flocculent appearance ; a thick concave plate of bone, fully two inches in length, and half an inch in breadth, was formed in the substance of the capsule anteriorly. The ligamentum
teres was the sole remaining attachment of the head of the bone. The limb was shortened one inch and a half.
Case VIL — Mary Lamb, est. 80. — Fracture of the neck of the femur, with absorption of the superior fragment to the level of the brim of the acetabulum : the lower fragment was nearly
altogether absorbed, and the surface of the bone from which, in the natural state, the neck of the femur springs, was formed into an expanded, shallow cavity, covered throughout the greater part of
FRACTURES OF THE NECK OF THE FEMUR.
73
its extent by a fibrous structure ; ligamentous bands passed from the internal surface of the capsule to both the superior and infe- rior fragments. The capsule, every where thickened, was in some places semi-cartilaginous. The fracture was the result of a fall upon the trochanter, and the limb was shortened three-quarters of an inch. The patient died of bronchitis and anasarca twelve months after the accident, and at the period of her death the limb was two inches shorter than the other.
Case VIII. — Margaret Burke, aet. 90. — Fracture of the neck of the femur within the capsule ; the under surface of the superior fragment is slightly exca- vated, the lower fragment comminuted, and the cervi- cal ligament lacerated nearly throughout its whole circum- ference; its attachments are perfect only along the conca- vity of the cervix, and here it has been perforated by a spicula of bone connected with the lower fragment; a large quantity of blood was poured out between the frag- ments. The shortening of the limb amounted to half an
inch. The patient died of sloughing of the nates upon the day following her admission into the hospital, and a fortnight after the occurrence of the accident.
Case IX. — Margaret Myler, set. 78. — Fracture of the neck of the femur close to the line of junction of the ceirvix with the head of" the bone. A thin layer of the compact tissue hangs down from the margin of the fracture, the under surface of the cotyloid fragment is excavated, and dense in its structure ; the greater part of the femoral fragment has been absorbed, and seve- ral portions of its compact tissue seem to have been turned in upon the fractured surface and united to it : the cervical ligament was entire only along the concavity of the neck of the bone. The amount of retraction of the limb, which followed immediately vipon
74
FRACTURES OF THE NECK OF THE FEMUR.
the receipt of tlie injury, was only a quarter of an inch. The patient died two months after the occurrence of the accident, the prominent symptoms during the progress of the case having been insomnia, prostration of strength, and occasional delirium. The integuments covering the sacrum sloughed, and for some time before death purulent matter was voided with the urine.
Case X. — A female, set. 65. — Fracture of the neck of the femur within the capsule, with absorption of the cervix ; the head of the bone had lost its globular form, and was extremely irregu- lar upon its surface ; the slight- est pressure was sufficient to break down its structure, which was copiously infiltrated with oil; the cells of the reticular tissue were enlarged, and alto- gether the bone presented a re- markable specimen of senile atrophy ; the acetabulum was irregular in its form, deepened, and deprived of its cartilage; the glutajal muscles were pale and atrophied, and an unhealthy adeps occupied the place of the
muscular fibres in many situations. The limb was shortened one inch, and the foot everted. The patient had been bedridden for several years before her death.
Case XL — Patrick Doolan, set. 60. — Fracture of the neck of the femur within the capsular ligament. The head of the bone was intimately united to the acetabulum by an exceedingly dense fibrous tissue ; the lower surface of the cotyloid fragment was con- vex, the neck of the bone completely absorbed, and a large socket, as it were, was formed in the widely expanded surface of the lower fragment, to receive the convex surface of the superior. Both these surfaces were smooth and polished, and possessed the hard- ness and density of enamel. The capsule was exceedingly thick ; there was complete eversion of the foot, and at the time of the patient's death (seven years after the occurrence of the accident)
FRACTURES OF THE NECK OF THE FEMUR.
75
the shortening amounted to two inches. This man died of aneu- rism of the thoracic aorta, which proved fatal without rupture of
the sac ; it sprung from the first portion of the arch, and was as large as an orange.
Case XII. — Michael Curry, ast. 40. — Fracture 'of the neck of the femur within the capsule, with absorption of a large portion of each fragment, and complete destruc- tion of the cervical ligament ; the round ligament was the only remaining at- tachment of the head of the bone ; all the tissues entering into the composi- tion of the joint had been the seat of acute inflammation. The upper por- tion of the shaft of the bone, for about two inches below the cervix, presented evidence of having been the seat of acute osteitis; the periosteum was de- tached, and the osseous tissue highly vascular, and the surface of the bone
presented a corroded appearance, owing to the removal of the compact structure, and the exposure of the cancellated tissue.
76
FRACTUKES OF THE NECK OF THE FEMUR.
Purulent matter was found between the periosteum and the bone, and an enormous abscess surrounded the articulation, which was itself filled with pus and flakes of lymph ; the capsule was de- tached from the anterior intertrochanteric line, and a communi- cation was thus established between the external abscess and the interior of the joint. The patient was admitted into the hospital, December 5, 1837, and the injury was received (while he was in a state of intoxication) on the 15th November. When he was admitted he had high fever, attended with rigors and occasional delirium, and the hip-joint was the seat of most excruciating pain. He died December 16, one month after the occurrence of the accident. The foot was everted, and the limb shortened one inch and a quarter.
Case XIII. — Mathew Reilly, set. 46. — Fracture of the neck of the femur close to the head of the bone. The under surface of the superior fragment was deeply excavated, and co- vered by a false membrane of considerable thickness; a small part of the lower firag- ment was absorbed, and its surface was covered by a fibro -cartilaginous tissue ; the cervical ligament was lace- rated in front and internally, but remained perfect poste- riorly and above; the frag- ments were united by a dense fibrous tissue, and the neck
of the bone was covered by a thick and fimbriated layer of lymph. The limb was shortened half an inch. The patient lived four months after the receipt of the injury.
Case XIV.— Sarah Ashton, ^t. 65. — Fracture of the neck of the femur within the capsule : the surface of the superior frag- ment was concave, and as polished as ivory ; the greater part of the neck of the bone was absorbed, and the surface of the lower frag- ment covered partly with a fibrous tissue and partly with a struc- ture resembling porcelain ; an organized layer of lymph invested the
FRACTURES OF THE NECK OF THE FEMUR.
77
cartilage of the head of the bone ; a considerable portion of the neck of the femur was absorbed ; the fragments were connected to each other by por- tions of the cervical ligament, which remained entire along the upper and under surface oi the neck of the bone ; the joint contained a large quantity of synovia; the limb was short- ened one inch and a quarter. The patient survived the re- ceipt of the injury nine years, and died of erysipelas of the leg.
Case XV. — Elizabeth Casey, set. 50. — Fracture of the neck of the femur within the capsule, passing obliquely from above downwards and forwards ; the surface of the cotyloid fragment had become concave, and was covered with a fibro-cartilaginous structure ; the lower fragment had suffered very little from ab- sorption ; the cervical ligament was perfect only along the conca- vity of the neck of the bone. The shortening of the limb amounted to three-quarters of an inch. The patient lived several years after the receipt of the injury.
Case XVI.— Robert Robin- son, set. 50. — Fracture of the neck of the femur within the cap- sule : the head of the bone was in many places destitute of carti- lage, and covered with a false membrane ; the surface of the upper fragment was covered by a dense fibrous tissue through- out the greater part of its ex- tent ; where this structure was deficient the surface was dense, and as smooth as ivory. The lower fragment presented similar appearances. The fracture had oc-
78
FRACTURES OF THE NECK OF THE FEMUR.
curred several years before the death of the patient, and was caused by a fall upon the trochanter ; the neck of the bone was completely absorbed. At the period of the patient's decease, the shortening of the limb amounted to two inches.
Case XVIL— Ellen Walker, set. 70. — Fracture of the neck of the femur, close to the margin of the cartilage of the head of the bone ; the fracture passed ob- liquely from before downwards and outwards ; the cervical liga- ment, torn in front, was perfect posteriorly. The injury proved fatal upon the seventh day after its occurrence, from the super- vention of irritative fever. The limb was shortened half an inch.
Case XVIII. — Laurence Keilly, ^t. 56. — Fracture of the neck of the femur within the capsular ligament, with absorption of the entire of the cervix ; the upper fragment had disappeared to the level of the cotyloid liga- ment ; a ligamentous band of great strength extended from the capsule to the under surface of this fragment ; the head of the bone was joined to the acetabu- lum by a very vascular mem- brane ; the lower fragment ap- peared to have been the seat of very acute osteitis; the perios- teum was inflamed, and separated from the bone, the compact tissue of which had been recently ab- sorbed, and the rough surface of
the reticular tissue was thus exposed : this tissue was vascular in the extreme, and in some places covered with lymph, flakes of which, mixed with pus, were contained in the cavity of the joint, and a
FRACTURES OF THE NECK OF THE FEMUR. 79
large collection of dark and foetid purulent matter surrounded the articulation. In this case the sternum was broken at the junc- tion of the first with the second bone ; and in the situation of this fracture was another abscess, the matter of which presented the same unhealthy character as that already mentioned as exist- ing in the vicinity of the hip-joint ; the lower lobe of each lung presented the anatomical characters of the first stage of pneu- monia.
The patient, a miserable-looking man, exhausted apparently by poverty and distress of every description, was admitted into the hospital, December 31, 1839 ; he had been knocked down by a cart loaded with hay, and it was stated that the vehicle had passed over his body. The usual symptoms of fracture of the neck of the femur were present ; the limb was shortened two inches. It was at first supposed that the lesion of the neck of the femur had been the result of the recent accident, but it was afterwards ascertained to have been of several years' duration. The patient survived the receipt of the recent injury only one week. The symptoms which preceded death were analogous to those of difiuse inflammation.
Case XIX. — Joseph Seaton, set. 90. — Fracture of the neck of the femur within the capsule. Almost the entire of the cervix had been absorbed ; a false membrane which, in the recent state, was covered with minute arborescent vessels, invest- ed the head of the bone ; a similar mem- brane covered the acetabulum, but these layers were not adherent to each other. The bone presented a remarkable ex- ample of that peculiar atrophy which afi^ects the osseous system of the aged ; it extended throughout the whole of the shaft, which in many places yielded to a very moderate degree of pressure ; the medullary canal and the cells of the areolar tissue were
enlarged, and filled with a substance more resembling oil than medulla, and an unhealthy fatty deposition separated from each
80
FRACTURES OF THE NECK OF THE FEMUR.
Other the pale and atrophied fibres of the muscles around the joint. The fracture had occurred seven years before the patient's death, during the whole of which period he had been bed-ridden. The limb was shortened one inch and a quarter at the time of his decease.
Case XX. — A female, set. 65. — Fracture of the neck of the femur within the capsule, with complete absorption of the cervix • The shaft of the femur, where, in the normal state, it joined the neck of the bone, presented a smooth flat surface ; the head of the femur and the aceta- bulum were smaller upon this side than upon the opposite. The patient had sustained the injury several years be- fore her death, and was bed-ridden from the time of the occurrence of the accident up to the period of her de- cease, at which time the shortening of the limb amounted to two inches and a half; the limb was likewise much reduced in size as compared with the opposite one.
Case XXI. — Thomas Connolly, set. 50. — Fracture of the neck of the femur, close to the head of the bone, and directed transversely with respect to the axis of the cervix; the cervical ligament had been torn nearly throughout the whole extent of its anterior surface ; blood was effused between the frag- ments, and a large ecchyraosis sur- rounded the articulation. The patient survived the receipt of the injury about ten days : he sunk under an at- tack of fever, which set in immediately after the occurrence of the accident, and which was occompanied with de- lirium. There was complete e version of the foot, and the limb was shortened three-quarters of an inch.
FRACTURES OF THE NECK OF THE FEMUR.
81
Case XXII. — Bridget Misset, ast. 72. — Fracture of the neck of the femur within the cap- sule, passing obliquely from before backwards and out- wards ; the cervical ligament was almost everywhere torn ; a small portion, a few lines in breadth, at the concavity of the arch of the neck of the bone, alone prevented the complete separation of the fragments. In this case the eversion of the foot was very remarkable. The shortening amounted to an inch. The pa- tient lived ten weeks after the occurrence of the fracture.
Case XXIII — A female, set. 50. — Fracture of the neck of the femur within the capsule, with absorption of the entire of each fragment of the cervix : the surface, from which the neck of the bone springs in the normal state, was inti- mately united to the under surface of the head of the bone by an exceedingly dense liga- mentous structure, arranged in bands about one-eighth of an inch in length ; the en- tire of each surface was thus covered, and from the inte- rior of the capsule several strong and thick ligamentous productions passed, to be in- serted into the margin of the head of the bone, the cartila- ginous surface of which was covered with a thin, organized mem- brane. The patient survived the accident several years, and en-
G
82
FRACTURES OF THE NECK OF THE FEMUR.
joyed very considerable motion of the limb, being able to walk well with the assistance of a stick. The shortening amounted to one inch, and the foot was completely everted.
Case XXIV. — Catherine Mooney, set. 60. — Fracture of the neck of the femur within the capsule, passing obliquely from before backwards, and from within outwards; a dense fibrous tissue, covering the surface of each fragment, had united them closely together ; the surface of the head of the bone surrounding the ligamentum teres was destitute of cartilage ; the bone was remarkably light, its compact tissue thin, and its medullary canal large ; the interior of the head and of the cervix contained several very large cells, filled with an oily medulla ; several of the long bones were in a state of senile atrophy. This woman lived five years after the occurrence of the fracture. The foot was everted, and the limb shortened one inch.
Case XXV. — Robert Donovan, set, 80. — Fracture of the neck of the femur within the capsule. The surface of the superior frag-
ment was concave, smooth, and polished ; the neck of the bone absorbed, and the cartilage of the head atrophied, and in some places totally removed ; the capsule was unusually thickened, and
FRACTURES OF THE NECK OF THE FEMUR.
83
organized lympli adhered to its internal surface. There was no union of any description between the two portions of the bone ; the trochanter was drawn upwards towards the dorsum of the ilium, where it formed a remarkable tumour. The patient lived two years after the receipt of the injury, and at the period of his death the limb was shortened one inch and a half.
Case XXVI.— Mary Woods, «t. 70. — Fracture of the neck of the femur within the capsule, passing obliquely from above and without downwards and in- wards: the superior and anterior portions of the cervical ligament were torn, but the portions corres- ponding to the inferior and poste- rior surfaces of the neck of the bone were entire ; several frag- ments of the posterior surface of the cervix adhered to this un- broken portion of the cervical liga- ment, from several parts of which delicate bands of organized lymph passed, to be inserted into the sur- face of the superior fragment. The head of the bone had sunk below the level of the summit of the trochanter major, and a sharp spicula, connected with the inferior surface of the upper fragment, had penetrated the adjoining portion of the capsular ligament, and rested upon the upper surface of the trochanter minor. The foot was everted, and the shortening of the limb amounted to one inch. Throughout the whole progress of the case the patient complained of severe pain in and around the articulation. She had a considerable degree of fever, and occa- sionally a rigor. A large abscess at length formed among the muscles of the glutseal and superior portion of the femoral regions, from the constitutional effects of which the patient died, three months after the occurrence of the accident. Upon examination after death, purulent matter and lymph were found within the capsular ligament; the synovial membrane was everywhere in- flamed, and the bone itself presented evidence of having been the seat of increased vascular action.
G 2
84
FRACTURES OF THE NECK OF THE FEMUR.
Case XXVII. — Bridget Harper, set. 70. — Fracture of the neck of the femur within the capsule. The cervical ligament was lacerated superiorly, but the portions investing the anterior, posterior, and inferior surfaces of the neck of the bone were entire ; thin and delicate bands of lymph passed from its inner surface to the superior fragment. The head of the bone had sunk down nearly to the level of the summit of the trochanter major, and the frac- tured surfaces presented eminences and depressions which mutually accommodated each other. In this case the patient survived the occur- rence of the accident only ten
days. The limb was shortened half an inch, and the foot slightly everted.
Case XXVIII. — A female, set. 55. — Fracture of the neck of the femur within the capsule : the greater part of the neck of the bone has been absorbed, and the opposed surfaces of the fracture have become united, throughout the greater part of their extent, by a strong fibrous tissue ; anteriorly, several ligamentous bands passed from the capsular ligament to the upper fragment ; the fragments were in close apposition, and a ridge of bone was formed along the anterior margin of the infe- rior, corresponding in direction to the anterior intertrochanteric line; portions of organized lymph, at- tached to the capsule, were spread out over the surface of the head of the bone, but did not adhere to it. The limb was shortened
FRACTUKES OF THE NECK OF THE FEMUR.
85
one inch and a quarter. The woman survived the receipt of the injury several years.
Case XXIX. — Patrick Murphy, set. 80. — Transverse serrated fracture of the neck of the femur external to the capsule, at the line of junction of the cervix with the shaft of the bone: a second fracture detached the trochanter major, which was drawn upwards and backwards, carrying with it the insertions of the pyriformis, gemelli, and obturator muscles. The trochanter minor was likewise separated from the shaft of the fe- mur, and, along with it, the inser- tion of the psoas and iliacus inter- nus ; a large qiiantity of blood was poured out between the fragments, and among the muscles around the joint. The limb was shortened
two inches, the foot inverted, and the entire limb in a state of ad- duction; the trochanter major could be felt upon the dorsum of the ilium, a little above the situation of the sciatic notch. This case was at first supposed to have been an example of luxation upon the dorsum of the ilium. The patient died upon the four- teenth day after the accident.
Case XXX. — Alicia Harris, set. 70. — Fracture of the neck of the femur external to the capsule : the greater and lesser trochanter have both been separated from the shaft of the bone, and the former broken into two portions ; the pos- terior surface of the femur, between the two roots of the linea aspera^ was also detached. Five days be- fore her admission into the hospi- tal, this woman had been thrown down with great violence, and having with much difiiculty arisen,
86
FRACTURES OF THE NECK OF THE FEMUR.
fell a second time ; the parts around tlie joint were swollen, tense, and painful, and the limb shortened one inch and a half. She died of bronchitis ten days after the accident.
Case XXXI. — James Stanford, set. 67. — Comminuted fracture of the neck of the femur, external to the capsule. The fracture is oblique from above and without, downwards and inwards : at its upper part it extends within the capsule ; the trochanter major has been broken into four pieces, and the trochanter minor has also been separated from the shaft ; a large quantity of semi-coagulated blood was found effused between the fragments, and among the muscles around the j oint. The foot was everted, and the hmb shortened two inches. Upon the fourth day after the occur- rence of the accident, the patient be- came exceedingly restless, and endea- voured to get out of bed. He died
of traumatic delirium upon the eighth day from the receipt of the injury. He had been a man of most intemperate habits.
Case XXXII. — A man, a^t. 50. — Fracture of the neck of the femur, ex- ternal to the capsular ligament. The fracture has passed through the centre of the lesser trochanter, one half of which thus remained connected with the shaft of the bone ; the trochanter major was broken off, and split into two portions, and copious haemorrhage had taken place among the muscles. The limb was shortened two inches, and the foot everted. The injury (which was the result of a fall upon the trochanter) was followed by severe constitutional
disturbance, which proved fatal upon the fourteenth day after the occurrence of the accident. There had been delirium at night.
FRACTURES OF THE NECK OF THE FEMUR.
87
Case XXXIII.— Mary Kelly, ast. 56.— Fracture of the neck of the femur external to the capsule : in front; a triangular portion of bone has been separated both from the shaft and from the neck of the femur ; the trochanter was broken into four distinct pieces. The limb was shortened one inch and a quarter, and the foot was everted. The patient survived the occurrence of the accident only eleven days, her death being ap- parently owing to the severe shock caused by the injury. There was a large quantity of blood ef- fused among the muscles around
the articulation, and between the fragments of the comminuted trochanter, the fibrous structures covering which were lacerated.
Case XXXIV. — Ellen Bryan, set. 65. — Fracture traversing the neck of the femur, external to the capsular ligament, at its line of junction with the shaft of the bone ; a second fracture, com- mencing near the summit of the tro- chanter major, terminates at the tro- chanter minor, detaching the pos- terior half of each of these processes, together with the intervening por- tion of the bone, and the centre of this detached portion is traversed by a third fracture. The superior extremity of the lower fragment was deeply excavated, in conse- quence of the neck of the bone having been forcibly driven into its cancellated texture ; the cavity
thus formed was filled with blood, which was also effused between the muscles. The patient died of bronchitis five days after the receipt of the injury. There was no appreciable e version of the foot ; the shortening of the limb amounted to one inch and a half.
88
FRACTURES OF THE NECK OF THE FEMUR.
Case XXXV. — Margaret Connolly, set. 89. — Fracture of the neck of the femur, external to the capsule; a second fracture, pass- ing through the posterior intertro- chanteric space, separated both tro- chanters from the shaft, together with the whole of that portion of the bone comprised between the two roots of the linea aspera; a large quantity of blood was effused between the fragments. The pa- tient, an exceedingly infirm old wo- man, survived the occurrence of the accident only twelve days. The limb was shortened one inch and a half, and the foot everted.
Case XXXVI.— Thomas Murphy, set. 41.— Fracture of the neck of the femur, external to the capsule, with comminuted frac- ture of the trochanter major. The bone was broken into six distinct fragments, independent of the frac- ture through the cervix. The mus- cles around the joint were pale and flaccid, and the cancelli of the femur were filled with an oily fluid. The injury was the result of the applica- tion of a very slight force, but most of the long bones in this individual were in a morbid state. The oppo- site femur was the seat of several fractures; one passed transversely through the shaft, about three inches above the condyles, and was united with but little deformity ; a second
traversed the bone obliquely near its centre ; this was also united, but the lower fragment overlapped the upper to the extent of four inches; a third fracture, which had separated both trochanters from the shaft, was united by a ligamentous tissue. There also
FRACTUEES OF THE NECK OF THE FEMUR.
89
existed, upon this side, an intracapsular fracture, with complete absorption of the neck of the bone. An enormous quantity of osseous matter, of an extremely porous texture, and highly vas- cular, was deposited throughout the entire extent of the femur ; the muscles were wasted, and contained between their fibres a pale, unhealthy adeps, and the bony tissue was infiltrated with oil. The patient had been bed-ridden for ten years preceding his death, and during the latter part of his life he suifered great agony ; he at length died of diarrhoea. The olecranon process was broken during an efibrt of the patient to raise himself upon his elbow in bed.
Case XXXVII. — A male, set. 60. — Fracture of the neck of the femur, external to the capsule. The neck of the bone was broken transversely at its base ; it had been driven into the can- cellated tissue between the trochanters, in an oblique direction,
so that the broken extremity of the cervix was forcibly impelled against the trochanter major. The whole of that portion of the bone which constitutes the intertrochanteric space, together with the lesser trochanter, was completely detached from the shaft, comminuted, and displaced. The neck of the femur formed a
90
FRACTURES OF THE NECK OF THE FEMUR.
right angle with the shaft, which was drawn upwards in front of the anterior surface of the cervix. The fracture of the trochanter was firmly united by osseous matter, deposited copiously along the line of the solution of continuity in the bone, but the lesion of the neck of the femur itself had been repaired only by a liga- mentous structure. In this case the limb was shortened two inches, the foot was inverted, and the injury was supposed to have been a dislocation upon the dorsum of the ihum. The patient died about six months after the occurrence of the accident.
Case XXXVIII.— A male, set. 65. — Fracture of the neck of the femur, external to the capsule, with comminuted fracture of the trochanter major, which was broken into six pieces. The fibrous coverings of the trochanteric region were everywhere lacerated, and the fragments of the bone enveloped in extravasated blood. The foot was everted, and the short- ening of the hmb amounted to two inches. The patient died upon the tenth day after the occurrence of the accident.
Case XXXIX. — Michael Doolan, ^t. 75. — When this pa- tient was admitted into the hospital the limb presented the fol- lowing appearances. The region of the hip-joint was considera- bly swollen; the trochanter major seemed to be much larger than natural ; it was drawn upwards nearly to a level with the anterior spine of the ilium ; there was an evident hollow in the groin, and the limb was four inches shorter than the sound one ; the foot was inverted ; rotation outwards caused severe pain ; crepitus was easily produced. The patient stated that, about a fortnight be- fore his admission into the hospital, he had fallen upon a heap of stones upon the left hip ; that he was at once rendered incapable of rising, and was carried to the hospital. He further stated that, many years ago, he had noticed a stifihess in the hip-joint, which was the seat of the recent injury ; that by very slow degrees the limb became shortened ; that he walked lame, but was never con-
FRACTURES OF THE NECK OF THE FEMUR.
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fined to bed in consequence of the affection. He died one month after the occurrence of the accident. Upon examination of the joint after death, it was found that the neck of the femur was fractured at its base ; the trochanter major was broken obliquely
from the shaft of the bone, the fracture running in such a direc- tion as to leave attached to the trochanter the pyriformis, gemelli, quadratus femoris, and obturator muscles ; the trochanter minor was also separated, along with nearly two inches of that portion of the shaft from which it springs ; the psoas and iliacus muscles were attached to this fragment.
When the interior of the joint was laid open, the state of the parts here disclosed satisfactorily accounted for the train of symp- toms which the patient described as having occurred previous to the receipt of the injury. Osseous matter was deposited at the junction of the cervix with the head of the femur ; the ligamen- tum teres had disappeared ; the head of the femur was destitute of cartilage, for which was substituted a smooth, polished substance like ivory ; the head of the bone was enlarged and altered in form ; the acetabulum was also enlarged, and lined by the same ivory- like material as that covering the head of the femur. When the fractured portions were restored to their proper relative position, it was found that the neck of the bone was quite horizontal, and that the trochanter major was situated above the level of the head of the femur. A considerable degree of shortening (the re- sult of chronic rheumatic arthritis) had thus existed before the occurrence of the fracture.
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FRACTURES OF THE NECK OF THE FEMUR.
Case XL. — Eliza M'Cabe, set. 80. — This woman was ad- mitted into the hospital upon the 13th of December, 1845 ; she had just been violently thrown down in the street. The usual signs of the extracapsular fracture of the neck of the femur were present, the limb was shortened one inch and a quarter, and the foot everted. During the night of the 17th she got out of bed, and contrived, without assistance, to make her way across the ward to the fire, beside which she remained sitting upon the floor until morning ; upon several subsequent occasions she left her bed, threw her weight upon the broken limb, and hobbled about the ward, raving occasionally and unconscious of pain. Opium failed to tranquillize her; in fact she mani- fested most of the symptoms of trau- matic delirium. When the limb was examined after several of these at- tempts to walk, it was found that the shortening of the limb had reached two inches, and that there was a de- cided tendency to inversion of the foot. Two exceedingly sharp spicule of bone, belonging to the lower frag- ment, threatened to perforate the in- teguments close to Poupart's ligament, and a bony tumour could be felt towards the dorsum of the ilium. Upon the 8th of January, 1846, she was at- tacked with diarrhoea, and died upon the 30th, about six weeks after the occurrence of the accident.
Upon examination of the joint after death, the neck of the femur was found fractured external to the capsule ; it li9,d been driven into the cancellated tissue of the lower fragment,
FBACTURES OF THE NECK OF THE FEMUR.
93
breaking off the entire of the trochanter major; the neck of the bone and the trochanter formed a right angle with the shaft ; the former had suffered a very singular rotation, in consequence of which its anterior surface was directed upwards, and its posterior surface downwards ; its concavity looked forwards, and its upper surface backwards. The head of the bone was directed back- wards, and the broken extremity of the cervix forwards ; the tro- chanter was displaced along with the neck of the bone ; the ante-