is properly adjusted. Loose cotton batting always becomes displaced.
Four splints are generally required: one for the anterior surface,
extending from the groin below the anterior spines of the pelvis to
within half an inch of the patella; one for the posterior surface, ex-
tending from the tuberosity of the ischium to a point two inches
below the knee ; one for the inside, extending from near the perineum
to the inner condyle; and one for the outside extending from above
the trochanter major to the outer condyle. These splints ought to
encircle the limb completely, only leaving an interval of from half an
inch to one inch between each of the adjacent splints. The outer and



Digitized by



Google



424 FRACTURES OF THE FEMUR.

inner splints may be extended below the knee when the fracture is
low down; but in that case they must be carefully fitted to the ir-
regularities of the condyles. The posterior splint is the most impor-
tant of them all. It should be wider and longer than either of the
other splints, and it must be fitted with great accuracy to the back of
the thigh, ham, and upper part of the leg. It is important also to
cover this with a sac of cotton cloth so that it may be stitched to the
centre of the bands, which are to inclose all the splints. If this is
not done, it is very liable to become displaced.

A long side splint must now be prepared, long enough to extend
from about four inches below the axilla to five inches below the heel ;
four and a half inches wide, by half an inch in thickness, and provided
with a cross-piece at the lower end, two feet long by three inches wide
and half an inch thick. The purpose of this splint is not to make
extension or to serve as a side coaptation splint, but solely to prevent
eversion of the foot, which purpbse is never accomplished effectively
by junks or by any other method I have yet seen adopted. It is to
be employed in all fractures of the thigh, including fractures of the
neck. The inner surface of this long splint must be padded through
its whole length, and thus fitted accurately to the sides of the body
and limb.

Four or six strips of cotton cloth, each two inches wide by one
yard in length, are now stitched by their centres to the outer surface
of the long back splint, and these are laid upon the bed in position
for the splint to receive the limb.

Fig. 179.

I



(



Mode of applying adhesiTo plaster.



Supplied with rollers, several additional strips of bandage, and
cotton-batting, we are now ready to reduce and dress the fracture.
The patient being placed in position upon the bed, one assistant



Digitized by



Google



TRACTURES OF THE SHAFT OF THE FEMUR. 425

Seizes the limb by the knee, and a second by the foot, drawing upon
it firmly and steadily, while the surgeon lays the extremities of the
extension strips upon each side of the leg, with the centre, containing
the foot-piece and the rope, about one inch below the sole of the foot.
"With a muslin roller, inclosing the limb from near the metatarso-pha-
langeal articulation to the tuberosity of the tibia, the adhesive strips
are held in place. As a rule, and especially in the case of women, and
of persons of a delicate lax fibre, it is well to lay against the tendo
Achillis, and over the instep, a little cotton batting before applying the
roller. In some cases I am in the habit of applying a thin sheet of
cotton wadding over the whole surface of the limb. Any excess of
the bands at the upper end are disposed of by turning them down,
and inclosing them in a few additional turns of the roller. As soon as
the application of the adhesive strips is completed the weight may be
adjusted, and extension applied. The amount of extension required
for adults will vary from eighteen to twenty-three pounds. In a
large proportion of cases twenty or twenty-one pounds will be borne
without complaint; and the ability of the patient to tolerate the ex-
tension, alone limits the amount. Occasionally, even a few pounds,
when first applied, causes pain in the ligaments about the knee-joint ;
but in a few hours the amount may be increased. It is better to
apply eighteen or twenty pounds at once, if it can be borne. Lifting the
knee slightly by a pad placed underneath, will often relieve the pain
cansed by the extension.

Sometimes, in the case of very muscular patients, and where the
primary shortening is considerable, I believe we make a positive and
permanent gain if we place the patient under the influence of chlo-
roform for a few minutes, when the weight is first applied. In these
cases, as in dislocations, I generally prefer chloroform to ether, for the
reason that the patient is less liable to muscular contractions when
he is passing under the influence of the anaesthetic.

Fig. 180.



Author*8 dreadDgi for fraetare of thaft of femor, eompleto.

Extension being effected, and the patient already resting upon the
posterior coaptation splint, the three other side splints are applied,
and the whole secured in place by the four or six transverse bands
already described as attached to the posterior splint ; the bands being
tied over the front splint firmly.
28



Digitized by



Google



426 FRACTURES OF THE FEMUR.

It remains only to lay the long splint beside the body, and to secare
it in place by a few separate strips of bandage.

From this time onward, the patient should be seen daily, and the
coaptation splints loosened or tightened from time to time, as may be
required. Ordinarily it is not necessary to disturb the extension antil
the union is completed. The usual time required for consolidation in
the case of an adult is from six to eight weeks ; but if the bone feels
pretty firm at the end of four weeks, the extension may be a little
relaxed. When at length the patient is permitted to leave his bed,
a pair of crutches are indispensable ; and during the following two
months but little weight should be borne upon the limb.

Fractures of the thigh in children have generally been found more
difficult to manage than fractures of the same bone in the adalt,
owing chiefly to the shortness of the limb, the delicacy of the skin, and
the restlessness of the patient. I have tried nearly all forms of appa-
ratus in these cases, including double-inclined planes, boxes, single
long splints, &c., and the result of my experience is that they are all
inefficient; and for some years I have employed a mode of dressing,
partly my own and partly the suggestion of others, but of which I
am able to say that it never disappoints me in the result obtained ;
while it is simple, easy of management) and comfortable to the little
patients.

Extension by means of adhesive plaster and a weight, employed
in the same manner as in adults, constitutes a valuable aid in most
cases ; but I cannot say that it is indispensable, since, with children
under five or seven years, the fractures are pretty often so nearly
transverse that, when once reduced and well supported by lateral
splints, union without shortening may generally be expected ; but these
results become less and less frequent asVe advance toward adult
life. It is safe and proper, according to my experience, to employ in
any case extension, somewhat according to the following rule. One
pound for a child one year old, two for a child two years old, and so
on, adding one pound for every year up to the twentieth. Of much •
more consequence, however, is it to confine, at the same time, both
limbs, for as long as one is at liberty it is almost impossible to secure
any degree of quiet. It is of equal importance, in my opinion, to
give to the limbs an extended rather than a flexed position.

My plan of treatment, therefore, in the case of children, is in all
essential respects the same as in adults, except that instead of one
long side splint, I employ two. The accompanying illustrations will
explain more fully my meaning. Two long side spKnts connected
by a cross piece at the lower ends, and reaching upwards to near the
axillae, separated a little more widely below than above, so as to
render the perineum more accessible, are laid upon each side of the
bpdy. The leg of the broken limb is secured to the long splint with
a roller. The remainder of the limb, the opposite limb, and the body,
are made fast with broad and separate strips of cloth. The coaptation
splints, in the case of children, may be made of binder's board.

Thus secured and laid upon a bed, such as I have already described
as appropriate for children, the least possible annoyance will be given



Digitized by



Google



FRACTURES OF THE SHAFT OF THE FEMUR.



427



to tie surgeon. The dressings are but little liable to become wet
'with urine, and when the bed is soiled, the child can be taken up with
tlie splint and carried to another; indeed, this may be done as often
as tlie patient becomes restless or weary, without any risk of disturb-
ing the fracture.



Fig. 181.



Fig. 182.



Author's tpllnt for fractore of the femur in
children.



Author's dressing for fkuctnre of the femur In
children, complete.



In case the surgeon desires to use extension with adhesive plaster
and weights, the necessary apparatus may be made fast to the bed-
stead, and taken off when the child is moved ; or it may, if thought
best, be made fast to the foot-piece of the splint.

Occasionally, with children, I employ, as a means of extra safety, a
perineal band, drawn moderately tight, and fastened to the top of the
splint on the side corresponding to the broken limb. The best peri-
neal band is a piece of soft cotton cloth, one or two yards long, by
three inches wide, folded lengthwise, to a flat band of one inch in
breadth, and inclosing, where it passes through the perineum and
under the nates, a few thicknesses of paper. The paper prevents its
drawing into a round cord. Sometimes I place between the paper



Digitized by



Google



428 FRACTURES OF THE FEMUR.

and the folded cloth, on the side which is to be laid next to the skin,
one or two thicknesses of cotton wadding. To absorb the moisture,
it is well to lay a piece of sheet lint between the band and the skio.
The perineal band may be removed daily and renewed ; and the peri-
neum examined and washed.

Four or five weeks is generally a suflBcient length of time for per-
fect consolidation, in children under five years of age

The treatment of compound fractures of the thigh, caused by gun-
shot injuries, will be considered in the chapter devoted to gunshot
fractures. Other badly comminuted and compound fractures of this
bone are to be manag^ upon the same general principles as gunshot
fractures.

Those compound fractures of the femur which have been caused
by the thrusting of the sharp fragments through the flesh, and in
which reduction has been easily effected, have in most cases done sls
well as simple fractures, except that the limb is generally a little
more shortened. The wound usually soon heals, and the future pro-
gress of the case is the same as that of a simple fracture. They may
be treated, therefore, in the same manner as those which have just
been described.

§ 5. Fractures of the Condyles.
(a.) Fractures of the External Condyle,

Dr. Alph B. Crosby,^ of New Hampshire, has published an account
of a case of simple fracture of the external condyle, in a young man
twenty-one years of age, and which happened from a sudden twist of
the limb, while he was undressing himself to
Fig. 183. bathe. He was " standing on a shelving bank,

with the right leg flexed over the left in order to
remove his pantaloons; he lost his balance, par-
tially twisted the leg, and fell to the ground."
Six months after, the fragment was removed by
Dr. Crosby, through an incision below the con-
dyle. The recovery of the young man has been
complete.

The accompanying drawing represents the
specimen as seen from its lower or cartilaginous
surface, and of its actual size.

Dr. T. S. Kirkbride has also reported an ex-
Dr. croHbjr'. •peciin«n of ample of simple fracturc of this condyle, which

fi^cture of the external con. ^^^ produced by the kick of a horSC, the bloW

having been received upon the inside of the knee.
When this patient entered the Pennsylvania Hospital, Dec. 1884, the
knee was much swollen, and crepitus was plainly felt, but the frag-
ment was not displaced ; the muscles upon the outer side, however, were
.so strongly contracted as to abduct the leg, and produce considerable

> Crosby, New Hampshire Joum. of Med., 1857.



Digitized by



Google



FRACTURES OP THE CONDYLES. 429

angular deformity. The limb could be easily Fig. 184.

made straight, but it returned to its former

position of abduction as soon as it was released.

When fully extended, slight bending of the

joint did not give severe pain ; but when in any

degree flexed, all motion was very painful.

The limb was placed in a long straight frac-
ture-box, and cold applications were made;

great swelling followed. It was kept extended

in this manner, or in the long splint of De-

sault, twenty-eight days; at which time union

seemed to have taken place, but the motions at

the joints were very limited, and productive of

great pain. From this period the limb was

laid in a splint, so constructed as that the angle

of the knee could be changed daily. At the

end of about six weeks he began to walk on

crutches, and he could then flex the leg to a

yicrVit flmrlft ^ ^^^ Astley Cooper** cMe of

o .°,', ,1 ii 1 fracture of the ozternal coa-

Sir Astley has related a case of compound dyie.
fracture of the same condyle, produced by fall-
ing from a curb-stone upon the knees. The man died on the twenty-
fourth day. On examination after death, the external condyle was
found to be broken ofi) and also a considerable fragment was detached
from the shaft higher up.^

(b.) Fractures of the Internal Condyle.

Dr. Thomas Wells, of Columbia, S. C, has reported an example of
fracture of the internal condyle, accompanied with a dislocation of the
liead of the tibia out^vards and backwards. The man was about forty
years old, and intemperate. Dr. Wells was not called until two days
after the injury was received, when he found the limb greatly swollen
and gangrenous. The man's account of himself was that while walk-
ing in the back yard he fell, and thus dislocated his knee, and that
he was then brought into the house, being unable to stand upon his
feet. It does not appear that any attempt was made to reduce the
limb, probably because his general condition indicated that speedy
death was inevitable. On the fourth day he died. The autopsy dis-
closed, in addition to the dislocation of the tibia, that a thick scale of
bone was broken from the inner part of the inner condyle, but it
remained attached to the ligaments.'

A case reported to me by Dr. Lewis Riggs, a very intelligent sur-
geon, practising in Homer, Oneida Co., N. Y.. was more successful.

A lad, 8Bt. 15, was kicked by a horse, the blow being received upon
the right knee. Dr. Riggs saw him within three hours after the acci-
dent, and found the internal condyle of the right femur broken off,

» Kirkbride, Amer. Joum. Med. Sc!., May, 1835, vol. xvi. p. 32.

« Sir A8tley Cooper, On Disloc, &c., op. cit., p. 289.

» Wells, Amer. Joum. Med. 8ci., May, 1832, vol. x. p. 25.



Digitized by



Google



430 FRACTUBES OP THE FEMUR.

carrying away more than half the articulatiag surface of the joint;
the tibia and fibula were at the same time dislocated inwards and
upwards, carrying with them the broken condyle and the patella. The
displacement upwards was about two inches, and the sharp point of
the inner fragment had nearly penetrated the skin. There was no
external wound. The knee presented a very extraordinary appear-
ance, and the lad was sulSering greatly. Being at a distance from
town, and the doctor having no chloroform or pulleys with him, be
was obliged to depend solely upon the aid of five men who were pre-
sent. The first attempt at reduction was unsuccessful; but in the
second attempt^ when the men .were nearly exhausted in their efforts
at extension and counter-extension, and while the doctor was pressing
forcibly with both hands upon the two condyles, the bones suddenly
came into position, except that the breadth of the knee seemed to be
slightly greater than the other, a circumstance which was probably
due to the irregularities of the broken surfaces, which prevented per-
fect coaptation.

Neither splints nor bandages were required to maintain the bones
in place ; but anticipating the probable occurrence of anchylosis, and
with a view to making " the limb as useful as possible in this condi-
tion," he was placed upon "a double-inclinea plane," which being
supplied with lateral supports, would also prevent any deflection in
either direction, in case the limb was disposed to such displacement.

The subsequent treatment consisted in the use of cold water dress-
ings. Very little inflammation followed. A portion of the integu-
ment sloughed, but the bone was not exposed, and it healed rapidly.
Qn the twenty-fourth day Dr. Biggs gave to the joint passive motion,
atid this was repeated at intervals until, at the end of three months,
he was able to walk with a cane. At the end of a year Dr. Biggs
examined the leg, and found the knee a very little larger than the
other, and he could not flex it quite as completely. In all other
respects it was perfect, and the boy himself declared it was as good as
the other.

Treatment of Fractures of either Condyle. — The few cases of these acci-
dents which I have seen reported have been, with one or two exeeptions,
treated in the straight position. In Kirkbride's case any degree of
flexion was painful, although there was little or no displacement of the
fragment; and we think we can see, in the relative position of the arti-
cular surfaces of the tibia and femur, a sufficient reason why the straight
or nearly straight position must generally be preferred. Whichever
condyle is broken, the remaining condyle will be sufficient to prevent
a dislocation and consequent shortening of the limb, unless, indeed,
the dislocation has already occurred as an immediate conseauenoe of
' the injury. It is very certain that it would not take place from the
action of the muscles when the limb was straight. In the flexed posi-
tion I can conceive that it might take place, but yet not easily, it is
not a dislocation of the limb, then, that we seek chiefly to avoid, but
a deflection of the leg to the right or to the left, according as one or
the other of the condyles has been broken. It will be readily seen
that, in order to resist this tendency, nothing but the straight position



Digitized by



Google



FRACTURES OF THE CONDYLES. 431

will answer, and that for this purpose it will be necessary to lay a
long spIiQt upon one or both sides of the limb, and to secure the
whole length of both thigh and leg to this splint. The long fracture-
box ased by Kirkbride, if well cushioned on all sides, seems to me at
once to answer most completely this important indication, rendering
it even unnecessary to employ a bandage, since the opposite sides of
the box will compel the limb to adopt the proper position.

As to the remainder of the treatment, it must consist essentially in
the active employment of such means as are calculated to prevent and
allay inflammation; especially ought the surgeon not to omit to avail
himself of so valuable an antiphlogistic agent as cool water lotions.

As soon as the union is consummated the joint surfaces should be
submitted to passive motion, in order to prevent anchyloHs; and it
would be better to commence this so early as to hazard somewhat a
displacement of the fragment, rather than to wait too long. It may
not, in some cases, be improper as early as the fourteenth day, and in
nearly all cases it should be practised as early as the twenty -eighth.

(c.) Fractures between the Condyles and across the Base.

Etiology, — A fracture of this character may be produced by a blow
received upon the side of the limb or upon the lower extremity of the
femur; sometimes the blow has been received directly upon the patella
when the knee was bent, and Bichat mentions a case in which it was
produced by a fall upon the feet.

Symptoms. — This fracture is easily distinguished from the preceding
by the much greater mobility of the fragment and by the palpable
shortening of the limb, since an overlapping of the broken end is
here almost inevitable. Each fragment may be felt to move separately,
and the motion will be accompanied with crepitus.

Prognosis. — The danger of violent inflammation in the joint is im-
minent, and anchylosis of the knee is to be anticipated as the most
favorable result, since the joint surfaces are likely to be rendered im-
movable by fibrinous deposits in their immediate vicinity, and also
by the adhesion of the muscles to one another and to the bone higher
np, where the fracture of the shaft has occurred. More fortunate
results than these may, indeed, be hoped for, inasmuch as they have
occasionally been noticed, but they cannot fairly be expected.

In a majority of cases, such accidents have demanded, either imme-
diately or at a later period, amputation. If recovery takes place, a
shortening of the thigh is inevitable. Mr. Canton, of London, has
twice performed successfully resection of the joint end of the bone in
such accidents.^

Treatment. — Malgaigne saw a patient who had been treated by
Guerbois with the aid of extension and counter-extension, who was
confined to his bed five months, and who had at the end of eight years
very little motion in the joint, and he seems disposed to charge in
some measure these unfortunate consequences to the position in which

1 Lancet, Aug. 2S, 1S5S. Trans. London Path. Soc, 1S60.



Digitized by



Google



482 FRACTURES OF THE FEMUR.

the limb was placed, namely, the straight position. But, in my opinion,
it is much more reasonable to suppose that^ if the treatment was at
all responsible for the results, the error consisted in too long and un-
necessary confinement, and in too much extension. I suspect that
the mere matter of position had nothing to do with the anchylosis.
Malgaigne does not, however, himself recommend anything more than
a very slight amount of flexion at the knee; and to this practice I
am prepared to give my assent; since it will give to the limb a usefal
position in case anchylosis does occur, and it is not inconsistent with
the employment of the moderate amount of extension which alone is
justifiable after this accident. If the young surgeon should differ
with me in opinion as to the necessity or propriety of using great
force to rttain the fragments in place and prevent overlapping, I beg
him to consider that this fracture probably never happens except from
the application of an extraordinary force, and that consequently intense
inflammation and swelling are almost certain to ensue; and that in
some cases, the very fact that immediately after the accident^ or for
some hours succeeding, no swelling occurs, or muscular contraction,
and that replacement of the fragments is easily accomplished, is evi-
dence only of the great severity of the injury, and that the whole
system is lying under the shock; to which, if the patient does not
succumb, sooner or later reaction will ensue, and the fragments will
be gradually drawn up with a resistless power. The surgeon ought
to remember also that to make extension in this case, he is obliged
to pull upon those very ligaments and tendons about the joint which,
having been torn or bruised, must soon become exquisitely sensitive.

The long straight box, already recommended when speaking of
fracture of one condyle, is equally applicable here ; only that it needs
a foot-board, or some sort of foot-piece to which an extending appa-
ratus may be secured, and that a pillow should be placed under the
knee to give the limb the proper flexion.

Oase. — A man was admitted into St. Thomas's Hospital, London,
Sept. 17, 1816, with a fracture between the condyles, accompanied also
with a fracture through the shaft higher up, occasioned by being
caught in the wheels of a carriage while in motion. There was a
small wound opposite the point of fracture, and the external condyle
was displaced outwards.

• The limb was laid in a fracture-box, and in a position of semi-
flexion.

On the 18th of November, the external condyle, having protruded
through the skin, and being dead, was removed with the forceps,
bringing with it a portion of the articular surface.