Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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upper fragment being slightly displaced forwards. When the catheter
was introduced into the urethra it was found to enter this wound, and
could be felt resting against the naked bone. From this time until
the twenty-sixth day, the urine continued to escape freely through the
wound. In about six weeks more the fistulous opening had entirely
closed, and after several months his recovery was complete.*

The signs of this accident are generally even more obscure than
those of fracture of the pubes, but in a case of doubt the bones ought
not only to be carefully examined from without, but the finger should
be introduced freely into the rectum and the anterior surface explored ;
or the tuber ischii may be grasped between the thumb and finger and
moved laterally in order to determine the existence of motion or crepi-
tus. If the patient is a female, this exploration can be best made
through the vagina. By flexing and extending the thigh, also, crepi-
tus may sometimes be discovered. The examination will generally
be made while the patient lies upon his back; but if turning is not
found too painful, it will be well to lay him upon his face, that the
tuberosities of the ischium may be more plainly brought into view.

A considerable proportion of the fractures of both the pubes and
the ischium are accompanied with lesions of the bladder or of the
urethra, either of which circumstances will render the prognosis very
unfavorable; but in simple fractures recoveries may generally be
expected, yet only after a tedious confinement.

It is not usual, except in cases which must almost necessarily prove
fatal, to find much displacement of the fragments ; nor is it probable
that by any manoeuvres the slight displacements which are found to
exist can be entirely overcome. Instances may occur, however, in
which careful pressure from without, or the introduction of a finger
into the rectum or vagina, may aid in the restoration.

The posture best suited to these cases will be indicated usually by
the sensations of the patient himself. Ordinarily he will prefer to lie
upon his back with his thighs flexed and supported by pillows ; and
his hips slightly elevated by a firm cushion laid under the upper part

' A. Cooper, by Bransby Cooper, Amer. ed., p. 140.

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of the sacrum. His knees ought also to be gently bound together ;
but if the patient finds this position painful or excessively irksome,
as. sometimes he will, he may be permitted to occupy any position
which he finds most comfortable.

§ 3. Ilium.

Fractures of the ilium are much more common than fractares of
either the ischium orpubes, and they assume a great variety of forms,
directions, and degrees of complication.

In the two following examples the anterior superior spinous process
alone was broken off: —

John Kelly, set. 86, admitted to the Hospital of the Sisters of Charity,
Dec. 28, 1852, having just fallen and broken the anterior superior
spinous process of the ilium. The fragment was displaced downwards
about one-quarter of an inch. Motion and crepitus distinct. A slight
ecchymosis existed over the point of fracture, and other signs of con-
tusion about the hip were present. He was intoxicated at the time of
the accident^ and could not tell how or where he fell.

He was laid upon his back in bed, with his thighs flexed upon his
body ; and in this position we attempted to reduce the fragment and
retain it in place with a bandage, but finding this impossible, we left
him with only instructions to remain quietly in bed. In about two
weeks the fragment was firmly fixed in its new position, and be was
allowed to get up and walk about, which he was able to do without

July 13, 1853, Matthias Morrison was caught under a bank of falling
earth, and on the following day Dr. Mixer, his attending surgeon,
requested me to see the case with him. He was unable to stand upon
his feet. There was a lacerated wound and an extensive braise on
his left hip ; but the thigh was not shortened nor everted, and he could
flex it slightly upon his body. Noticing a swelling and discoloration
in the region of the anterior superior spinous process of the ilium, I
pressed upon it and felt it recede with a distinct crepitus; the frag-
ment, however, immediately resumed its place when the pressure was
removed. I was able also, by a careful manipulation, to trace the line
of fracture, and to determiae that it included a small portion of the
anterior extremity and wing of the pelvis.

We directed the patient to remain quietly upon his bed with his
legs drawn up. He soon recovered, but I am unable to say what is
the present position of the fragment.

More frequently, however, the fracture involves a still larger por-
tion of the crest, as in the following examples : —

Joseph Joquoy, »t. 40, was caught by the bumpers between two
cars, Feb. 10, 1854, breaking obliquely the anterior superior portion
of the ilium. I saw him within an hour, and found him greatly pros-
trated ; the fragment of the pelvis broken off was quite movable, and
crepitus was easily detected. His abdomen was very tender and
slightly bloated.

He was laid upon his back with his legs drawn up, and hot fomenta-

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ILIUM. 841

tions of hops and vinegar were directed to be applied to his belly.
He also took one grain of morphine. The broken ala did not seem
disposed to become displaced. With no other treatment, his recovery
was rapid ; and the bones seemed to have anited without displace-

James Boche, 8Bt 41, fell Mfirch 7, 1854, from a height of fourteen
feet, breaking off the anterior superior portion of the right ala of the
pelvis. On the following day, I found him at the hospital of the
Sisters of Charity. The fragment, which was quite large, was mova-
ble, and occasionally a crepitus could be detected. It was displaced
downwards and forwards about three-quarters of an inch.

He was laid upon his back, with his thighs and legs moderately
flexed. At the end of two weeks he found himself able to walk with-
out much difficulty, and he immediately left the hospital. At this
time the fragment was displaced in the same manner and direction as
at first, but I cannot say whether it had united or not.

I have three other similar cases upon my records ; but in the last
example, the sixth, which has been especially recorded, the fracture
was caused by muscular action. William Alexander, set. 70, on the
fifth of September, 1869, after riding in a railroad car about half an
hour, arose to leave his seat, when he felt " something wrong" in his
right groin, and found himself unable to walk without great pain. He
was admitted to Bellevue Hospital on the same day, and I found a
fracture involving about three inches of the ilium, including the ante-
rior superior spinous process. It was inclined to fall outward, but
was easily replaced with a distinct crepitus.

I have once seen a fracture of the posterior superior spinous process,
and I do not know of any other example.

Miss B., 83t. 19, was thrown from her horse backwards, striking with
her back upon the ground. She was first attended by Dr. Coan, of
Ovid, N. Y. ; and she did not come under my care until two weeks
after the accident.

I found a small fragment broken from the posterior superior spinous
process of the ilium, and displaced backwards in the direction of the
spine about half an inch. It was movable, and by pressure it could
be partially restored to place, but it would immediately return to its
abnormal position when the pressure was removed. The injured hip
was painful, and occasionally it felt numb. She had previously suf-
fered from spinal irritation.

I laid a compress behind the fragment, and secured it in place with
a roller, enjoining perfect rest. She recovered from her lameness in
a few weeks, but I believe the fragment remains displaced.

Extensive comminuted fractures of the ilium are generally accom-
panied with so much injury of the pelvic viscera as to prove rapidly
fatal ; but the following example will show that this rule admits of

June 5, 1854, Bernard Duffie, sdt. 82, was crushed under a very
heavy stone which fell upon his back. I found the left ala of the
pelvis broken into several fragments, between the difierent portions of
which motion and crepitus were distinct. The fractures were near the

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superior part of the bone, commencing about two inches back of the
anterior superior spinous process, and extending backwards irregu-
larly. There was a narrow wound communicating with the fracture,
from which I removed a loose fragment of bone. The right leg was
also broken.

Four months after, he was still confined to his bed, and a fistulous
opening continued opposite the point of fracture ; there existed also a
large and irregular mass of ossific matter or callus around the frag-
ments. He soon after left the hospital.

Dr. Sargent, of the Massachusetts General Hospital, has reported a
case in which a man received a compound fracture of the left ilium,
and several small fragments were removed. He was discharged at
the end of three months with a fistulous opening still remaining, bat
in other respects he was quite well.^ Dr. Gheever, of the same hos-
pital, reports a case of fracture of the ilium, with fracture of the
ascending ramus of the pubes, resulting in complete recovery; bat
the leg became shortened and the toes inverted. Dr. Gheever believes
that the lines of fracture met in the acetabulum.'

The following case illustrates the more fatal injuries of this cha-
racter : —

John O'Keaf was crushed under a heavy stone, Oct! 28, 1861, break-
ing and comminuting the alsd of the pelvis on both sides, and wound-
ing also the iliac vein. He was taken to the hospital of the Sisters of
Gharity, and died in a few hours, partly from the shock to his system
and partly from the hemorrhage.

Lente, of the New York Hospital, has reported a case of dislocation
of the hip, which was accompanied with a fracture also of the ala of
the pelvis upon the same side. The dislocation was reduced on the
third day, and the patient soon after died. The autopsy disclosed
what had not been suspected during life, namely, that the left ilium
was broken horizontally about through its middle, and vertically
through the crest ; and also that there was a fracture extending through
the sacro-iliac synchondrosis, accompanied with considerable commi-
nution of the articular surfaces. It was also found that a portion of
the small intestine was ruptured, and probably by one of the sharp
fragments of the broken pelvis.*

It is seldom, I think, that the fragments become much displaced;
such, at least, has been my experience ; and I have noticed in Dr.
Neill's cabinet three specimens of fracture of the crest of the ilium, all
of which had united without any appreciable displacement. Dr. Neill
also called my attention to the fact that in two of these specimens the
ensheathing callus was confined to the outer surface of the bone ; an
observation which this gentleman assures me he has had frequent
ocicasion to make before where the fracture belonged to a flat bone.

If any displacement exists, the upper or loose fragment is generally
carried slightly inwards ; occasionally, however, it is found displaced
upwards, outwards, or downwards.

> Sargent, Boston Med. and Snrg. Jonm., vol. liii. p. 131.
' Cheeyer, Bost. Med. and Snrff. Journ., May 8, 1866.

> Lente, New York Journ. of Med., Jan. 1851, p. 29.

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Treatment. — ^In a large majority of cases the fragments, if displaced,
cannot be completely replaced. Occasionally, however, as where the
anterior superior spinous process is broken off with only a small por-
tion of tbe crest, the fragment may be seized with the fingers and car-
ried outwards or upwards, or in whatever direction may be necessary ;
but to retain it in this position is generally quite impossible. The
bandage or broad belt which we have recommended in certain frac-
tures of the pubes would be in these cases not only useless, but abso-
lutely mischievous, since its effect must be to press inwards the frag-
ments^ and thus to create a displacement which might not otherwise

The surgeon ought to determine by a careful examination the extent

and direction of the fracture, and, having done what was in his power

to replace the fragments, he should lay his patient upon his back with

the thighs drawn up and supported. This is the position which will

generally be found most comfortable ; but, as in other fractures of the

pelvis, it may be well always to try the effect of other positions, and

especially to determine their influence upon the fragments, and finally

to adopt that precise posture which accomplishes the indications best.

If the fracture is compound, and the fragments have penetrated the

belly, the wound* should be enlarged, and, as far as possible, every piece

of bone should be removed ; but if the fragments cannot be found,

the external opening should be allowed to remain seas to favor their

escape when suppuration shall have taken place.

§ 4. Acetabulum.

Although, strictly speaking, fractures of the acetabulum belong
always to one or all of those bones of the pelvis whose lesions have
already been described, yet the peculiar relations of this cavity to the
femur render it necessary that they should be considered as a separate
class of accidents.

Fractures of the acetabulum divide themselves naturally into two

First. Fractures of the base of the cavity, with or without displace-

Second. Fractures of the rim, with or without displacement.

lu fractures of the base of the cavity, not accompanied with displace-
ment, nothing but crepitus can be present as a sign of the accident ;
and this will scarcely be sufficient, in itself, to enable the surgeon to
distinguish it from a fracture of the neck of the femur within the
capsule without displacement.

It is probable, therefore, that its existence will only be determined
by dissection. Nor is it of much importance that the diagnosis should >
be made out ; since in either case neither splints nor any other sur-
gical appliances could be of service. An injury so severe as to frac-
ture the acetabulum will necessarily so much bruise the body, and
concuss the viscera of the pelvis, as to compel the patient to remain
quiet for a number of days, and this is all that would be thought
necessary if the nature of the accident was exactly determined.

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Dr. NeilPs cabinet contains a specimen of tbis kind, in which the
fracture, commencing near the centre, extends in three directions
across the cotyloid margins ; and in which perfect bony union has
occurred without displacement.

M. Bouvier related to the Academy the case of a man, set. 71, who,
in consequence of a fall from his bed, remained for three weeks unable
to walk, and never was able afterwards to walk without crutches. No
fracture could be discovered during life, but after his death, which
occurred some months subsequent to the accident, a fracture was
found extending from the ilio-pectineal eminence to the spine of the
ischium, and traversing the centre of the acetabulum. The fragments
were not displaced, but remained slightly movable.^

The following case was reported by Mr. Earle, to the London
Medico-Chirurgical Society, and will be found in the nineteenth
volume of its Transaclions. It is also referred to by Sir Astley, in
his Treatise on Fractures and Dislocations.

In the month of October, 1829, a man, SBt. 40, was admitted into
St. Bartholomew's Hospital, with a severe injury caused by having
fallen from a height of thirty-one feet and striking upon the left side.
The left leg was powerless, and shortened. The foot was everted.
Any attempt to rotate the limb caused great pain, and was accom-
panied with a sensible crepitus. The left trochanter was very much
depressed, and when it was pressed upon the patient complained of
deep-seated pain in the hip-joint.

He recovered in eight weeks, and was able to walk nearly as well
as before ; but he soon after died of disease in the chest.

On dissection, a fracture was found extending in two directions
through the acetabulum ; there was an extensive comminuted fracture
of the ilium, with great displacement, and the os pubis was broken in
three places.

The repair was very complete, and Mr. Earle remarked how nature
had guarded against any considerable deposit of new bone within the
articulation, which might have interfered with the functions of the
joint, while there was an abundant deposit of callus around the other
parts of the fractured bone.

Mr. Travers has reported two similar cases, and in the paper accom-
panying the report he maintains that very acute pain caused by press-
ing upon the projecting spine of the os pubis, and the inability of the
Satient to maintain the erect posture, may be regarded as signs
iagnostic of the accident.' It is doubtful, however, whether these
phenomena, so common to many other accidents, could be relied upon
as evidence of this peculiar lesion.

Fractures of the base of the acetabulum, with displacement of the
femur into the pelvic cavity, constitute a much more formidable, and
unfortunately a more common form of accident.

Like the preceding variety of acetabular fractures, they are pro-

1 Boayier, Amer. Joum. Med. 8ci., vol. zxiii. p. 486 ; from Ball6t. de TAcad.
Roy. de MM., August 15, 1838.
« Travers, Holmes* System of Surgery, vol. ii. p. 478.

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duced generally by falls upon the trochanter major, but the force of
the concussion has been greater.

Even here, it is not often that the diagnosis has been clearly made
out during life; and indeed, generally, the true character of the acci-
dent has not even been suspected, the surgeons believing that they
had to do with a fracture of the neck of the femur, or with a disloca-
tion. In two examples (Cases 71 and 72) mentioned by Sir Astley
Cooper as having been presented at St. Thomas's Hospital, the thigh
was thought to be dislocated backwards.

In the following example reported by Lendrick, of Dublin, the
patient was supposed to have a fracture of the neck of the femur: —

An old man, well known as the "Wandering Piper," was admitted
into the Mercer Hospital in January, 1839, suffering under phthisis
pulmonalis and acute inflammation of the hip-joiut. Some years
before, he had received a severe injury by the upsetting of a coach,
and was under treatment several months for what was supposed to be
a fracture of the neck of the femur. Since that time he had been
lame, but still able to take a great deal of exercise on foot both in
Great Britain and in America. The acute disease of the joint com-
menced about two months before his admission, and he was at first
under the care of Sir Philip Crarapton, who remarked that the thigh
was only shortened about half an inch, and expressed his surprise at
this fact.

This man died on the 17th of February, and the dissection showed
that there had been no fracture of the femur, but its head and neck
were affected with "morbus coxae senilis." The head was also thrust
through a rent in the acetabulum into the cavity of the pelvis ; but
the head had again been covered by a bony case, complete, except in
a small portion abdut the size of a shilling piece, and at this point the
covering was ligamentous.

The OS pubis had also been broken at the same time, and it had
united so much overlapped that the space between the iuferior ante-
rior spinous process and the symphysis pubis was shortened "nearly
an inch. A portion of intestine was found protruding through an
opening in the pelvis and adherent to the bone, in which situation it
seemed to have been caught by the broken fragmeats and retained.^

Morel-Lavall^e, in his thesis upon complicated luxations, mentions
a case which had come tinder his observation, and which had been
treated as a fracture of the neck of the femur. The patient survived
the accident many years; during a part of which time he suffered
such pain in the hip-joint as to induce a belief that it was itself
diseased. At his death he was found to have had a multiple fracture
of the bones of the pelvis, and the head of the femur had penetrated
more than an inch into the cavity of the pelvis, pressing upon the
obturator nerve to such a degree as to have, no doubt, caused the
severe pain from which he had suffered, and which had been ascribed
to coxalgia.*

' Lendrick, Amer. Joum. Med. Sci., vol. xxiv. p. 481 ; August, 1889 ; from
London Med. Gazette, March, 1839.
« Morel -Lavall^e, from Malgaigne, op. cit., vol. ii. p. 881.

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In the two cases mentioned by Sir Astley as having been receive
into St. Thomas's Hospital, the toes were turned in. In the examp
mentioned by the same author as having been presented at St. Ba
tholomew's Hospital, the toes were everted ; the two persons seen V
Lend rick and Morel-Laval l^e were supposed before death to have Kj
a fracture of the neck; it is probable, therefore, that in both of the
cases the toes were also everted. While Moore has dissected a subje
whose pelvis was broken into many fragments — the left os innomin
turn was divided into three portions, corresponding to the three bon<
of which it was composed in infancy; the head of the femur had con
pletely penetrated the basin; the limb was shortened two inches, an
in a position of slight flexion and adduction, but neither rotated ou
wards nor inwards.*

There seems, therefore, to be no certain rule in relation to the pos
tion of the limb; but it is found to take the one position or the othe
probably according to the direction of the force which has inflicted th
injury, and perhaps in obedience to circumstances not always easil

The shortening has been observed to vary from half an inch to tw
inches or more; the trochanter is also usually driven in toward th
pelvis. Pressure upon the trochanter occasions a deep-seated pair
If the limb is drawn down to the same length with the other, it im
mediately resumes its position when the extension is discontinued
Crepitus is more uniformly present than in fractures of the neck o
the femur, and it is especially felt while the limb is being extended o
while it is again shortening, and not so much in flexion or rotation.

If, in addition to all of these phenomena, we learn that the acciden
has occurred from a severe blow, or a fall from a great height upoi
the trochanter ; and that the viscera of the pelvis, and especially th<
bladder, seem to have suffered considerable injury; or if we detect a
the same time a fracture of some other portion of the pelvis — we maj
reasonably conclude that the head of the femur has penetrated th<
acetabulum. Yet it must be confessed that no one of these symptomi
is positively distinctive of this accident, and that they are seldom founc
sufficientlv grouped to render the diagnosis certain.

The old " Piper" mentioned by Lendrick, and the man dissected bj
Morel-Lavall^, lived many years, and managed to walk about, bui
not without considerable pain; the other three, to whom I hav<
alluded, died soon after the injuries were received.

Some have thought of treating these cases by extension and counter
extension ; the latter being accomplished through the aid of a perinea!
band ; but it is not probable that after an injury of this character, anj
patient will be able to endure the requisite pressure about the peri
neum or groins. It will be better to lay the patient upon DanielV
invalid bed, or some bed similarly constructed, so that it may be con
verted into a double-inclined plane; allowing the knees to be sus
pended over the angle thus formed, in order that the weight of the
body may have some effect to draw away the pelvis from the femur

> Moore, Med.-Chir. Trans., vol. xxxiv. p. 107, 1851.

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Or we may adopt extension without the perineal band, as will be
described hereafter when treating of fractures of the femur.

Fractures of the rim of the acetabulum have frequently been dis-
covered in dissections; and the records of surgery abound with cases
of unreduced dislocations of the femur, in which the failure to reduce
or to retain the bone in place has been ascribed, not always with suffi-

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 41 of 100)