Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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cient reason perhaps, to this fracture.

Dr. McTyer, of the Glasgow Royal Infirmary, published in the Olas-
gow Medical Journal for February, 1830, four cases of this fracture.

The first was that of a man, aet. 27, on whose back a number of
bricks bad fallen while he had his right knee placed on the bank of a
trench. His right leg was found shortened about one inch and a half,
bent, and the toes turned a little outwards. The limb could be moved
without much difficulty, but every motion gave him pain ; motion
was also attended with crepitus. On making extension, the limb was
easily brought to the same length with the other, but it became
shortened again immediately when the extension was discontinued.

The symptoms, difi'ering but little, if at all, from those which are
usually present in a case of fracture of the neck of the femur, led to
the supposition that this was actually the nature of the accident.
Subsequently, the toes became slightly turned in, but this circum-
stance was not regarded as sufficiently distinctive to warrant a change
in the diagnosis.

Having succumbed to the injuries after a few days, the autopsy
revealed a fracture extending through the bottom of the right aceta-
bulum, and about one inch and a half of the rim at its upper and
posterior margin completely detached, except as it was held in place
by a portion of the capsular ligament. The head of the bone could
be easily pushed upwards and backwards upon the dorsum, the frag-
ment of the acetabular margin being moved aside, and swinging upon
its fibrous attachment as upon a hinge, but resuming its place again
perfectly when the head of the femur was restored to the socket. The
femur was not broken.

In the second case the limb was found shortened, the knee slightly
bent, and turned a little forwards and inwards, and the toes pointing
to the tarsus of the other foot. It was thought to be a fracture also
of the neck of the femur, but the autopsy disclosed only a fracture of
the upper margin of the rim of the acetabulum.

In the third case, seen only after death, the limb was not shortened
much, but the toes were stretched downwards, and turned slightly
inwards. It was supposed at first to be a simple dislocation, but on
dissection the posterior and inferior margin of the acetabulum was
found to be broken and displaced towards the coccyx, while the head
of the femur rested upon the pyriformis muscle, over the ischiatic
notch.

The fourth example was found in the dissecting-room, and the his-
tory of the case is not known. A fragment of the superior and pos-
terior margin of the acetabulum had been broken off) and had reunited
slightly displaced.^

» McTyer, Amer. Joum. Med. 8ci., vol. viii. p. 517, Aug. 1881.



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848 FRACTURES OF THE PELVIS.

Several other similar examples have been established by dissection,
and we are able, therefore, to determine pretty accurately what art
the usual phenomena and terminations of this accident, though we an
far from having arrived at a satisfactory means of diagnosis ; indeed
the accident has seldom been recognized before death. Its causes arc
generally the same with those which produce dislocations of the hip
but in most instances the violence has been greater than in the cas<
of dislocations.

The symptoms are, first, such as indicate a dislocation, to which
must be added crepitus and a diflSculty, if not impossibility, of retain
ing the head of the femur in its place when it is reduced. The crepitus
is sometimes discovered the moment we begin to move the limb, and
this will aid us to distinguish it from a fracture of the neck of the
femur accompanied with much displacement, since, in the latter case,
crepitus is not felt usually until the extension is complete, and the
fragments are again brought into apposition.

The majority of these accidents, either from a failure to recognize
them, or from the impossibility of maintaining the head of the femur
in place when once it has been reduced, have resulted in a permanent
dislocation of the hip and a serious maiming. The following case
was recognized and reduced, but it was found impossible to maintain
the reduction.

February 8, 1847, a strong German laborer was crushed under a
mass of iron weighing several tons. Drs. Sprague and Loomis, of
Buffalo, were called, and found the left thigh dislocated upwards and
backwards, and by the aid of six men they succeeded in reducing it,
the reduction being attended, as the gentlemen have informed me, with
a slight sensation of crepitus. The legs were then laid beside each
other, and the knees tied together, the patient lying on his back ; and
now the two limbs appeared to be of the same length. On the second
and third days the injured limb was examined by the same gentlemen,
and there was no displacement. On the fourth day I was invited to
meet these gentlemen, the patient having had muscular spasms during
the previous night, and the thigh being reluxated.- I found the limb
shortened one inch and a half, adducted, and the toes turned in. We
immediately applied the pulleys, and soon drew the trochanter down
to a point apparently opposite the acetabulum, and a careful measure-
ment showed that the two limbs were of the same length. The pulleys
being removed, the leg did not draw up again, nor did the foot turn
in, yet we had felt no sensation to indicate that the bone had slipped
into its socket, nor had we felt crepitus. The legs and thighs were
now laid over a double-inclined plane, and well secured. He remained
in this condition three days more, during which time Dr. Sprague saw
him each day, and found nothing disarranged. On the night of the
seventh day the spasms returned, and in the morning the thigh was
displaced. The next day we again applied the pulleys, but soon

•» Maisonneuye, Chlnirg. Clin., 1S63, p. 168. Sir Astley Cooper on Disloc. and
Prac, 1823, -second London edition, p. 15. M. Beraud, Bulletin de la 8oc. de Chir.,
1862, torn., iii. p. 185. Ibid., p. 226. Bigelow on Hip- Joint, 1869, p. 189 et seq.



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SACRUM. 849

found that the bone would not remain in place one minute aflber the
pulleys were removed.

At this time, while moderate extension was being made at the foot
by rotating the foot inwards, we could distinctly feel a slight crepitus.
A straight splint was applied, and as much extension made a^ he could
conveniently bear, and in this condition the limb was kept several
weeks. Seven years after, I found the thigh still displaced upon the
dorsum ilii. He limped badly, but he could walk fast, and perform
as much labor as before the accident.

In one case mentioned by Mr. Keate, the bone had become dislo-
cated downwards, and could be felt lying against the tuber ischii, and
the presence of a " distinct grating as of ruptured cartilage" led him
to conclude that the cartilaginous labrum of the socket was broken
oflF; but as the fracture was in the lower margin of the socket, no
difficulty was experienced in retaining the bone in position.^

If the diagnosis is satisfactorily made out, and upon complete re-
duction the femur will not remain in place, the treatment ought to be
the same as for a fractbre of the thigh, except that no lateral splints
or bandages to the thigh will be necessary. The. limb ought to be
kept drawn out to its proper length, as far as this shall be found to be
practicable, by extending and counter-extending apparatus. A band
around the pelvis, so adjusted as to press the head of the bone into its
socket, may also be of service in preventing the tendency to displace-
ment; and in case the bone manifests little or none of this tenaency,
the hip bandage will probably alone be sufficient, yet even here no
harm could come of applying the long straight splint and the extend-
ing apparatus, secured moderately tight, simply as a measure of pre-
caution. Dr. Bigelow recommends angular extension, eflFected by
means of an angular splint, such for example as Nathan R Smith's, or
Hodgen's, suspended from the ceiling, or from some other point above
the patient; "or," he adds, ** if any manoeuvre has reduced the bone,
the limb should be retained, if possible, in the attitude which completed
the manoeuvre."

§ 5. Sacrum.

Simple fractures of the sacrum, known to be exceedingly rare,* are
occasioned either by such injuries as break at the same time the other
bones of the pelvis, or by blows or falls received directly upon the
sacrum. It may be broken at any point, and in any direction, when
the fracture is produced by the first of this class of causes ; but if the
fracture is the result of a fall upon the sacrum, it will generally be
transverse, and below the sacroiliac symphysis. The displacement in
this latter class of cases is almost invariably the same, the coccygeal
extremity being simply carried forwards, yet this is seldom sufficient
to interfere in any degree with the functions of the rectum and anus;
but in one case seen by Bermond it nearly closed the rectum. Some-

» Keate, Amer. Joum. of Med. Scl., vol. xvi. p. 225.

s Malgaigne has referred to eight cases ; and I have not been able to find a record
of any others.



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850 FRACTURES OP THE PELVIS.

times, also, tbere is a slight lateral deviation. There is also in the
Dupuytren mnseum, at Paris, a specimen in which the whole of the
lower fragment is displaced a little forwards.

The signs of this fracture are pain at the seat of injury, aggravated
greatly in the attempts to flex or elevate the body, and especially in
the efforts at defecation ; swelling and discoloration of the soft parts
covering the sacrum ; displacement of the coccyx forwards ; an angu-
lar projection at the point of fracture, with a corresponding retiring
angle upon the opposite side ; mobility.

Experience has shown that where the fracture of the sacrum is
accompanied with other fractures of the pelvis, the patients seldom
recover; and only because so extensive an injury implies usually
great force in the cause which produced the fractures, and, of neces-
sity, greater lesions among the pelvic viscera. Simple fractures, from
falls upon the sacrum, occurring below the sacro-iliac symphysis, are
generally followed by speedy recoveries, although the inward dis-
placement is not often completely overcome.

By introducing a finger into the rectum, the lower fragment can be
easily pressed back to its natural position, but the difficulty consists
in finding any means of retaining it there until bony union is effected.
Judes succeeded to his satisfaction with a wooden cylinder, which he
compelled the patient to wear forty-five days; removing it, however,
every third day, in order to cleanse the rectum with an enema. Ber-
roond introduced first a linen bag, which he immediately proceeded
to fill with lint; but during the night it became necessary to remove
it, in order to relieve the bowels of wind and stercoraceous matter.
He now substituted a silver canula covered with a shirt, which latter
he filled with lint in the same manner as before. This was retained
without much inconvenience nineteen days; having only been re-
moved once during this time. The union now seemed to be firm, and
the apparatus was removed. Plugging the rectum in this manner
may be necessary whenever the inward inclination of the lower frag-
ment is fouud to be considerable, but not otherwise ; ordinarily it will
be sufficient to lay the patient upon his back, with a firm cushion
above the point of fracture, so as to prevent the bed from pressing in
the lower fragment; and having emptied his rectum thoroughly by
an enema of warm water, he should be placed under the influence of
an opiate sufficiently to restrain the action of the bowels for several
days, or for as long a time as may be consistent with health or com-
fort. To the same end, also, the diet ought to be light and dry;
nothing should be allowed which might prove laxative. By consti-
pating the bowels, two ends may be gained. We shall prevent that
frequent action of the sphincters, which might tend to disturb the
union; and the hardened faeces, by their accumulation in the rectum,
may serve to press back the lower fragment of the sacrum, in a
manner much more natural and quite as effective as any apparatus
which can be contrived.

I {lave already mentioned u case of separation of the bones at the
sacroiliac symphysis, reported by Lente, but which was accompanied
also with a fracture of the ilium and a dislocation of the hip. Seve-



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COCCYX. 351

jral other similar examples have been reported, in some of which both
of the sacro-iliac symphyses have been separated, or displaced. Such
siccidents are the results only of great violence, and the subjects of
"them seldom recover.

Dr. J. T. Banks, of Griffin, Ga., has reported one example of com-
plete recovery in an adult male, in which the right sacro-iliac sym-
physis was separated "by a blow received upon the tuberosity of the
ischium, driving the ilium up an inch or more, causing complete pa-
ralysis and anaasthesia of the right leg for two or three weeks ;" motion
of the hip caused also severe pain. No attempt was made to reduce
the bones, but union occurred, and he gradually regained the use
of bis Ijmb.^ In a few instances this articulation has been known
to give way during labor, while the symphysis pubis has suffered
little or no diastasis; and in these cases recovery has generally taken
place.

In nearly all the traumatic examples reported, the diastasis has
been accompanied with a fracture extending parallel with the margins
of the synchondrosis; find it is for this reason that I have preferred to
consider these accidents as fractures, rather than as dislocations.

§ 6. Coccyx.

Cloquet mentions two cases as having come under his notice, one
produced by a kick, and the other by a fall. In the latter case one
thigh and both legs were also broken, and the coccyx having become
carious in consequence of the fracture, was gradually exfoliated.*

The symptoms, mode of diagnosis, and the treatment in case of a
fracture of the coccyx will scarcely demand of us consideration after
having treated fully of these points in their relation to fractures of
the sacrum.

It is more common, however, to meet with examples of separations
of the coccyx from the sacrum, which may be regarded in some cases
as veritable fractures, and in others as a species of luxation.

Due to the same causes which produce fractures of the coccyx itself,
its symptoms differ only in the increased length of the movable frag-
ment, and its consequent greater projection in the direction of its
displacement. If it is thrown forwards, as it usually is, the rectum
may be almost or completely blocked up by its presence ; or, if it is
carried backwards, its pointed extremity presses almost through the
skin.

Its mode of reduction and retention is the same as in fractures of
the coccyx and sacrum.

I Banks, Atlanta Med. and Snrg. Joum., May, 1866.
« Cloquet, art. Bdssin, of Diet. 3d vol.



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852



FRACTURES OF THE FEMUR.



CHAPTER 'XXVIII.



FRACTURES OF THE FEMUR.



Development of Femur, — The femur is formed from five centres of
ossification : namely, one for the shaft, commencing at about the fifth
week of foetal life ; one for the lower end, including the condyles, com-
mencing at the ninth month of foetal life ; one for the head, com-
mencing at the end of the first year after birth ; one for the great tro-
chanter, commencing during the fourth year; and one for the lesser
trochanter, commencing between the thirteenth and fourteenth years.
None of these epiphyses are joined to the shaft until
Fig. 110. after puberty, but consolidation is generally com-

pleted at the twentieth year. The order in which
union occurs is exactly the reverse of the order in
which ossification commences, the lower epiphysis
being the first to exhibit traces of ossification, and
the last to unite.

Division of Fractures. — Of 156 fractures of the femur,
not including gunshot, which have been recorded by
me, 63 belong to the upper third, 67 to the middle
third, and 26 to the lower third ; or, if we confine
our analysis to the shaft alone, 23 belong to the
upper third, 67 to the middle, and 26 to the lower.
The femur constitutes, therefore, a striking excep-
tion to the rule which my observations have estab-
lished, tkat in the case of the long bones the lower
third is most often the seat of fracture. The femur
is most often broken in its middle third, and gene-
rally near the upper end of this third ; that is to say,
above its middle.



Development of Femur.
(From Gray.)



§ 1. Neck of the. Femur.

Forty^of the whole number were fractures of the
neck, either intra- or extra-capsular. The youngest
of these patients, excepting one case of supposed epi-
physeal separation, was thirty-nine years, the oldest
eighty-four, and the average age was about sixty.

Seventeen were males and tvventy-three females. All were simple.

Thirteen were believed to be without the capsule, and sixteen were

believed to be within ; the remainder were undetermined.

Surgeons have differed in their opinions as to the relative frequency

of fractures of the neck of the femur within or without the capsule.



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NECK, WITHIN THE CAPSULE. 353

This has arisen, no doubt, in part from the difficulty and probable
inaccuracy of many of the diagnoses. Malgaigne, who has adopted a
mode of deciding this question which, it must be conceded, is much
less liable to error than simple clinical observation, namely, an exa-
mination of cabinet specimens, finds in four large collections sixty-
one intra-capsular fractures, and only forty-two extra-capsular. So
that, according to his observations, they stand in the proportion of
about three to two ; the intra-capsular being the most common. On
the contrary, N^laton believes that extra-capsular fractures are much
the most common, and Bonnet, of Lyons, affirms that they constitute
the immense majority. Bonnet made four dissections, and in each
case he found the fracture extra-capsular. This testimony, so far as
it goes, is positive, but the number is not sufficient to establish any-
thing more than a probability in favor of the greater frequency of
extra-capsular fractures.

Clinical observations are too uncertain to be made available in so
nice a question. Cabinet specimens may have been collected for
a special purpose, and this is well known to have been the fact with
the celebrated Dupuy tren collection, the specimens in which constitute
nearly one-third of the whole number referred to by Malgaigne. I
allude to the effi^rt which was made while the controversy was pend-
ing between Dupuytren and Sir Astley Cooper as to the probability
of bony union in intra-capsular fractures, to accumulate cabinet speci-
mens of this fracture ; and which effort extended itself, no doubt, both
to London and Dublin, from which sources alone Malgaigne has
gathered the balance of his figures. In Dr. Mutter's collection, at
Philadelphia, I think there are only three examples of intra-capsular
fracture, to seven extra-capsular.

Dr. Reuben D. Mussey, of Cincinnati, has in his cabinet twelve
examples of fractures of the neck of the femur without the capsule,
and only ten within.

We ought, therefore, to regard the question of relative frequency
as still undetermined.

(a.) Neck of the Femur vnthin the Capsule.

Causes. — In no other fractures do the predisposing causes play so
important a part as in fractures of the neck of the femur, and this
whether within or without the capsule ; indeed, experience has shown
that without the concurrence of those pathological changes which
usually accompany old age, these fractures can scarcely occur. Sir
Astley Cooper thought that the majority of fractures of the neck after
the fiftieth year were intra-capsular; but Robert Smith has given us
the ages of sixty persons having fractures of the neck of the femur,
and the average age of thirty-two in whom the fractures were within
the capsule, is sixty-two years, while the average age of twenty-eight
in whom the fractures were extra-capsular, is sixty-eight years. Mal-
gaigne has referred to this testimony in proof of the inaccuracy of the
opinion held by Sir Astley Cooper; but I trust it will not be regarded
impertinent or hypercritical for us to inquire how Mr. Smith became



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354 FRACTURES OF THE FEMUR.

Fig- 111- possessed of the ages of all these per-

sons from whom these specimens were
obtained; for more than half of tbe
whole number, that is, just thirty-two,
have their ages set down in roand deci-
mals, such as 60, 60, 70, &c., and it
would be easy to show by tbe inevita-
ble law of chances that this could not
possibly be a true statement. If Mr.
Smith does not pretend to have given
the ages with accuracy, but only to have
arrived as near to the truth as his sources
of information would permit, then I pro-
test that these tables do not constitute
proper evidence in relation to this point ;
and until better evidence is furnished I
shall continue to think, with Sir Astley
Cooper, that fractures within the cap-
Fracturewuhin the capsule. sulc bcloug generally to an older class

of subjects than fractures without the
capsule. This opinion, confirmed by my own experience, does not,
however, as Malgaigne seems to think, imply that fractures within
the capsule may not occasionally occur in persons much younger than
the average limit, namely, under fifty years.

It is also believed that intra-capsular fractures are more frequent
in women than in men.

The position of the neck of the femur, and the great thickness of the
muscular coverings, render its fracture from a direct blow a very rare
circumstance; indeed, it can only happen as the result of gunshot
accidents, or other similar penetrating injuries:

It is broken therefore usually by indirect blows, such as a fall upon
the bottom of the foot, upon the knee, or upon the trochanter major ;
or by muscular action alone, as has sometimes happened with very
old people, who, in walking across the floor, have tripped upon the
carpet, breaking the bone in the effort to sustain themselves. We
must not always infer, however, because the patient has tripped, that
the bone was broken by muscular action ; since it is quite as likely
that the fall, consequent upon the tripping, has occasioned the frac-
ture; and we ought in such cases to make a careful examination of
the hip over the trochanter to ascertain whether it has been braised,
and to interrogate the patient as to the manner of the fall.

Rodet has attempted to show by a series of experiments made upon
the dead subject, and by other observations, that the direction in
which the force had acted will determine the situation and directioa
of the fracture. Thus he maintains that when the person has fallen
upon the foot or knee, the fracture will be intra-capsular and oblique ;
that if the front of the trochanter receives the blow, the fracture will
be intra-capsular also, but transverse ; if the back of the trochanter is
struck, the fracture will be partly intra- and partly extra-capsular ;
and if the person falls directly upon the side, or receives the blow



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NECK, WITHIN THE CAPSULE. 855

fairly upon the outer side of the trochanter, the fracture will be en-
tirely without the capsule.*

Without intending to give ray unqualified assent to these proposi-
tions so ingeniously maintained by Rodet, I am nevertheless prepared
to aflmit their general accuracy; and especially has my experience led
me to believe that falls upon the feet or knees in most cases produce
intra-capsular fractures, and that falls upon the outside of the hip, or
upon the great trochanter, generally produce extra-capsular fractures.
I have seen also the intra-capsular fracture produced by so slight a
cause as stepping down unexpectedly two or three inches upon an
irregular surface.

Pathology. — I have already, when speaking of partial fractures,
expressed ray conviction of the possibility of a partial fracture, or a
fissure of the neck of the femur, and I have referred to the case re-
ported by Dr. J. B. S. Jackson, of Boston, as having determined this
question beyond all possibility of a doubt; yet its occurrence must be
regarded as an exceedingly rare, and, we may say, improbable event.

It is much more common to meet with examples of complete frac-
ture of the neck both within and without the capsule, unaccompanied



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 42 of 100)