Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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with a rupture of either the periosteum or the reflected capsule. Such
was the fact in eight cases examined by Colles; in three of which,
however, he believed the fracture not to have been complete, but
Robert Smith thinks they yfQVQ all of them examples of complete
fracture.* Stanley has also related a case of complete separation of the
bone unaccompanied with laceration or injury of either the periosteum
or capsular ligament. This was in the person of a man aged sixty
years, who had been knocked down in the street. On being admitted
into St. Bartholomew's Hospital, shortly after the injury, he com-
plained of pain in the htp, but there was neither shortening nor ever-
sion of the limb, and its several motions could be executed with
freedom and power. A fracture was not suspected ; but five weeks
after this he died of inflammation of the bowels. The dissection
showed a fracture extending through the neck, accompanied with a
slight bloody effusion, but no displacement of the fragments or lacera-
tion of the soft parts.*

In other examples the bone is not only broken, but displaced to
such an extent that the capsule is completely torn in two.

But in a large majority of cases both the capsule and the periosteum
are only partially torn asunder.

The intra-capsular fracture is generally somewhat oblique, and its
direction is usually from above downwards and from within outwards.
Sometimes its direction is such as to include a portion of the head;
occasionally it is quite transverse. In one example of an old frac-
ture I have seen the ends dove-tailed upon each other, the fracture
having a double obliquity, and not admitting of displacement.

There may occur also a species of impaction, the lower portion of

1 L'Exp^rience, March 14, 1844.

« Colles, Dublin Hosp. Reports, vol. it. p. 839.

* Stanley, Med.-Chir. Trans., vol. xiii.



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356



FRACTURES OF THE FEMUR.



Fig. 112.



Impacted fractare within the capinle.



the neck entering the cancellous structare
of the head, while its upper portion rides
upon the articular surface, a circumstance
which is well illustrated by the annexed
wood-cut (Fig. 112), copied by Mr. Smith
from a specimen in the Dupuytren Mu-
seum at Paris ; or the impaction may occur
without any degree of either upward or
lateral displacement.

Mr. Listen says: " Even in children sepa-
ration of the head of the bone may, on good
grounds, be supposed occasionally to take
place ;"^ by which we understand him to
mean that a separation of the epiphysis
which completes the head of the femur may
occur. Mr. South relates a case in a boy ten
years of age, who had fallen out of a first-
floor window upon his left hip. The limb was slightly turned out,
but scarcely at all shortened. The thigh could be readily moved
in any direction without much pain, but on bending the limb and
rotating it outwards, a very distinct dummy sensation was frequently
felt, apparently within the joint, as if one articular surface had slipped
oflf' another. This was regarded by both Mr. South and Mr. Green as
an example of epiphyseal separation, and he was placed upon a double-
inclined plane, but he felt so little inconvenience from it that he
several times left his bed and walked about. We have no informa-
tion as to the result or as to the further progress of the case.*

A girl, aet. 18, was brought before Dr. Parker, of New York, at his
surgical clinic, Nov. 1850, who had been injured by a fall upon a
curbstone, when eleven years old. The accident was followed by
suppuration and a fistulous discharge, from which, however, she finally
recovered, but with the foot everted, and a shortening of one inch
and a half. ** Flexion and rotation of the joint occasioned no incon-
venience." Dr. Parker thought this circumstance alone sufficient to
distinguish it from hip disease in which anchylosis is the termination.^
At a meeting of the Kappa Lambda Society, held in New York,
March 25, 1840, Dr. Post mentioned a case which he had seen in a
girl sixteen years old, who, in taking a slight step with a child in her
arms, made a false movement, and feeling something give way, she
was obliged to lean against a wall. Dr. Post saw her the next day,
when he found the affected limb one inch shorter than the opposite
one, movable, the toes turned outwards, no swelling, some slight pain
at the upper part of the thigh. The trochanter major moved with the
shaft. There was also crepitus. From the age of the patient, and the
slight amount of violence by which the injury was produced, Dr. Post
thought a separation of the epiphysis of the head had taken place.

« Liston, Elemente of Surgery, Phila. ed., 1887, p. 480.

* South, Note to Chelius^s Surgery, vol. i. p. 619.

» Parker, Amer. Med. Gazette, vol. 1. p. 842, Nov. 30, 1850.



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NECK, WITHIN THE CAPSULE. 357

[Tie extending apparatus was applied, but the limb remains from a
[uarter to half an inch shorter than its fellow.^

Aug. 14, 1865, Andrew Leroy, set. 15, in attempting to escape from
he House of Refuge, fell from the fourth story. On the following
naming he was admitted into my wards, at Bellevue Hospital. I
bund his right thigh shortened three-quarters of an inch, and slightly
tbducted; toes everted. Placing him under the influence of chloro-
brm, we detected h dull crepitus in the vicinity of the joint. It was
inlike the crepitus of broken bone. With fifteen pounds of extension
¥6 were able to overcome the shortening entirely, and to put the limb
n position. This was maintained with Buck's apparatus. At the end
)f two weeks, however, it was ascertained to be shortened half an
nch. Four more pounds were then added. At the close of my term
)f service, I lost sight of the boy, and have not been able therefore to
srerify my diagnosis; but I believe it to have been a separation of the
jpper epiphysis.

These lour constitute the only examples of this accident which I
5nd reported or of which I have any knowledge, and although there
may be much reason to suppose that the diagnosis was correct in each
instance, I cannot regard any one of them as actually proven ; nor
can I admit the accident as fairly established, or the diagnostic signs
as being properly made out, until these important points have received
the confirmation of at least one dissection.

Symptoms. — Whether the limb will be shortened or not must de-
pend upon whether the fragments have become displaced in the direc-
tion of the axis of the shaft of the femur. It is well established that
in this fracture the broken ends frequently remain in contact for
several hours or days, or until the gradual contraction of the muscles
or the weight of the body upon the limb occasions a separation, and
that consequently there is often at first no appreciable or actual short-
ening of the limb. To determine, however, its existence, it is not
sufficient to lay the patient upon his back, and place the limbs beside
each other; we ought also to measure carefully with a tape-line from
the pelvis to the leg or foot, and from various other points, until we
have placed this question beyond a doubt.

If shortening occurs, it may vary from one-quarter of an inch to
two inches, or even more ; but this extreme shortening is not reached
usually, except after the lapse of several weeks or months, when the
ligaments have gradually given way under the weight of the body in
walking, or not until the neck has undergone a partial or almost
complete absorption.

Sir Astley CJooper has stated that a shortening to this degree may
occur at once ; but Boyer, Earle, and others doubt the accuracy of
this opinion, and Robert Smith declares that he does not think the
capsule would admit of such an amount of immediate displacement,
unless it were extensively torn, an occurrence which he thinks very
rare indeed.

With this qualification, the opinion of Mr. Smith does not differ

» Post, New York Joum. Med., vol. iii. p. 190, July, 1840.



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358



FRACTURES OF THE FEMUR.



from that entertained by Sir Astley, who only admits its possibilitj
as a rare event ; in a large majority of cases the shortening does not
exceed one inch.

Crepitus, unlike shortening, is generally absent when the displace-
ment of the fragments is complete ; but under no circumstances is it
easily developed. When the fragments remain in apposition, and the
femur is rotated for the purpose of moving the broken surfaces upon
each other, the small acetabular fragment, resting in a smooth cup-like
socket, and holding upon the opposite fragment by denticulations oi
by the untorn periosteum, or capsule, glides about in obedience to the
motions of this latter, and no crepitus can be produced. Nor is the
difficulty rendered less by pressing firmly upon the trochanter, as
some surgeons have recommended, since, while this pressure tends,
no doubt, to fasten the upper fragment in the acetabulum, it tends
much more to fasten the broken ends together, and thus defeats the
purpose in view. When, on the other hand, the fragments have be-
come completely separated, it is almost impossible to bring them again
into contact. The limb may, perhaps, be easily brought down to the
same length with the other, but it must by no means be inferred that,
consequently, the broken ends are in apposition. It is almost certain,
indeed, that in its progress downwards the trochanteric fragment has
caught upon the acetabular frargment, and pushed its floating and
broken extremity downwards before it. Under these circumstances,
the discovery of a crepitus must be accidental, and is scarcely to be
looked for. Sometimes, however, we may recognize a sound not un-
like crepitus, but less harsh, produced by the friction of the trochan-
teric fragment against the rim of the acetabulum or dorsum of the
ilium.

One thing we ought never to forget, namely, that by extraordinary
efibrts to obtain a crepitus we may lacerate the capsule or produce a
displacement of the fragments which we never can remedy, and
which, without such unwarrantable manipulation, might never have
occurred.

Eversion of the foot is almost uniformly present in some degree,
taking place immediately or more gradually, in proportion as the
fragments become displaced, and the external rotators contract. The
opposite condition or an inversion of the foot is occasionally present,
and sometimes also the foot is neither turned in nor out, but the toes
point directly forwards. In sixty cases of fracture of the neck seen
by Cloquet the foot was never turned in, and Boyer never met with
such an example in all of his immense experience; but Langstafi^
Guthrie, Stanley, and Cruveilhier have each seen one example*, and
Kobert Smith has seen two.^ I have myself seen one.

The explanation of the fact that the foot is usually everted is not
difficult. In the case of an intra-capsular fracture it is probably due,
first, to the relative friability of the laminated or cortical structure on
the posterior aspect of the neck, in consequence of which this portion
gives way more readily than the cortical structure on the anterior

' Robert Smith, op. cit., p. 25. A. Cooper by B. Cooper, op. cit., p. 151, note.



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NECK, WITHIN THE CAPSULE. 859

aspect ; second, to the natural form and position of the foot and le|
which incline them to fall outwards by their own weight; and thir
to the powerful action of the external rotators, which are so feebly
antagonized upon the opposite side. In the case of an extra-capsular
impacted fracture, in addition to the second and third causes assigned
as influencing the position of the limb in intra-capsulur fractures,
there are other special causes. The cortical lamina on the posterior
aspect of the neck everywhere more frail than upon the anterior
aspect, becomes greatly weakened as it approaches the trochanter by
dividing itself into two laminae, one of which penetrates towards the
centre of the bone, and the other, the thinnest of the two, being scarcely
thicker than a sheet of paper, forming the wall of the bone as it
becomes continuous with the trochanter.

Fig. 113. Fig. 114.



HorlzonUl section of neck of femnr. Extra-capsalar fractnre, with inreralon.

(From Blgelow.) (Prom Bigelow.)

This delicate papery wall easily gives way under the application of
force, while the anterior wall yields only partially, constituting thus a
sort of hinge upon which the rotation of the thigh is performed. It is
probable, also, as suggested by M. Robert, that the angle at which the



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860



FRACTURES OP THE TEMUR.



external surface of the trochanter unites with the neck increases the
tendency to fracture and impaction posteriorly.

An explanation of the fact already stated, that in rare and excep-
tional cases the limb is inverted or the toes are permitted to point
directly forwards, has been thought to be more difficult. Dr. Bigelow
has had an opportunity of examining a specimen taken from an old
woman iij the dissecting-room, and he concludes that the inversion
was due to the extent of the comminution, which had separated the
walls of the shaft so as to receive in the interval the whole neck, in-
stead of the posterior wall only, as commonly occurs. Dr. Robert
Smith, of Dublin, cites a similar case verified by the autopsy ; and Dr.
Bigelow remarks that the specimen numbered 248, in the Miitter
museum, at Philadelphia, presents the same kind of impaction without
either inversion or eversion.

Fracture of the neck of the femur within the capsule is not usually
attended with much pain when the patient is at rest, but any attempt
to move the limb produces intense suffering, and especially when an
attempt is made to rotate the limb inwards, or to carry it upwards
and inwards.

Occasionally, also, during the first few days or hours after the
fracture, a spasmodic action of the muscles compels the patient to cry
out from the severity of the pain which it produces. At first the
sufferer is unable to indicate clearly the seat of this pain, or, perhaps,
it is diffused and uncertain in its position; but after a time he is able
to refer it chiefly to the region of the groin, opposite the neck of the
bone, or to near the point of attachment of the psoas magnus and
iliacus internus. There is also usually in this region a great degree
of tenderness and an unusual fulness.

If now the limb be seized, and extension gradually but firmly
applied, it will soon be made of the same length with the opposite
thigh; but, the moment the extension is discontinued, the shortening
and eversion will recur, accompanied with pain, and perhaps crepitus.

The trochanter major is less prominent than upon the opposite side,
and if eversion of the limb exists, the trochanter may be felt indis-
tinctly upwards and backwards from its usual position. The patient
having been placed under the influence of an anaesthetic, we may
prosecute the investigation still farther, and by rotating the limb in-
wards and outwards as far as it will admit, we shall notice that the
trochanter describes the arc of a smaller circle than in the opposite
limb, or that the length of its radius has been shortened. It ought to
be sard at once, however, that this amount of manipulation is oflen in-
jurious, and seldom proper.

The patient is generally unable to move his limb, or to bear the
least weight upon it ; but many examples are on record of persons
who walked some distance after the fracture had taken place, the
capsule, and perhaps also the periosteum, not being torn, and conse-
quently the fragments not being displaced ; or, possibly, it was at first
an impacted fracture.

Finally, after having examined the patient as well as we are able to
do, in the recumbent posture, if any doubt remains, and it is found



i



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NECK, WITHIN THE CAPSULE. 361

practicable for the patient to be elevated upon his sound foot, this
should be done. The broken limb can now be examined thoroughly
on all sides, and a more accurate opinion formed of the amount of
shortening and eversion. It will be especially noticed that if the
weight of the body is allowed to rest upon the limb in the slightest
degree, it produces insupportable pain. Dr. Packard, of Philadelphia,
informs me that M. Maisonneuve has lately suggested and practised
the following method of diagnosis in certain doubtful cases. Lay the
patient flat on his belly, and then bring the suspected thigh into ex-
treme extension backwards. If it is not broken, the neck will strike
against the posterior lip of the acetabulum and the progress of the
thigh in this direction will be arrested. If it is broken, it can be car-
ried backwards much farther.

Of this method as a means of diagnosis, it seems proper to say that,
if the fragments have slid past each other and the limb is shortened,
it is unnecessary ; and if they are still in apposition, it will be pretty
certain to cause displacement, and thus do irreparable mischief.

Prognosis, — The question of bony union after a complete fracture
of the neck of the femur within the capsule has occupied the attention
of the ablest surgeons and pathologists for a long period ; and while
great diflferences of opinion have been expressed as to the probability
of the occurrence, and as to the value of the testimony on the one side
or the other, very few have ventured to deny its possibility.

Among these latter are found, however, the distinguished names of
Cruveilhier, CoUes, Lonsdale, and Bransby Cooper. It has been
repeatedly affirmed, also, that Sir Astley Cooper taught the same doc-
trine, but with how much show of reason, the following paragraphs
from his own pen will determine : —

" In the examinations which I have made of transverse fractures of
the cervix femoris, entirely within the capsular ligament, I have only
met with one in which a bony union had taken place, or which did
not admit of a motion of one bone upon the other. To deny the pos-
sibility of this union, and to maintain that no exception to the general
rule can take place, would be presumptuous, especially when we con-
sider the varieties of direction in which a fracture may occur, and the
degree of violence by which it may hJive been produced. For example,
when the fracture is through the head of the bone, with no separation
of the fractured ends ; when the bone is broken without its periosteum
being torn ; or, when it is broken obliquely, partly within and partly
externally to the capsular ligament, I believe that bony union may
take place, although at the same time I am of opinion that such a
favorable combination of circumstances is of very rare occurrence.
Much trouble has been taken to impress the minds of the public with
the false idea that I have denied the possibility of union of fracture
of the neck of the thigh-bone, and therefore I beg at once to be under-
stood to contend for the principle only, that I believe the reason that
fractures of the neck of the thigh-bone do "not unite, is that the liga-
mentous sheath and periosteum of the neck of the bone are torn
through, that the bones are consequently drawn asunder by the mus-
cjles, and that there is a want of nourishment of the head of the bone;
24



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FRACTURES OF THE FEMUR.

\ readily believe, if a fracture should happen without tb*
igament being torn, that as the nutrition would continue, tht
ht unite; but the character of the accident would differ
3 of the injury could scarcely be discerned, and the patient^i
Id unite with little attention on the part of the surgeon,
oof of the correctness of my opinion, I enumerated, in the
ions of this work, forty-three specimens of this fracture, Ie
collections in London, which had not united by bone. Al
It day these might be multiplied, were it necessary,
has been the accumulated evidence of the want of power ol
of the femur to unite by bone, in my practice of forty years,
bich period I have seen but two or three cases which mili
ist this opinion, for many of the preparations which have
aght for my inspection as specimens of united fractures ol
have proved to be nothing more than the result of the
joncomitant with old age ; and in many of them the twc
es of the same subject had undergone the same alteration is
id in form."^

lowing passages from a communication made by Sir Astlej
ndon Medical Gazette, for the 25th of April, 1834, areequalij

in a report of the Baron Dupuytren's lecture that he attri
ne the opinion that fractures of the neck of the thigh-bone
3 capsular ligament, not only ' never unite, but that it is im
hat they should unite by bone.'

quite true that, as a general principle, I believe that those
unite by ligament, and not by bone, as do those of the patellj
anon. But I deny that I have ever stated the impossibility
ssific union ; on the contrary, I have given the reason whj

occasionally unite by bone.

ollowing are my words : ' To deny the possibility of theii
i to maintain that no exception to this general rule maj
3, would be presumptuous,' " &c. &c.

jlusion. Sir Astley remarks: "I should not have given yoi
►le, nor should I have taken it myself, but for the respect ]
friend, the Baron Dupuytren ; for although I have already
I myself to be misrepresented by many individuals, yet ]
I sorry to be misunderstood by so excellent a surgeon and sc
d friend as Le Baron Dupuytren.'"

iley, then, so far from denying, frankly admitted the possi
)ony union when the neck was broken within the capsule, and

the circumstances under which he believed it might occur
point in dispute was, whether certain cabinet specimens were
examples of complete fractures, wholly within the capsule
r bone. Some of them Sir Astley thought were only ex-

ey Cooper on Dislocations and Fractures of the Joints, edited by Bransbj
ner. ed., p. 156.

i Sir Astley's letter to Prof. Cox, written in 1835, and published in the
and Surg. Joum. for July 12, 1848, New York Joum. Med. for Sept.
ppendix to Cooper on Dis. and Frac., Amer. ed., 1851, p. 482.



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NECK, WITHIN THE CAPSULE. 363

amples of chronic rheumatic arthritis, or of interstitial and progressive
absorption. Some were partial rather than complete fractures ; x)ther8
were ^partly within and partly without the capsule; and for this he
was accused of wilful blindness or stupidity, chiefly by those who
themselves being owners of these rare pathological treasures, might
possibly have felt somewhat annoyed at seeing their value thus de-
preciated, and who, no doubt, would be quite as apt to fall into blind-
ness and partisanship as Sir Astley himself. The truth is, however,
that although the claim has been set up and stoutly maintained for
more than thirty cabinet specimens, in one part of the world or
another, a majority of these, including several whose claims were
urged upon Sir Astley, have been at length declared by all parties
unsatisfactory, or absolutely fictitious, and only a fraction of the whole
number continue to be mentioned by any surgical writer as probable
examples.^

Eobert Smith reduces the number to seven, but Malgaigne recog-
nizes only three, namely: Swan's case, admitted by Sir Astley him-
self; Stanley's case, and one specimen in the Dupuytren museum. In
neither of these cases, he affirms, has the neck lost anything of its
form or length by absorption, from which we are to infer that he
would reject as doubtful all such specimens as had undergone these
pathological changes.

Indeed, I think, we are not left in doubt as to Malgaigne's opinion
upon this point. Six of the nineteen cases which I have enumerated
are declared by him to resemble much more rachitic alterations of the
neck than true fractures ; and yet Robert Smith admits three of the
six as well-established examples ; but as to the precise grounds upon
which he rejects these cases, he shall speak for himself: "And il is
sufficient that we consider the beautiful drawings designed by Sir
Astley Cooper, to illustrate certain varieties of the alterations, to place
us on our guard against every pretended consolidation which presents
itself, accompanied with a shortening and deformity of the head and
neck. When fractures unite by bone, they do not suffer such enormous
losses of substance which it would become necessary to admit for the
neck of the femur."^

> The following European surgeons have claimed to have in their possession,
each, one example: Langstaff (Med.-Chir. Trans., vol. xiii. 1827); Brulatour
(Ibid., vol. xiii. 1827); Stanley (Ibid., xviii.); Swan (Swan on Diseases of Nerves,



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 43 of 100)