Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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p. 804); Adams (Todd's Cyclop., p. 813); Jones (Med.-Chir. Trans., vol. xxiv.);
Chorley (Amesbury on Frac, p. 125); Field (Ibid., p. 128); Soemmering (Chelius's
Surgery by South, vol. i. p. 621); South (Ibid., p. 621). South also mentions
another example as being in the museum of St. Bartholomew's Hospital. This is
probably Jones' case, which Robert Smith says is preserved in this museum, and
which has already been enumerated. Bryant (Memphis Med. Rec, vol. vi. p. 108,
from British Med. Jour^, March 14); Fawdington (Amer. Joum. Med. Sci.,
vol. XV. p. 534, from London Med. Gaz., Aug. 16, 1834); Harris (Ibid., vol. xviii.
p. 246, from Dublin Joum., Sept. 1885). Robert Hamilton says that Prof Tilanus
showed him three specimens in the museum of the Hospital of St. Peter, at Amster-
dam (Ibid., vol. xxxi. 470, from Lond. Med. Gaz., Jan. 6, 1843). Malgaigne says
there are three specimens in the Pupuytren museum which have been described
with the same interpretation. The whole number claimed by transatlantic surgeons
is therefore nineteen.

> Malgaigne, Traits des Fractures et des Luxations, torn. i. p. 678. •



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364



FRAC.TUKES OF THE FEMUR.



A reference to Stanley's case, as reported by Eobert Smith, will
show that, contrary to Malgaigne's statement, this was also shortened
and deformed, and that, consequently, according to his own rules of
exclusion, it also must be rejected; after which only two remain,
namely Swan's case, admitted by Sir Astley himself, and No. 188 of
the Dupuytren museum.

I should do injustice to my own convictions, moreover, were I not
to refer my readers to the very judicious criticism upon Mr. Swan's
case made by Dr. Johnson, and published in the Netv York Journal
of Medicine, vol. ii., 3d series, p. 295.

Since writing the above, my friend Dr. Voss, of this city, has placed
in my hands an elaborate paper on this subject, from the pen of Dr.
Edward Zeis, of Dresden, and which has been translated by Dr. B.
Newman, Prosector to Chair of Surgery, Long Island College Hos-
pital. Dr. Zeis, after rejecting all other European specimens, claims
that bony union has occurred within the capsule in a specimen now
in his possession, and also in a specimen which may be found in the
pathological cabinet of the medico-chirurgical academy of Dresden.^
I regret that I am not able to publish these cases at length, as well,
also, as the able review of their claims sent to me by Dr. Newman, in
which Dr. Newman clearly shows that Dr. Zeis has completely failed
to establish the correctness of his opinions. There is no conclusive
evidence that the bones were ever broken, nor, if they were broken,
that the fractures were entirely within the capsule.

On this side of the Atlantic, the number of specimens for which
the honor is claimed is nearly equal to the original number in Europe;
but they have not yet, all of them, been subjected to the same sifting
process as their foreign congeners ; and it remains to be seen how
many of them will come successfully out of a similar fifty years'
contest.

Three of the specimens belonged to Eeuben D. Mussey, late Pro-
fessor of Surgery in the Miami Medical College, at Cincinnati, Ohio.
He has himself furnished a complete history and description of the
specimens, accompanied with drawings.^ One may be found in the
Wistar and Horner Museum, at Philadelphia;^ one belongs to Willard
Parker, of this city;* two to the Albany College Museum;* two to the
Harvard Medical College, Boston;* one to the Mutter collection (Spe-
cimen B, 71); one to Dr. Pope, of St. Louis. Dr. Sands, of this city,
has also lately presented a supposed example to the New York Patho-
logical Society.^

In the former editions of this book I have examined the claims of
several of these specimens very much at length; but as new specimens
are every now and then being presented to our notice, for each of

* Description of two specimens of intra-capsular fracture of the neck of the femur,
and union by callus, by Dr. Edward Zeis, Dresden, 1864.

2 Amer. Joum. Med. Sci., April, 1857.

3 H. H. Smith's Surgery, p. 399.

^ Johnson's paper on intra-capsular fractures, 6p. cit.
s Trans. New York State Med. Soc, 1858.
» Bigelow on Dislocation, &c. of Hip, 1869, p. 125.
7 New York Med. Rec, June 1, 1869.



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NECK, WITHIN THE CAPSULE.

which special claims are set up, and inasmuch as no practical results
are likely to follow upon a further discussion of this point, or upon its
definite decision, I have concluded to refer those of my readers who feel
a particular interest in the matter to either one of my earlier editions,
and to the various monographs to which I have furnished references.

I have also in my own cabinet a femur of no inconsiderable preten-
sions, belonging clearly to that class of specimens recognized hy
Robert Smith. Its neck is greatly shortened, and this surgeon would
regard it, I think, as au impacted intra-capsular fracture, but its claim
would be promptly denied by Malgaigne, on account of the absorption
and distortion of its neck. Its history is as follows: —

About the year 1833, Mrs. Wakelee, of Clarence, Erie County, New
York, aet. 68, who was then very low with tubercular consumption,
and so ill as to be scarcely able to walk across the floor, tripped upon
the carpet and fell, striking upon her left
side. She was unable to rise, but was laid Fig. 115.

upon a bed by her son. Dr. Wakelee, a
very intelligent physician, residing in the
same house, who did not suspect a frac-
ture. Dr. Bissel saw her on the following
day, and, on rotating the limb outwards,
he says that he discovered a crepitus.
His examination was greatly facilitated
by her extreme emaciation.

Mrs. W. was placed upon a double-
inclined plane, with apparatus for exten-
sion, &c., and left in charge of Dr. Wakelee.
On the fifth day the splint was removed, and
from this time no dressings of any kind
were applied. The reason for this change
of treatment was, that she was likely to
live but a few days, in consequence of the
state of her lungs, and that such confine-
ment would only hasten her death. Con-
trary, however, to all expectations, she ^^^^^^^^ ^^.^^^ ^, ^^^ ^^,^j^.,

gradually convalesced, so that alter two femar, aceUtbulum, and capsule.

or threie years she could walk on crutches,

her toes turning out and her limb becoming somewhat shortened.
Four years after the accident she died, and Dr. Bissel obtained from
Dr. Wakelee the specimen, of which the accompanying drawing is a
faithful delineation.

Within the last few years. Dr. Geo. K. Smith, of the Long Island
College Hospital, has made a most valuable contribution to our know-
ledge of the anatomy and pathology of the hip-joint, which will
explain in a great measure the discrepancies of opinion which at
present exist among surgeons as to the character of certain specimens,
and may hereafter enable us to decide with more accuracy, and may
lead to a better agreement of opinion.

His observations prove that anatomists have not hitherto correctly
described the attachment of the capsule; that the capsule is seldom, if



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366 FRACTURES OF THE FEMUR.

ever, attached at the same point in different persons, while it is as
uniformly found attached at the same point in the opposite feniurs of
the same person. In order, therefore, to determine whether the line
of fracture in any given specimen was without or within the capsule,
we must always compare the fractured bone with its congener, and not
with the femur of another person.

He has further shown that after a fracture, and the consequent
absorption of the neck, the normal position of the capsule is almost
constantly changed; so that its present attachment does not declare
what were the points of its attachment before the fracture occurred,
and finally that the absorption proceeds unequally and irregularly,
yet with great rapidity, in the two fragments ; and as the bony union,
if it ever takes place, probably occurs subsequent to the arrest of the
absorption, the line of union cannot in itself alone determine whether
the fracture was near the head or near the trochanters.^

It seems to me probable that under certain favorable circumstances
this union will occur ; these favorable circumstances have relation to
several conditions, such as age, health, degree of separation of the
fragments, laceration of the periosteum and capsule, treatment, &c.
Robert Smith thinks it is not likely to occur unless the fragments are

impacted, but Sir Astley Cooper,
Fig. 116. as we have already seen, admitted

its possibility whenever the re-
flected capsule and the periosteum
were not torn, and at the same
time the fragments were not dis-
placed. If to these conditions
we were to add moderate but
not extreme age, with good
health, we can see no sufficient
reason why, under judicious
treatment, bony union might not
occasionally be expected. Bat
such a combination of circum-
stances is probably exceedingly
rare ; and, what is more unfortu-
nate, if they exist, the fracture is
not likely to be recognized, and
the surgeon will fail to avail
himself of those advantageous
coincidences which might, if un-
derstood and properly treated,
secure a bony union. Dupuy-

IrapRctod fracture within the cap«nl«. (From ^^^^ gj^yg^ ^J^^jj ^^IQ fragments

'**^^* are not displaced "its existence

may be suspected, but cannot be
positively asserted." There will not be wanting, however, examples
in which surgeons will believe or aflSrm that they have recognized

* Geo. K. Smith, Insertion of the capsular ligament of the hip-joint, and its rela-
tion to intra-capsular fracture. Medici and Surgical Reporter, Philadelphia, 1863.



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NECK, WITHIN THE CAPSULE. 367

the fracture and wrought the cure. I have heard of many such instances,
and Mr. Smith has referred to one, which is quite pertinent, as having
been reported in the Gazette des ffopitaitx. A woman, sBt. 64, was
treated for an intra-capsular fracture of the neck of the femur at one
of the hospitals in Paris, and " at the end of four weeks she was dis-
charged perfectly cured, and without shortening." We fully partake
of Mr. Smith's surprise at the impudence of this claim, yet we do not
see in it much greater improbability than in Mr. Swan's case, received
by both Mr. Smith and Sir Astley himself, where the neck was found
almost wholly united by bone in five weeks, although the woman was
80 years old, and actually dying while the process was going on!
Says Dupuytren, " I would lay it down as a general principle that all
fractures of the neck of a cylindrical bone should be kept at rest
twice as long as ordinary fractures of the same bone ; and even after
that period I have seen displacement take place. The term may,
therefore, be lengthened to a hundred days, or even longer in aged
and feeble persons, whose powers of reparation are much deteriorated."
It is not the purpose of the writer to describe particularly all of
the accidents or pathological conditions with which these fractures
may be confounded. It is sufficient to allude to them, and leave to
others the labor of a complete historical record ; but I am tempted to
devote a paragraph to what has been variously termed " morbus coxae
senilis" {Robert Smith) ; " chronic rheumatic arthritis" {Adams) ; " inter-
stitial absorption of the neck of the thigh-bone" (jB. Bell) ; " rheu-
matic gout" (Fuller)] and by others "interstitial and progressive ab-
sorption ;" but the exact nature and cause of which morbid changes
are not yet fully understood. Mr. Collesdoes not think this partakes
of the nature of rheumatism. I have myself a specimen of what has
been more generally called chronic
rheumatic arthritis, occurring in the Fig. 117.

knee-joint, accompanied with a flatten-
ing and eburnation of the articular sur-
faces, and Gulliver has* shown that
similar changes of form in the neck of
the bone may occur in tolerably young
persons.

I suspect also that it will be found to
occur under a greater variety of circum-
stances, and to present a greater variety
of forms, than have yet been described ;
and we shall perhaps find a partial. ex-
planation of this diversity and fre-

single circumstance,

iar anatomical struc-

. The neck of the

rly at a right angle

at an angle so great section or & Bound adalt femur.

of the body, even in

ect to gradually depress the head below the top of
jor, and to diminish its length. This* is seen con-



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368 FRACTURES OF THE FEMUR.

stantly in the striking change of form which occurs between child
hood and old age. Now, if from any cause whatever, such as a bloiw
upon the trochanter or upon the foot, the neck or head is made U
suffer, and inflammation, or perhaps only a slight degree of.increase<3

Fig. 118.



Chronic rheumatic arthritis. (Miller.)

action in the absorbents, ensues, resulting in an equally slight soften-
ing of the bony tissue, these pathological circumstances may end,
sooner or later, in a striking change of form in the neck or head.
But it is not necessary to suppose an external injury to explain the
occurrence of this inflammation, and consequent softening of the bone ;
a scrofulous, or rickety, or tuberculous constitution may occasion it,
and we see no reason why these conditions' are not as likely to lead
to a change of form here as in the bones of the leg or of the spine.
A change of form in the head may be the result of an ulceration of
the cartilage ; and a change of form in the neck, of ulceration of the
neck. Among other causes, also, "chronic rheumatic arthritis may
operate in a large proportion of those examples which belong to ad-
vanced life. One case, reported by Gulliver, would seem to show
that a deformity may occur here as a result of disease, and indepen-
dently of pressure,' yet it is plain, from the direction which the devia-
tion of the head and neck usually takes, that pressure performs an
important part in the causation.

From these various causes, operating in these diverse ways, we shall
have the different deformities enumerated and described by surgical
writers. The head flattened, irregularly spread out, depressed and
polished ; the neck shortened and irregularly thickened and expanded ;
the trochanter major rotated outwards and drawn upwards ; sinuous

' Gulliver, Lond. Med.-Chir. Rev.,- vol. xxxix. p. 544.



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369

ersing the neck, produced by ulceration; and finally,
f the neck, by a true interstitial absorption, and with
ncrease in its breadth, the trochanter major also being
rards. It would be strange, moreover, if the interior of
did not present some changes in structure, such as have
itly observed, namely, an irregular expansion or conden-
cellular tissue, and which latter might easily be supposed,
was inattentive to all of these circumstances, to indicate
Q imaginary fracture.

^ing example will illustrate the incipient stage of one class
5S, namely, that in which the neck is not only shortened,
ice is irregularly seamed, as if it had been broken and
united.

kson, set. 43, was admitted into the Toronto Hospital, C.
1858, with tubercular consumption, of which he died on
ihe same month.

jen under the care of Dr. Scott, and it having been noticed
)lained of his right hip at the time of admission, an autopsy
n the 25th, at which I was, through the courtesy of the
)n, permitted to be present.

ined both hip-joints, and found the neck of the right femur
specially in its posterior aspect. At the junction of the
e neck, posteriorly, and extending about half-way around,
I carious, and so far absorbed as to leave a sulcus of a line
pth, and of about the same width. Adjacent to this, also,
s quite soft, yielding under the slightest pressure of the
re was no other appearance of disease. The opposite
Dund.

tai record furnished the following account of his case, so
jury to his hip was concerned : —

le months before admission, then laboring under the ma-
h he finally died,. he received a blow upon his right tro-
r since which he had been lame, and suffered pain in the
1 hip-joint. The pain was felt especially in the groin, when
Br was pressed upon, or when the sole of his foot was per-
B thigh was slightly flexed ; the toes a little everted ; and
rith some halt.

)f the soldier, Fox, reported by Gulliver, and who died of
presents a case also exactly in point, but illustrating a
►r the completion of the same process,
cise nature of the changes in the two following examples
sertain, since they have not been determined by dissection,
rve, however, to illustrate the usual history and progress
able number of cases. They certainly were not examples

Brown, when twelve years old, fell from a tree and struck
tit foot. Dr. Silas Holmes, of Stonington, Ct., was called,
jular symptoms at this time, I have only learned that the
shortened. The doctor laid a plaster upon his hip, and
lOut any further treatment. In three days he was able to



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870 FRACTURES OF THE FEMUR.

walk on crutches; in three weeks he walked without crutches, and ia
four months was at work as usual. There was at this time no short-
ening or deformity of any kind.

Mr. Brown subsequently enlisted as a soldier in the war of the
American Revolution, and experienced no diflBculty in this hip until
after a severe illness which followed upon an unusual exposure, when
he was about thirty-five years old. At this period the leg began to
shorten, but the shortening was unaccompanied with pain or soreness.

He consulted me, July 17, 1845, at which time he was eighty-three
years old, and a remarkably strong and healthy -looking man. The
shortening, which had ceased to progress some years before, amounted
at this time to two and a half inches.

An ofl&cer in the United States army addressed to me the following
letter, dated Nov. 13, 1849:—

" My mother-in-law, Mrs. S., of D., some three years since fell down
a flight of stairs, striking on her side upon a stone, injuring the hip-
joint severely ; but, upon examination, her physician declared that
there was neither a fracture nor a dislocation, and said that she would
gradually recover. Something like one year since the injured limb
commenced shortening, so that she can now barely, touch her toe to
the floor as she walks. She can bear but little weight upon it, and
is compelled to use a crutch or a cane constantly. So much time has
now elapsed, and the limb is so little better, and constantly becoming
shorter, I have proposed to ask your opinion," &o.

I need scarcely say that I had no hesitation in pronouncing this a
case of chronic inflammation of the bone, accompanied with softening
an4 gradual change of form, either of the neck or head, or of both.

It is proper that I should state briefly, before I leave this subject,
what constitute the chief difficulties in the way of union by bone
within the capsule.

The persons to whom the accident occurs are generally advanced in
life, and consequently the process of repair is feeble and slow.

The head of the bone receives its supply of blood chiefly through
the neck and reflected capsule, and when both are severed, the small
amount furnished by the round ligament is found to be insufficient.

When the fragments are once displaced, it is difficult, as I have
already explained, if not impossible, to replace them.

The direction of the fracture is generally such, that the ends of the
fragments do not properly support and sustain each other when they
are in apposition.

The fracture is at a point where the most powerful muscles in the
body, acting with great advantage, tend to displace the broken ends.

Aged persons, who are chiefly the subjects of this accident, do not
bear well the necessary confinement, and especially as the union
requires generally a longer time than the union of any other fracture ;
so that a persistence in the attempt to confine the patient the requisite
time often causes death.

Whether the absence of provisional callus as a bond of union, and
the interposition of synovial fluid between the ends of the fragments,
constitute additional obstacles, I am not fully prepared to say. In the



Dinitiyfirl h\



Gooalp



NECK, WITHIN THE CAPSULE. 371

opinion of many surgeons these circumstances constitute very serious,
if not the chief, obstacles.

It remains only to consider what is the usual result of this fracture.

The fragments, more or less displaced, undergo various changes.
The acetabular fragment is generally rapidly absorbed as far as the
head; and occasionally a considerable portion of this latter disappears
also ; while the trochanteric fragment appears rather as if it had been
flattened out by pressure and friction, it having gained as much gene-
rally in thickness as it has lost in length. To this observation, how-
ever, there will be found many exceptions. Sometimes the trochanteric
fragment forms an open, shallow socket, into which the acetabular
fragment is received; or its extremity may be irregularly convex and
concave, to correspond with an exactly opposite condition of the ace-
tabular fragment. (Fig. 119.)

Ordinarily the two fragments move upon each other, without the
intervention of any substance ; but often they become united, more or
less completely, by fibrous bands (Fig. 120), which bands may be

Fig. 119. Fig. 120.



Fraetare of cerTix fomoris within capsule. Mayors specimen. United by ligament. Patient

^auniied. Opposite snrfkoes irregularly con- lived nine months after the accident. The tro-

▼ex and coneave, and polished ; moving slightly chanter minor arrested the descent of the head,

vpoa each other. (From a specimen in the pos- (From Sir A. Cooper.)
K«ion of Dr. Crosby.)

abort or long, according to the amount of motion which has been
niaintained between the fragments while they are forming, or to the
degree of separation which exists.

The capsular ligaments are usually considerably thickened, and
elongated in certain directions, and not unfrequently penetrated by
spicula of bone. They are also found sometimes attached by firm
l^nds to the acetabular fragment.

A permanent shortening, either with or without eversion of the



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372 FRACTURES OF THE FEMUR,

limb, are the invariable consequences of this accident. Indeed, not a
few succumb rapidly to the injury, perishing from a low, irritative
fever, or from gradual exhaustion, within a month or two from the
time of its occurrence. Says Eobert Smith : " Our prognosis, in cases
of fracture of the neck of the femur, must always be unfavorable. In
many instances the injury soon proves fatal, and in all the functions
or the limb are forever impaired; no matter whether the fracture has
taken place within or external to the capsule — whether it has united
by ligament or bone — shortening of the limb and lameness are the
inevitable results."

TreatmenL — In case, then, of a complete fracture within the capsule,
existing without laceration of the reflected capsule, or displacement of
the fragments, and equally in case of a fracture at the same point with
impaction, the treatment ought to be directed to the retention of the
bone in place, by suitable mechanical means, for a length of time
suf&cient to insure bony union, or for as long a time as the condition
of the patient will warrant.

The means which are, in my judgment, best calculated to fulfil this
important indication, are complete rest in the horizontal posture, the
limb being secured by the same -apparatus which we employ with so
much success in fractures of the shaft. In fractures of the neck, how-
ever, whether within or without the capsule, we employ no coaptation
splints ; and the amount of extension ought to be only one-half of
that generally employed in fractures of the shaft, say about ten
pounds. The long side-splint, with a foot-board, to prevent eversion
of the limb, must not be omitted. In my hands, and in the hands of
my expert house surgeons, the apparatus has undergone so many
modifications from the original plans of Crosby & Buck, that I shall
hereafter find it necessary to designate it as my own.

Fig. 121.



Author's apparatm for fractares of the neck of the femur.

Another apparatus formerly employed by me, in fractures of the
neck of the femur, but for which I have lately substituted my own,
is Gibson's modification of Hagedorn's, in which the sound limb is
first secured to the foot-board, and the broken limb is subsequently



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 44 of 100)