Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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brought down to the same point. By this method, as by my own
apparatus, we may avoid the necessity of a perineal band, which is so
painful, insupportable often when the fracture is at the neck.

In treating this fracture, supposing no displacement to exist, no



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NECK, WITHIN THE CAPSULE.



373



extension beyond that which is necessary to insure perfect quiet can
l)e proper, inasmuch as the fragments are not overlapped ; and they
need only a moderate assistance to enable them to maintain their
present position against the action of the muscles. Moreover, if the
fragments are impacted, violent extension would disengage them, and
render their displacement and non-union inevitable.




Gibson's modification of Hagedorn's splint.

Fig. 123.



/



Gibson's modified splint applied.



I am prepared to affirm, from my own experience, that more pa-
tients will endure quietly the position of extension for a length of
time than the flexed position, whether in this latter the patient is
placed upon his side or upon his back.

How long the patient will submit to this, or to any other mode of
securing perfect rest, is very uncertain, and the decision of this ques-
tion must rest with the individual cases and the good sense of the
surgeon. Not very many old and feeble people will bear such con-
finement many days without presenting such palpable signs of failure
as to demand their complete abandonment.

Horizontal extension was adopted in Jones' case, and also in the
case reported by Fawdington, and is said to have been successful. In
Brulatour's case the limb was kept extended two months ; in Mussey's
second case Hartshorne's straight splint for extension remained upon
the limb eighty -four days; in Bryant's case a long splint was used
" some weeks."

It is true, however, that other plans of treatment seem to have been
equally successful. In the case reported by Adams the limb was
placed over a double-inclined plane, made of pillows, five weeks; and
in Mussey's third example the limb remained in the same position
three months. Chorley laid his patient upon the sound side, with the
thighs flexed, for a space of two weeks, and then turned him upon his



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374 FRACTURES OF THE FEMUR.

back, still keeping the thighs flexed. At the end of six weeks he
was placed in a straight position, &c.

But in a majority of the examples reported, the existence of tbe
fracture was either not suspected, or bony union was not anticipated
or desired, consequently no treatment having in view the confinement
of the broken bone was adopted. Yet, the success, it was claimed,
was as great as that which has followed either of the other plans-
Harris' patient was simply laid on a sofa. Field's patient, who broke
the neck of both femurs within the capsule at different times, was in
each case left without treatment, except that she lay upon her becL
Mussey himself removed all dressings from Dr. Dalton's patient on the
eighteenth day, and placed him upon his feet, and Dr. Wakelee re-
moved the apparatus from his mother on the fifth day.

Nor are we without evidence that the careful and judicious appli-
cation of splints, long continued, and employed under the most favor-
able circumstances, will sometimes fail. The two following cases
confirm these remarks. The first occurred in the practice of Dr.
James E. Wood, of this city : " M. J., a young lady, aBt. 16 years; of
vigorous constitution; perfectly free from any constitutional taint,
either of scrofula, syphilis, or cancer, was caught between the wheels
of two carriages, the one stationary, the other in motion. The blow
was received directly on the trochanter major of the right side. The
symptoms which presented themselves showed conclusively that there
was a fracture. There was shortening, loss of voluntary motion, and
eversion; by placing the finger on the trochanter major, and the
thumb in the groin, a well-marked crepitus could be felt on extension
and rotation being made. There was no laceration or other compli-
cation of the injury. She was placed on Amesbury's splint, with side
splints accurately adjusted, and every precaution taken to insure a
perfect union. The limb was kept on this splint without being dis-
turbed for six weeks. At the end of that time it was taken from the
splint, and examined with care. The signs of fracture still remained;
the limb was replaced on the splint, and the dressings as before ;
everything was attended to in the general management of the case
which the doctor thought would be conducive to perfect union. The
patient was kept for three weeks longer on the splint, which was then
removed. It was found that there was no union. Patient lived for
three years, and was so lame that she was always obliged to use a
crutch in walking. At the expiration of three years she died of an
acute disease.

" On examination of the cervix femoris, it was found that there had
been a transverse fracture of the bone just at the junction of the head
and neck. The head of the bone was still attached to the acetabulum
by the ligamentum teres. The process of absorption had been going
on, and the head of the bone had already been absorbed below the
level of the acetabulum, and what remained was soft and spongy,
easily broken with the handle of the scalpel. The neck of the bone
was rounded off* and covered with a fibrous deposit. This was not a
case of diastasis, as has been suggested by an eminent surgeon, who



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NECK, WITHIN THE CAPSULE. 875

judged simply from the age of the patient. She was full sixteen when
the accident happened, and over nineteen when she died."

The second was in the person of a man, set. 25 years, who was at
the time of the accident robust and in good health. " He was dancing
at his sister's wedding ; while cutting a pigeon wing, he struck the
foot upon which he was resting from under him, and fell, striking
directly upon the trochanter major. He was unable to rise; a car-
riage was called, and he was taken directly to the New York Hospital.
There he came under the charge of Dr. J. Kearney Eodgers. A frac-
ture was immediately diagnosticated, and for a few days he was kept
on the double-inclined plane. The straight splint was then used, and
the dressings kept up for six weeks; at the end of that time they were
taken off, and the limb examined ; there was no union. The limb
was continued in the straight splints for three weeks longer, and again
examined ; there was still no union. The patient was again replaced
in the straight splint for two weeks longer, but no union occurred.
At the end of three months from his admission he was discharged; he
was in good health, but so lame that he was obliged to use two crutches
in walking. After his discharge the patient became very intempe-
rate ; and in the course of a few weeks he applied for admission to
Bellevue Hospital. He was much debilitated, and had an exhausting
diarrhoea. Shortly after his admission an immense abscess formed
over the joint, which discharged profusely. The man died shortly
after from exhaustion, and the specimen came into Dr. Yan Buren's
hands, the patient having been in his service. Dr. Van Buren was
aware of the patient's previous history, the treatment, etc., at the New
York Hospital, and a careful examination was made.

"The capsular ligament was destroyed entirely by the suppurative
process; there was a formation of callus upon the trochanter major;
the ligamentum teres was entirely absorbed; the head of the bone was
spongy, as if worm-eaten ; the direction of the fracture was oblique,
commencing just at the articulating surface of the head and ending
just within the capsule; the upper end of the shaft of the bone showed
this same appearance that was marked in the head. These points are
beautifully shown in the specimen at the present time. The opinion
of Charles E. Isaacs, M.D., the able Demonstrator of Anatomy of the
University Medical College, is, that this fracture was entirely within
the capsule.'" The bone may be seen in the museum of the University
Medical College, New York.

Such equal results from opposite plans, and unequal results from
similar plans of treatment, are not calculated to increase our faith in
the testimony which most of the foregoing examples are supposed Ijo
furnish of the possibility of bony union. On the contrary, they can-
not fail to suggest a doubt as to whether some of them, at least, were
not inaccurately diagnosticated.

But admitting that they were not, the testimony which they furnish
in relation to treatment is too inconclusive to be made available for

» Johnson, op. cit., pp. 13-15.



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376 FRACTURES OF THE FEMUR.

instruction, and we are still at liberty to adopt that which fieems most
rational, without reference to the experience of others.

The reasons why I would prefer my own plan have already l>eeii
stated in part, to which I will now add, that if an error should occur
in the diagnosis — if it should prove finally to have been a fracture
without the capsule — then this treatment would be correct, and no
injury would come to the patient from the error in diagnosis; but if
we adopt Sir Astley Cooper's suggestion, namely, to get the patient
upon crutches as soon as possible, perhaps as soon as fourteen days,
an error in diagnosis might be followed by the most disastrous con-
sequences.

(b.) Neck of the Femur wilhout the Capsule,

Causes, — Like fractures within the capsule, these also occur most
frequently in advanced life ; age may therefore be regarded as the
grand predisposing cause.

As to the immediate causes, we have already mentioned in the pre-
ceding section that fractures without the capsule seem to be the result
generally of falls or of blows received directly upon the trochanter ;
occasionally, also, they are produced by falls upon the feet or upon
the knees.

Pathology. — These fractures may occur at any point external to the
capsule, but generally the line of fracture is at the base, corresponding
very nearly with the anterior and posterior inter-trochanteric crests.
Almost invariably the acetabular penetrates the trochanteric fragment
in such a manner as to split the latter into two or more pieces. The
direction of the lesions in the outer fragments preserves also a remark-
able uniformity; the trochanter major being usually divided from near
the centre of its summit, obliquely downwards and forwards towards
its base, and the line of fracture terminating a little short of the tro-
chanter minor, or penetrating beneath its base ; while one or two lines
of fracture usually traverse the trochanter major horizontally.

In an examination of more than twenty specimens, I have noticed
but two or three exceptions to the general rules above stated.

In Dr. Mutter's collection, specimen marked B 115 is not accompa-
nied with either impaction or splitting of the trochanteric fragment;
but the neck having been broken close to the inter-trochanteric lines,
has, apparently, slid down upon the shaft about one inch, at which
point it is firmly united by bone.

Dr. Neill has also a specimen of fracture at the same point, but with-
out union of any kind, in which no traces remain of a fracture of the
trochanters. The acetabular fragment has moved up and down upon
the trochanteric until it has worn for itself a shallow socket three
inches and a half long ; the approximated surfaces being smooth and
polished like ivory.

The trochanter major is usually turned backwards, the shaft of the
femur being rotated in this direction, the same as is usually observed
in other fractures of the neck of the femur. I have seen one exception
to this general rule in a specimen belonging to Dr. Mutter (No. 29);



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NECK, WITHOUT THE CAPSULE. 377

the trochanter in this instance is turned forwards, so that the neck is
shorter in front than behind.

Fig. 124. Fig. 125. Fig. 126.



Impacted extra-capsalar fractures. (R. Smith, and Erichsen.)

The upper fragments of the trochanter major, whenever the lines of
fracture are transverse, are generally inclined inwards toward the neck,
as if displaced in this direction by the force of the blow, or perhaps
by the resistance offered by certain muscles and ligamentous bands
which find an insertion upon its summit.

The neck is found, in most cases, standing inwards at nearly a right
angle with the shaft, the head being much more depressed than the
outer extremity of the neck ; in consequence of which the lower margin
of its broken extremity is driven much deeper into the trochanteric
fragment than is the upper margin.

Malgaigne believes that impaction, with consequent fracture of the
trochanters, is never absent in true extra-capsular fractures, unless it
be in that very unusual variety in which the trochanter forms a part
of the inner fragment (fractures through the trochanter major and
base of the neck). Eobert Smith entertains the same opinion, although
Malgaigne does not seem to have so understood him. I cannot agree,
however, with either of these gentlemen that the rule is so invariable,
since I am confident that no such splitting has occurred in either of
the two specimens to which I have referred as belonging respectively
to Drs. Mutter and Neill. It is true these are both old fractures, and
to some extent the signs of fracture may have become obliterated, but
in Mutter's specimen an abundant callus indicates plainly enough
where the shaft separated from the neck, while the trochanter major
is smooth as in its normal condition, nor does its summit incline
either way from its usual position. Neill's specimen, though less
satisfactory, does not fail to convince me that neither impaction nor
splitting of the trochanters ever occurred.

It is certain, however, that impaction and comminution of the outer
25



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i'RACTURES OF THE FEMUR.

constant, and that, whether the fracture is produced
feet or upon the trochanter major. But the impac-
3ssarily continue ; sometimes, indeed, it does, and
limb, whatever it may be at the moment, remains
either very little or considerably shortened, accord-
of impaction ; rotated outwards or inwards, or in
ierhaps, according to the direction of the force and
nminution. In other cases, owing to the extreme
to the wide separation of the trochanteric fragments,
Dn of the muscles inserted into the top of the feniur,
f the body in attempts to walk, or to injudicious
rt of the surgeon, such as forcible rotation, by which
3 act as a lever, and to actually pry the fragments
extension, by which the impaction is overcome —
or several of these causes it often happens that the
,and the leg becomes immediately more shortened,
3 inclined to rotate outwards.
5 symptoms which indicate a fracture of the neck
)ut the capsule, are pain, mobility, crepitus, short-
i of the limb. The trochanter major is not as pro-
3 opposite side ; and, especially where the fragments
but are completely separated, it rotates upon a
re are also several other signs to which I shall refer
the differential diagnosis.

nderness, accompanied sometimes with swelh'ng and
lituated most often in front of the neck of the bone,
in a majority of cases, even when the fragments are
the limb can be moved pretty easily in any direc-
)n, but not without producing pain or provoking
yet the patient himself is unable to move the limb
n, or he can only move it slightly.
ent whenever there exists a moderate but not com-
It is also present generally when, the trochanteric
been extensively comminuted and loosened, the
I excessive; and it is only afbsent when the impac-
le fragments are completely and firmly locked into

inevitable, at least in all cases accompanied with
•r permanent impaction, and we have seen that one

seldom fails. According to Sir Astley Cooper the
rom half an inch to three-quarters of an inch, but

established the following distinction. When the
tpsular and impacted, that is, when it remains im-
ling is only moderate, varying from one-quarter of
ih and a half; in fourteen cases measured by him
fraction over three-quarters of an inch ; but when
I impacted it ranges from one inch to two inches
1, Mr. Smith mentions one example in which the
I four inches, and forty-two cases gave an average
?thing more than one inch and a quarter.



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NECK, WITHOUT THE CAPSULE.



879



Eversion of the toes is very constant ; but in a Fig- 127.

few instances upon record the toes have been
found turned in, or even directed forwards.
During the winters of 1864 and '65, 1 found a case
of this kind in my wards at Bellevue Hospital.
In the specimen referred to as being found in Dr.
Mutter's collection, with an inward or forward
rotation of the trochanter major, the same relative
position of the whole limb must have existed ;
and in my remarks on fractures of the neck within
the capsule, I have referred to several examples,
some of which were probably extra-capsular.

The trochanter major usually seems depressed
or driven in, and when the two main fragments
are completely separated, if the limb is rotated,
the trochanter will be found to turn almost upon
its own axis, or upon a very short radius.

In enumerating the signs of extra-capsular frac- '
ture, it will be seen that I have, with only slight
variations, repeated the signs of a fracture within
the capsule. It will become necessary, therefore,
to indicate, as far as possible, a differential diag-
nosis. And without pretending that all of the
differential signs which I shall enumerate are thoroughly established,
or that in every case, even after a careful grouping of all the symp-
toms, a satisfactory diagnosis can be made out, I shall state briefly
my own conclusions, or rather what seem to me to be the probable
facts.



Fracture of the neck of the
femur. (Fergnsson.)



SlGl^S OF A FRACTURE WITHIN THE
CAPSULE.

Produced often by slight violence.
A fall upon the foot or knee, or a trip
upon the carpet, &c.

Generally over fifty years of age.
More frequent in females.

Pain, tenderness, and swelling less and
deeper.



(The two following measurements to
be made from the anterior superior spinous
process of the ilium to the lower extremity
of the malleolus extemus or intemus.)

Shortening at first less than in extra-
capsular fractures, often not any.

Shortening after a few days or weeks

freater than in extra-capsular fractures,
ometimes this takes place suddenly, as
when the limb is moved, or the patient
steps upon it.

Measuring from the top of the tro-
chanter to the condyles or to the malleoli,
the femur is not shortened.



Signs of a fracture without the

CAPSULE.

Produced usually by greater violence.
A fall upon the trochanter major.

Often under fifty years of age.

Relative frequency in males or females
not established.

Pain, swelling, and tenderness greater
and more superficial. It is especially
painful to press upon and around the
trochanter.



Shortening at first greater, almost
always some.

Shortening after a few days or weeks
less than in intra-capsular fractures.
That is, the amount of shortening changes
but little, if at all ; if the impaction con-
tinues, not at all ; if it does not continue,
it may shorten more.

Measuring from the top of the tro-
chanter to the condyles or to the malleoli,
the femur may be found a little short-
ened.



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380 FRACTURES OF THE FEMUR.



Signs of a fracture within the

CAPSULE ieontinued).
Trochanter major moves upon a rela-
tively longer radius.



Signs of a fracture without the

CAPSULE {continue).
Trochanter major moves upon a rela-
tively shorter radius.



If the patient recovers the use of the ! If the patient recovers the use of the



limb, restored in six or eight weeks.
Enlargement or irregular expansion of



limb, not restored under three or four
months.

No enlargement or apparent expansion
of the trochanter major, after recovery, trochanter, which may be felt sometimes
from deposit of bony callus. ' distinctly through the skin and muscles.

Progressive wasting of the limb for : The limb preserving its natural
many months after recovery. | strength and size.

Excessive halting, accompanied with Slight halt, motions of hip natural
a peculiar motion of the pelvis, such as
is exhibited in persons who walk with an
artificial limb.

Prognosis. — In attempting to establish the differential diagnosis, we
have necessarily been led to consider most of the essential points of
prognosis. Very little, therefore, remains to be said upon this subject.

Union generally^ occurs as rapidly in this fracture as in fractures
of the shaft, and perhaps even sometimes more promptly, owing to
the existence of impaction. .

But whether it occurs promptly or slowly, or, indeed, if it does not
occur at all, a remarkable deposit of ossific matter almost invariably
takes place along the inter-trochanteric lines, where the bone has
separated from the shaft, and also, not unfrequently, along the lines of
the other fractures of the trochanter.

Fig. 129.
Fig. 128.



Extr»-c»ptalar fractare. (Erlchsen.) Extra>capsalar fr&etare. (R. Smith.)

This deposit is no less remarkable for its abundance than for its
irregularity, long spines of bone often rising up toward the pelvis and
forming a kind of nobby or spiculated crown, within which the
acetabular fragment reposes. In a few instances these osteophites
have reached even to the bones of the pelvis, and formed powerful



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881

abutments which seemed to prevent any farther displacement of the
limb in this direction, and, by some writers, they have been supposed
thus to fulfil a positive design. A sufficient explanation of their ex-
istence, however, we think, can be found in the fact that they proceed
entirely from the trochanteric fragments, whose extensive comminu-
tion and great vascularity would naturally lead to such results. The
same, but in a less degree, has already been noticed as occurring in
impacted fractures at the anatomical neck of the humerus, where cer-
tainly such bony abutments could not serve any useful purpose.

TVeatment. — The same principles of treatment are applicable here as
in fractures of the nec^^ within the capsule; by which I mean to say that,
as in all of those examples of fracture within the capsule where the rela-
tion of the fragments is such as to warrant a hope that a bony union may
be consummated, namely, where the frag-
ments are not displaced or are impacted, Fig. 180.
the straight position, with only moderate
extension, constitutes the most rational
mode of treatment; so also in this fracture,
whenever the fragments are impacted and
remain impacted, the straight position, with
moderate extension, employed only as a
means of retention, but not so as to over-
come impaction, is the most suitable. It
is only by employing this plan of treat-
ment, which no one has yet shown to be
inapplicable to either of these two varie-
ties of accidents — I do not speak of the
opinions which men may have entertained,

but of the practical testimony — it is only, Extra-capauUr fracture.

I say, by employing this uniform plan of

treatment in both cases, that those serious misfortunes to the patient
can be avoided which would necessarily continue to occur if Sir Ast-
ley Cooper's advice were followed, namely, to allow the patient in the
one case to dispense with splints wholly, and to get upon his crutches
as soon as the condition of his limb and of his body will permit, when
it is certain that in the other case some retentive apparatus is gene-
rally necessary. . This conclusion is based upon the admitted difficulty
of diagnosis. If, as is well understood, the diagnosis between these
two varieties of fracture is often impossible during the life of the pa-
tient, then how shall we know in any given case which of the two
plans to adopt. If we act upon the supposition that it is within the
capsule, adopting Sir Astley Cooper's method, and it proves to have
been a fracture without the capsule, we have, I fear, done irreparable
injury to our patient. It is precisely here that this distinguished sur-
geon committed his great error; not in denying that certain specimens
were fractures of the neck of the femur within the capsule united by
bone, nor in constantly urging upon his contemporaries the improba-
bility of such an event, but in that, while he admitted its possibility,
he chose to recommend a plan of treatment which was unlikely to



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 45 of 100)