Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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insure such a union, and which, in the uncertainty if not impossibility

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3011 his supposed authority, to be adopted
sular fractures.

3 extra-capsular and not impacted, or the
y cause, overcome ; or, if the fracture be
icted, or if the capsule is lacerated and the
ince displaced; then again no injury need
f we adopt the straight position with raode-
r be obtained from the use of my own ap-
er*s. That it is not impacted we may know
amount of displacement, although we may
the fracture is within or without the cap-
shortening will determine properly enough
to be employed. In either case, however,
ch extension as in fractures of the shaft;
e we shall only gain a shorter and firmer
other we shall insure a better and more

pon the suggestions here made, shall con-
son in the horizontal posture, with or with-

Fig. 131.

extra-cApsular fraotares. (From Miller.)

le powers of nature have become exhausted,
laders have already been admonished may
Id responsible for his want of judgment or
1 this plan of treatment only for so long a
f the patient renders it entirely safe. No
iber of cases it will have to be abandoned
iconsiderable proportion all constraint will
im the heginning; and it is for such ex-
ecommended by Sir Astley Cooper for all
jht to be reserved.

partly vnthin and partly vnthout the Capsule.

say that the line of fracture through the
such, that it shall be in part within and in
md such fractures will be even more diffi-
ither of those forms of which we have just
ill be mainly, however, those which cha-
le capsule, while the treatment ought to be

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such as we would adopt in those fractures which are wholly without
the capsule. The chances for bony union are increased in proportion
as the line of separation extends outside of the capsule, and we ought
to be diligent in our eflforts, if we have made ourselves certain that
the fracture is partly extra-capsular, to secure a good bony union ; a
result which experience has shown may be reasonably anticipated.

The necessity for some extension, and of firm retentive apparatus
in this form of fracture, furnishes another argument in favor of the
employment of the same means in fractures wholly within the capsule.
We shall thus avoid the mischief which might arise from mistaking a
fracture of the character of which we are now speaking, for a fracture
wholly within the capsule.

§ 2. Fracture through the Trochanter Major and Base of the
Neck of the Femur.

This fracture, which Sir Astley Cooper calls a fracture of the "femur
through the trochanter raajor,"^ passes obliquely upwards and outwards
from the lower portion of the neck, but instead of traversing the neck
completely, it penetrates the base of the trochanter major ; the line of
fracture being such as to separate the femur into two fragments, one
of which is composed of the head, neck, and trochanter major, and the
other of the shaft with the remaining portions of the femur.

The following two examples are all in relation to which we possess
any positive information, or in which the diagnosis has been con-
firmed by an autopsy. The first is thus related by Sir Astley Cooper.

" The first case of this kind I ever saw was in St. Thomas's Hos-
pital, about the year 1786. It was supposed to be a fracture of the
neck of the thigh-bone within the capsule, and the limb was extended
over a pillow rolled under the knee, with splints on each side of the
limb, by Mr. Cline's direction. An ossific union succeeded, with
scarcely any deformity, excepting that the foot was somewhat everted
and the man walked extremely well. When he was to be discharged
from the hospital, a fever attacked him, of which he died ; and upon
dissection, the fracture was found through the trochanter major, and
the bone was united with very little deformity, so that his limb would
have been equally useful as before.'**

The second example is reported by Mr. Stanley.

"A woman, in her sixtieth year, fell in the street and injured her
right hip. On examination, the limb was found slightly everted, and
shortened to the extent of three-quarters of an inch, but movable in
every direction. The extremity of the shaft of the femur was in its
natural situation ; but behind the femur, and at a little distance from
it, a bony prominence was discovered, resting upon the ilium, toward
the great sciatic notch, strongly resembling the head of the femur.
Various opinions were entertained as to the nature of the injury, some
believing it to be dislocation, and others a fracture. After a confine-
ment of several months to her bed, the woman was sufficiently re-

> Sir Astley Cooper, op. cit., p. 183. « Op. cit., p. 184.

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covered to walk with the assistance of a crutch, and in this state sho
continued till her death, which took place about three years after the
accident, during the whole of which period I had watched the pro-
gress of the case. Having obtained permission tb examine the seat of
the injury, I ascertained that there had been a fracture extending-
obliquely through the trochanter major, and through the basis of the
neck into the shaft of the femur, and that the prominence which had
been mistaken for the bead of the bone was occasioned by the posterior
and larger portion of the trochanter drawn backwards toward the
ischiatic notch."*

Sir Astley relates three other examples in which he believes the
fractures to have been of the character above described ; and he details
the peculiar plans of treatment which, in each case, he saw fit to recom-
mend. I can see no reason, however, why the treatment need diflfer
from that which has already been recommended for fractures of the
neck, since 'the indications are nearly identical in all of these cases;
namely, moderate extension, and steady support of the limb in its
natural position.

§ 3. Fracture of the Epiphysis of the Trochanter Major.

, So far as I know, the only well-authenticated example of this acci-
dent is the one reported by Mr. Key to Sir Astley Cooper.^ The sub-
ject of this case was a girl, aged about sixteen years, who fell, March
15, 1822, upon the side-walk, and struck her trochanter violently
against the curb-stone. She arose, and, without much pain or diflBiculty,
walked home. On the 20th she was received into Guy's Hospital, and
the limb was examined by Mr. Key. The right leg, which was the
one injured, was considerably everted, and appeared to be about half
an inch longer than the sound limb. It could be moved in all
directions, but abduction gave her considerable pain. She had perfect
command over all the muscles, except the rotators inwards. No
crepitus could be detected. Four days after admission she died, having
succumbed to the irritative fever which followed the injury.

The autQpsy disclosed a fracture through the base of the trochanter
major, but without laceration of the tendinous expansions which cover
the outside of this process, so that no displacement of the epiphysis
had occurred, nor could it be moved, except to a small extent upwards
and downwards. A considerable collection of pus was found, also,
below and in front of the trochanter.

The absence of displacement in the fragment, with its peculiar and
limited motion, sufficiently explained why the fracture could not be
detected during life.

In the eighth volume of the Transactions of the Medical and Physical
Society of Calcutta (1835), J. Clarke, Esq., reports a case of comminuted
fracture of the trochanter major, which has been mentioned by Mal-
gaigne as an example of simple fracture of the trochanter ; but, after

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

* Sir Astley Cooper on Dislocations and Fractures, etc., Amer. ed., 1851, p. 193.

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an (



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simple statement of the facts, so far as they are known, leaving all
mere speculative inferences to those who choose to make them.

§ 4. Fracturks of the Shatt of the Femur.

Etiology. — Unless the fracture has taken place just above the con-
dyles, or immediately below the trochanter minor, in a very large
proportion of cases it has been produced by a direct blow, such as
the passage of a loa(}ed vehicle across the thigh, or the fall of a piece
of timber directly upon it. An analysis of twenty-one cases, taken
indiscriminately, presents three fractures immediately above the con-
dyles, and these were all produced by falls upon the feet; but of the
remaining eighteen, all of which occurred higher in t,he limb, only
two were the result of falls upon the feet or of indirect blows, and
one of these was a fracture just below the trochanter minor.
• Pathology. — It has already been remarked that this bone is most
frequently broken in its middle third, and usually at a point some-
what above the middle of the shaft. I have made the same observa-
tion in an examination of specimens belonging to Dr. Miitter. In
his cabinet, of twenty-four fractures of the shaft, three belonged to the
upper third, two to the lower, and nineteen to the middle third.

In the adult, these fractures are, with only an exceedingly rare ex-
ception, oblique ; and the obliquity is generally greater than in the
case of other bones. This fact, which it is very difficult to deter-
mine, in most cases, upon the living subject, I have established by a
considerable number of observations made upon cabinet specimens.
A transverse fracture is found only twice in Dr. Mussey's collection,
containing thirty examples of fracture of the shaft ; and in Dr. Mut-
ter's collection, specimen B 71 is an adult femur, broken nearly trans-
versely through its middle third ; and it is united with a shortening
of about one inch. Indeed, it is more common to find a transverse
fracture in the middle third than at any other point of the bone; hut
in the upper third the obliquity is extreme and almost constant.

At whatever point of the shaft the bone is broken, the degree of
obliquity is generally such that the fragments cannot support each
other when placed in apposition ; unless indeed the fracture is near
the condyles, where the greater breadth of the bone creates an addi-
tional support ; but even here the cabinet specimens still present a
striking obliquity, with more or less overlapping. I believe that in
each of the three specimens of fracture at this point found in the
collection belonging to the Albany Medical College, the obliquity is
such that the fragments were not supported, and an overlapping has
taken place. In specimen 719 the fracture extends into the joint;
and although it is united by bone, a shortening of about one inch has

In the case of children, and especially of infants, the rule is reversed;
the bone is either broken transversely or nearly transversely, or it is
serrated or denticulated, so that complete lateral displacement is much
less frequent.

The same remark is probably true of some fractures occurring in

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extreme old age; but as the shaft of the femur is not often broken in

very old persons, owing to the readiness with which the neck yields

to violence, I have not had an opportunity to verify this opinion.
The direction of the obliquity varies exceedingly, especially in the

middle and upper thirds; in the middle third, however, it is generally

downwards and inwards; but in the lower

third its direction is, with only rare excep- ^g- 183.

lions, downwards and forwards, and the su-
perior fragment is found lying in front of

llie inferior.
In one instance I have found both femurs

broken at the same point and in the same

manner. Mr. L. Brittin, aged about fifty-five

years, while employed upon a building, fell

from a fourth story window upon the stone

pavement below, striking upon his feet. In

addition to several other fractures, I found

both femurs broken obliquely downwards
and forwards, just above the condyles. Very
little infiammation ensued, and although it
was found impossible to employ extension,
union occurred readily, and with only a mode-
rate overlapping. In the left limb, however,

the upper fragment pressed down sufficiently Fracture at ba»e of condyle*,
to interfere somewhat with the patella, and

the patient was unable, after several months, to straighten the knee
completely. The motions of the right knee were unimpaired.

I have only once met with a fracture at this point in which the line
of separation was downwards and backwards. As the case presents
several points of interest, it will be proper to narrate the facts some-
what at length.

George Taylor Aiken, of Lockport, N. Y., a9t. 7. May 18, 1854, in
jumping down a bank of about three feet in height, he broke the right
thigh obliquely, just above the knee-joint. Direction of the fracture
obliquely downwards and backwards.

Dr. G., an accomplished surgeon, residing in Lockport, was called.
The limb was not then much swollen. He applied side splints, rollers,
&c^ carefully, and then laid the limb over a double-inclined plane.
The knee was elevated about six or eight inches. Before applying
the splints, suitable extension had been made, and after completing
the dressings, the tWo limbs seemed to be of the same length.

Od the second or third day, Dr. G. noticed that the toes looked
unnaturally white, and were cold.

Counsel was now called at the request of Dr. G., when it was de-
termined to abandon all dressings, and direct their efforts solely to
saving the limb.

The result was that slowly a considerable portion of his foot died
and sloughed away, leaving only the tarsal bones The fracture
united, but with considerable overlapping and deformity.
Feb. 26, 1856, the boy was brought to me by his father. On ex-

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amining the fracture, I noticed that the anterior line of the femur
seemed nearly straight, and this appearance was owing in some de-
gree to the muscles which covered and concealed the bone, and in
some degree, also, to the manner in which the fragments rested upon
each other; the pointed superior end of the lower fragment resting
snugly upon the front of the upper fragment, so that no abrupt angle
existed in front. On the back of the limb, however, the lower end
of the upper fragment, quite sharp, projected freely downwards and
backwards into the popliteal space, so that its extreme point wa3
only about half an inch above the line of the articulation. The limb
had shortened one inch, and this enabled us to determine accurately
that the lower point or the commencement of the fracture was one
inch and a half above the articulation, while the point where the line
of fracture terminated in front was probably quite three inches and a
half above the joint. .

The motions of the knee-joint were pretty free. The leg was ex-
tremely wasted, and the anterior half of the foot having sloughed off,
the sores had now completely healed over. He was able to walk
tolerably well without either crutch or cane.

Subsequently, Dr. G. found it necessary to sue the father of the
child for the amount of his services, when Mr. Aikin put in a plea of
malpractice, and that consequently the services were without value.

The case was tried in the March term of the Niagara circuit of
1856, at Lockport, N. Y., the Hon. Benj. F. Greene presiding.

On the part of the defence, it was claimed that the death of the foot
was in consequence of the bandages being too tight. They failed,
however, to show that they were extraordinarily or unduly tight.
While on the part of Dr. G., the prosecutor, it was shown that the
death of the toes was preceded by a total loss of color, and that it was
not accompanied with either venous or arterial congestion. The medi-
cal gentlemen examined as witnesses declared that this circumstance
furnished the most positive evidence which could be desired that the
death of the toes was not due to the tightness of the bandages, but that
its cause must be looked for in an arrest of the arterial or nervous
currents supplying the limb, or in both. They believed, also, that
the projection of the superior fragment into the popliteal space was
sufficient to cause this arrest. They also believed that overlapping
and consequent projection could not have been prevented in this case,
and that, therefore, the treatment was not responsible for this unfor-
tunate result: indeed, they regarded the treatment as correct, and the
result as a triumph of skill, in that any portion of the limb was saved ;
the leg and foot now remaining being far more useful than any artifi-
cial leg and foot could be.

The Hon. Judge, in a speech remarkable for its clearness and libe-
rality sought to impress upon the jury the value of the medical testi-
mony. The jury returned a verdict for Dr. G., allowing the amount
of his claim for services, with the costs of suit.

Specimen 121, in Dr. March's collection at Albany, presents a
similar disposition of the fragments. The fracture is oblique, from
above downwards and backwards, and the upper portion lies behind

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the lower. It is firmly united by bone, but with an overlapping of
from two and a half to three inches. The young gentleman who
showed me the specimen remarked that it had been found impossible,
owing to an ulcer upon the heel, and to other causes, to employ in the
treatment any degree of extension.

These two are the only examples which have come under my ob-
servation in which a fracture at this point has taken this direction.

Sir Astley Cooper does not seem to have recognized this form of
fracture and displacement. Amesbury has, however, recorded one
case, which came under his own observation, where, although the
bloodvessels and nerves escaped, the bone projected through the skin .
in the ham, and finally exfoliated.^ And he thinks the point of bone
may sometimes so penetrate the artery and injure the nerves as to
render amputation necessary, in order to save the life of the patient.
M. Coural also has related a case in which an epiphysary disjunc-
tion, occurring in a child twelve years old, was attended with a dis-
placement of the upper fragment backwards, and amputation became
necessary.' I shall refer to this case again.

1 know of no other cases of this rare accident which have been re-
ported. Lonsdale refers to it as " the rarest direction for a fracture to
take ;" and thinks that in case of its occurrence, the vessels in the
popliteal space will stand a chance of being wounded ; but he mentions
no example. The popliteal artery hugs the bone so closely at this
point, that a displacement of the upper fragment in a direction down-
wards and backwards must always greatly endanger its integrity.
Indeed, it is here that the artery and vein are in the closest contact
with each other, and with the bone; an anatomical fact which has
been used by Eicherand and others to explain the greater frequency
of aneurisms in the ham.

The direction of the displacement, however, in fractures of the shaft
of the femur, does not always depend upon the direction of the line of
fracture. In fractures of the upper third, whatever may be the direc-
tion of the line of fracture, the lower end of the upper fragment in-
clines forwards and outwards, and the upper end of the lower frag-
ment inwards; unless, indeed, this inclination is controlled by actual
entanglement of the broken ends with each other.

In the middle third the fragments also generally take the same rela-
tive position, whatever may be the direction of the fracture ; but when
the fracture takes place at or near the condyles, where the diameter
of the bone is nluch greater, the direction of the obliquity determines
pretty uniformly the direction of the displacement.

Symptoms. — The symptoms which characterize a* fracture of the
shaft of the femur are those which are common to all fractures,
namely, mobility, crepitus, displacement of the fragments, pain, and
swelling, to which are added generally a shortening of the limb, with
eversion of the foot and leg.

Owing to the great amount of muscle covering the thigh, and some-

' Remarks on Fractures, &c., by Joseph Amesbury, vol. i. p. 293. London, 1831.

2 Archiv. G6n. de M6d., torn. ix. p. 267.

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times to the swelling which immediately follows the injury, it is often
very difficult to determine at what precise point the fracture has
occurred, and still more difficult to say whether the fracture is obliqae
or transverse ; indeed, this latter question is sometimes decided ap-
proximately by a reference to the age of the patient rather than by
the examination of the limb.

The immediate shortening varies from half an inch to an inch and
a half, or even more ; and it will average about one inch in the ca^se
of healthy adults.

Prognosis. — Whatever may have been the general opinion of ex-
perienced surgeons as to the question of shortening in other fractures,
very few certainly have ever claimed that in fractures of the femur a
complete restoration of the bone to its original length was generally
to be expected. There seem, however, to have existed only certain
vague and indefinite notions as to the proportion and amount of this
shortening, and which have had for their basis nothing better than a
few imperfectly analyzed observations.

Says Scultetus (quoting first from Hippocrates): "'For the bones of
the thigh, though you do draw them out by force of extension, cannot
be held so by any hands; but when the first intention slacks, they will
run together again ; for here the thick and strong flesh are above
binding, and binding cannot keep them down.' — Hippocrates defracL
W hich Celsus seems to confirm, Lib. 8, cap. 10, where he writes as
follows of the cure of legs and thighs : ' For we must not be ignorant
that if the thigh be broken, that it will be made shorter, because it
never returns to its former state.' And Avicenna, Lib. 4, Fen. 6, saith
' that it is a rare thing for the thigh once broken to be perfectly cored

"These words admonish us," continues Scultetus, "that we should
never promise a perfect cure of the thigh ; but rather, using all dili-
gence, we should foretell that it is doubtful that the patient will be always
lame ; but when this shall happen from the nature of the fracture, or,
which most frequently falls out, from the impatience of the sick per-
son, it fnay be imputed to our mistake, and, instead of a reward, bring
us disgrace."^

Says Chelius : " Fracture of the thigh-bone is always a severe acci-
dent, as the broken ends are retained in proper contact with great
difficulty. The cure takes place most commonly with deformity and
shortening of the limb, especially in oblique fractures, and those which
occur in the upper and lower third of the thigh-bone. Compound
fractures are so much more difficult to treat."^

Says John Bell : " The machine is not yet invented by which a
fractured thigh-bone can be perfectly secured." And Benjamin Bell
declares that " an effectual method of securing oblique fractures in
the bones of the extremities, and especially of the thigh-bone, is
perhaps one of the greatest desiderata in modern surgery." "In all

> The Chirurgeon's Store-house, by Johannes Scultetus, a Famous Physician
and Chirurgeon of Ulme in Sue via. London, 1674.

« System of Surgery, by J. M. Chelius, translated, &c., by South. First Amer.
ed., vol. 1. p. 627, 1847. See also p. 625, paragraph 679.

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ages," he adds, "the diflSculty of this has been confessedly great; and
frequent lameness, produced by shortened limbs arising from this
cause, evidently shows that we are still deficient in this branch of

Velpeau says that "after fractures of the femur there is no limp-
ing unless the shortening exceeds three-quarters of an inch ; and the
same is true if the shortening occurs in the tibia." The reason is, that
the pelvis inclines toward the shorter limb, and thus compensates for
the deficiency in length. In speaking of the various contrivances for
dressing the fractured femur, he remarks that " most of them fail to

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 46 of 100)