9. In whatever manner a fracture of the os femoris may have occurred
(7), its existence is characterized by the following signs: severe
local pain at the instant of the accident; a sudden inability to move
the limb; a preternatural mobility occurring in some particular part;
a crepitation sometimes distinct, when the two fragments are rubbed
against each other; and a deformity, which may be considered under the
threefold relation, of length, thickness, and direction.[22] These
signs, being common to most fractures, exhibit but few circumstances
peculiar to those of the os femoris, except that of the deformity.
Respecting this circumstance, in particular, it is essentially
necessary to possess accurate ideas, because, having an incessant
tendency to recur, especially in oblique fractures, it must constitute
a primary object of attention during the treatment.
[22] (_La longueur, l’epaisseur, et la direction._) That is, the
thigh may be shorter than natural, owing to the ends of the broken
bone overlapping each other; it may have a protuberance on one
side, in consequence of these ends being separated or displaced
laterally; or the direction of the limb may be changed, by a bend
or angle being produced in the bone at the place of the fracture.
TRANS.
10. It may be laid down as a general principle, that all fractures of
the os femoris are accompanied with some deformity; the exceptions to
this rule are too few to be worthy of notice. If this deformity be
considered in relation to length, it will be found that, in oblique
fractures, the limb is always shorter than that of the opposite side, a
circumstance which plainly points out an overlapping of the fragments.
But, on examining the place of fracture, it is easy to discover, that
this overlapping arises from the inferior fragment mounting upwards on
the superior one, which itself remains immoveable. Now, what power,
but the contraction of the surrounding muscles, can communicate to the
inferior fragment a motion from below upwards? Attached, on the one
hand, to the pelvis, and on the other to this fragment, to the rotula,
the tibiæ, and the fibula, these muscles have on the former their
fixed, and on the latter their moveable points, and, drawing the leg,
the knee, and the inferior portion of the thigh upward, they produce
the displacement and shortening either mediately or immediately.
In this displacement, the adductores, the semi-tendinosus, the
semi-membranosus, the rectus anterior, the rectus internus, &c. are the
principal agents.
11. The following case communicated to Desault by a surgeon, who
had been formerly his pupil, proves how great the influence of
this cause is; a cause which is indeed generally acknowledged, but
not sufficiently attended to by practitioners, with a reference to
permanent extension. It is this that induces me to relate the case.
CASE I. A carpenter falling under the ruins of his scaffold, was
immediately taken up and carried home, where a surgeon discovered an
oblique fracture of the os femoris, but without any displacement. The
thigh, which appeared even a little longer than the other, was fixed in
an apparatus too slack to prevent muscular action. Next day, the length
of the thigh was the same, but the whole extremity was in a paralytic
state, accompanied by an entire inability to discharge urine.
The moxa was proposed. The patient being placed in the position
directed by Pott, for fractures of the os femoris, the fire was
applied; some movements were the consequence; the application being
repeated on the sixth day, the muscles instantly recovered their power
of action, and then the shortening of the limb became evident, and
still returning immediately after being removed by extension, rendered
it necessary to have recourse to an apparatus calculated for permanent
extension.
12. In this case, the muscular influence is evident. Indeed the shock
having produced a temporary suspension of the excitability of the part,
the fragments remained in place and in proper contact with each other:
but the moxa having awakened the excitability again in the muscles
of the thigh, they resumed their action and caused, as usual, the
inferior fragment to mount on the superior.
13. Hence it follows, 1st, that it is principally to the action of the
muscles that we must attribute the displacement, in the longitudinal
direction of the bone; 2dly, that, as that action, being the effect of
an inherent power, is constantly exerted, the limb must have a constant
tendency to this displacement, particularly in oblique fractures, where
the two extremities of the bone represent two inclined plains, which
readily glide along each other.
14. To this must be still added another cause, which operates
injuriously in the course of the treatment. However solid the bed
may be on which the patient lies, the nates or buttocks, being the
most projecting part of the body, soon form a depression in it; hence
arises an inclination or descent of the plain or surface on which
the body lies. The body therefore sliding downwards, pushes before
it the superior fragment, and makes it overlap the inferior one. In
consequence of this, the muscles, being irritated by the points of
the bones, increase the force of their contractions, and, as we have
already observed (10), draw the inferior fragment upwards. This double
movement of the two ends of the bone in contrary directions, produces
only a single effect, namely, the overlapping of these ends, but
carries this overlapping to a higher degree.
15. Transverse fractures are less exposed to displacement, in the
longitudinal direction of the bone, because the fragments when in
contact, support each other. In such a case, the inferior fragment,
drawn by the muscles, finds a point of resistance against the superior
one, while the latter, when pressed downward by the weight of the body,
pushes the former before it, and thus both preserve their relative
position.
16. A deformity of the fractured os femoris, in the direction of
its cross-diameter or thickness (9), always accompanies that in its
longitudinal direction, and sometimes exists alone. This takes place
when, in a transverse fracture the two ends of the bone, losing their
contact, are carried, the one outward, and the other inward, or when
the one remains in its place, while the other is separated from it. In
such a case, the superior fragment is not, as in the preceding one,
immoveable by means of muscular action; because the action of the
pectineus, the psoas, the illiacus, and the first adductores, derange
its natural direction, and contribute to its displacement.
17. The deformity of the limb, in relation to its direction, in other
words, the crookedness of the limb (9) is either the result of the
stroke which fractured it, or, what is more common, of the ill directed
efforts of those who lift and carry the patient, and, by an improper
position, bend the two fragments, so as to make them form an angle with
each other. Desault was once called to a patient, whom he found seated
on a bed, in such a manner, that the upper part of the thigh was in a
horizontal position, and the lower, hanging with the leg in almost a
perpendicular one. Doubtless the triceps femoralis, equally attached to
both fragments, bends them by its contraction, and produces a change in
the direction of the limb.
18. Whatever may be the kind of the deformity, whether in a
longitudinal or lateral direction, the inferior fragment may either
preserve the natural position in which it is placed, or experience a
rotatory motion on its axis outwards, which is a common occurrence,
or inwards, a circumstance which is more rare. This rotation always
renders the displacement more serious, and ought to have an influence,
as I shall presently observe, on the means of reduction.
§ IV.