of the thigh-bone, with bony union, is supposed to have taken place;
but there are strong grounds for suspecting that many such have not
sustained actual fracture. The neck of the bone may be shortened,
and set on awkwardly, and there may be masses of new osseous deposit
round the neck and the trochanters. Perhaps the history of the case
is known.—An old person sustains an injury of the hip by falling,
or by a blow on the trochanter; great lameness ensues, and, after a
confinement of many weeks, the patient begins to use the member, which,
however, remains considerably shortened. But all this may have taken
place, and on examination after death, the parts may have presented the
appearances above alluded to, without any fracture. The change in the
bone is the consequence of diseased action induced by the injury. The
bloodvessels of the bone and its coverings are excited, and new osseous
matter is formed at various points; at the same time, interstitial
absorption of the cancellated texture of the neck gradually advances,
and the bone is consequently altered in length and form. These
appearances alone, therefore, do not warrant the confident belief of
fracture having occurred, even though the history should seem to favour
the assumption. And it ought to be recollected, that mere bruising of
the parts about the hip is not unfrequently attended with inability to
move the limb, with eversion of the foot, so as to relax the muscles
which have suffered, and sometimes with slight apparent lengthening.
This change in the form of the head and neck of the thigh-bone is not
found only in old subjects. Some drawings from patients under forty and
fifty years are given at pages 87 and 88, exhibiting in a remarkable
manner this deformity.
In many patients advanced in life, who have sustained fracture of the
neck of the femur, there is little, if any, chance of union. In these
cases, the application of apparatus with the view of adapting and
retaining the parts, is productive of great annoyance, and is apt to
produce either ulceration or sloughing of the integuments at various
parts; and confinement to one constrained position for a considerable
time has a mischievous effect on the general health. Instead, the
limb is placed in the easiest posture, either extended and slightly
retained, or bent over a double inclined plane formed by pillows,
with the knee of the affected side fixed to the opposite; a broad
band is passed round the trochanters and pelvis, so as to restrain
motion without causing inconvenience; and when pain about the thigh is
troublesome, fomentation may be used. After some weeks, when the uneasy
feelings have subsided, the position is changed, the patient is set
up, and encouraged to move about, supporting the weight of the body
upon crutches.
In more favourable subjects, whether the fracture is suspected to be
without or within the joint, either entirely or partially, the broken
surfaces are to be brought in contact, and retained immoveably in
apposition for a time sufficient to admit of union. The limb is put
up in apparatus not requiring removal, and but little readjustment.
This can be effected only in the extended position. Many splints,
with foot-boards, straps, and screws, are intended for this purpose,
some to be attached to the injured limb, others to the sound one; but
the apparatus which is most simple, and easily procured at all times
and in all circumstances, is at once the best and the most efficient.
This is a straight wooden board, not too thick to feel cumbrous, and
not too thin to be pliable or easily broken; in breadth corresponding
to the dimensions of the limb, in length sufficient to extend, from
two, three, or four inches beyond the heel, to near the axilla, deeply
notched at two places at its lower end, and perforated by two holes
at the upper. The splint, well padded, is applied to the extended
limb, the ankles being protected by proper adjustment of the pads.
The apparatus is retained by bandaging. A common roller is applied
round the limb, from the toes to near the knee, so as to prevent
infiltration, which would otherwise follow pressure above by the rest
of the apparatus. The splint is then attached to the limb by involving
both in a roller from the foot to above the knee; and in doing this,
the bandage, after having been turned round the ankle, should be passed
through the notches, so as to be firmly attached to the end of the
splint, thereby preventing the foot from shifting. A broad bandage is
applied round the pelvis over the groin, and down the thigh, investing
all that part of the limb left uncovered by the previous bandaging. A
broad band, like a riding belt, is fastened round the pelvis, so as to
bind the splint to the trunk, and thereby keep the broken surfaces of
the bone in contact. A large handkerchief, or shawl, is brought under
the perineum, and its ends secured through the openings at the top of
the board. It is evident that, the splint being thus securely fixed and
made as part of the limb, tightening of the perineal band will extend
the member, and preserve it of its proper length. By care and attention
in applying the apparatus, and in adjusting the cushions about the
ankle and perineum, there is little or no risk of the skin giving
way. The bandages will require to be reapplied once or twice during
the cure, and the perineal band should be tightened frequently. The
apparatus is retained for six or eight weeks, the time necessary for
union varying according to circumstances. After its removal, great care
must be taken at first in moving the limb and in putting weight upon
it: it should be accustomed to its former functions very gradually.
The same apparatus in the most effectual for all fractures of the
thigh; but those near the distal extremity, and in the lower third
of the bone, may be managed tolerably well on the double inclined
plane—M’Intyre’s splint, the thigh-piece of which is double, the one
portion sliding on the other, and made to shorten and lengthen by means
of a screw, without removal from the patient. To this the limb is
secured by bandaging from the toes upwards; the upper bandage, which
should be broad, being continued close to the perineum, and then passed
several times round the loins. By elongating the thigh-piece by means
of the screw, extension is kept up. Great complaint is commonly made by
the patient of pain and stiffness in the knee for a long time after the
treatment of broken thigh in the bent position.
There is no possibility of treating fracture of the thigh, with any
satisfaction or credit, on the outside of the limb with the knee bent;
however attentively the splints are placed, shortening, eversion of
the foot, and deformity of the whole limb, are sure to follow. No
greater absurdity and cruelty are conceivable than leaving the fracture
unadjusted for weeks, making attempts to subdue consequent over-action,
and then endeavouring to reduce and retain the bones at a period when
otherwise they should have been firmly united. “Experience teacheth”
not “fools,” and cannot amend those whom prejudice has blinded.
Compound fracture of the thigh, if circumstances do not forbid attempts
to save the limb, is to be reduced and retained in the same way as
the simple, the wound being attended to, and means taken to subdue
inflammatory action. Abscesses must be opened timeously, the limb must
be equably supported, and the powers of the system preserved.
The application of force may, in young persons, detach the epiphysis
of the lower end of the femur, and displace it to a greater or less
extent; and if the accident be not detected, the epiphysis will become
consolidated with the shaft in this unnatural position, impairing
the usefulness of the member, and probably laying the foundation
for disease in or around the articulation. Reduction is easy, and
the retentive treatment is the same as that recommended generally
for fracture of the thigh near the knee-joint. I have met with one
well-marked case of this form of diastasis. A girl sustained an injury
of the knee when fourteen years of age, in consequence of the limb
having been entangled amongst the spokes of a carriage-wheel in motion;
the knee continued painful and swollen, and she had a halt in walking.
After the lapse of about three years, extensive suppuration occurred in
the lower part of the thigh and round the knee-joint, and amputation
very soon became indispensable for the preservation of life. The
synovial apparatus was much diseased, and the epiphysis of the lower
end of the femur was found displaced forwards and upwards, so that only
the posterior part rested on the tibia; in fact, it was turned, as here
shown, almost half round on the shaft: firm union by bone had taken
place.
[Illustration]
Fracture of the _Patella_ is generally simple. It is occasioned either
by great force applied to the bone directly, or by the action of the
strong extensor muscles—the knee being suddenly bent, and the bone
snapped across over the end of the femur. The degree of immediate
swelling, and of incited action, will vary according to the mode of
infliction. When the injury is caused by a blow upon the part, the bone
may be broken either transversely or vertically, or both; either the
upper or the lower portion may be vertically split, usually the upper;
sometimes there is considerable comminution. Muscular action produces
transverse fracture only.
The nature and extent of the injury is readily ascertained. The patient
is unable to extend the limb, and cannot support weight on it; in the
bent position, a space is felt in the situation of the patella, the
lower portion is found nearly in its place, but the other is drawn
upwards on the fore part of the thigh; by extension of the limb and
flexure of the thigh the portions are approximated, and crepitus
is perceived when they are brought in contact. These symptoms are
perceptible through any quantity of bloody effusion. By attentive
manipulation, comminution and vertical splitting may also be detected.
The circumstances attending the accident will, in most instances, lead
to a tolerably accurate expectation of the state of parts.
The ligament of the patella does not often give way from muscular
action; it is much stronger than the bone, and the latter consequently
snaps. It may be, and has been, divided, along with the superimposed
integument, by a fall on a sharp substance. This accident is followed
by lameness, the ligamentous tissue does not soon unite, and the limb
is long in regaining its usefulness; sometimes the union is imperfect,
and the member remains weak.
Division of the integuments over a fractured patella is a very serious
accident. The joint is opened, and such a state both of the limb and
of the constitution must in general sooner or later occur as to cause
necessity for amputation. Cases have, however, occurred, in which
compound fracture of the patella has been cured.
The bone unites, under favourable circumstances, in the same way as any
other. In longitudinal fracture there is almost always bony union. In
transverse, the obstacles to correct apposition are great; the upper
portion is acted on by the muscles on the fore part of the thigh, to
a greater or less degree, in almost any position; there is increase
and vitiation of the synovial secretion, and when the bones are
approximated, this fluid is interposed. The union is therefore almost
uniformly ligamentous, and, fortunately, this is as strong and as
rapidly effected as that by bone. When the treatment is not of the most
approved kind, a long portion of ligament is produced, and the limb
remains weak. But union by a short ligament is undoubtedly the most
desirable result, the member is as useful as when bone is the uniting
medium, and ligament is less subject to disruption; bony union is, for
a long time, apt to give way on the application of even slight force.
The fragments are to be approximated, and brought nearly into contact,
by placing the limb, with the knee extended, and the thigh slightly
bent on the pelvis. The limb is retained in this position by the
application of a straight splint behind, hollowed at the extremities,
extending from a little below the tuberosity of the ischium to below
the middle of the leg, and retained by a roller, not at all tight; the
foot and lower part of the limb must be previously bandaged to prevent
infiltration. All apparatus with straps, buckles, and apertures to
receive the portions of the bone, are worse than useless. The splint
requires to be worn for some time after the patient gets into the erect
position, which ought not to be before six weeks after the accident.
_Fracture_ may occur at any part of the _leg_. One or both bones
may give way, either transversely or obliquely, according to the
application of the force. The transverse fracture is produced by a
direct blow, by a heavy body striking or falling on the limb, or by the
lower part of the limb being fixed whilst the body is in rapid motion;
the oblique is caused by force applied in the direction of the bones—as
when a person falls or leaps from a height, and alights on one foot,
the limb being extended and the body erect. In the latter description
of accident, it is frequently supposed, erroneously, that but one bone
has given way; fracture of the tibia perhaps is perceived some few
inches from the distal end, whilst the fibula at that part is entire;
but, by attentive manipulation, it will often be found that the fibula
has sustained fracture, within a short space of its upper extremity;
the force was applied to the ends of the bones, and they gave way, each
at the weakest part.
The tibia is broken at its upper part near the tuberosity, with
or without similar injury of the fibula. There is considerable
displacement, particularly in the bent position of the knee; there is
no restraint to the action of the extensor muscles inserted immediately
above the point of fracture, and these, though not acting with unusual
power, cause protrusion of the upper end of the tibia, the condyles of
the femur serving as a fulcrum over which the muscles are stretched.
This injury is usually the result of direct violence.
Fracture of one bone, at a point lower in the limb, is not attended
with much displacement or deformity. Indeed, attentive manipulation
is often required to detect the site of the injury; and a sense of
crepitation is perceived, only when the lower and upper portions of the
bone are pressed on alternately or during rotation of the foot. When
both bones are broken, the displacement and swelling are great. The
foot is sometimes turned inwards, but usually it falls outwards; and
if there has been much laceration of the soft parts, with or without
division of the integuments, the lower portion of the limb hangs quite
loose.
By the application of great force, as by a rope being twisted round
and run tight on the limb, both bones and soft parts may be reduced
almost to a pulp, without much or any division of the integument. Such
an accident is followed by rapid and great swelling, violent incited
action, gangrene, and severe constitutional disturbance. The progress
of the mortification is not in all cases uniform; in some, the swelling
and discoloration extend to the groin and trunk in two or three days,
attended with furious delirium; in others, the disorganisation of the
limb is very slow, some days elapsing before it reaches the knee, and
in these the constitutional symptoms are less severe.
In some cases there is extensive wound of the integuments, without
serious injury of the bone, muscles, or vessels. The skin either has
been divided by the external force acting upon the resisting bone, or
the sharp fractured end of the bone has been thrust through. Sometimes
the bone is protruded to a considerable extent, and entangled amongst
the more superficial soft parts.
Fractures of the lower portions of the bones are generally the
consequence of twisting and partial displacement of the ankle. The
fibula is most frequently broken by twisting of the foot outwards, and
the fracture is almost uniformly between two and three inches above the
articulation. The broken ends are displaced inwards upon the tibia. The
injury is detected by moving the foot, and tracing the line of bone;
after swelling has taken place, examination, though almost equally
easy, is productive of much more pain, and it is of importance to
ascertain the nature of the injury at once, and immediately after the
accident. The outer malleolus sometimes gives way from the same cause;
or it may be snapped off by a direct blow. The lower portion of the
tibia is sometimes longitudinally split by bending inwards of the foot,
the patient having fallen from a considerable height; occasionally
the inner malleolus is broken transversely. Inquiry as to how the
accident happened, particularly as to the direction of the twist, the
displacement of the foot, and the degree and extent of crepitation,
will determine the nature of the injury.
The astragalus, os calcis, the other bones of the tarsus, and those
of the metatarsus, are sometimes broken by the application of great
force, but they are not much displaced. Sometimes the foot is violently
concussed in consequence of a fall from a height, and though no
fracture may have occurred, the patient is equally lame and pained;
severe inflammation is sure to supervene rapidly, and may terminate
untowardly.
Fracture of the upper part of the tibia is to be treated in the
straight position, for it has been already observed, that when the
knee is bent the upper portion necessarily projects. A hollowed splint
of wood, extending from the middle of the thigh to near the heel, is
applied behind, whilst one of pasteboard may be placed on each side:
all are secured by bandaging, the foot and lower part of the limb being
rolled previously to prevent infiltration; by this simple apparatus,
motion of the knee-joint, and of the ends of the bones on each other,
is completely prevented; the heel is raised, if necessary, for complete
adaptation.
Fractures of the middle and lower portions of the bones are treated
most advantageously, whether simple or compound, in the bent position,
the angle being made more or less obtuse, according to the degree of
flexion most conducive to easy reduction and retention. Extension is
made on the limb, and the parts brought into as natural and handsome
a shape as possible; in doing so, the appearance of the sound member
should be kept in view. There is seldom any difficulty in accomplishing
reduction; the extending and counter-extending power need be but
slight; the upper part of the limb is steadied by an assistant, whilst
the lower is stretched and moulded by the hands of the surgeon. In
compound fractures at this part, the portions of bone completely
detached from the hard and soft parts are to be extracted. And if
reduction cannot be effected in consequence of a sharp and long end of
the bone projecting through a narrow wound, either the portion must be
abridged by the saw or cutting pliers, or the wound must be enlarged.
Sometimes the one mode is preferable—sometimes the other—occasionally
both are required. When the protruding portion composes but a small
portion of the shaft, though perhaps of considerable length, it should
be taken away; when, on the contrary, it is more thick than long, it is
better to enlarge the wound; but on this subject no general rules can
be laid down. The splint is the same as that recommended when treating
of fractured thigh, composed of a thigh and leg-piece, with a moveable
foot-board—the double inclined plane, improved by the late Mr. M’Intyre
of Newcastle and others. A very simple and efficient apparatus has been
used in our hospital for some years back. It answers every purpose
fully better than the others, and can be had of all the instrument
makers for a third of the expense of those previously in use. The
foot-board is fixed so as to make the leg-piece of the proper length,
and the splint is secured at a convenient angle. It is padded by means
of a cushion filled with oat chaff. The foot is rolled separately;
the limb is then raised carefully, and laid down on the splint placed
quickly beneath by an assistant; it is retained in a proper position by
the hands of the assistant, whilst a roller is carried from the toes
round the foot-board, and along the limb to the knee. A broad roller
is then made to surround the thigh and splint, and having been turned
several times round the loins, is secured to the upper part of the
cushion. The limb is thus rendered independent of the motions of the
trunk; it is made as of a piece with the splint. It should be raised
considerably above the level of the trunk, whilst the patient is in
bed, in order, by favouring the return of blood, to prevent swelling
and inflammatory action. The wound, if any, is to be approximated. If
discharge follow, part of the bandage may be undone from day to day,
for the purpose either of employing fomentation or of applying suitable
dressing, and still the limb is kept perfectly steady. Abscesses must
be opened early—spiculæ removed—constitutional symptoms warded off,
and, if they do occur, combated,—at one time inflammatory action must
be kept down—at another and more advanced stage, the strength must
be supported by all means. In simple fracture it is seldom necessary
to undo the bandage, till the apparatus is loosened by subsidence of
the swelling—and if the fracture be early reduced, and kept steady,
that will be but slight. Then the bandages are undone and reapplied,
and the position of the limb attended to. It is seldom necessary to
interfere with the leg during readjustment, but should there be any
deviation, even considerable, from the proper position, it is easily
remedied at the end of the first, second, third, or even of the fourth
week; but the sooner the better. The patient may be removed from bed,
and may sit up during the greater part of the day, with the heel on a
level with the pelvis, within the first week. His health, appetite,
and spirits, are thus kept up, sore back is avoided, the tedium of
confinement diminished, and the cure greatly accelerated. At the end
of five, six, seven, or eight weeks, according to the age, and as
the consolidation advances, the patient may be allowed to move about
on crutches, some few days after removal of the apparatus, the foot
and leg being still bandaged, and supported by light splints, or the
bandages may be starched and applied moist, with portions of coarse
brown paper interposed. A firm case is thus formed for the protection
of the limb and retention of the bones. No weight should be put on the
limb for several weeks after, otherwise a leg cured well and straightly
may become bent, twisted, and deformed.
Fractures of the lower extremities of the bones, and of the malleoli,
are reduced by placing the foot straight, and retaining it so by
the application of a wooden splint; the parts are protected by a
wedge-shaped pad, and the whole is retained by a common roller. The
splint is made to project two inches or two inches and a half beyond
the ankle, and to reach near to the knee-joint. It has two perforations
in the upper end; to these a bandage is attached by its split end, and
it is then carried down along the inside of the splint, and rolled
round the foot and ankle; thus the apparatus is prevented from shifting
upwards. The other extremity of the bandage, during its convolutions
round the foot, is made to pass through notches in the farther end of
the splint; the foot is thus turned to the side opposite to that in
which it was placed by the accident, and ought to be retained so till
consolidation has taken place. The splint is of course always placed on
the side of the limb opposite to the fracture.
_Disunited Fracture._—In some cases union takes place very slowly.
On removing the splints, with the expectation of finding the bones
firmly united, the ends can be moved very freely on each other without
crepitation or much pain. This, as already stated, may be referrible
to various causes,—necessary or accidental evacuations, natural or
not—diversion of the nutritious fluids to some particular organ, as
in pregnancy—the period of life—a diseased state of the bone of the
periosteum or medullary web. By keeping the parts immoveable and firmly
compressed for some time longer, consolidation may be brought about.
But in spite of every care, the ends of the bones in some cases remain
unconnected by any save a soft medium. This happens, however, very
rarely under proper management. I have had but one case of it in my own
practice, when the patient was from the first under my own inspection
and care; and in that the occurrence of false joint was attributable
solely to the absurd conduct of the patient. He was tripped up on the
street by some individuals following their avocation as pickpockets,
fell, and broke his forearm. The fracture was immediately reduced and
splints applied—one of pasteboard on each side, with a wooden one
exteriorly till the pasteboard hardened. He soon cut away the ends of
the splints—within thirty-six hours after they had been put on—so as
to allow motion of the fingers and hand, sufficient for indulgence in
card-playing. The splints were still farther shortened, and wholly
removed much too soon; shortly afterwards he fell from horseback. No
union took place by bone. Unless in the case of previous disease of
the bone, disunion is generally attributable to some carelessness or
recklessness, either of the surgeon or of the patient.