INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH
FRACTURES OF PELVIS: _Varieties_--INJURIES IN REGION OF HIP: Surgical
anatomy; _Fracture of head of femur_; _Fracture of neck of femur_;
_Fracture below lesser trochanter_--DISLOCATION OF HIP:
_Varieties_--Sprains--Contusions--FRACTURE OF SHAFT OF FEMUR.
FRACTURE OF THE PELVIS
For descriptive as well as for practical purposes, it is useful to
divide fractures of the pelvis into those that involve the integrity
of the pelvic girdle as a whole, and those confined to individual
bones.
In all, the prognosis depends upon the severity of the visceral
lesions which so frequently complicate these injuries, rather than
upon the fractures themselves.
#Fractures implicating the pelvic girdle as a whole# usually result
from severe crushing forms of violence, such as the fall of a mass of
coal or a pile of timber, or the passage of a heavy wheel over the
pelvis. The force may act in the transverse axis of the pelvis, or in
its antero-posterior axis. The pelvic viscera may be lacerated by the
tearing asunder of the bones, or perforated by sharp fragments, or
they may be ruptured by the same violence as that causing the
fracture.
As a rule, more than one part of the pelvis is broken, the situation
of the lesions varying in different cases.
_Separation of the pubic symphysis_ may result from violence inflicted
on the fork, as in coming down forcibly on the pommel of a saddle;
from forcible abduction of the thighs; or it may happen during
child-birth. In some cases the two pubic bones at once come into
apposition again, and there is no permanent displacement, the only
evidence of the injury being localised pain in the region of the
symphysis elicited on making pressure over any part of the pelvis. In
other cases the pubic bones overlap one another, and the membranous
portion of the urethra, or the bladder wall, is liable to be torn. The
displaced bones may be palpated through the skin, or by vaginal or
rectal examination.
The _pubic portion_ of the pelvic ring is the most common seat of
fracture. The bone gives way at its weakest points--namely, through
the superior (horizontal) ramus of the pubes just in front of the
ilio-pectineal eminence, and at the lower part of the inferior
(descending) ramus (Fig. 55). The intervening fragment of bone is
isolated, and may be displaced. These fractures are frequently
bilateral, and are often associated with separation of the sacro-iliac
joint, with longitudinal fracture of the sacrum (Fig. 55), or with
other fractures of the pelvic-bones.
[Illustration: FIG. 55.--Multiple Fracture of Pelvis through
Horizontal and Descending Rami of both Pubes, and Longitudinal
Fracture of left side of Sacrum.]
Injuries of the membranous urethra and bladder are frequent
complications, less commonly the rectum, the vagina, or the iliac
blood vessels are damaged.
Localised tenderness at the seat of fracture, pain referred to that
point on pressing together or separating the iliac crests, and
mobility of the fragments with crepitus, are usually present. The
fragments may sometimes be felt on rectal or vaginal examination. In
all cases shock is a prominent feature.
_The lateral and posterior aspects_ of the pelvic ring may be
implicated either in association with pubic fractures or
independently. Thus a fracture of the iliac bone may run into the
greater sciatic notch; or a vertical fracture of the sacrum or
separation of the sacro-iliac joint may break the continuity of the
pelvic brim. In rare cases these injuries are accompanied by damage to
the intestine, the rectum, the sacral nerves, or the iliac blood
vessels.
[Illustration: FIG. 56.--Fracture of left Iliac Bone; and of both
Pubic Arches.]
_Treatment._--It is of importance that the patient be moved and
handled with care lest fragments become displaced and injure the
viscera. He should be put to bed on a firm mattress, which may be
made in three pieces, for convenience in using the bed-pan and for the
prevention of bed-sores.
Before the treatment of the fracture is commenced, the surgeon must
satisfy himself, by the use of the catheter and by other means, that
the urethra and bladder are intact. Should these or any other of the
pelvic viscera be damaged, such injuries must first receive attention.
The treatment of the fracture itself consists in adjusting the
fragments, as far as possible by manipulation, applying a firm binder
or many-tailed bandage round the pelvis, and fixing the knees together
by a bandage (Fig. 57).
[Illustration: FIG. 57.--Many-tailed Bandage and Binder for Fracture
of Pelvic Girdle.]
When there is displacement of fragments extension should be applied to
both legs, with the limbs abducted and steadied by sand-bags.
Compound fractures, being commonly associated with extravasation of
urine, are liable to infective complications. Loose fragments should
be removed, as they are prone to undergo necrosis.
The patient is confined to bed for six or eight weeks, and it may be
several weeks more before he is able to resume active employment.
The #acetabulum# may be fractured by force transmitted through the
femur, usually from a fall on the great trochanter, less frequently
from a fall on the feet or other form of violence. It may merely be
fissured, or the head of the femur may be forcibly driven through its
floor into the pelvic cavity, either by fracturing the bone or, in
young subjects, by bursting asunder the cartilaginous junction of the
constituent bones. When the femoral head penetrates into the
pelvis--the _central dislocation of the hip_ of German writers--the
condition simulates a fracture of the neck of the femur, but the
trochanteric region is more depressed and the trochanter lies nearer
the middle line. The limb is shortened, and movements of the joint are
painful and restricted, especially medial rotation. In some cases
there is pain along the course of the obturator nerve.
On rectal or vaginal examination there is localised tenderness over
the pelvic aspect of the acetabulum, and in some cases a convex
projection, or even crepitating fragments can be detected. The
diagnosis is completed by an X-ray picture.
When the head of the femur penetrates the acetabulum, reduction should
be attempted by traction and manipulation. The pelvis is held rigid,
and the thigh is flexed and forcibly adducted, while the medial side
of the thigh rests against a firm sand-bag; the femoral head is thus
lifted out of the pelvis. In a recent injury the amount of force
required is relatively slight. The head is kept in its corrected
position by extension.
Fracture of the _upper and back part of the rim_ of the acetabulum may
accompany or simulate dorsal dislocation of the hip. Crepitus may be
present in addition to the symptoms of dislocation, and after
reduction the displacement is easily reproduced. The treatment is by
extension with the limb adducted.
#Fracture of Individual Bones of the Pelvis.#--_Ilium._--The expanded
portion of the iliac bone is often broken by direct violence, the
detached fragments varying greatly in size and position (Fig. 56).
The whole or part of the _crest_ may be separated by similar forms of
violence.
When the fracture implicates the _ala_ of the bone, it usually starts
at the triangular prominence near the middle of the crest, and runs
backwards or forwards, passing for a variable distance into the iliac
fossa. The displaced fragment can sometimes be palpated and made to
move when the muscles attached to it are relaxed. This is done by
flexing the thighs and bending the body forward and towards the
affected side. Pain and crepitus may be elicited on making this
examination.
These fractures are treated by applying a roller bandage or broad
strips of adhesive plaster over the seat of fracture, and by placing
the patient in such a position as will relax the muscles attached to
the displaced fragment--in the case of the iliac spine by flexing the
thigh upon the pelvis; in the case of the crest or ala by raising the
shoulders. Union takes place in three or four weeks.
In young persons, the _anterior superior spine_ has been torn off and
displaced downwards by powerful contraction of the sartorius muscle;
and the _anterior inferior spine_ by strong traction on the
ilio-femoral or [inverted Y]-shaped ligament. These injuries are best
treated by fixing the displaced fragment in position by a peg or
silver wire sutures and relaxing the muscles acting on it.
Fracture of the _ischium_ alone is rare. It results from a fall on the
buttocks, the entire bone or only the tuberosity being broken. There
is little or no displacement, and the diagnosis is made by external
manipulation and by examination through the rectum or vagina.
A longitudinal fracture of the _sacrum_ may implicate the posterior
part of the pelvic ring, as has already been mentioned. In rare cases
the lower half of the bone is broken _transversely_ from a fall or
blow, and the lower fragment is bent forward so that it projects into
the pelvis and may press upon or tear the rectum, or the sacral nerves
may be damaged, and partial paralysis of the lower limbs, bladder, or
rectum result. These fractures are frequently comminuted and compound,
and the soft parts may be so severely bruised and lacerated that
sloughing follows. On rectal examination the lower segment of the bone
can be felt, and on manipulating it pain and crepitus may be elicited.
Fracture of the _coccyx_ may be due to a direct blow, or may occur
during parturition. As a result of this injury the patient may have
severe pain on sitting or walking, and during defecation. The loose
fragment can be palpated on rectal examination. There is considerable
difficulty in keeping the fragment in position, and if it projects
towards the rectum it should be removed. If the lower fragment unites
at an angle so as to cause pressure on the rectum, it gives rise to
the symptoms of _coccydynia_, which may call for excision.
INJURIES IN THE REGION OF THE HIP
These include the various fractures of the upper end of the femur;
dislocation and sprain of the hip-joint; and contusion of the hip.
#Surgical Anatomy.#--The strength of the hip-joint depends primarily
on its osseous elements--the rounded head of the femur filling the
deep socket of the acetabulum, to the bottom of which it is attached
through the medium of the ligamentum teres. The edge of the acetabulum
is specially strong above and behind, while at its lower margin there
is a gap, bridged over by the labrum glenoidale (cotyloid ligament).
In relation to fractures of the upper end of the femur, it is to be
borne in mind that as the antero-posterior diameter of the neck is
less than that of the shaft, and as a considerable portion of the
great trochanter lies behind the junction of the neck with the shaft,
the greater part of any strain put upon the upper end of the femur is
borne by the neck of the bone and not by the trochanter. The head and
neck of the femur are nourished chiefly by the thick, vascular
periosteum, and through certain strong fibrous bands reflected from
the attachment of the capsule--the retinacular or cervical ligaments
of Stanley. The integrity of these ligaments plays an important part
in determining union in fractures of the neck of the femur, both by
keeping the fragments in position and by maintaining the blood-supply
to the short fragment. Whether it be true or not that an alteration in
the angle of the femoral neck takes place with advancing years, it is
generally recognised that this change is of no importance in relation
to fractures in this region.
The articular capsule of the hip is of exceptional strength. It is
attached above to the entire circumference of the acetabulum, and
below to the neck of the femur in such a way that while the whole of
the anterior and inferior aspects of the neck lies within its
attachment, only the inner half of the posterior and superior aspects
is intra-capsular. The capsule is augmented by several accessory
bands, the most important of which is the _ilio-femoral or [inverted
Y]-shaped ligament_ of Bigelow, which passes from the anterior
inferior iliac spine to the anterior inter-trochanteric line, its
fasciculi being specially thick towards the upper and lower ends of
this ridge. The medial limb of this ligament limits extension of the
thigh, while the lateral limits eversion and adduction. The weakest
part of the capsular ligament lies opposite the lower and back part of
the joint.
The hip-joint is surrounded by muscles which contribute to its
strength, the most important from the surgical point of view being the
obturator internus, which plays an important part in certain
dislocations, and the ilio-psoas, which influences the attitude of the
limb in various lesions in this region.
Except in thin subjects, the constituent elements of the hip-joint
cannot be palpated through the skin. A line drawn vertically downwards
from the middle of Poupart's ligament passes over the centre of the
joint, which in adults lies on the same level as the tip of the great
trochanter. In children it is somewhat higher.
For purposes of clinical diagnosis it is necessary to locate certain
bony prominences, the most important being--(1) The _anterior superior
iliac spine_, which is most readily recognised by running the fingers
along Poupart's ligament towards it. (2) The _ischial tuberosity_,
which in the extended position of the limb is overlapped by the lower
margin of the gluteus maximus muscle, and is therefore not easily
located with precision. By flexing the limb and making pressure from
below upwards in the gluteal fold, the smooth, rounded prominence can
usually be detected. (3) The quadrilateral _great trochanter_ is
readily recognised on the lateral aspect of the hip. Its highest point
or _tip_ can best be felt by pressing over the gluteal muscles from
above downwards.
_Clinical Tests._--If a line is drawn from the anterior superior iliac
spine to the most prominent part of the ischial tuberosity, it just
touches the tip of the great trochanter. This is known as _Nelaton's
line_ (Fig. 58).
[Illustration: FIG. 58.--Nelaton's Line.]
_Bryant's test_ (Fig. 59) is applied with the patient lying on his
back, and consists in dropping a perpendicular AB from the anterior
superior iliac spine, and drawing a line CD from the tip of the great
trochanter to intersect the perpendicular at right angles. This is
done on both sides of the body, and the length of the lines CD
compared. Shortening on one side indicates an upward displacement of
the trochanter, lengthening a downward displacement. The third side AC
of the triangle indicates the distance between the anterior spine and
the tip of the trochanter.
[Illustration: FIG. 59.--Bryant's Line.]
_Chiene's test_, which is simpler than either of these, consists in
applying a strip of lead or tape across the front of the body at the
level of the anterior superior iliac spines, and another touching the
tips of the two trochanters. Any want of parallelism in these lines
indicates a change in the position of one or other trochanter.
FRACTURE OF THE UPPER END OF THE FEMUR
The fractures of the upper end of the femur that are liable to be
confused with one another and with dislocations of the hip, include
fractures of the head, the neck, the trochanters, and separation of
the upper epiphyses, and fracture of the shaft just below the
trochanters.
Fracture of the #head of the femur# is rare, and is usually a
complication of backward dislocation of the hip. It takes the form of
a split of the articular surface caused by impact against the edge of
the acetabulum, and is analogous to the indentation fracture of the
head of the humerus, which may accompany dislocation of the shoulder.
The #epiphysis of the head#, which lies entirely within the capsule
of the joint (Fig. 60), is occasionally separated, and the symptoms
closely simulate those of fracture of the narrow part of the neck. If
the condition is overlooked or imperfectly treated, it may in course
of time be followed by coxa vara.
[Illustration: FIG. 60.--Section through Hip-Joint to show epiphyses
at upper end of femur, and their relation to the joint.
_a_, Epiphysis of head.
_b_, Epiphysis of great trochanter.
_c_, Epiphysis of small trochanter.
_d_, Capsular ligaments.
(After Poland.)]
FRACTURE OF THE NECK
It has long been customary to divide fractures of the neck of the
femur into two groups--"intra-" and "extra-capsular"; but as in a
considerable proportion of cases the line of fracture falls partly
within and partly without the capsule, this classification is wanting
in accuracy. It is more correct to divide these fractures into (1)
those occurring _through the narrow part of the neck_, which are
nearly always purely intra-capsular; and (2) those occurring _through
the base of the neck_ in which the line of fracture lies inside the
capsule in front, but outside of it behind.
It is of considerable importance to distinguish between fractures in
these two positions. The first group occurs almost exclusively in old
persons as a result of slight forms of indirect violence, and it is
liable, on account of the feeble vascular supply to the upper
fragment, to be followed by absorption of the neck, which delays or
may even entirely prevent union (Fig. 61). The second group usually
occurs in robust adults, and results from severe forms of violence
applied to the trochanter. In this group firm osseous union usually
takes place.
[Illustration: FIG. 61.--Fracture through Narrow Part of Neck of Femur
on section. The Neck of the bone has undergone absorption.]
#Fracture of the Narrow Part of the Neck# or #Intra-capsular
Fracture#.--This fracture is most frequently met with in elderly
persons, especially women, and is usually produced by comparatively
slight forms of indirect violence--such, for example, as result from
the foot catching on the edge of a carpet, a stumble in walking, or
missing a step in going downstairs.
The line of fracture, which is usually transverse but may be oblique
or irregular, lies for the most part within the capsule, and the
posterior part of the neck is more comminuted than the anterior. The
distal fragment, which includes the base of the neck, the
trochanters, and the shaft, is usually displaced upward and rotated
laterally. If the periosteum and the retinacular ligaments remain
intact, displacement is prevented and union favoured.
Impaction is less common than in fracture through the base of the
neck; it usually results from the patient falling on the trochanter,
the distal fragment being driven as a wedge into the proximal (Fig.
62).
[Illustration: FIG. 62.--Impacted Fracture through Narrow Part of Neck
of Femur.]
_Clinical Features._--In non-impacted cases the limb is at once
rendered useless, and the patient is unable to rise. There is pain and
tenderness in the region of the hip on making the slightest movement;
and a specially tender spot may be localised, indicating the seat of
fracture.
On placing the pelvis as square as possible, and comparing the
measurements of the limbs from the anterior superior spine to the
medial malleolus, shortening of the injured limb to the extent of from
1 to 3 inches may be found. On applying Nelaton's, Bryant's, or
Chiene's test, the tip of the great trochanter will be found elevated.
It is also farther back and less prominent than normal.
The whole limb is usually everted to a greater or less degree, and is
slightly abducted. In some cases, when the impaction is of the
anterior portion of the neck, the limb is inverted. On comparing the
ilio-tibial band of the fascia lata on the two sides, it is found to
be relaxed on the side of the injury.
The violence being as a rule indirect, there is at first little or no
discoloration in the vicinity of the hip, but this may appear a few
days later.
Crepitus is not a constant sign, and should not be sought for, as the
necessary manipulations are liable to disengage the fragments and to
increase the deformity. For the same reason rotatory movements are to
be avoided.
In all cases in which the diagnosis is uncertain, the patient should
be put to bed, and treated as for a fracture. In the course of a few
days it is nearly always possible to make an accurate diagnosis.
In examining an old person who has sustained an injury in the region
of the hip, it should be borne in mind that the limb may be shortened
and everted as a result of arthritis deformans, and that the symptoms
of that disease may simulate those of fracture. In arthritis
deformans, however, the ilio-tibial band of the fascia lata is not
relaxed as it is in fracture.
[Illustration: FIG. 63. Fracture of Neck of Right Femur, showing
shortening, abduction, and eversion of limb.]
In some cases, and particularly in those in which the periosteum of
the neck and the retinacular ligaments remain intact, the shortening
does not become apparent till a few days after the accident. As the
other symptoms are correspondingly obscure, the condition is apt to be
mistaken for a bruise. In all doubtful cases the part should be
examined from day to day, and, if possible, the X-rays should be used.
In _impacted_ cases the signs of fracture are often obscure, and the
patient may even be able to walk after the accident. The skin over the
trochanter is generally discoloured from bruising. Eversion is usually
present, but there may be little shortening. Crepitus is absent. In
old people it is never advisable to undo impaction, as the
interlocking of the bones favours the occurrence of osseous union.
_Prognosis._--A fracture of the neck of the femur in an old person is
always attended with danger to life, a considerable proportion of the
patients dying within a few weeks or months of the accident from
causes associated with it. In some cases the mental and physical shock
so far diminishes the vitality of the patient that death ensues within
a few days. It is possible that fat embolism may account for death in
some of the more rapidly fatal cases. In others, the continued dorsal
position induces hypostatic congestion of the lungs, or, owing to the
difficulties of nursing, bed-sores may form and death result from
absorption of toxins. Frequently the prolonged confinement to bed, the
continuous pain, and the natural impairment of appetite wear out the
strength. In many cases the patient becomes peevish, irritable, or
mentally weak.
Osseous union is the exception in intra-capsular fracture, especially
when the periosteum and the retinacular ligaments have been completely
torn, but in sub-periosteal and in impacted fractures it sometimes
occurs. As a rule, however, the neck of the femur becomes absorbed and
disappears, the head of the bone comes to lie in contact with the base
of the trochanter, and a false joint forms (Fig. 64). Chronic changes
of the nature of arthritis deformans may occur in and around such
false joints.
[Illustration: FIG. 64.--Fracture of Narrow Part of Neck of Femur. The
neck has become absorbed, the head has not united, and a false joint
has formed.]
When osseous union fails to take place, although the patient may
eventually be able to get about, he can do so only with the aid of a
stick or crutch, and as there is marked shortening, he walks with a
decided limp. There is considerable antero-posterior thickening of
the neck of the femur, and the femoral vessels may be pushed forward
in Scarpa's triangle.
_Treatment._--In treating a fracture through the narrow part of the
neck, it is necessary to consider the age and general condition of the
patient; whether the fracture is impacted or not; and the site of the
fracture--whether in the narrow part of the neck or at its base. "The
first indication is to save life, the second to get union, and the
third to correct or diminish displacements" (Stimson).
In old and debilitated patients, bony or even firm fibrous union
seldom takes place, and it is generally advisable to get them out of
bed as speedily as possible. For the first few days the patient may be
kept on his back, the limb massaged daily, and in the interval
steadied by sand-bags; but on the first sign of respiratory or cardiac
trouble he should be propped up in bed, and as soon as possible lifted
into a chair. In all such cases care should be taken to avoid undoing
impaction.
When the general condition of the patient permits of it, an attempt
should be made to secure bony union.
_Extension_ is applied by one or other of the methods described for
fracture of the shaft (p. 149), so modified as to maintain the limb
_in the abducted position_, which ensures the most accurate apposition
of the fragments (Royal Whitman). This position may be maintained by a
hinged long-splint, an adaptation of Thomas' hip splint. The fragments
may be fixed to one another by a long steel peg introduced through the
skin over the great trochanter, and passed so as to transfix them; or
they may be exposed by operation and sutured together. Albe uses a
bone peg.
#Fracture of the Neck of the Femur in Children.#--The use of the
X-rays has shown that this fracture is comparatively common in
children, as a result of a fall or a forcible twist of the leg. The
fracture is most frequently of the greenstick variety; when complete,
it is usually impacted. There is shortening to the extent of a half or
three-quarters of an inch, a slight degree of eversion, the movements
of the hip are restricted, and there is some pain. The patient is
often able to move about after the accident, but walks with a limp.
Unless the use of the X-rays reveals the fracture, the condition is
liable to be overlooked.
When the lesion is diagnosed, the deformity should be completely
corrected, any impaction that exists being undone; and the limb is put
up in a wide abduction splint (p. 221) or in a plaster-of-Paris case
in the position of extreme abduction.
If the condition is not recognised and treated, it is liable to be
followed by the development of coxa vara (Royal Whitman) (Fig. 65).
[Illustration: FIG. 65.--Coxa Vara following Fracture of Neck of Femur
in a child.]
#Fracture through the Base of the Neck.#--This fracture is usually
produced by a fall on the great trochanter, although it is
occasionally due to a fall on the feet or knees.
[Illustration: FIG. 66.--Non-impacted Fracture through Base of Neck.]
Although often spoken of as "extra-capsular," the line of fracture is
generally partly within and partly without the capsule. The fracture
usually lies close to the junction of the neck with the shaft, and in
the great majority of cases is accompanied by breaking of one or both
trochanters. This is due to the neck being driven as a wedge into the
trochanters, splitting them up. When the fragments remain interlocked,
the fracture is of the _impacted_ variety (Fig. 67).
[Illustration: FIG. 67.--Fracture through Base of Neck of Femur with
Impaction into the Trochanters.]
_Clinical Features._--Although this fracture is commonly met with in
strong adults, it may occur in the aged.
The lateral aspect of the hip shows marks of bruising, and there is
severe pain and a considerable degree of shock. The limb lies
helpless; there is generally marked eversion, with shortening, which,
in _non-impacted_ cases, may amount to 1-1/2 or 2 inches, and is
evident immediately after the accident; it is due to the distal
fragment being drawn up by the muscles inserted into the great
trochanter and upper end of the shaft. In a limited number of cases
the distal fragment lies in front of the proximal, and there is
inversion of the limb.
[Illustration: FIG. 68.--Non-impacted Fracture through Base of Neck.
Union has occurred with diminution of angle of neck--Coxa Vara.]
On applying the various tests, the great trochanter is found to be
displaced upwards, there is some antero-posterior broadening of the
trochanteric region, and the ilio-tibial band is relaxed. On pressing
the fingers into the lateral part of Scarpa's triangle, a mass
consisting of the bony fragments may be felt, and is tender on
pressure. Unnatural mobility with crepitus may be elicited.
In the _impacted variety_, the shortening seldom exceeds one inch; the
eversion is less marked; there is some power of voluntary movement;
and crepitus is absent. The broadening of the trochanteric region is
greater, and the great trochanter is approximated to the acetabulum.
_Prognosis._--The risks to life in the aged are similar to those of
intra-capsular fracture. In youths and healthy adults the chief danger
is that the limb may be shortened and its function thereby impaired.
As the periosteum and retinacular ligaments which transmit the blood
vessels to the proximal fragments are intact, bony union is the rule.
There is always, however, considerable thickening in the region of the
trochanter due to displaced fragments and callus, and in a certain
number of cases, even with the greatest care in treatment, there is a
varying degree of shortening and eversion of the limb. In cases in
which the distal fragment lies in front of the proximal there is
permanent inversion.
_Treatment._--As this fracture usually occurs in robust patients,
there is no danger from prolonged confinement to bed; and as union
without deformity can be attained in no other way, this is always
advisable. When the shortening and eversion are excessive, they should
be completely corrected under anaesthesia before the retentive
apparatus is applied, any impaction that exists being undone. When the
deformity resulting from impaction is slight, however, it is best to
leave it, as it facilitates speedy and firm union.
Extension is obtained by the same appliances as are used in fracture
of the shaft, and the limb should be kept in the abducted position.
Fracture of the #greater trochanter# occurring apart from fracture of
the neck usually results from direct violence, but may be due to
muscular action. The trochanter is displaced by the gluteal muscles,
causing broadening of the lateral aspect of the hip. In young persons
the _epiphysis_ of the great trochanter may be separated, but this is
rare. The treatment consists in retaining the fragments in position by
keeping the limb abducted between sand-bags, or by pegs driven in
through the skin.
#Fracture immediately below the lesser trochanter# may be produced by
direct or by indirect violence, and the displacement depends largely
on whether the line of fracture is transverse or oblique. The proximal
fragment is kept tilted forward, rotated laterally, and abducted by
the ilio-psoas muscle and the lateral rotators inserted in the region
of the great trochanter. The lower fragment passes upward, and is
rotated laterally by the weight of the limb; the displacement is
aggravated by the contraction of the flexor and adductor muscles. The
tilting of the proximal fragment may be increased by the displaced
distal fragment pushing it forward.
On account of the difficulty of controlling the short proximal
fragment, union is liable to take place with considerable shortening
and deformity (Fig. 69).
[Illustration: FIG. 69.--Fracture of the Femur just below the Small
Trochanter united, showing flexion and lateral rotation of upper
fragment.]
_Treatment._--When it is found, under an anaesthetic, that the
displacement can be completely reduced, and does not tend to recur,
this fracture is treated on the same lines as fracture of the shaft of
the bone.
In cases in which the proximal fragment cannot be brought into line
with the distal one, however, it is necessary to flex, evert, and
abduct the thigh in order to get the fragments into apposition and
into line. A Hodgen's splint (Fig. 77) is applied with the highest
sling under the upper end of the lower fragment and with sufficient
extension to correct overriding. The upper end is then strongly lifted
by a counter-weight of about 15 lbs. This secures apposition of the
fragments with slight forward angulation at the seat of fracture. By
the end of a month sufficient callus has formed to prevent
re-displacement, and if the counter-weight is gradually diminished the
two fragments sag back together into a normal alignment (J. N. J.
Hartley). A double-inclined plane (Fig. 70), with extension applied in
the axis of the thigh, gives satisfactory results.
[Illustration: FIG. 70.--Adjustable Double-inclined Plane.]
DISLOCATION OF THE HIP
It is unnecessary for our present purpose to attempt a comprehensive
classification of the numerous varieties of dislocation that have been
met with at the hip-joint. It will suffice if we divide them into
those in which the head of the femur passes backward, and comes to
rest on the dorsum ilii, or in the vicinity of the great sciatic
notch; and those in which it passes forward and comes to rest in the
obturator foramen, or on the pubes (Fig. 71).
[Illustration: FIG. 71.--Diagram of the most common Dislocations of
the Hip.]
The backward are much more common than the forward dislocations, in
contrast to what obtains at the shoulder, where the forward varieties
predominate.
On account of the great strength of the hip-joint, dislocation is by
no means a common injury. It occurs most frequently in strong adults
after the epiphyses have ossified, and before the bones have commenced
to become brittle; and it is much more common in men than in women. It
is invariably the result of severe violence, the limb at the moment
being in such a position that the ligaments are on the stretch and the
muscles taken at a disadvantage. The head of the femur usually leaves
the joint at the lower and back part, where the socket is most shallow
and the ligaments weakest. The ligamentum teres is almost always torn
from its femoral attachment, and one or more of the muscles inserted
in the region of the trochanters may be ruptured. The [inverted
Y]-shaped ligament, on the other hand, is seldom torn, and so long as
it remains intact the dislocation belongs to one or other of the types
above named. All atypical dislocations, such as the supra-cotyloid,
infra-cotyloid, ilio-pectineal, are due to rupture of some part of the
[inverted Y]-ligament, and are so rare as not to call for individual
description. The central dislocation of German authors, in which the
head is driven through the floor of the acetabulum, is described on
page 126.
Like other dislocations, those of the hip may be complicated by
laceration of muscles, blood vessels, or nerves, or by fracture of one
or other of the bones in the vicinity.
#Dislocation on to the Dorsum Ilii.#--This, the commonest form of
dislocation of the hip, is usually the result of the patient falling
from a height, or receiving a heavy weight on the back while stooping
forward with the thigh flexed, slightly adducted, and rotated
medially. It is also said to have occurred from muscular action. The
shaft of the femur acts as the long limb of a lever of which the neck
is the short limb, the femoral attachment of the [inverted Y]-ligament
forming the fulcrum. The head, thus brought to bear upon the lower and
back part of the capsule, tears it and leaves the socket, passing
upwards and coming to rest on the dorsum of the ilium, above and
anterior to the tendon of the obturator internus (Fig. 73). The
articular surface is directed backward, while the trochanter looks
forward.
[Illustration: FIG. 72.--Dislocation of Right Femur on to Dorsum
Ilii.]
_Clinical Features._--The affected limb is flexed, adducted, and
inverted, so that the knee crosses the lower third of the opposite
thigh, and the ball of the great toe lies on the dorsum of the sound
foot. There is shortening to the extent of from 1-1/2 to 2 inches, the
trochanter being displaced above Nelaton's line, and lying nearer to
the anterior superior iliac spine than on the normal side. The patient
is unable to move the limb or to bear weight upon it; abduction and
lateral rotation are specially painful; and traction fails to restore
the limb to its proper length. On making these attempts a
characteristic elastic resistance is felt.
The head of the femur in its new position may sometimes be felt
through the fibres of the gluteus maximus, but swelling of the soft
parts often obscures this sign. The normal depression behind the
great trochanter is lost, the gluteal fold is raised, and there is
often a degree of lordosis which compensates for the flexion. The
fingers can be pressed more deeply into Scarpa's triangle on the
dislocated than on the normal side--a point in which this injury
differs from fracture of the base of the neck of the femur.
In a certain number of cases the lateral limb of the [inverted
Y]-ligament is ruptured and the limb is everted--_dorsal dislocation
with eversion_.
[Illustration: FIG. 73.--Dislocation on to Dorsum Ilii. Note relation
of neck of femur to tendons of obturator internus and gemelli
(diagrammatic).]
#Dislocation into the Vicinity of the Great Sciatic Notch#, or
"_dislocation below the tendon_."--This variety of backward
dislocation is less common than that on to the dorsum, although
produced in the same way. The head of the femur passes beneath the
obturator internus, and this tendon, catching on its neck, checks its
upward movement (Fig. 74).
The _clinical features_ are the same as those of the dorsal variety,
but, on the whole, are less marked.
_Differential Diagnosis._--Backward dislocation of the hip is usually
easily recognised. When dislocation below the tendon occurs in a stout
person, however, it is liable to be overlooked on account of the
difficulty of feeling the displaced bone, and of the comparatively
slight amount of deformity present. The nature of the accident, the
absence of broadening of the trochanter, and the adduction and
inversion of the limb are usually sufficient to prevent a dislocation
being mistaken for an impacted extra-capsular fracture.
#Dislocation into the Obturator Foramen# (Fig. 71).--This dislocation
is produced by great force applied from behind while the thigh is
flexed and abducted, as when a weight falls on the back of a man
stooping forward with the legs wide apart. It may also result from
violent abduction by wide separation of the thighs.
The capsule gives way at its medial and lower part, and the head of
the femur comes to rest on the surface of the external obturator
muscle, its articular surface looking forward, while the trochanter
looks backward.
_Clinical Features._--In the standing position the thigh is slightly
flexed and abducted, with the foot pointing directly forward or a
little outward. The body is bent forward to relax the ilio-psoas
muscle and the [inverted Y]-ligament, the foot is advanced and the
heel drawn up. It is not uncommon for the patient to be able to walk
after the accident, and only to seek advice some time later on account
of inability to adduct and extend the limb. There is apparent
lengthening of the limb due to tilting of the pelvis downward on the
affected side. The hip is flattened, the trochanter less prominent
than usual, and the head of the bone may sometimes be felt in its
abnormal position.
[Illustration: FIG. 74.--Dislocation into the vicinity of the
Ischiatic Notch. Note relation of neck of femur to tendons of
obturator and gemelli, "Dislocation below the tendon" (diagrammatic).]
#Dislocation on to the pubes# is a further degree of the obturator
form (Fig. 71). It is usually produced by forcible hyper-extension and
lateral rotation of the hip, such as occurs when the body is bent back
while the thigh remains fixed.
The capsule is torn farther forward than in the other varieties, and
the head rests on the horizontal ramus of the pubes against the
ilio-pectineal line.
_Clinical Features._--There is marked eversion, flexion, and
abduction, but the shortening is inconsiderable. The ilio-psoas and
[inverted Y]-ligament are tense. The head of the femur may be felt in
the groin, with the femoral vessels over, or to one or other side of
it. There is sometimes pain and numbness in the distribution of the
femoral (anterior crural) nerve. The prominence of the great
trochanter is lost.
#Treatment of Dislocation of the Hip.#--For the reduction of a
dislocation of the hip complete anaesthesia is necessary, and the
patient should be placed on a firm mattress on the floor to give the
surgeon the best possible purchase upon the limb. The surgeon grasps
the ankle with one hand, while the other is placed behind the head of
the tibia, the leg being held at right angles to the thigh. An
assistant meantime steadies the pelvis by making firm pressure over
the iliac crests.
As the chief obstacle to reduction is the tension of the ilio-femoral
ligament, the first indication is to relax this structure by flexing
the hip _to its fullest extent_.
In the _backward_ varieties (dorsal and sciatic) the [inverted
Y]-ligament is relaxed by flexing the thigh upon the pelvis in the
position of adduction. The thigh is then fully abducted, to cause the
head of the bone to retrace its steps forwards towards the rent in the
capsule; and at the same time rotated laterally to relax the rotator
muscles. This combined movement tends also to open up the rent in the
capsule. Finally, the limb is quickly extended to cause the head to
enter the socket. This object is often aided by making vertical
traction or lifting movements on the abducted and laterally rotated
limb before extending.
For the reduction of the _forward_ varieties (obturator and pubic),
the thigh is first fully flexed on the pelvis, but in the abducted
position. The limb is then strongly rotated medially and abducted, and
finally extended. Lifting movements may be found useful in these cases
also.
All methods of reduction by forcible traction on the extended limb are
to be avoided, as they fail to meet the primary indication of relaxing
the [inverted Y]-ligament.
After reduction, the limb is steadied by sand-bags; massage is carried
out from the first, and movement after a few days. The range of
movement is gradually increased, and the patient is allowed to use the
limb with caution in from two to three weeks.
When the rim of the acetabulum has been fractured, the patient must be
confined to bed with extension for six to eight weeks, to avoid the
risk of re-dislocation.
Changes of the nature of chronic arthritis are liable to occur in and
around the joint in old and rheumatic subjects; and atrophy or
paralysis of muscles may follow, if their nerves are implicated.
#Old-standing Dislocation.#--It is impossible to lay down any
time-limit for attempting reduction in old-standing dislocations of
the hip. Manipulation may succeed in cases of some months' standing,
and may fail when the bone has been out only a few weeks. In certain
cases, even after reduction has been effected, there is a marked
tendency to re-displacement. In any case, the attempt does good by
breaking down adhesions, provided no undue force is employed such as
may damage the sciatic nerve or vessels, or fracture the neck of the
femur, and success may attend on a second or even a third attempt at
intervals of from three to five days. If manipulation fails, and if
the deformity is great and the usefulness of the limb seriously
impaired, an attempt may be made to effect reduction by operation; the
operation, however, is one of considerable difficulty, and in the
event of failure the head of the bone should be excised. If the head
has formed a new socket for itself and there is a fairly useful joint,
the condition should be left alone.
_Congenital dislocation of the hip_ is described with Deformities of
the Extremities.
#Sprain# of the hip is comparatively rare. It results from milder
degrees of the same forms of violence as produce dislocation. The
ligaments are stretched or partly torn, and there is effusion of fluid
into the joint. Pressure over the joint elicits tenderness; and the
limb assumes the position of slight flexion, abduction, and lateral
rotation, but there is no alteration in length. Such injuries, unless
carefully treated by massage and movement from the outset, are apt to
be followed by the formation of adhesions, resulting in stiffness of
the joint.
#Contusion# in this region, on the other hand, is not uncommon. It is
produced by a fall on the trochanter, and gives rise to symptoms which
simulate to some extent those of fracture of the neck. The limb lies
in the position of slight flexion, but the bony points retain their
normal relationship to one another, and there is no shortening. The
swelling and tenderness often prevent a thorough examination being
made, and when any doubt remains as to the diagnosis, the patient
should be kept in bed till the doubt is cleared up by the use of the
X-rays. If the bone has been broken, this will reveal itself in the
course of a few days by the occurrence of shortening and other
evidence of fracture.
In elderly patients, contusion of the hip may be followed by changes
in the joint of the nature of arthritis deformans; and it has been
stated, although proof is wanting, that absorption of the neck of the
femur sometimes occurs. These injuries are treated by rest in bed,
massage, and the other measures already described as applicable to
sprains and contusions.
FRACTURE OF THE SHAFT OF THE FEMUR
This group includes all fractures between that immediately below the
lesser trochanter and the supra-condylar fracture.
_In adults_, when due to direct violence, the fracture is usually
transverse, and may be attended with comparatively little
displacement. Indirect violence, on the other hand, usually produces
an oblique fracture, which is frequently comminuted and often
compound. The break is most commonly situated a little above the
middle of the shaft, the obliquity being downward, forward, and
medially, and of such a nature that the fragments tend to override one
another (Fig. 75). The most serious forms are those associated with
gun-shot wounds.
[Illustration: FIG. 75.--Longitudinal section of Femur showing recent
Fracture of Shaft with overriding of Fragments.]
The direction and nature of the displacement depend more upon the
fracturing force, the weight of the lower part of the limb, and the
action of the muscles attached to the respective fragments, than upon
the direction of the obliquity. As a rule, the proximal fragment
passes forward and laterally, and is maintained in this position by
the ilio-psoas and glutei muscles, while the distal fragment is
displaced upward and medially and is rotated outward by the combined
action of the weight of the limb, the longitudinal muscles, and the
adductors.
_Clinical Features._--The limb is at once rendered useless, and there
is great swelling from effusion of blood in the region of the
fracture. This, together with the muscularity of the part, often
renders an accurate diagnosis as to the site and direction of the
fracture exceedingly difficult. The shortening varies from 1/2 inch to
3 or 4 inches--averaging about 1 inch in adults--and eversion is
always marked. Mobility may be detected and crepitus elicited without
disturbing the patient, by placing the hand under the seat of fracture
and gently attempting to raise the limb; or by fixing the proximal
fragment by one hand placed in front of it while the distal part of
the limb is carefully lifted. It will be found that the great
trochanter does not rotate with the lower segment of the femur. These
tests must be employed with great caution lest the deformity be
increased or the fracture rendered compound.
In many fractures of the thigh, and especially in those produced by
indirect violence, the knee is sprained, and there is a considerable
effusion into the joint, and this may lead to stiffness unless massage
is employed from the outset.
_Treatment._--Fracture of the shaft of the femur is one of the most
difficult fractures in the body to treat successfully. In cases of
oblique fracture, the patient should be warned that shortening to the
extent of from 3/4 to 1 inch is liable to result, however carefully
the treatment may be carried out. This does not necessarily imply a
permanent limp, as by tilting the pelvis he may be enabled to walk
quite well; if this is not sufficient to equalise the length of the
limbs, the sole of the boot may be raised. A general anaesthetic is
necessary to ensure accurate reduction, and extension must be applied
to maintain the fragments in apposition and prevent shortening. The
splint which has been found most generally useful is the Thomas' knee
splint, the ring of which rests against the ischial tuberosity. To
admit of flexion at the knee the Thomas' splint should have a hinged
attachment on which the leg is supported. This leaves the knee free
and allows of movement being made to prevent stiffness. The limb is
suspended by broad strips of flannel or linen, fixed to the side bars
of the splint by means of safety pins or strong spring paper clips.
In simple fractures extension may be obtained by means of broad strips
of adhesive plaster applied to each side of the thigh and reaching
well above its middle. The plaster is secured by a bandage, and to its
lower ends are attached broad tapes which are buckled to a stirrup
through which traction is made by means of a cord passing over a
pulley fixed to an upright at the foot of the bed.
The lower end of the splint is suspended, and the counter-extension is
obtained by pressing the ring against the ischial tuberosity. To
prevent the ring overriding the tuberosity and pressing on the soft
tissues of the buttock, it is slung by the rope to a cross-bar above
the bed, _e.g._ the Balkan frame (Fig. 81).
In compound fractures the presence of a wound may prevent adhesive
plaster being used, and it is necessary to take the extension directly
through the bone. A posterior gutter splint is applied to prevent
sagging. After pulling the skin upward, a small incision is made over
the upper expanded border of each condyle, and the points of an
ice-tong calliper are made to grip the bone without penetrating into
the cancellous tissue. A cord attached to the handles of the calliper
passes over a pulley and supports the weight necessary to give the
desired amount of traction (Fig. 81).
An alternative method of exerting traction directly through the bone
is by means of Steinmann's apparatus (Fig. 76). In a moderately
muscular adult, a weight of from 12 to 15 pounds by means of strips of
plaster applied to the skin, or 10 to 25 pounds by direct traction on
the bone, should be applied in the first instance. The correct weight
to employ is that which maintains the length of the limb at its
normal, and is therefore liable to revision from time to time.
[Illustration: FIG. 76.--Radiogram of Steinmann's Apparatus applied
for Direct Extension to the Femur.]
_Hodgen's splint_ is a comfortable and efficient means of treating
these fractures, as it allows the patient a certain amount of
movement, admits of the part being massaged, and facilitates nursing.
It consists of a wire frame (Fig. 77) to one side of which a series of
strips of flannel about 4 inches wide are attached. Extension
strapping is first applied, and then the frame, which extends from the
level of Poupart's ligament to well beyond the sole, is placed over
the front of the limb, and the loose ends of the flannel strips
brought round behind the limb, and fixed to the other side of the
frame, convert it into a sling. The tapes attached to the extension
strapping are now tied to the end of the frame. By suspending the limb
in this splint by means of cords passing obliquely over a pulley
attached to an upright at the foot of the bed, the weight of the limb
is made to act as the extending force.
[Illustration: FIG. 77.--Hodgen's Splint.]
The retentive apparatus should be worn for from six to eight weeks,
after which the patient is allowed up with crutches, which he usually
requires to use for three or four weeks longer, before he can bear his
weight upon the limb. The old dictum of Nelaton, that the treatment of
fracture of the thigh should last for a hundred days, is a safe
working-rule. In fractures of the shaft an ordinary Thomas' knee
splint, or a "walking calliper splint" which is fixed to the heel of
the boot, may be worn when the patient gets up.
Union may be exceedingly slow in fracture of the femur, and may even
be delayed for months. Mal-union sometimes occurs, the fracture
uniting with an angular deformity outward and forward.
Re-fracture is liable to occur if the patient falls or twists the limb
within a few months of the original injury. It has happened not
infrequently just after the retentive apparatus has been removed from
the nurse raising the limb by the foot in order to wash it.
_Liston's long splint_ is only employed as a temporary expedient for
immobilising the fragments during transport; a Thomas' splint, if
available, is better for this purpose.
[Illustration: FIG. 78.--Long Splint with Perineal Band.]
_Operative treatment_ is sometimes called for when simpler measures
fail to reduce the displacement, and in cases of un-united fracture or
of vicious union. The incision, which must be free, is preferably
placed in the line of the lateral intermuscular septum; the
periosteum is interfered with as little as possible. The application
of extension by the calliper method is often of great service, during
the operation, in enabling the operator to get the fragments into
position; sometimes no fixation is required, but, if necessary,
recourse is had to plating or pegging, or an intra-medullary pin. The
extension apparatus is retained for three or four weeks. The
after-treatment is carried out on the same lines as for simple
fracture, but the retentive apparatus must be worn for a considerably
longer period.
[Illustration: FIG. 79.--Fracture of Thigh treated by Vertical
Extension.]
#Fracture of the Femur in Children.#--In children, especially below
the age of ten, this fracture is quite common. It is often of the
greenstick variety, or, if complete, is transverse and sub-periosteal,
and as it is accompanied by few symptoms and but little deformity, is
liable to be overlooked.
When there is displacement, the deformity is similar to that in
adults, and the treatment is carried out on the same lines.
In young children the nursing is greatly facilitated by applying
vertical extension to one or both lower extremities (Fig. 79). If the
fracture is transverse and shows little tendency to displacement, the
local Gooch splints may be dispensed with; in any case, massage should
be employed from the first.
The patient may be allowed out of bed in from three to four weeks,
wearing a retentive apparatus.
The shaft of the femur is sometimes fractured _during delivery_,
particularly in breech cases. The simplest and most efficient means of
controlling the fracture is by extension strapping fixed to the lower
end of a Thomas' knee splint.