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It, and Is Very Satisfactory in Its End-Result. Complications, As View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by ZENODO and bandage only makes a bad matter worse, the materially in differentiating the variety and location vessels and nerves being compressed between bone of the fracture. The major or direct causes almost and board. That which is absolutely essential to invariably cause the extracapsular variety of frac¬ thoroughly satisfactory répair, is early and complete ture with or without impaction, while the minor or adjustment. This is one of the few fractures in which indirect cause produces intracapsular fracture. the chief difficulty lies in securing not maintaining Symptoms.—In all cases of suspected fracture of apposition. Once secured, only the simplest after- the neck of the femur, the entire person, from the treatment is really required ; a band around the wrist anterior superior spinous process of the ilium to the perhaps, to lessen the after-spreading due to separa¬ toes, with the exception of the external genital or¬ tion of and later somewhat misplaced attachment of gans which can be protected from view by a napkin, the inter-articular cartilage. should be exposed to inspection. After the clothing In view of possible after-ligation, as professional has been removed above the pelvis we are at once en¬ opinion is now, it is wiser as a rule to employ some abled to see the relationship of the two opposite tro- form of splint, plaster-of-paris or other, never extend¬ chanters to each other, their corresponding appear¬ ing below the wrist line and thus supporting the ance, their relative prominence. We can also observe hand, which should be allowed to hang free. But the relative positions of the two limbs throughout the use of such splint is not necessary so far as the their entire length, and also we can better detect the break is concerned, provided (and this proviso must slightest eversión of the foot in the least departure in be kept constantly in mind) complete apposition of its direction, and at the same time detect the least the fragments is secured. degree of shortening of the limb. Much of the in¬ Its manner of production well understood, the formation gained by this investigation is in these difficulties in the way of primary adjustment duly cases derived from comparative observation. The recognized, and the first dressing properly made, this trochanter should first be examined. In the fractured fracture becomes one of the simplest to treat, causes bone, except in cases of impaction and non-displace¬ little inconvenience, comparatively, to the subject of ment of the fractured ends, the trochanter is de¬ it, and is very satisfactory in its end-result. pressed and flattened compared with the sound side, and when moved from side to side the arc of the motion is considerably reduced. Extending our in¬ FRACTURES OF THE NECK OF THE FEMUR vestigation downward, we observe the lower or tibial AND THEIR TREATMENT. end of the patella does not correspond with that on the sound side. It is from a to an inch Read in the Section on Surgery and Anatomy, at the Forty-fifth Annual quarter Meeting of the American Medical Association, held at San Francisco, above the line of that of the sound limb. June Continuing 5-8,1894. our observations to the foot we find a shortening of BY BEDFORD BROWN, M.D. the limb to the extent of from a quarter to an inch ALEXANDRIA, VA. and a quarter in length. At the same time we find My personal experience in fractures of the neck of the foot of the injured limb everted. When by our the femur comprises fourteen cases. Of these about own aid we correct this eversión it invariably returns 10 per cent, died in less than twelve months from spontaneously, and when the patient is requested to complications, as inflammation and suppuration at correct it, she is unable to comply with the request. the seat of injury, and fever. Two per cent, were Here we have a typical picture of a simple fracture bed-ridden for the balance of life. The remainder of the cervix femoris,—first the depressed flattened recovered sufficiently to walk with the aid of a cane or trochanter, the difference in the line of the corre¬ crutch for the balance of life. All the bed-ridden sponding patellse, the shortening of the limb and cases were of the extracapsular variety while the eversión of the foot. When the entire person is ex¬ cases that recovered the power of locomotion were of posed without any movements of the patient, or the intracapsular non-impacted variety. manipulation on our part, the eye can detect these All of these cases of fracture of the neck of the peculiarities at a glance. femur occurred in females varying in age from 60 to Then again, in non-impacted fracture, if an assis¬ 85 years old. These fourteen subjects presented tant grasps the foot of the injured limb and alter¬ every variety of conformation of figure. In two nately extends and relaxes the limb while the atten¬ there was great obesity. In some the figure was tall dant grasps the trochanter and presses it firmly and spare, while in others it was quite petite, and towards the pelvis, distinct crepitus may be detected. very delicate and slight. In one the figure was that Methods of Differentiation between Intracapsular and of a very robust woman a little over 60. In one, a Extracapsular Fractures.—In determining the impor¬ woman of 85, the weight did not exceed eighty pounds tant question whether a fracture is intra or extra¬ and the person was very emaciated. capsular, is non-uniting or uniting, the peculiar Causes of fracture of the cervix femoris.—The causes character of the cause assumes diagnostic importance. of this fracture may be classified as the direct or It may be said with much degree of certainty that major and the indirect and minor. shortening of the limb to the extent of a half or one The major form of causéis always from direct vio¬ inch, eversión of the foot, moderate pain in the hip, lence, as a sudden fall from a distance on the hip, or no indications externally of contusion, some crepitus a violent blow or great pressure from mechanical on extension, flattening of the trochanter occurring causes on the same point. On the contrary, the minor after a slight indirect injury, as a very sudden mis¬ causes are always of the indirect variety from un¬ step, striking the foot against the floor or steps forci¬ usual sudden pressure on the foot while walking, a bly, or a sudden twist or wrench of the foot from any slight misstep, a sudden twist of the foot while slight cause in the aged, denote intracapsular frac¬ walking. ture with no possible tendency to unite. On the con¬ A knowledge of the major and minor, or direct and trary, shortening of the limb to the extent of from indirect character of the existing causes will aid us one to two inches with eversión of the foot, great Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/08/2015 pain in the hip, flattening of the trochanter, effusion expect union of the fractured bones, but on the con¬ in the surrounding tissues in front and rear of tro¬ trary to so conduct the management of the case as chanter, crepitus on extension in the comparatively will, if possible, insure a good, strong, false joint, by young, much contusion of soft parts, from a major which after a time the patient can regain a fair de¬ form of cause as a violent fall, blow or pressure di¬ gree of locomotion for the balance of life. To bring rectly on the trochanter denote extracapsular fracture about this desirable object, the pelvis from the an¬ with tendency to union of ligament. terior superior spinous process is enveloped with a Then again a slight shortening of the limb and broad flannel roller four inches wide and fifteen feet eversión of foot, with much pain on attempted mo¬ long, applied down below the trochanters. This tion, absence of crepitus, slight ability to raise the flannel bandage gives comfort by the support that it limb or stand upon the foot, great effusion in front affords the fractured bones, and the prevention of and rear of trochanter, from a violent direct injury too much motion, and gives opportunity to the soft to the trochanter with contusion of soft parts, indi¬ parts involved to throw out adhesive exudations. cates impacted fracture. This is the full extent of the apparatus to be applied. Diagnosis of Impacted Fracture of the Cervix Femori. As for the balance of treatment, pillows long and —The two cases of impacted fracture of the neck of short, small and large, are to be relied on for splints the femur which came under my observation both and supports. Comfort of position is to be the guid¬ resulted from indirect and violent causes. In one ing rule in the management of this class of cases. the patient was 70 years old, and had a violent fall The ingenuity of surgeon and nurse will be taxed to directly on the trochanter of that side. The tro¬ so arrange the pillow splints as to insure comfort, re¬ chanter was found on comparison with the opposite lieve pain and secure sleep. When these objects are side to be flattened and depressed, and very tender accomplished all has been accomplished that judg¬ on pressure. There was considerable swelling back ment and experience can do until inflammatory action of the trochanters, and in front below Poupart's lig¬ subsides, and the process of fibrinous exudation is ament there was great swelling and much pain and completed, and then the false joint is ready for use.
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