ABNORMAL CONDITIONS OF THE HIP-JOINT. 



805 



ces relative to the neck of the bone itself, ren- 

 dering it very liable to fracture in the aged. I 

 mean the expansion of the cells, by which the 

 strength of the interior of the bone is dimi- 

 nished ; and, secondly, by the partial removal 

 by absorption of that long bony arch of com- 

 pact tissue, upon which in the adult depends, 

 we believe, the principal strength of the neck 

 of the bone (jig. 318) ; and even in many aged 

 subjects, we rind the partitions of the bony 

 cells removed, and a large cavity filled with 

 fatty medulla occupies the centre of the cervix 

 femoris. All these alterations obviously weaken 

 this portion of the thigh-bone, and we feel very 

 little doubt but that when the condition of the 

 bone above alluded to exists, even without a 

 fall a fracture may occur. \Ve have noticed 

 specimens of senile degeneration of the neck of 

 the femur in museums, in which the neck of 

 the femur had been removed gradually by ab- 

 sorption, so .that the head of the bone had ap- 

 proximated to the trochanters. Such specimens, 

 where the history of the case was unknown, 

 have, we doubt not, been from time to time 

 adduced as evidences in favour of the possibi- 

 lity of bony consolidation of the intra-capsular 

 fracture. These observations on the effects of 

 senile degeneration of the neck of the thigh- 

 bone sufficiently account for the remarkable 

 frequency of the intra-capsular fracture of the 

 cervix femoris in the aged subject from the 

 most trivial causes. The fracture, under such 

 circumstances, should, in our minds, be looked 

 upon more as a stage of morbid alteration, 

 from which no amendment is to be expected, 

 than as an accidental lesion, which the efforts 

 of nature and the aid of surgery can be deemed 

 adequate to repair. 



B. Estra-capsular fracture of the neck, and 

 fracture of the superior portion of the shaft 

 the femur. Fracture of the neck of the femur 

 may occur in a part of the bone immedi- 

 ately external to the synovial sac and capsu- 

 lar ligament; it may pass obliquely through 

 the cervix femoris and trochanters, or it may 

 occur in the cellular and spongy portion of the 

 bone which is immediately external to these 

 processes. In all these cases the accident is 

 usually met with in young and vigorous indivi- 

 duals, and is often very severe. There is in 

 these cases much deformity, great eversion of 

 the limb, with considerable shortening and 

 swelling. The fracture having traversed the 

 bone external to the capsular ligament, there 

 is but little to resist the full force of muscular 

 action upon the lower fragment of the bone, 

 while the upper is forced downwards by the 

 weight of the body, so that, from both these 

 causes, much shortening is produced. The 

 muscles are in a state of spasm, and at first 

 resist the surgeon's efforts to bring down the 

 limb to its normal length. The muscles gra- 

 dually yield to gentle and continued extension, 

 and if now a movement of rotation be commu- 

 nicated to the broken femur, a crepitus can be 

 felt by the hand pressing on the great troch n- 

 ter, which on rotation of the femur is perceived 

 to move in a small circle. Kversion of the 

 whole limb, in cases of fracture of the upper 

 extremity of the femur, has been noticed as 



one of its most prominent symptoms, and the 

 cause of it may be fairly attributed to the pre- 

 ponderating influence of the rotators outwards, 

 to which the lower fragment is abandoned 

 when fracture has occurred : the rotators out- 

 wards are the glutaeus maximus, the three ad- 

 ductors, the pectinalis, the psoas magnus, and 

 iliacus internus, together with the obturators, 

 pyriformis, and other muscles, inserted into the 

 posterior inter-trochanteric line. These mus- 

 cles are solely opposed by the rotators inwards, 

 which are few and comparatively weak. Not- 

 withstanding the violence of the injury in ge- 

 neral, and the deformity, the prognosis in these 

 cases is much more favourable than in the case 

 of the intra-capsular fracture, because in the 

 former a solid bony union of the fragments 

 may be reasonably hoped for. 



In considering the symptoms of fracture of 

 the superior extremity of the shaft and of 

 the neck of the femur, whether the seat of 

 fracture be within or without the synovial cap- 

 sule, it should be recollected that extraordi- 

 nary cases may occur; thus there may be 

 fracture combined with inversion of the limb. 

 The cause of this inversion, in particular cases, 

 has been sought for, and Mr. Guthrie gives 

 ingenious anatomical reasons for this rare symp- 

 tom, depending upon the line of direction the 

 fracture may have taken ; if, for example, the 

 fracture may have taken such a course as to 

 detach from the shaft of the femur the neck, 

 and at the same time also the lesser trochanter, 

 to which is attached the great rotator outwards, 

 the psoas and iliacus, and if at the same time 

 the attachments of the gemini, obturators, and 

 pyriformis be destroyed, in this case Mr. Guthrie 

 supposes that there is an anatomical reason for 

 the rotation inwards, as the tensor vaginae femo- 

 ris and the anterior fibres of the glutaeus me- 

 dius remain unopposed. This explanation is 

 ingenious, but the cause of occasional inversion 

 of the limb in fracture, noticed by Petit, De- 

 sault, and all subsequent writers, has not yet, in 

 our mind, been sufficiently elucidated. The 

 phenomenon of inversion of the foot, in cases 

 of fracture of the upper extremity of the femur, 

 is extremely rare, but it has been noticed in 

 the intra-capsular fracture, (Stanley, Smith,) 

 in the extra-capsular fracture, (Guthrie,) and 

 we have ourselves seen it in all these cases. 

 The deviation inwards, says Dupuytren, is so 

 rare, that we can scarcely reckon upon meeting 

 it once in a hundred cases. The surgeon of the 

 Hotel Dieu attributes much of the rotation out- 

 wards in fractures of the neck of the thigh-bone 

 to the action of the adductor muscles, but adds, 

 " il faut dire aussi, qu'on notice presqueaucune 

 partie d'une autre cause, qui cependant pent 

 seule rendre compte de la deviation en dedans, 

 et apprendre a y remedier. Je veux parler de 

 I'obliquite des fragmens dans la fracture du col 

 du femur, si le fragment interne se porte en 

 arriere, et 1'externe en avant, il y a alors devia- 

 tion en dehors. Si, au contraire, la fracture est 

 oblique, en sens inverse, la deviation aura lieu 

 en dedans. C'est done par I'obliquite des frag- 

 mens, que ces varietes de deviation peuvent 

 ctre apprecices." 



(J . Fracture of the neck oj 'the fanur, cvwpli- 



