806 



ABNORMAL CONDITIONS OF THE HIP-JOINT. 



cated with fracture through the trochanter 

 major. In the thirteenth volume of the Medico- 

 Chirurgical Transactions, Mr. Stanley has re- 

 marked that among the more complicated inju- 

 ries to which the hip-joint is liable, that of 

 fracture of the trochanter major, combined with 

 fracture of the neck of the femur, has, under 

 certain circumstances, a strong resemblance to 

 dislocation of this bone. Whenever the frac- 

 tured portions of the trochanter can be brought 

 into contact, a crepitus will be perceived, which 

 will enable the surgeon to ascertain the precise 

 nature of the injury ; but when from the direc- 

 tion of the fracture, one portion of the trochan- 

 ter major has been drawn by the muscles to- 

 wards the sciatic notch, no crepitus can then be 

 discovered. A direct source of mistake will 

 then arise from the positive resemblance of the 

 fractured portion of the trochanter to the head 

 of the femur, the former occupying the place 

 which the latter would do in dislocation, and 

 if, with these circumstances, there should hap- 

 pen to be inversion of the injured limb, the 

 difficulty of diagnosis must be considerably in- 

 creased. The writer has seen such cases as 

 those alluded to by Mr. Stanley, and when he 

 confined his observations to the consideration 

 of the joint only, he felt all the difficulty alluded 

 to in forming an opinion ; but in these cases 

 the limb can in general be brought down to its 

 natural length by forcible extension, and it is 

 possible, too, to flex the thigh on the abdomen, 

 which we know to be impracticable in the case 

 of luxation. In most of the cases which the 

 writer has witnessed of the fracture traversing 

 obliquely the superior extremity of the shaft of 

 the femur, detaching the trochanters, the foot 

 and whole of the injured extremity were everted, 

 a position it were impossible for the limb to 

 assume, were the globular-shaped head of the 

 bone on the dorsum of the ilium, or placed to- 

 wards the ischiatic notch, and indeed, in the 

 cases which he has seen, with inversion of the 

 limb, the inverted position was not permanent, 

 as when the patient was raised out of bed, and 

 assisted to stand for a few minutes on the 

 sound extremity, the injured limb gradually 

 assumed an inclination forwards and outwards; 

 the inclination, though slight, was always to a 

 degree which it were impossible to give to the 

 limb if the head of the bone were placed on 

 the sciatic notch. Finally, as to the remark- 

 able symptom of inversion of the limb, com- 

 bined with fracture, we have never seen this in- 

 version so rigid as it is in the luxation ; the in- 

 version can be overcome, and we have mostly 

 found that in the cases in which this symptom 

 was noticed, there existed a comminuted frac- 

 ture of the superior extremity of the shaft of 

 the femur, and the limb, if left to itself, would 

 be found sometimes to be everted, sometimes 

 to be inverted, and generally to possess a re- 

 markable degree of flexibility, yielding to any 

 movements the surgeon wishes to communicate 

 to it. Such has been the result of the writer's 

 individual observations on these cases. 



D. Fractures of the neck of the thigh-bone, 

 with impact ion of the superior or cotyloid frag- 

 ment into the cancellated tissue of the upper extre- 

 mity of the sliaft of the femur. We have spoken 



of a fracture of the neck of the thigh-bone, in 

 which the fracture runs transversely with respect 

 to the direction of the axis of the neck of the 

 bone, and also of oblique fractures of the cervix 

 femoris (Dupuytren). In the former, i. e. the 

 transverse fracture of the neck, the two opposite 

 surfaces of the fragments are generally fairly 

 confronted to each other, and each presents a 

 granular broken surface ; but instances have 

 been met with in which there existed an inter- 

 locking of these surfaces. A bony spicula or 

 dentiform process, as it were, has been seen to 

 proceed from the broken surface of the superior 

 or cotyloid fragment, and to sink into an alveo- 

 lar-like depression on the upper surface of the 

 lower fragment ; to use the words of Cruveil- 

 hier : " L'engrenement des fragmens s'observe 

 moins souvent, peut-ctre dans la fracture intra- 

 capsulaire que dans la fracture extra-capsulaire. 

 Cependant je 1'ai observee plusieurs fois ; 

 dans un cas de fracture intra-capsulaire du col, 

 observe sur un adulte tres vigoreux, j'ai trouve 

 un engrenement reciproque forme ainsi qu'il 

 suite le fragment superieur et le fragment infe- 

 rieur presentaient chacun une cavite, et une 

 avance osseuse ; la cavite de 1'un recevait 

 1'avance de 1'autre et reciproquement, 1'engrene- 

 ment etait, qu'il y avail immobilite complete." 

 In the species of fracture which we are now 

 about to consider, the superior or cotyloid frag- 

 ment is firmly impacted into the cancellated 

 structure of the superior part of the shaft of the 

 femur. In this case the limb is shortened 

 somewhat, though not much, and consequently 

 the case may be mistaken for the intra-capsular 

 fracture. When, however, the surgeon endea- 

 vours to bring the limb to its normal length, 

 and to elicit crepitus, or by rotation of the 

 femur he endeavours to ascertain whether the 

 trochanter moves in a larger or smaller circle, 

 he finds that he cannot elongate the shortened 

 limb, nor elicit crepitus by rotation, nor can he 

 learn anything* satisfactory by the movement of 

 the trochanter. In general the fracture is com- 

 plete of the compact and reticular tissue of the 

 neck of the bone, and the upper fragment is 

 wedged into the lower, as is the fang of a tooth 

 into its alveolus ; but cases, we believe, have 

 occurred, in which the fracture of the cervix 

 femoris was incomplete, and had engaged 

 merely the under stratum of the compact tissue 

 of the neck of the bone. To comprehend well 

 what occurs in the partial as well as in the im- 

 pacted fracture, we should attend a little to the 

 normal anatomy of the interior of the cervix femo- 

 ris, and the disposition of the compact and reti- 

 cular tissue, a subject the writer has elsewhere 

 stated has been much overlooked, see Dublin 

 Journal, vol.vi. p. 222, from which we quote the 

 following words : " Let us make a vertical sec- 

 tion through the neck of a healthy femur, in the 

 direction of its long axis, and continue it down 

 through the shaft of the dry bone, the section 

 leaving one-half of the femur in front, and the 

 other behind with the lesser trochanter, as has 

 been done in the specimen of the healthy femur 

 of a well-formed adult man, from which Jig. 318 

 has been taken. This simple view shews us, that 

 the principal strength of the neck resides in au 

 arch of compact tissue, which begins small 



