803 



ABNORMAL CONDITIONS OF THE HIP-JOINT. 



his weight on the fractured limb, then it is 

 more particularly that the power of the obtu- 

 rator externus is called into action to restrain 

 the ascent of the trocbanter major, which is 

 kept downwards by the obturator and by the 

 strength of the capsular ligament, which under- 

 goes a corresponding change of structure. The 

 capsular ligament has been found semi-cartila- 

 ginous, and occasionally even spiculae of bone 

 have been found in it ; we have also known it 

 to be much elongated, so as to allow the lower 

 fiagment to ascend much on the dorsum of the 

 ilium. We have found the capsular ligament 

 usually entire in old cases, but occasionally the 

 bursa, which exists in front of or under the 

 psoas muscle, seems to have freely communi- 

 cated with the interior of the joint. In some 

 cases the natural thickness of the capsule is 

 not much increased ; in others it is very con- 

 siderably so. In one of the cases alluded to 

 by Mr. Colles, the capsular ligament was a 

 quarter of an inch thick, in some places half an 

 inch, and it had, at the same time, a firmness 

 of texture which might be termed semicartila- 

 ginous. Two or three particles of bone were 

 found in it. The synovial membrane, where it 

 meets the neck of the femur, has been fre- 

 quently found lacerated in -recent cases; in 

 older, inflamed, and in older still, adhesions of 

 the synovial structures to each other have been 

 observed. Thus the head of the fractured 

 femur has been found adherent to the acetabu- 

 lum, and we have frequently found filamentous 

 adhesions between the synovial membrane of 

 the neck of the bone and the interior of the 

 synovial lining of the fibrous capsule. The 

 synovial membrane, in the normal state, where 

 it invests the narrowest part of the neck of the 

 bone, is thrown into longitudinal plicae or folds; 

 some of the lowest and most distinct of these 

 are denominated by \Veitbrecht " retinacula." 

 We do not believe that this accurate anatomist 

 gave this name to these nbro-synovial folds 

 with any practical knowledge of the functions 

 which they occasionally perform in cases of 

 fracture ; but we know very well by experience 

 that, in recent cases of the simple intra-capsular 

 fracture of the neck of the femur, it very fre- 

 quently, if not generally, happens that, although 

 the neck of the femur is 'broken transversely 

 with respect to its longitudinal axis, the cylin- 

 der of fibro-synovial membrane, which is re- 

 flected over the neck of the bone, is sometimes 

 left unbroken, or is only partially lacerated. 

 The fibrous periosteum, which is here added to 

 the synovial investment of the neck of the 

 femur, strengthens much this part of the mem- 

 brane, and both together, in cases of intra-cap- 

 sular fractures, serve the purpose of keeping 

 nearly in apposition the broken fragments; and 

 in cases in which the greater part of this cylin- 

 drical investment of the neck of the bone re- 

 mains entire, or nearly so, the unbroken mem- 

 brane and the vessels which pass along it must 

 be the medium of vascular communication be- 

 tween the fragments. 



The phenomena which extra-capsular fractures 

 present are not unlike those which are the result 

 of fractures elsewhere of the femur. We may 



remark, however, that one of the results of this 

 lesion of the neck of the femur (as it is, in- 

 deed, of almost all other injuries or alterations 

 of structure of this part of the bone) is, that 

 the posterior part of the neck of the femur is 

 diminished one-half in its normal length ; the 

 posterior inter-trochanteric ridge of bone ap- 

 proaches to within half an inch of the circular 

 line which marks the junction of the head and 

 neck of the bone. A large quantity of callus 

 is usually thrown out in the line of the extra- 

 capsular fracture, and the trochanter major be- 

 comes much deformed by it, and the neck so 

 much shortened, that there is danger of the 

 motions of the hip-joint being interfered with. 



In recent cases in which intra-capsular fracture 

 had occurred, little or no change has been ob- 

 served worth noticing ; but in old cases several 

 phenomena of importance present themselves. 

 1st, In some cases we find a false articulation 

 to have been formed ; 2dly, there is union of 

 the broken surfaces of the upper and lower 

 fragment by means of ligamentous bands; 

 3dly, it is reported that complete bony union 

 is effected, but the controversy upon this sub- 

 ject can scarcely be said to be yet terminated. 



Very soon after intra-capsular fracture has 

 occurred, the surfaces of the broken frag- 

 ments undergo changes ; they are smoothed off 

 by the power of the absorbents, or are mechani- 

 cally rubbed down by the friction of the broken 

 surfaces, or by both these processes combined. 

 In general the neck of the femur disappears 

 altogether, and the basis of the head of the 

 bone corresponds to the level of the circular 

 brim of the acetabulum. The surfaces are ge- 

 nerally brought into contact by the muscles, 

 and frequently adhesions are formed between 

 the neck of the bone and the internal surface 

 of the capsular ligament, which, as has already 

 been remarked, is greatly thickened ; an oily 

 fluid, resembling natural synovia, is shed over 

 the broken surfaces, and here are all the ele- 

 ments of a false articulation present. The tro- 

 chanters are, in consequence of the removal of 

 the neck of the bone, brought near to the edge 

 of the acetabulum, and bony growths generally 

 shoot out from these processes and from the 

 inter-trochanteric line posteriorly. These bony 

 projections or vegetations sometimes rise as 

 high as the edge of the acetabulum, and when 

 the patient stands or walks, these bony growths 

 rising up from the trochanter are supposed to 

 afford a prop to the pelvis, and thus to assist 

 somewhat the structures which perform the 

 functions of the false articulation. It has been 

 noticed that, in general, the removal of bone 

 from the upper fragment extends as far as the 

 basis of the head and the level of the circular 

 brim of the acetabulum ; but in some cases this 

 fragment has been hollowed out. Again, in 

 obedience to influences which we cannot ex- 

 plain, it has happened that the lower surface of 

 the upper fragment formed an uniform convex 

 surface, looking downwards, and corresponded 

 to a large excavation formed in the substance 

 of the great trochanter. This, we find, occurred 

 in one of Mr. Colles's cases : the lower surface 

 of the upper fragment was convex, and covered 



