Extra-Capsular Fractures of the Neck of the Femur. 3

.ART. II.--Extra-Capsular Fractures of the Nec]c of the Femur. a By ALEXANDER GORDOn, M.D., Professor of Surgery, Queen's College, Belfast.

(~ontlnued frora Vol. ZXXI., p. 507.)

Second Form.--In the form which I have described as the first, the line of fracture in front may be through the anterior inter- troehanteric line, or it may include a large portion of the anterior surface of the upper part of the shaft extending almost to its outer surface. Now in this, the second form, the line of fracture in front is along the inner margin of the anterior intertrochan- teric line; above and behind it is at the point of reflection of the compact tissue of the base of the neck, where it changes its direc- tion to form the apex of the trochanter and the posterior intertro- chanteric line, above or below the lesser trochanter. Its course is, therefore, more limited to the base of the neck than the first form. From the direction of the force which is applied to the fore and upper part of the head, the base of the neck in front penetrates behind the compact tissue forming the upper part of the shaft ; and, as the line of fracture behind is at the junction of t h e base of the neck with the posterior intertrochanteric line, it follows that the entire base of the neck penetrates the troehanter, and, in consequence of this mode of penetration, the trochanteric fragment is much greater than in any of the other forms. I have applied to this the term penetration en masse. In many instances nearly the whole of the trochanter is separated from the shaft above. Behind it extends almost, in some instances, to the outer surface of the shaft and below, including the lesser trochanter and part of the shaft below and behind it all in one fragment. In one of the specimens before me at present the depth of the trochanteric fragment is four inches, and its breadth two inches. The angle formed between the neck and the shaft varies but little ; it is often a right angle, or sometimes more or even less than a right angle. As the base of the neck is directed more or less backward, there is very little eversion of the limb. Sometimes there is well-marked inversion, and occasionally neither eversion nor inversion. Owing to the depth to which the base has penetrated, there is well- marked shortening of the limb, and a manual examination of the upper end of the shaft renders the diagnosis usually very easy-- the great increase in the antero-posterior diameter, from the

" Read before the Ulster Medical Society, lOth May, 1881.

4 Extra-Capsular Fractures of tile Neck of t]~e Femur.

flattening of the great trochanter, and the great size of the trochanteric fragment, and also often a well-marked trochanteric groove. As nearly the whole of the apex of the trochanter is broken off and carried backwards, measurement of the outer surface of the femur shows a shortening in many instances equal to the depth of the trochanter, or more than an inch. Passing the finger along the outer bifurcation of the linea aspera detects at once the prominence of the fragment, contrasting remarkably with the opposite femur. If there is not much swelling, and the limb slightly everted, we may be able to feel the prominence of the anterior intertrochanteric line,-which in recent cases would be very painful on pressure. I think that in this case the moment the fracture occurs, instead of the pelvis gravitating backwards as in the first form, it falls forwards; or, in other words, the patient will be found immediately after the accident lying on his back, with the toes remarkably turned out, in the first form, while in this, the second form, the patient will be found prone, with the limb scarcely at all everted or inverted. I t is this form which some authors have described as non-impacted extra-capsular fracture that is to say, where the base of the neck rests upon the large flattened trochanteric fragment and the upper end of the shaft, where penetration has been carried to such an extent that impaction no longer exists.

I have several specimens of the extra-capsular non-impacted fracture. They all occurred in persons of extreme old age, in which there was great fragility of the bone, from senile atrophy, and the force which caused the accident was not of extreme violence, but was by simply falling and alighting on the trochanter.

Treatment.--The treatment of this form is the same as that of the first. Indeed, when I compare two well-marked specimens, I find, in the first form, if the force had been continued it would have placed the base of the neck upon the front of the shaft, with the trochanteric fragment attached to the shaft, whereas, in the second form, the base of the neck would have gone behind the shaft, with the neck attached to the trochanteric fragment.

As regards the impaction of bone, I may here remark that I have never seen any bone whatever, no matter how deeply the fragments were driven into each other, held firmly together. I f I take an axe and drive it into a piece of wood, the resiliency of the wood will hold it firmly impacted, but in bone it is the fibrous tissue and not the osseous tissue that holds the fragments firmly together,

By DR. ALEXANDER GORDON. 5

for if we remove the fibrous tissue the osseous fragments will drop apart from each other.

Third Form.--The basis upon which I found the third form is the deep penetration of the trochanter above and behind, the result of which is a great increase of the angle between the shaft and the neck.

I have only two specimens of this form, and the propriety of considering them as a third form might be questioned, as the mode of penetration above is not exactly the same in each. In one the penetration is deeper above and behind, breaking off a comparatively small part of the upper and posterior part of tho trochanter. The increase of the angle is very decided, and the shortening was so slight that it could not be detected by m~asure- ment. Iu other respects it resembles the first form in which the head is carried backwards, the base of the neck forming a salient angle in front.

Diagnosis.--The diagnosis could have been easily made out by the prominence of the base of the neck in front, the increase of the antero-posterior diameter being confined to the apex of the trochanter, without shortening of the limb. In the second specimen the base of the neck has penetrated deeply above, fissuring the trochanter, whilst below it is started forwards, slightly overlapping the shaft in front of the lesser trochanter. The angle is very obtuse. A similar specimen is figured by Mr. (afterwards Sir) Charles Bell in his work on "Fractures of the Thigh Bone."

Fourth Form.--In the fourth form, as in some specimens of the other three varieties, the fracture follows the base of the neck as described by anatomists. The penetration, although slight, is most marked between the lesser trochanter and the anterior internal ridge of the shaft. The compact tissue being thick and strong here, the base of the neck entering as a wedge splits the shaft. In one instance the fracture passes downwards to four inches below the base of the trochanter, in the other it is eight inches in length. In one of these the trochanter is simply fissured above. The patient from whom this specimen was obtained was under my own care in hospital. On making my usual visit I inquired from the house-surgeon the nature of the case. He replied it was a very oblique fracture of the upper third of the femur. On the fourth day afterwards the patient was attacked with traumatic delirium, and as he had displaced the long splint which had been applied, I saw and felt on the outer surface of the

6 Extra-Ca~vsular Fractures of the ~Tec~ of the Femur.

thigh four inches below the lesser trochanter the lower end of the upper fragment sharp, thin, and prominent. There was no shorten- ing or eversion of the limb. He died on the seventh day. The femur was removed after death, and when given to me by the house-surgeon I thought it was a very oblique fracture proceeding from the base of the neck below, running down across the rough ridge from the attachment of the gluteus maximus. After that it coursed round the outer surface of the femur, and ran up to the capsule at the middle of the base of the neck. On removing the capsule and soft textures I found that the base of the neck moved upon the trochanter, and that this really oblique fracture was caused by the base of the neck penetrating the shaft opposite the lesser trochanter. Had this patient escaped traumatic delirium, there would have been no evidence whatever that he had sustained an extra-capsular fracture. There would have been no eversion, inversion, or shortening of the llmb; there would have been no fracture of the trochanter capable of detection. The attachment of the gluteus maximus behind to the linea aspera prevented shortening. In front the upper end of the shaft was firmly attached to and fixed by the capsule. In no part was the penetration greater than half a line.

The second specimen was presented to me by a former pupil of mine, Dr. Chambers. In it the portion of the shaft attached to the trochanter is eight inches in length. I t was even sharper and thinner than the first specimen. The amount of penetration of the base of the neck, however, was nmch greater, but in neither of the two instances was the trochanter broken in the usual way in these fractures. Indeed, in both specimens it may be said to consist of head and neck one fragment, the greater and lesser trochanter to the upper and outer surface of the shaft form the second fragment, whilst the remainder of the shaft forms the third fragment.

Now, this form is exceptional in several respects :--=(1) The trochanter will be felt to be normal. (2) There will be no shorten- ing, (3) inversion, (4) or eversion. The obliquity and thinness of the fragment, which is split from the upper and outer part of the shaft of the femur, would be sufficiently diagnostic, and I could hardly conceive any other force excepting the base of the neck forming such an oblique and thin fragment. (5) I t is also exceptional in its treatment, as it would require the use of the long splint to hold the split fragments together.

Medical Report of Cork-street Fever Hospital. 7

Fifth Form.--In the fifth form the fracture of the base is the usual one, but it acts on the neck by running obliquely upwards towards the head, splitting the neck into two unequal parts. The diameter of the neck being thus diminished, that portion of the neck attached to the head penetrates deeply, and reaches in the two specimens which I have to the inner surface of the upper end of the shaft. Indeed, I have several specimens in which large portions of the neck have been broken off and have disappeared, leaving merely the portion of the neck which was attached to the head. The trochanter is also fissured, but not widened so much as to enable us to detect any lesion of it.

Diagnosis.--In the diagnosis the signs would be regarded as indicating an intra- rather than an extra-capsular fracture.

ART. III.--Medical Report of the Fever Hospital and House of _Recovery, Cork-street, Dublin, for tl~e year ending 31st March, 1881. By JOHn WILLIAM MOORE, M.D., M.Ch. Univ. Dub. ; Fellow and Ex-Censor of the King and Queen's College of Physicians; Physician to the Hospital, and to the Meath Hospital and County Dublin Infirmary; Lecturer on Practice of Medicine in the Carmichael College of Medicine, Dublin, &c.

THE present Annual Medical Report of Cork-street Hospital and House of Recovery proceeds upon the same lines as the Reports for previous years. The statistical tables, in which are contained the data for the medical history of the year, have been compiled, as usual, by Dr. G. Purcell Atkins, who has spared no pains in the effort to make the tables as comprehensive as possible, and thoroughly accurate. To him I desire to express my acknow- ledgments for the valuable aid he has thus given me in the writing of this Report.

From the yearly statement of patients it appears that the admissions to the hospital were 1,250 in number. The correspond- ing numbers for the preceding four years were : - -

1876-77, - - - 666 1877-78, - - - 936 1878-79, . . . . 2,151 1879-80, - - - 1,083

As my colleague, Dr. Harvey, pointed out in his Report of last year,