James Alderson
1879 The Lancet  
6 Bigelow, and delineated by Fig. 13 , page 63, of his most interesting work on "Dislocations and Fractures of the Hip-joint," a copy of which figure is here inserted. The patient having been brought under the influence of chloroform, I easily traced with my finger the outline of the trochanter major, and found that its upper border was directed downwards and backwards. I could not discover the ball of the femur, and therefore came to the conclusion that it remained in the acetabulum. On
more » ... etabulum. On rotation of the thigh, the trochanter major did not describe the segment of a circle, as in a dislocation, but was observed to revolve on its own axis, as in fracture of the neck of the thigh-bone, and during rotation slight crepitation was elicited. From the above symptoms, I was convinced that this was a case of fracture of the neck of the femur with flexion, adduction, and inversion of the limb, a variety of fracture not hitherto described, as far as my reading has enabled me to judge. Having formed this opinion, I reduced the fracture by taking hold of the knee with one hand and the foot with the other, by placing the leg at a right angle to the thigh, by abducting, rotating outwards, and bringing down the limb by the side of the other-in short, reduction was accomplished by practising the last three movements adopted by Bigelow for reduction of dislocation of the head of the femur on the dorsum of the ilium. When the limb was thus brought into proper position, it exhibited no tendency to eversion or inversion, and there was scarcely any appreciable shortening. For the first twenty-four hours following reduction the affected extremity was kept at rest by placing a long sandbag by the side of the patient's trunk and limb, and afterwards by applying to the outer side of her pelvis, thigh, leg, and foot a long splint, composed of long broad bandages charged with plaster-of-Paris, and moulded into the shape of a Desault's splint. The test-line of the ilio-femoral triangle, shown by Bryant to be so valuable for enabling the surgeon to arrive without excessive manipulation at a reliable diagnosis in fractures of the neck of the thigh-bone and Nelaton's test-line for dislocation of the head of the femur backwards, were not available in this case, owing to the extraordinary position of the femur; but the already described symptoms produced a decided conviction in my mind that the case was one of fracture of the neck of the thigh-bone with the limb in a position which I had never before seen in any example of that injury, and the postmortem examination made six weeks after the reduction of the fracture proved that my diagnosis was correct. From the moment that the limb was made straight the patient remained perfectly free-from pain in the hip, but frequently complained of pain at the knee, which was perfectly sound. This pain was chiefly seated within and at the inner side of the joint-a symptom so common iii morbus coxæ, --sometimes misleading an unwary surgeon; but rarely, if ever, met with in injuries of the hip-joint" judging from my own experience. If the conditions in which this symptomatic pain is experienced be disease at the filamentous terminations of one branch of a nerve, and the pain reflected to the terminations of another branch of the same nerve, conditions furnished by the anterior branch of the obturator nerve supplying the hip, and the posterior branch the knee-joint, it is difficult to understand why the symptomatic pain is experienced so severely and frequently at the knee in disease, and so rarely, if ever, in painful accidents, of the hip-joint. Six weeks after the application of the plaster-of-Paris bandage-splint, and three days before the death of the patient, the splint was removed, and the limb remained straight, without any tendency to eversion or inversion, and there was no appreciable shortening. Notwithstanding the occasional and unavoidable contact of urine with the denuded surface on the patient's back, which was covered with a large gangrenous slough on her admission, by the application of turpentine, carbolic, and other dressings, and the removal of all pressure by means of a water-pillow ring filled with air, the slough eventually was removed, and granulations made some advancement; but these attempts at healing were fruitless, owing to the great weakness and age of the patient. The weakening effects of this large sore, together with amyloid degeneration of the kidney, caused death fifty days after the occurrence of the injury. The post-mortem examination was conducted by Dr. Rodger, pathologist to the Aberdeen Royal Infirmary, who found that the capsular and ilio-femoral ligaments were per* fectly entire, the latter being thicker and stronger than usual; that the neck of the femur was fractured close to the ball of the bone, the plane of the fracture being at a right angle to the long axis of the neck ; that the outer fragment was considerably shortened, debris occupying the plane of the fracture ; that there were no bands uniting the fractured surfaces to one another, and that there was no effusion into the joint, and no signs of the inflammatory process. The round ligament was perfectly entire, showing that the ball of the bone had never left the cavity of the acetabulum. I believe that the integrity and tension of the ilio-femoral ligament was the cause of the adduction, flexion, and inversion of the limb, and that by its causing the centre of motion to be situated at its attachments to the anterior inter-trochanteric line of the femur was the explanation of the facility with which the outer fragment was returned into its proper position by the manipulation of the limb. Of the one hundred and thirty cases of intra-capsular fracture of the neck of the thigh-bone which have come under my notice, and where the accuracy of diagnosis was verified by dissection, this is the only case I know of with flexion, adduction, and rotation inwards of the limb. Of the remaining number, in one case only have I met with rotation inwards, the limb in other respects occupying the usual straight position. I watched that case of intra-capsular fracture with inversion during life, and had an opportunity of verifying the diagnosis after death, and have been for many years in the habit of exhibiting the preparation to the students of surgery in the University of Aberdeen.
doi:10.1016/s0140-6736(02)42342-2 fatcat:kjr3txgdbre4pdpw77ywgxwkii