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common location is the posterior, the neck being driven, as it were, into the trochanter. Very rarely is the trochanteric portion driven into and received by the neck. These are the more common, though by no means all, of the pathological conditions found in this class of injury, and apply more particularly to the aged individual than to the younger adults. The classical symptoms of fracture, namely: deformity, crepitus, preternatural mobility and loss of function, obtain here, but with less constancy, and in less degree than in fractures in other locations. There is a loss of function more or less complete, eversion or occasionally inversion of the toe, shortening, immediate or increasing, and elevation of the trochanter.

In reference to the limb, there is marked helplessness of this member in the majority of cases, although there are recorded instances in which the patient has walked after receiving the injury. Pain is almost always present, and at times is so severe as to contribute to and maintain a marked degree of shock for a long period of time. The pain is aggravated by manipulation or attempts at voluntary motion. There is fullness in the fold of the groin anteriorly, and pressure down upon this fullness in the direction of the neck occasions paroxysms of pain. The limb is abducted and rotated outward, as a rule, although a case occasionally presents itself in which the toe is inverted.

There is shortening and slight flexion of the limb as the patient lies upon the bed. Sometimes he can, with a moderate degree of suffering, flex the thigh upon the body. Though able to perform this flexion, he is wholly unable to extend the leg upon the thigh. Eversion may be marked, the outer border of the foot resting upon the bed, while again this symptom is so slight that, as Professor Bigelow has suggested, "it is best recognized by comparing the extent to which both toes can be inverted." The cause of eversion is probably almost always mechanical, or, in other words, the result of gravitation; for, "while the patient is upon his back, the tendency of both limbs is to eversion, there being a slight, though distinct effort necessary to maintain the toes in an erect position." Eversion is favored by an angular displacement of the fragments. However, this symptom has been noted in simple contusion, and in fractures in which the periosteum was not torn. As a symptom of this condition then, it is in nowise pathognomonic, and can only be used in connection with, and as a part of the whole symptom complex. The cause of inversion when present is not known, being attributed by Smith to the overriding of the inferior fragment. Swelling' is a symptom of some importance, and appears rather soon.

Ecchymosis is present, but usually makes its appearance after the diagnosis should have been made, at the end of twenty-four or forty-eight hours.

Shortening of the limb is present, and is caused by alteration of the angle between the shaft and the neck, or by overriding.

The degree of shortening may vary from a small fraction of an inch to as much as three inches, and may be immediate, but as is more commonly observed, is present to a small degree, gradually or suddenly attaining its maximum. In intracapsular fractures, shortening may be absent, or slight at first, gradually increasing, and does not exceed one and onefourth inches at its maximum, unless the periosteum be extensively torn, allowing an unusual degree of displacement. The degree of immediate shortening is limited only by the amount of impaction and extent of the injury.

To determine shortening, the measurements should be taken from the anterior spine of the ilium to the external malleolus. To insure correctness in the measurements, the degree of abduction and eversion in both limbs should be as nearly equal as possible. A good way is to stretch a line from one anterior iliac spine to the other, and drop a cord perpendicularly from the middle of this line, letting it fall between the feet. The feet, or internal malleoli, should now be brought to within equal distances of this line, and the measurements then taken.

The shortening can usually be readily overcome by moderate traction and by sufficient rotation of the limb outward to overcome the inversion.

In this particular fracture, crepitation is a very inconstant sign, but is sometimes manifest upon slight manipulation, rotation and gentle traction. The absence of this sign is no doubt largely due to the degree of impaction present. It should not be repeatedly sought for, since in many and forcible manipulations necessary to produce it, impactions are broken up and connecting bands of periosteum severed, thereby removing the most essential means to reunion of the fragments. "Enlargement of the trochanter when it has been split by impenetration of the neck, is easily made out, when the soft parts are not swollen, by grasping it between the thumb and fingers."

The rotation of the trochanter upon a shorter radius than normal is spoken of as a prominent symptom, and while theoretically correct, is one that is rarely demonstrated in the living subject.

In the diagnosis, the differentiation of the intracapsular from the extracapsular forms may well be disregarded, since in most instances it is simply impossible to differentiate one form from the other; and since the treatment in either case is practically the same, the condition resolves itself into one of surgical curiosity rather than one of practical utility..

Given a history of a fall, with slight or severe violence in a person of advanced years, particularly a female, with loss of power in the limb, shortening, eversion or inversion, crepitus, pain and swelling in the hip, and elevation of the trochanter, there can, of course, be no doubt; but in the face of a slight injury, the limb not entirely powerless, absence of crepitus, shortening and eversion, the temptation to conclude there is no fracture is great. Hodgson, a century ago, advised that in an elderly

patient, "inability to use the limb after a fall upon the hip should be deemed sufficient evidence to presuppose a fracture of the neck of the femur." Stimson says "this warning has oftentimes, and still is, disregarded to the great damage of the patient, and sometimes also of the surgeon."

This authority further says "that the rule should be firmly established in practice; that every doubtful case, especially in the elderly, should be treated at first as a fracture, and all the more so if the violence has been slight, as a stumble or a fall while walking."

The X-ray affords means of making a correct diagnosis, and should be used when available as an accessory method. This, however, should not be entirely relied upon, for many times it is not available, and the surgeon who places his sole reliance upon this means of diagnosis places himself at a great disadvantage by prostituting his most valuable asset, an understanding born of an experience based upon the knowledge of the anatomy, physiology and pathological changes of the parts.

The complications to be expected are shock, which is generally immediate and more or less great; a sharp inflammatory reaction, accompanied by high fever and delirium, followed by pneumonia; fatty embolism, thrombosis, and the patient, "overwhelmed by the mental and physical shock, dies within a few days."

"The patient's strength may fail rapidly without much inflammatory reaction from the injury, and he dies cachectic, usually from intercurrent pneumonia."

Again, a purely marantic condition may supervene, resulting in death; and cases have been observed to undergo suppuration, resulting in varying degrees of injury, from a constant state of discomfort and inconvenience to one in which the injury is followed by death.

In fractures of the neck of the femur the question of repair is one of importance only in so far as its probability is possible without the sacrifice of the most vital interests of the patient, namely, that of saving his life, even at the expense of the loss of function of the limb, together with the deformity incident to this injury.

In the face of the probable survival of the patient every available means should be taken to obtain union, or, failing in this, to restore so far as is possible the function of the member. That union is possible even at an advanced old age is well attested by many competent observers such as Gurlt, Stanley, Swan, Cushing, and others; and from specimens obtained from these and other observers, there is abundant evidence that in many instances of injuries of this kind, even in extreme old age, a large per cent of them undergo very good repair. These specimens were from patients. whose ages ranged from eighteen to eighty-one years. There was absorption of the neck in one of these, and varying degrees of deformity in the remainder, all of which would go to show that in fractures of the neck of

the femur, especially in the aged, that union without more or less shortening is a result not to be expected, much less to be sought, for various obvious reasons.

Stimson says "there are three possibilities worthy of consideration so far as the process of repair is concerned; first, that bony or close fibrous union is possible; second, that preservation of enough of the periosteum of the neck to make a vigorous vitality of the head possible is probably common; third, that the primary displacement usually does not separate the fractured surfaces, so that if it is not increased by early attempts to use the limb, or, more rarely, by the action of the muscles in the absence of proper retention, the conditions for reunion are favorable."

However, it is well to remember that after advanced old age has been attained our old patient has not the potential reparative energy left him sufficient for the manufacture of many new skeletons. In other words, old people do not make new bones. The first consideration in the treatment of this injury is to save the life of our patient. This is very often hazarded, and even lost, by attempts to secure union and restore usefulness to the limb.

The excitement incident to an accident of this kind can best be controlled by slow and rational treatment.

On being called to sec and treat a case of this kind, to relieve shock is of the first importance. These old patients suffer with varying degrees of severity from the mental and physical shock, more often severe than otherwise, the relief of which prevents a serious drain upon the vitality. of an already exhausted supply, thereby contributing to the benefits to be secured by placing the limb in retention.

For this purpose, the administration of morphia hypodermically, in combination with atropia, is the most useful, relieving pain, stimulating the respiratory and circulatory functions, dispelling fear and giving, instead, a sense of security and comfort.

From a fourth to one-half grain of morphine, with one one-hundredfiftieth of atropine, is the dose to be so administered, the size to vary with the weight and potentiality of the patient.

A fracture-bed should be made by placing heavy boards beneath the mattress, and upon the frame of the bed. The patient, when placed upon this may receive treatment by any of the numerous means suitable to his condition, without sinking down in his mattress.

The patient should now be put upon the fracture-bed, his thigh flexed at about right angles to the body, the leg flexed upon the thigh to the same extent, slightly abducted and inverted, in which position it should be retained by means of sand-bags so arranged as to maintain the position described, with no effort upon the part of the patient.

Extension should be secured by the application of wide adhesive strips to the inner and outer surfaces of the thigh, covered by a gauze

bandage, and extending from the trochanter externally, and perineum internally, to and below the inferior extremity of the bone, where a loop is formed, and fastened to a rope running over a pulley, which is suspended from the ceiling, bearing a weight suitable to the musculature of the injured individual. The foot of the bed should now be raised upon blocks or brick about six inches above the floor in order to secure counter-extension. The sand-bags must be readjusted at intervals, as they gradually settle, allowing the limb to fall out of line and proper position. The chief difficulty with this mode of treatment lies in the fact of its continuous confinement to the bed of the patient in the dorsal position. This position in the aged is very conducive to hypostatic pneumonia, and, besides, if continued for a period exceeding a few days or a week, tends to depreciate the vitality and general condition of the patient. To obviate this difficulty some means must be devised to get him out of bed.

The last three fractures of this kind which were treated from this office after having been confined in this manner from eight to twelve days, were placed in a splint fashioned somewhat after the style of the Hennequin hip splint.

A tinner was secured, who, from light galvanized iron, made a hipsplint encircling the back and sides of the pelvis. To this was made a groove-splint for the entire length of the thigh, set at nearly right angles with the pelvic portion, having a light cap to cover. To this, and at almost right angles with the grooved portion for the thigh, another piece was made to receive the leg, extending down the upper two-thirds, for which a cap was also furnished. That part of the splint to receive the leg and thigh was set at a degree of abduction midway between the normal and the extreme, and extension bars and cross-piece was set eight inches from and in the same axis as the portion receiving the thigh. This splint was now padded with cotton, the patient placed in it, and the caps applied, and retained by roller bandages, and extension was made from the cross-bars of the splint. Extension may be made across the pulley overhead, as before, the patient retaining the splint while in bed. In a dressing of this kind he may be removed from bed and placed in a rolling or rocking chair, and, if necessary, extension may be kept up, both while in a sitting and recumbent position.

With a splint of this kind we also treated a fracture of the right thigh, at the junction of the upper and middle third, in a boy aged seven. In all four of these cases the results were all that could be desired.

As a preliminary to this or any other dressing, it is frequently necessary to administer a general anesthetic for diagnostic purposes. During anesthesia great care should be taken to avoid the breaking up of impactions. This applies particularly to old patients. In the younger individual anesthesia should always be induced when possible, and the manipulations may be more extensive, the object of attaining perfect contour and func

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