straight. Smith records a case (No. LVIII.) in which there was slight inversion. COMMINUTED FRACTURE OF THE TROCHANTERS WITHOUT IMPACTION. The alleged injury thus described detaches the entire neck from the shaft, and is generally represented in museums by specimens, the comminuted fragments of which are reunited in their normal position. Museum specimens of this fracture are less frequent than those of the common impacted fracture, and might be still more rare were it not that the impaction, which I conceive to be the rule in fracture at the base of the neck, does not always persist, being sometimes liberated by the extensive comminution of the bone, or by force subsequently applied. The impacted bones are undoubtedly separated, in many cases from want of care both in the examination and in the subsequent treatment of the patient, and likewise in the process of their preparation as specimens. It is fair to suppose that local crepitus can be felt in the trochanteric region, so extensively comminuted. The lines of fracture present great variety. The anterior and posterior trochanteric walls, or either of them, may be detached entire or in fragments. The posterior intertrochanteric ridge may be split off partially or wholly, and the trochanter minor broken off by itself. The summit of the outer trochanter, and in fact the whole upper region of the shaft, may be comminuted and driven in as by a blow from above. As in other fractures of this part, inversion of the limb is here the rare exception, and eversion the rule. Smith cites twenty-eight cases of extra-capsular fracture, of which four only were inverted. Assuming that anterior impaction is essential to inversion, we may seek the cause of the latter both in the direction of the blow received and in the action of the muscles. The influence of these is well illustrated in the case already detailed (Figs. 4, 5), where the mass of large and small rotators evert the upper fragment only, leaving the shaft to be inverted by the anterior fibres of the gluteus medius, and especially of the gluteus minimus, which is inserted lower down. This occurs when both the trochanters are detached, whether separately or (as in this specimen) in a single piece. Smith's four cases of inversion1 sufficiently illustrate these points, as does also a specimen in the Chatham Museum, where, in addition, "an arch of new osseous matter . . extends from the anterior inferior spinous process of the haunch-bone across the joint to the upper part of the shaft of the thigh-bone," and which, it may be inferred from its insertions, was the Y ligament and the neighboring fibres (see Fig. 22, page 74 of this volume). Shortening not unfrequently results from mere depression of the neck without corresponding rotation of the shaft, as in the regular impacted fracture; and the transverse neck may then be displaced outward upon the shaft, so as to resemble a hammer upon its handle. FRACTURE OF THE NECK OF THE FEMUR RESULTING IN FALSE JOINT. The frequency of this lesion is attested by the common museum preparations, showing the hemispherical head of the bone slipping upon the absorbed and shortened neck, or upon a broader surface with more restricted motion nearer the shaft. In the latter case the lower surface of the neck 1 A Treatise on Fractures in the Vicinity of Joints, etc. Cases XXIX., XXXVII., XXXIX., XLVI. 2 See the third Fasciculus of Anatomical Drawings, etc., Army Medical Museum of Chatham; also, A Case of Fracture of the Neck and Trochanter of the Thigh-bone with Inversion, etc. By George Gulliver. Edinburgh Medical and Surgical Journal, vol. xlvi. p. 312. 1836. not unfrequently rests upon a bony projection near the lesser trochanter. False joint is a frequent result of unimpacted fracture, and is not to be averted by any special form of apparatus. CRACK IN THE NECK OF THE FEMUR. FIG. 8.2 It is obvious that while a simple crack or fissure of the femur would produce no immediate deformity, it might yet give rise, as in the radius at the wrist, to lameness and inflammation of long duration, with corresponding obscurity of diagnosis. The tendency of glass tubes and other brittle cylinders to crack in a spiral line is well known; and M. Gerdy has remarked upon the occurrence of oblique or spiral fissures in the long bones, producing at their intersection acute angles like the letter V. Those of the tibia sometimes exhibit a singular symmetry and mutual resemblance.1 The annexed woodcut (Fig. 8) represents a portion of a left femur from a patient who died under my care at the Massachusetts General Hospital, of fracture and internal injuries. The specimen is now in the Museum of the Medical School of Harvard University, and has been described by 1 See Pratique Journalière de la Chirurgie, p. 67. Par Adolphe Richard, Chirurgien de l'Hôpital Beaujon, etc. Paris, 1868. 2 Crack of the femoral neck. hook-like extremity of the fissure, from the main line of fracture. Near the lesser trochanter is seen the separated by a narrow interval of bone Dr. J. B. S. Jackson, Dr. Mussey, and Dr. Hamilton. The femur is large and well marked. A spiral fracture ascends the shaft and winds round the neck, completely detaching it, except at a narrow isthmus in front half an inch wide. The shaft is broken transversely, eight inches below the trochanter. Here a spiral fissure begins, near the linea aspera, and winds upward and inward to the front of the bone, crossing the anterior intertrochanteric line midway between the trochanters; thence vertically upward to the outer edge of the cartilage; thence transversely across the top of the neck to its posterior surface, here touching the cartilage again; thence vertically down behind the neck to a point half an inch from the lesser trochanter, terminating on the under side of the neck in an S-shaped extremity, half an inch from the point where the fissure crosses the intertrochanteric line in front. The elastic bony pedicle thus formed allows a slight springing motion of the head, but maintains it firmly in place. THE TRUE NECK OF THE FEMUR: ITS STRUCTURE AND PATHOLOGY.1 1. STRUCTURE. SOME of the later numbers of Virchow's Archives contain a protracted yet interesting discussion upon the interior structure of bones, notably of the head of the femur. According to Merkel,2 G. H. Meyer, in 1867, pointed out certain arching fibres in their cancellated structure as "a well-marked architecture, which stands in the closest relation to the static and dynamic forces of the bones." In 1870,3 Wolff made further investigation of this subject; and in addition, this writer incorporated into his paper certain elaborate mathematical calculations of Culmann, of Zurich, showing that interior braces intended to aid in supporting a weight upon the end of a cylinder, curved like the thigh-bone, or like a crane or derrick, should be placed, in order to act to best advantage, precisely where the trabeculæ of the spongy tissue of this bone actually exist. "Nature," says Wolff, "has built the spongy bones as an engineer would construct a truss bridge, mathematically." This recent German investigation, apart from the mathematical calculation which Merkel avows his inability to follow, was anticipated, so long ago as 1850, by the late Professor 1 The Boston Medical and Surgical Journal, Jan. 7, 1875. Ibid., 1870; vol. 1. p. 389. |