Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Fig. 75.—Longitudinal section of Femur showing recent Fracture of Shaft with overriding of Fragments.

In adults, when due to direct violence, the fracture is usually transverse, and may be attended with comparatively little displacement. Indirect violence, on the other hand, usually produces an oblique fracture, which is frequently comminuted and often compound. The break is most commonly situated a little above the middle of the shaft, the obliquity being downward, forward, and medially, and of such a nature that the fragments tend to override one another ([Fig. 75]). The most serious forms are those associated with gun-shot wounds.

The direction and nature of the displacement depend more upon the fracturing force, the weight of the lower part of the limb, and the action of the muscles attached to the respective fragments, than upon the direction of the obliquity. As a rule, the proximal fragment passes forward and laterally, and is maintained in this position by the ilio-psoas and glutei muscles, while the distal fragment is displaced upward and medially and is rotated outward by the combined action of the weight of the limb, the longitudinal muscles, and the adductors.

Clinical Features.—The limb is at once rendered useless, and there is great swelling from effusion of blood in the region of the fracture. This, together with the muscularity of the part, often renders an accurate diagnosis as to the site and direction of the fracture exceedingly difficult. The shortening varies from 1/2 inch to 3 or 4 inches—averaging about 1 inch in adults—and eversion is always marked. Mobility may be detected and crepitus elicited without disturbing the patient, by placing the hand under the seat of fracture and gently attempting to raise the limb; or by fixing the proximal fragment by one hand placed in front of it while the distal part of the limb is carefully lifted. It will be found that the great trochanter does not rotate with the lower segment of the femur. These tests must be employed with great caution lest the deformity be increased or the fracture rendered compound.

In many fractures of the thigh, and especially in those produced by indirect violence, the knee is sprained, and there is a considerable effusion into the joint, and this may lead to stiffness unless massage is employed from the outset.

Treatment.—Fracture of the shaft of the femur is one of the most difficult fractures in the body to treat successfully. In cases of oblique fracture, the patient should be warned that shortening to the extent of from 3/4 to 1 inch is liable to result, however carefully the treatment may be carried out. This does not necessarily imply a permanent limp, as by tilting the pelvis he may be enabled to walk quite well; if this is not sufficient to equalise the length of the limbs, the sole of the boot may be raised. A general anæsthetic is necessary to ensure accurate reduction, and extension must be applied to maintain the fragments in apposition and prevent shortening. The splint which has been found most generally useful is the Thomas' knee splint, the ring of which rests against the ischial tuberosity. To admit of flexion at the knee the Thomas' splint should have a hinged attachment on which the leg is supported. This leaves the knee free and allows of movement being made to prevent stiffness. The limb is suspended by broad strips of flannel or linen, fixed to the side bars of the splint by means of safety pins or strong spring paper clips.

In simple fractures extension may be obtained by means of broad strips of adhesive plaster applied to each side of the thigh and reaching well above its middle. The plaster is secured by a bandage, and to its lower ends are attached broad tapes which are buckled to a stirrup through which traction is made by means of a cord passing over a pulley fixed to an upright at the foot of the bed.

The lower end of the splint is suspended, and the counter-extension is obtained by pressing the ring against the ischial tuberosity. To prevent the ring overriding the tuberosity and pressing on the soft tissues of the buttock, it is slung by the rope to a cross-bar above the bed, e.g. the Balkan frame ([Fig. 81]).

In compound fractures the presence of a wound may prevent adhesive plaster being used, and it is necessary to take the extension directly through the bone. A posterior gutter splint is applied to prevent sagging. After pulling the skin upward, a small incision is made over the upper expanded border of each condyle, and the points of an ice-tong calliper are made to grip the bone without penetrating into the cancellous tissue. A cord attached to the handles of the calliper passes over a pulley and supports the weight necessary to give the desired amount of traction ([Fig. 81]).

An alternative method of exerting traction directly through the bone is by means of Steinmann's apparatus ([Fig. 76]). In a moderately muscular adult, a weight of from 12 to 15 pounds by means of strips of plaster applied to the skin, or 10 to 25 pounds by direct traction on the bone, should be applied in the first instance. The correct weight to employ is that which maintains the length of the limb at its normal, and is therefore liable to revision from time to time.