A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

83. The division, rarely oblique, is almost always transverse: sometimes, in the latter case, the neck remains enclosed or imbedded, as it were, in the body of the bone, being fractured in such a way, as to present a hollow or notch of greater or less depth. Several cases of this kind occurred to Desault; one of them, modelled in wax, is deposited in the collection of the School of Health, and the original preparation is in my possession. The fracture, though frequently simple, is sometimes complicated with that of the great trochanter.

Case V. A man having received a kick from a horse, on the external and upper part of the left thigh, fell down, and, not being able to move, was carried home. Desault being called to him, discovered, 1st, that the great trochanter, separated from the bone, yielded readily to every impression it received: 2dly, that the limb was perceptibly shortened; that the least effort was sufficient to restore to it its natural length; and, that the foot was turned outwards, all which are characteristic signs of a fracture of the neck.

§ XIV.

OF THE SIGNS.

84. Whatever may be the mode and place of the fracture, its diagnosis presents difficulties which experience and habit may doubtless overcome, but which too frequently puzzle and embarrass the most enlightened practitioner. Let us endeavour to diminish them somewhat, by tracing, in their order of succession, the symptoms which characterize the accident.

85. At the time of the fall, a sharp pain is felt; sometimes a report is plainly heard; a sudden inability to move the limb occurs; the patient cannot rise, a circumstance, however, which does not always take place. A case is recorded in the fourth volume of the Memoirs of the Academy of Surgery, where the patient walked home after the fall, and even rose up on the following day. Some examples of a similar nature fell under the notice of Desault, one of which he has recorded. The interlocking of the two fragments formerly mentioned (83), may serve to explain this fact, which is, however, in general, very rare.

86. A shortening almost always occurs in the broken limb, but this is more or less perceptible, according as the extremity of the fragments is retained by the capsule, or as, the division being without the cavity, no resistance is made to their displacement. The muscular action, drawing the lower fragment upwards, and the weight of the trunk, pushing the pelvis and the superior fragment downwards, furnish here, as in fractures of the body of the bone, the two-fold cause of this shortening. I will not repeat what has been already said on this subject (10...14); I will only observe, that, in the present case, the influence of the muscles is even more considerable, because, the lower fragment being much longer, is of course attached to a greater mass of muscular fibres. A slight effort is sufficient, in general, to remove this shortening, which, however, soon returns, when the effort ceases. This circumstance Goursault and Sabatier have observed, not to occur in certain cases, till some time after the accident. A tumefaction appears in the anterior and upper part of the thigh, almost always proportioned to its shortening, of which it appears to be the effect.

87. The projection of the great trochanter is almost entirely removed. That protuberance, being directed upward and backward, is approximated to the spine of the ilium. But if it be pushed in the opposite direction, it readily yields, and then, returning to its proper level, allows the patient to move the thigh.

88. The knee is a little bent. A severe pain always accompanies the motions of abduction, when they are communicated to the limb. If, while the hand is applied to the great trochanter, the limb be made to rotate on its axis, this bony protuberance is perceived to turn on itself as on a pivot, instead of describing, as it does in its natural state, the arch of a circle, of which the neck of the os femoris is the radius. This sign, which was first observed by Desault, is very perceptible, when the fracture is at the root of the neck, less, when it is in the middle, and very little, when it exists towards the head of the bone; these are circumstances, the cause of which it is unnecessary to unfold. In rotatory motions, the lower fragment, rubbing against the upper one, produces a distinct crepitation, a phenomenon which does not however always occur.

89. The point of the foot is usually turned outwards; a position which Sabatier, Bruninghausen, and most other practitioners regard as a necessary effect of the fracture, although Ambrose Pare and Petit have borne witness that it does not always exist. Two cases, reported on this subject by celebrated surgeons, have been thought unfounded by Louis, who has attributed them either to an error in language, or a mistake of the transcriber. But the practice of Desault has fully confirmed their possibility. The first patient whom he had under his care, at the hospital of Charity, after he was appointed surgeon in chief, laboured under a fracture which presented this phenomenon. Many other examples occurred to him afterwards, and he believed it might be laid down as an established principle, that, in fractures of the neck of the os femoris, the direction of the foot outwards is to that inwards as 8 to 2.