Elements of Surgery

by Robert Liston

A portion of the crest of the ilium may be broken off, without serious mischief ensuing, and may unite favourably. More extensive fractures, deeper in the pelvis, as in the neighbourhood of the acetabulum, are attended with excruciating pain on the least motion; in these the existence of fracture may be suspected from the first, but the extent of the injury is not fully known till after death. Fractures near the symphysis, and of the rami, either of the os pubis or ischium, are usually attended with injury to the bladder or to the urethra. Wound of the bladder is almost necessarily fatal; extravasation of urine, with all its fearful consequences, taking place in the loose cellular tissue connecting the upper part of the viscus to the parietes of the pelvis, and in the cellular tissue behind the peritoneum. The urethra may be lacerated by the sharp edge of fractured bone, or it may be ruptured by direct violence applied to itself. The latter case sometimes accompanies partial diastasis of the symphysis, produced by the person falling astride on a beam. Either injury separately is sufficiently dangerous, and a patient with both is in a very precarious situation. Great extravasation of blood takes place in the perineum, scrotum, penis, and tops of the thighs, infiltration of urine quickly follows, retention supervenes, abscesses form, and the patient perishes under a train of symptoms already detailed when treating of the urinary organs.

The treatment is seldom satisfactory. Absolute rest must be procured, and with this view the limbs are to be secured, and a broad band passed round the pelvis. The state of the viscera must be attended to; collections of matter must be evacuated; and all other untoward symptoms must be actively met, and their consequences either adverted or got over as far as possible.

Fracture of the Sacrum is uncommon, as also detachment or fracture of the Coccyx. The former accident happens in consequence of a fall from a great height. There is little or no displacement whether the fracture is transverse or longitudinal; sometimes there is splintering of the bone. Acute pain is occasioned by motion of the limbs and of the trunk, and by pressure over the injured part. Abscess is apt to follow, both under the integument, and in the concavity of the bone, and the chief duty of the surgeon is to prevent this if possible.

Fractures of the Thigh.—On account of the thick muscular covering, much attention is required to enable the surgeon to form an accurate diagnosis regarding the effects of an injury of the upper part of the femur. The necessity for ascertaining what the injury really is, need not be insisted on. Consequences dreadful to the patient have too often followed blunders in diagnosis. As in the accidents of the shoulder-joint, some idea as to the exact injury may be formed by ascertaining how the force was applied; but this, alone, may sometimes mislead. Careful manipulation is to be chiefly trusted to.

Fracture within the capsule is met with most frequently in those of advanced age, when the form of the neck of the bone has been altered,—when it has become shorter, and attached less obliquely to the shaft, as is sometimes the case; the bones, too, are then more brittle than in earlier life. The accident often happens from slight force, applied either to the farther end of the bone or to the trochanter, as by a fall in going up or down stairs. Though the height often be not great, yet the patient’s energies are weakened, he can make no effort to break the fall, and the weight of the body is thrown on either the fore or the back part of the trochanter. Though the fracture, in such an accident, generally extends beyond the capsule, and the processes are broken to a greater or less extent, yet occasionally the head of the bone is separated by transverse break of the neck without farther injury. This fracture occurs sometimes in those of middle life; and even in children, separation of the head of the bone may on good grounds be supposed occasionally to take place.

The marks of fracture within the capsular ligament are inability to move the limb, pain about the joint on attempts being made to move it, and shortening to a slight extent, as ascertained by comparison with the sound limb; the patient being laid straight on his back, with the crests of the ilia in a line, either the knees or the ankles are looked to, and the comparative length of the limbs thereby observed. In some cases, neither shortening nor deformity is apparent for some time after the accident; there is merely want of power, and crepitation produced by rotation; but retraction of the thigh would after a time inevitably occur, and has done so when the nature of the injury was not at first ascertained, nor proper treatment adopted. Most frequently there is eversion of the toes, and to a considerable extent; sometimes there is inversion, and this is owing to the limb either having been placed in that position in falling, or having acquired it after the injury has been inflicted. The rotators outward are the more powerful; the limb naturally inclines outwards, and when in the recumbent posture, the weight of the foot favours eversion. But in fracture the muscles do not act as in a sound limb; and when the limb is once placed, the patient will not by his own efforts alter the position. Thus it is that inversion not unfrequently happens in this form of fracture, although the opposite state is that which, from a consideration of the muscles involved, is à priori to be expected. In inversion the limb presents somewhat of the appearance arising from the most common luxation; but it possesses greater mobility, and has not the want of prominence occasioned by displacement of the articulating extremity of the bone. The facility of lengthening the member, and the crepitation felt on a proper and more attentive manipulation, will remove all doubt.

On examining the injured hip, motion to some extent can be effected, though with excruciating suffering to the patient. On stretching the limb to its original length, and then rotating slightly, crepitation can be felt by the hand, or heard by the ear, placed over the trochanter major.

Fracture is much more frequently met with outside of the capsular ligament, generally passing obliquely through the trochanters, and communicating with fissures in various directions. Splinters are often detached, and sometimes the small trochanter is broken off. Here, also, there is inability to move the joint, violent pain on attempting it, swelling and deformity of the member; there is shortening to a greater extent than in the fracture within the capsule; there is free motion in all directions; rotation, abduction, adduction, flexion, and often extension, can be effected to an unnatural and unusual extent—the degree of motion is no longer limited by the ligamentous attachments of the head and neck of the bone. Here, also, the limb is most frequently everted, but occasionally inverted; and that even when, from the direction and extent of the fracture, neither the rotators outwards nor the rotators inwards have been deprived of the power of acting.

In some cases of fracture, partly within and partly without the capsule, all the usual marks of this injury are present, but it is impossible to move the limb without employing considerable force. This arises from the broken portions being jammed together, the neck of the bone being, as it were, driven into and wedged in the cancellated texture of the trochanter major, or of the upper part of the shaft.

The trochanter major is sometimes, though rarely, detached, without separation of the neck of the bone from its shaft. In this injury there is apparent lengthening of the limb, and flattening of the hip; the patient is able to use the member, though not freely. Before swelling has taken place, crepitation can be perceived on laying hold of the trochanter whilst the limb is in motion; and the trochanter itself is found to be in a slight degree moveable.