Elements of Surgery

by Robert Liston

Fracture of the upper part of the shaft is attended with immediate and great shortening; the limb is much misshapen, and lies on its outer side, with the knee partially bent. The upper fragment of the bone projects; the resistance to the action of the psoas and iliacus is in a great measure done away with, consequently these muscles raise the upper, whilst the lower end falls back and is drawn upwards behind the other. In mismanaged cases, I have found on dissection the lower end of the bone lying in the sacro-ischiatic notch, and a process advancing very different from reparation—necrosis. The marks of this accident are so conspicuous, that the surgeon is satisfied of what has happened without enquiring for crepitation. Rapid and great swelling takes place, if reduction and coaptation are not soon resorted to; the bloodvessels are torn more and more by the ends of the bone, and effusion of blood into the intermuscular cellular tissue is easy. Very soon more extensive and dangerous swelling takes place, the result of inflammatory action, accompanied with startings of the muscles and greater retraction of the limb.

Fractures of the middle and lower thirds of the bone are not attended with such great risk, and are more manageable in every way. There is less disfiguration—the ends of the bone are not drawn by the action of the muscles so far apart. The fracture is either oblique or transverse, according to the direction of the force applied; and the bruising and the degree of swelling are also dependent on the same circumstance. From transverse fracture fissure sometimes extends, separating one or other condyle.

The reparation of injury in the upper part of the femur is opposed by a variety of circumstances. Fractures of the neck of the bone are almost uniformly met with in those whose powers of life have been nearly exhausted. The whole injury is confined within the synovial capsule, and the fibrous tissues which support that are unyielding, and but slightly vascular; consequently, in fracture of the neck of the femur, there occurs none of the swelling and increased vascularity of the surrounding tissues, which follow fracture of other bones, or other parts of this bone: no temporary callus can be formed; from this cause, support of the disunited parts is deficient. The head and neck of the bone are not so well supplied with bloodvessels as the other parts; those arteries which pass along the ligamentum teres are the chief support. And perhaps the influx of blood is not increased, in consequence of injury, to such a degree as in other parts; in these, when the surrounding parts are bruised or otherwise injured by fracture in their immediate vicinity, their vascular action is soon excited, the vessels ramifying on the periosteum are enlarged, and blood is poured into the bone at all points. Instead of these salutary changes, the secretion of synovia is increased, and a fluid, perhaps vitiated, surrounds the bone, and is interposed betwixt its ends. There is also difficulty in performing accurate adaptation of the broken ends, and in securing retention so long as is necessary for union; the limb has a tendency to retraction; in readjusting the apparatus, when become loose, the broken surfaces are rubbed on each other, and thus any union which may have been in progress is interfered with. In consequence of all this, union seldom takes place by bone; it has occurred, and will occur, in favourable cases, when the fibrous investment of the neck of the bone does not happen to be torn, and under good treatment. Two sketches which, through the kindness of Sir Astley Cooper, I am enabled to introduce here, show the union complete: the patient from whom this was taken had received other severe injuries, and very little attention had been paid to that of the hip. But it is an undeniable fact, that the circumstances which of a necessity follow fracture at this point are inimical to its effective reparation. The broken ends are sometimes united by fibrous tissue. Most frequently no union takes place, and the broken surfaces gradually become smooth, polished like a bit of china, and adapted to each other; a false joint is formed, but at the same time the capsular ligament, and tissues exterior to it, are thickened and strengthened, and so the unnatural motion is limited. The rough and irregular portions of the bone are absorbed, and the neck of the femur, from interstitial absorption, almost disappears; its diminished head lies in and is attached to the cotyloid cavity, and is rubbed upon by the opposed surface of the shaft. Shortening of the limb is an inevitable result: at first the power of motion is slight, and the support afforded to the body weak; in course of time the member becomes strong and useful.

Many bones are preserved and exhibited, in which fracture of the neck of the thigh-bone, with bony union, is supposed to have taken place; but there are strong grounds for suspecting that many such have not sustained actual fracture. The neck of the bone may be shortened, and set on awkwardly, and there may be masses of new osseous deposit round the neck and the trochanters. Perhaps the history of the case is known.—An old person sustains an injury of the hip by falling, or by a blow on the trochanter; great lameness ensues, and, after a confinement of many weeks, the patient begins to use the member, which, however, remains considerably shortened. But all this may have taken place, and on examination after death, the parts may have presented the appearances above alluded to, without any fracture. The change in the bone is the consequence of diseased action induced by the injury. The bloodvessels of the bone and its coverings are excited, and new osseous matter is formed at various points; at the same time, interstitial absorption of the cancellated texture of the neck gradually advances, and the bone is consequently altered in length and form. These appearances alone, therefore, do not warrant the confident belief of fracture having occurred, even though the history should seem to favour the assumption. And it ought to be recollected, that mere bruising of the parts about the hip is not unfrequently attended with inability to move the limb, with eversion of the foot, so as to relax the muscles which have suffered, and sometimes with slight apparent lengthening. This change in the form of the head and neck of the thigh-bone is not found only in old subjects. Some drawings from patients under forty and fifty years are given at pages 87 and 88, exhibiting in a remarkable manner this deformity.

In many patients advanced in life, who have sustained fracture of the neck of the femur, there is little, if any, chance of union. In these cases, the application of apparatus with the view of adapting and retaining the parts, is productive of great annoyance, and is apt to produce either ulceration or sloughing of the integuments at various parts; and confinement to one constrained position for a considerable time has a mischievous effect on the general health. Instead, the limb is placed in the easiest posture, either extended and slightly retained, or bent over a double inclined plane formed by pillows, with the knee of the affected side fixed to the opposite; a broad band is passed round the trochanters and pelvis, so as to restrain motion without causing inconvenience; and when pain about the thigh is troublesome, fomentation may be used. After some weeks, when the uneasy feelings have subsided, the position is changed, the patient is set up, and encouraged to move about, supporting the weight of the body upon crutches.

In more favourable subjects, whether the fracture is suspected to be without or within the joint, either entirely or partially, the broken surfaces are to be brought in contact, and retained immoveably in apposition for a time sufficient to admit of union. The limb is put up in apparatus not requiring removal, and but little readjustment. This can be effected only in the extended position. Many splints, with foot-boards, straps, and screws, are intended for this purpose, some to be attached to the injured limb, others to the sound one; but the apparatus which is most simple, and easily procured at all times and in all circumstances, is at once the best and the most efficient. This is a straight wooden board, not too thick to feel cumbrous, and not too thin to be pliable or easily broken; in breadth corresponding to the dimensions of the limb, in length sufficient to extend, from two, three, or four inches beyond the heel, to near the axilla, deeply notched at two places at its lower end, and perforated by two holes at the upper. The splint, well padded, is applied to the extended limb, the ankles being protected by proper adjustment of the pads. The apparatus is retained by bandaging. A common roller is applied round the limb, from the toes to near the knee, so as to prevent infiltration, which would otherwise follow pressure above by the rest of the apparatus. The splint is then attached to the limb by involving both in a roller from the foot to above the knee; and in doing this, the bandage, after having been turned round the ankle, should be passed through the notches, so as to be firmly attached to the end of the splint, thereby preventing the foot from shifting. A broad bandage is applied round the pelvis over the groin, and down the thigh, investing all that part of the limb left uncovered by the previous bandaging. A broad band, like a riding belt, is fastened round the pelvis, so as to bind the splint to the trunk, and thereby keep the broken surfaces of the bone in contact. A large handkerchief, or shawl, is brought under the perineum, and its ends secured through the openings at the top of the board. It is evident that, the splint being thus securely fixed and made as part of the limb, tightening of the perineal band will extend the member, and preserve it of its proper length. By care and attention in applying the apparatus, and in adjusting the cushions about the ankle and perineum, there is little or no risk of the skin giving way. The bandages will require to be reapplied once or twice during the cure, and the perineal band should be tightened frequently. The apparatus is retained for six or eight weeks, the time necessary for union varying according to circumstances. After its removal, great care must be taken at first in moving the limb and in putting weight upon it: it should be accustomed to its former functions very gradually.

The same apparatus in the most effectual for all fractures of the thigh; but those near the distal extremity, and in the lower third of the bone, may be managed tolerably well on the double inclined plane—M’Intyre’s splint, the thigh-piece of which is double, the one portion sliding on the other, and made to shorten and lengthen by means of a screw, without removal from the patient. To this the limb is secured by bandaging from the toes upwards; the upper bandage, which should be broad, being continued close to the perineum, and then passed several times round the loins. By elongating the thigh-piece by means of the screw, extension is kept up. Great complaint is commonly made by the patient of pain and stiffness in the knee for a long time after the treatment of broken thigh in the bent position.

There is no possibility of treating fracture of the thigh, with any satisfaction or credit, on the outside of the limb with the knee bent; however attentively the splints are placed, shortening, eversion of the foot, and deformity of the whole limb, are sure to follow. No greater absurdity and cruelty are conceivable than leaving the fracture unadjusted for weeks, making attempts to subdue consequent over-action, and then endeavouring to reduce and retain the bones at a period when otherwise they should have been firmly united. “Experience teacheth” not “fools,” and cannot amend those whom prejudice has blinded.

Compound fracture of the thigh, if circumstances do not forbid attempts to save the limb, is to be reduced and retained in the same way as the simple, the wound being attended to, and means taken to subdue inflammatory action. Abscesses must be opened timeously, the limb must be equably supported, and the powers of the system preserved.