[Fig. 309] illustrates a serious complication that ensued in one case after multiple fractures of the pelvis and hip, with synostosis at the hip, as well as extensive deformity following fracture of the shaft of the femur.
Treatment.
—Treatment of pelvic fractures should comprise, first, absolute rest. This means not merely confinement in bed, with traction applied to one or both limbs, but probably fixation of the pelvis and perhaps the thighs, either in a compressing bandage or in a plaster-of-Paris double spica, the pelvic jacket running as high as may be necessary upon the trunk of the body. Cases which seem to permit of operation and suturing are entitled to it, but they will constitute but a small proportion of the total. While patients are so rigidly confined provision should be made for free elimination, and possibly conveniences provided for receiving the evacuations without possibility of infection. Recovery is in many instances complete; occasionally it occurs with considerable displacement. If the viscera escape injury much may be expected in the way of repair of the bones under suitable treatment.
The margin of the acetabulum is occasionally chipped off, sometimes by itself, sometimes as a complication of dislocation of the hip. The posterior margin of the brim is the part which usually suffers. Diagnosis should be made by the ease with which such a dislocation recurs after manual reduction. Sufficient traction to keep the limb from displacing the fragment, and snug bandaging with pressure, especially around the injured hip and above the trochanter, is indicated in such cases.
The coccyx and even the lower portion of the sacrum are occasionally broken loose, either by external violence or during parturition. Here the fragment is drawn forward by the levator ani, displacement is marked, and pain and soreness are great. Should there be doubt as to the nature of the injury, combined manipulation, with a finger in the rectum, will make diagnosis positive. Fibrous union is about all that can be expected in either of these cases. The fragment may be justifiably removed at any time.
FRACTURES OF THE THIGH.
Fractures at the upper end of the thigh are more common than those at the lower. At the upper end there may be fractures of the head, of the neck, those which pass between the trochanters, and epiphyseal separations. All of these are rare except those of the neck.
Fractures of the neck of the femur occur most commonly in those who have passed the fiftieth year of life. They occur, however, during the middle period and even in children, and, as Whitman has shown, are by no means so rare in the young as was until recently supposed.
The shape and structure of this portion of the bone, and the peculiar changes which occur with advancing years, constitute the explanation for the frequency of this injury in late life. As the jaw begins to change in shape, and the teeth to drop out, there occur also unseen changes within the cancellous structure of the head and neck of the femur by which the strength of the latter is materially reduced. It is still further weakened by the change in shape which the bone also undergoes as it loses its obtuse angle and becomes set more at a right angle with the shaft. The reduced ability to resist strain produced by these changes is remarkable, and accounts for the ease with which fractures occur, even from so apparently trivial an accident as tripping on the floor. With all the violence directly transmitted there is usually present an element of twist or torsion by which fracture is still further favored.
As between so-called intracapsular and extracapsular fractures surgeons have made distinctions to which unnecessary importance has been attached. Anteriorly the capsule is attached to the intertrochanteric line, while posteriorly it does not extend nearly so far outward; it can thus be seen that many fractures are partly intracapsular and partly extracapsular. These lines vary in different individuals, especially that of the posterior insertion; it is not usually possible to make minute distinctions of this kind. The principal importance which attaches to them is in the direction of prognosis, for if the fragment be absolutely intracapsular it can derive its blood supply only through the ligamentum teres, which is, to say the least, a precarious method of existence and usually disappointing. In general it may be assumed that a fracture close to the head is intracapsular, but that when it occurs well out toward the shaft it may partake of both characters. In this connection the x-rays will afford, usually, more satisfactory information than can be obtained by even extensive or rude manipulation.