FRACTURE OF THE FEMUR IN AN INFANT.
DR. H. AUGUSTUS WiLsoN reported the case of a well-nour ished infant of three months, who was brought to him with a marked fulness in the upper and inner part of the left thigh, which was palpably due to a bony mass just below the great trochanter.
Examination showed the enlargement of the thigh to be probably due to a mass of callus and malposition following a frac ture, the fragments having united at an obtuse angle, the apex pointing forward. There was no demonstrable shortening, and it was inferred that no overlapping had taken place.
He availed himself of the presence in Philadelphia of Dr. H. M. Sherman, of San Francisco, who operated upon the patient on May 5, 'goo, at the Philadelphia Hospital. Incision of the soft parts overlying the mass showed that the swelling was due chiefly to a very large mass of callus, and that there had been a fracture just below the great trochanter, and union had taken place, as surmised, with angular deformity, which was far less than exter nal appearances indicated.
The exuberant callus was chiselled away, the fracture repro duced, and the fragments put in apposition in proper position. It was found impossible to make the delicate bone hold a silver wire suture, and therefore maintenance of apposition was secured by splint. The wound was closed with catgut suture, a small sterile gauze drain being tucked into its middle, which was re moved the next day without removing the outer gauze dressings.
The plaster-of-Paris splint included both legs and extended up to the chest, being in effect a double spica of the thighs and hips. The legs were moderately abducted and a light stick, reach ing across from one foot to the other, was included in the bandage, and thereby increased stability.
During the application of this apparatus, Dr. Sherman de voted his especial attention to the position of the affected leg, to secure the best possible position of the fragments. Recovery was uninterrupted, and at the expiration of four weeks the original dressings were finally removed, and the result found to be perfect.
Dr. Wilson said that the question of causation of this fracture was of moment from the medico-legal stand-point, as the obstetric procedures at the child's birth were unusual. The delivery was accomplished by Dr. Edward P. Davis, who would state the diffi culties encountered.
In the opinion of Dr. Sherman the history was one of a plain procedure with no serious complications. The only force applied to or transmitted through the femur was simple traction, slight leverage was used, or could have been used. Furthermore, the whole of the traction force did not act on the femur, for the mus des between the tibia and the pelvis, both on the front and back of the thigh, must have taken some of it. It may be that, rarely, this procedure could cause a dislocation of the hip ; but it is very unlikely, hip dislocations being much more easily accomplished if the thigh is flexed on the abdomen and then force applied to the knee, pushing the femoral head over the lower and hinder part of the rim of the acetabulum where it is low.
The clinical history after delivery showed no immediate dis ability, but one that developed a few days after birth. The infer ence is unavoidable that the fracture was either intrauterine or occurred after delivery. As no history of fall can be obtained, it would appear that the fracture was intrauterine, with slight manifestations which made it possible to overlook its existence at the casual examination made by Dr. Davis's instructions imme diately after delivery.
Dr. Sherman had further called attention to the fact that obstetricians endeavor, in getting hold of the child's limbs in utero in order to move them, to seize them near a joint. Naturally, the hip-joint would be the one most accessible, and the femur the bone most frequently grasped. If a finger is slipped into the groin and traction made to extend the thigh, and so pull down the leg, the work is done at a disadvantage, for the weight, the leg, and foot are on the long arm of the lever, that is, the distance between the finger and the knee.
Kustner (Handbuch der Geburtshilfe Muella, iii, p. 311) says that if the finger or a hook slips upon the femur in doing this, the bone will break at its upper third, as that is its thinnest part, and that the fracture occurs at that part, if the force is used near it.
A case was 'reported from Professor Rubeska's Clinic in 1893 in which the femur broke at this place in a spontaneous delivery. In Archly fur Gynaleologie, Band xxx, p. 264, is reported a case with many fractures, both femora at the middle among them. Still, it would seem to be right to get the finger slipped along the front of the thigh to the knee as soon as possible to get the force near to the weight and shorten that arm of the lever. He was permitted to report also two cases seen by Dr. H. M. Sherman, as follows : 1. June 23, 1894. An eleven weeks' old girl normal apart from a deformity which consisted in a shortened condition of the left thigh, all the tissues being affected, the shortening being 4.5 centimetres. The history was of an easy non-instrumental birth, after a healthy and comfortable preg nancy. The mother was twenty-three years old, and this was her first child. The shortened condition existed at birth, but the child kicked the leg normally. During the last few days the child has held the leg flexed, and has cried if it was moved or handled.
Examination shows a depression or dimple in the skin on the outer side of the thigh at its middle. The knee and the leg and foot are normal, and of the same size as those of the other side. It is not possible to make out the femur through the soft tissues above the middle of the thigh. A false point of motion can be made out at about this point, and at times crepitus can be felt. There has evidently been an intrauterine fracture and much over lapping, and this must have occurred so early in intrauterine life as to have permitted the soft tissues to fit themselves to the short ened bone. Union probably took place with this overlapping, and a refracture has occurred within the past few days. There is nothing in the history of the mother's pregnancy that can explain the occurrence of the fracture.
July 30, 1894. This baby was put in a portable apparatus which permitted vertical traction to be made on the limb, and this was removed a few days ago. The child now kicks the leg about as she does its fellow. It is still impossible to palpate the upper part of the femur or the trochanter through the soft tissues.
August 14, 1894. To-day the presence and position of the trochanter can be made out. The limb is, roughly, 6.25 centi metres shorter than its mate.
December 12, 1894. To-day, through the dimple or cicatrix on the outer side of the thigh, the lower end of the upper frag ment of the thigh can be felt. The shortening is the same.
July 15, 1896. The shortening is now eight centimetres, and is all in the femur. With a lift under the shoe, to compensate the shortening, the function of the limb is perfect.
August 16, 1897. The shortening is now nine centimetres. Child healthy and active.
August 28, 1898. The shortening is now 10.5 centimetres. and all in the femur.
September, moo. This child has been found and has been radiographed, and the result is very confusing. There is a plain coxa vara, with the appearance of the femoral neck having been fractured rather than bent down. This was probably the site of the fracture that was diagnosed, but incorrectly located, in June, 1894. There is no evidence of there ever having been any injury to the shaft of the femur, and the apparent discovery of the lower end of the upper fragment, in December, 1894, was a mistake, which is not now possible of explanation. The limb is still shorter, and the location of the fracture may explain the constant increase in the shortening by a possible injury of the epiphysis and inter ference with growth, both directly at the epiphysis and, by reflex action, through the whole femur.
The thigh is now, September, 19oo, twelve centimetres the shorter, that is, the shortening has increased 7.5 centimetres since birth. The leg is of the same length as its fellow. The function of the joint and limb is perfect, and with a high patten, to com pensate the shortening, the child gets about as well as other children.
If this case was one of fracture of the femoral neck in a new born baby, the case must be a unique one.
II. September ii, 1899. The child, a seven months' old baby, was born with the left thigh much shorter than the right. The skin and other tissues fit the short leg, i.e., the tissues of the limb are shortened. No history of injury to the mother during pregnancy. No injury to child during delivery.
There is an angular deformity of the shaft of the femur, due to union in a faulty position after, possibly, intrauterine fracture of the femur. Child otherwise apparently normal.
The radiograph shows delayed ossification at the lower epi physis and the entire absence of the upper epiphysis of the femur. Ossification in the shaft ends a little above the middle, and at the middle is a curve or knuckling of the bones or a faulty position after a fracture.
The prospect of benefiting the boy is slight ; treatment is withheld, at any rate, for three months.
DR. EDWARD P. DAVIS said that the case which Dr. Wilson had described was that of a rhachitic pelvis, in which labor began with the vertex presenting and the back directed to the left side of the mother. When the mother became exhausted, the forceps was applied and the head brought into the pelvic cavity, but the effort to deliver the head was not successful. It was found that the shoulders had become impacted at the pelvic brim, the body of the child being turned transversely, and that delivery could not proceed. Accordingly, the forceps was removed and version was performed. The selection of version as a mode of delivery arose from the fact that in version one can much better control the delivery and passage of the shoulders through the pelvic brim.
In performing the version, it was found that owing to the long-continued labor, the escape of the amniotic liquid, and efforts at delivery, the child's body had become extended, the limbs being no longer flexed, but the feet and knees being in the fundus of the uterus. The legs were grasped near the knees, the grasp upon the limbs being as extensive as possible, and gentle traction was made, while the body of the child was rotated during traction in such a manner as to bring the back of the child towards the mother's abdomen. This was not a case in which the finger or an ingrument was hooked into the groin, because this was not a case of breech presentation. The version was exceedingly diffi cult because of the long-continued labor and the fact that the child had become unfolded. Considerable force was applied upon the femora and in the actual turning of the child's body ; this force must not have been that of traction only, but of rotation as well. The child was slightly asphyxiated when delivered, but was soon resuscitated.
Immediately after birth, the child was examined, but no frac ture or luxation was made out at that time. About ten days afterwards, the Resident Physician reported impaired motion and pain upon handling in this infant. The child was accordingly examined a second time, but still without eliciting evidence of fracture. It seemed that very probably the sacro-iliac joint upon the affected side had been injured. The child's general develop ment proceeded without interruption. The possibility of a green stick fracture or of injury to the epiphyses was always considered and admitted.
In this connection, he added a report of a case of complete fracture of the humerus occurring under the following circum stances. The patient was in labor without medical attendance. During the labor, the head presenting, the hand of the child presented also. A woman who was assisting the patient, becom ing frightened, made traction on the hand, and by vigorous pull ing ended the labor. The arm of the child was found broken at about the middle. Mother and child were brought to the Jefferson Maternity, when a complete fracture was evident. The child was dressed by utilizing the body as a splint and bandaging the arm to the trunk. It made a perfect recovery in function, length of limb, and continuity of form.
Dr. Davis further remarked that in general, from the stand point of obstetric surgery, surgeons may be called upon to deal with fractures of the cranium, fractures of the clavicle, and of the long bones of the extremities. Omitting fractures of the cranium, excessive width of the shoulders may result in fracture of the clavicle, and in some cases it is necessary to sever this bone to perform delivery. Fracture usually occurs in difficult version or in cases of head presentation where the arm or shoulder is pulled upon vigorously to secure delivery. In performing embryotomy, if the shoulders of the child be excessively broad, obstetricians sometimes perform cleidotomy, cutting the clavicles with stout blunt-pointed scissors. This allows the shoulders to collapse, reducing the transverse diameter of the trunk.
Injuries to the shaft of the humerus occur in version where the arms become extended. In bringing down the arms, the effort is made to pass the fingers along the humerus to the elbow, thus forearm and carrying the arm towards the body of the child. In spite of this traction, cases occur in which the mother's condition is so grave that delivery must be effected at once, regardless of injury to the child. He recalled the case of a woman, thought to be dying from disease of the heart, in whom it was necessary to perform version and extract the child as rapidly as possible. The child's elbow became impacted at the brim of the pelvis, and in bringing down the arm the humerus was frac tured. The child made a good recovery with the application of simple dressings. Separation of the epiphyses of the humerus may occur instead of fracture in version. Fractures of the fore arm are rare. Fractures in the shaft of the femur are not com mon, and usually follow cases of breech presentation, in which strong traction is made with a hook upon the child's extended thighs.
Luxations of the large joints of the fcetal body may occur as the result of difficult delivery. The joints of the pelvis are sub jected to considerable strain in moderately contracted pelves when the child presents by the breech, and the descent of the breech must be brought about by traction in the groins of the foetus. A blunt hook, such as that found upon the handle of the Hodge forceps, is sometimes inserted into the groin and traction made in this manner. Whenever possible, the finger should be used in place of the hook, as injury is not so likely to occur.
So far as Dr. Wilson's case is concerned, it had been his im pression that the fracture resulted during the version. It may have been but partial, as it was not detected at the time, and may have become complete when the child was bathed and dressed, and when it grew strong enough to move its limbs.
DR. W. REYNOLDS WiLsoN spoke of a case of supposed epi physeal separation of the femur, with reference to the manipula tive procedure which might have been responsible for the lesion. The fcetus, in the oblique position, namely, with the back forward and the head in the left innominate fossa, presented by the right shoulder. The right arm was prolapsed. He anesthetized the patient and attempted to perform podalic version. An attempt was made to grasp both knees of the fcetus and bring the breech to the inlet, allowing the child to ride up out of the pelvis. In an attempt to grasp both knees, he found the greatest difficulty in rotating the child ; but in making a secorid attempt, when he seized the upper knee only, the child was rotated without diffi culty. It was still necessary for him to use great force to deliver the breech. As he extracted the breech, he felt distinctly what impressed him as a separation of the deeper structures of the anterior thigh. He afterwards dissected the child, which had been born dead, and studied the femur carefully. He found no frac ture and no epiphyseal separation. Experimentally he wished to see what the bone would stand. He found that it resisted con siderable force. In attempting, also, to separate the epiphysis at the head of the femur, he found that the juncture was protected by the capsular ligament which is carried down to the periosteum of the shaft proper, a condition of the parts which seems to be especially adapted to the protection of the continuity at this point. It appeared to him that the condition of ossification in utero must necessarily have much to do with the fractures and separation of parts of the bones, the seat of lesion found after delivery. In his examination of the bone of the femur, he was impressed with the spongy condition of the upper and lower portions of the shaft, also with the cartilaginous condition of the head of the bone.
DR. JOPSON remarked that since fracture of the femur at the time of birth is somewhat rare, he would report a case that he had seen two or three years ago at the Children's Hospital, in an infant three or four days old. The seat of fracture was about at the junction of the middle and upper third. There was marked tendency to flexion of the upper fragment, as in the first case reported by Dr. Wilson, in which the bone became united in that position. The child was several days old at the time of its first visit to the hospital, and the spasm of the muscles at this time was very great, probably due to the fact that the fracture had received no treatment up to that time. He treated it by applying a lateral pasteboard moulded splint, such as is often used with good results in fractures of the femur in infants ; but the spasm was so great that the deformity had returned on subsequent visits. After two or three visits, the father discontinued bringing the child.
DR. WHARTON said that he had seen quite a number of cases of fracture of the femur in infants. These are usually in infants brought to the Children's Hospital, varying from a few hours to a few weeks of age. In many of these cases he could not find, in obtaining the history of the that the labor had been a diffi cult one. He was inclined to think in the majority of cases that the injury resulted from accidents after birth. In many cases the child had been allowed to fall, and in very few cases was there history of difficult or instrumental labor. In the majority of cases the injury seems to be in the upper third or near the middle of the shaft of the femur, and in such cases he usually found that there was an anterior deformity, due to flexion of the thighs, the upper fragment being drawn upward. He had been able to correct the deformity, and get satisfactory results without resorting to oste otomy. He had done osteotomy for correction of deformity fol lowing fracture of the thigh in older patients. In one a girl nine or ten years of age, there was a marked deformity in which a very good result followed an osteotomy. He had seen several fractures of the humerus in infants, coming under observation a few days after birth, which had apparently resulted from some manipulation during labor. He had also seen one or two cases of fracture to the clavicle following labor ; but in his opinion fracture of the femur was much less common from labor than was supposed, and often fracture accredited to labor was due to some accident after labor.
DR. RODMAN said that recently he had seen a premature child at seven months, and very badly developed, who had a frac ture of the right femur, with marked deformity. He had been asked to see the case with the attending physician on account of the fact that the latter feared to give an anzsthetic to such a pre mature and poorly developed child. He was able later to bring the limb into very good position without the aid of an anwsthetic.
DR. STEINBACH remarked that among the cases of fracture in infants which he had seen was one 9f fracture of the femur about the junction of the middle and upper third, with displace ment of the upper fragment upward and outward. The breech had presented, and the accoucheur had experienced difficulty in extracting the child by hooking the index-finger into the groin. He saw the child on the fourth day. The fracture was a com plete one. In treatment he used the inclined Wire was shaped to the buttock and to the back of the thigh, which was flexed upon the abdomen, and the leg, which was flexed upon the thigh, securing these with a plaster bandage which held the frag ments in firm position. The whole abdomen was surrounded by several turns of a like bandage. Within about sixteen days there was perfect union and the dressing could be dispensed with; only one dressing being necessary for the purpose. The child rested comfortably. The dressings were not soiled during defecation.
DR. WILLARD said that he had seen several cases of fracture of the femur occurring during delivery, and, although the fracture frequently was not discovered until several days after birth, yet on questioning the mother or nurse they admitted that the child had cried whenever it had been handled. It seemed to him that this late discovery of these fractures explains the statement of Dr. Wharton attributing these injuries to falls after birth. In many cases the fracture has been produced by the application of the hook in the groin; direct traction upon the femur, instead of dislocating the head or carrying off the epiphysis, has resulted in fracture. He had always dressed these injuries immediately with plaster of Paris from the thorax to the foot, making strong trac tion on the fragments and putting them in position at the time. In every case he had had good union without any noticeable de formity, and union has always been speedy.
DR. H. AUGUSTUS WILSON said that he believed that in a large majority of cases the so-called obstetric fractures are coin cidental, and not due to the obstetric procedures. He believed that they were, in the majority of cases, intrauterine, and he was drawn to that conclusion by statements made that fractures have been discovered at the time of birth, or shortly afterwards, in cases where the births have been very easy, and, in addition, by the statement of Dr. W. Reynolds Wilson in showing the tremendous power employed in podalic version in the case reported by him without injury to the bone.
He had tried his best with a number of fcetal femurs to break them by some such manipulation as Dr. Davis had resorted to. He had been unable in one of them to produce a fracture above the middle third. He had been able to produce a fracture at the middle third, and it was done by a pull and a twist at the same time. But in the case reported by him the fracture had occurred just below the trochanter, where the bone is thicker at the time of birth than the middle of the shaft, and where the strain would be possibly not as great as it would be either at the hip-joint or middle third ; so he felt that Dr. Davis, with the strong hand and finger that he possesses, is unable to produce a fracture by his method of procedure.
In conclusion, he directed attention to the medico-legal aspect of the subject under discussion. He believed there was more than enough evidence that this fracture did not occur at birth, but previously, due to faulty process of ossification, and that it was a coincidence that forcible delivery was instituted.
Stated Meeting, December 3, 1900.
The President, DE FOREST WILLARD, M.D., in the Chair.