FRACTURES INVOLVING THE HIP JOINT.
Dr. Plummerread a paper on the "Pathology and Diagnosis of Fractures involving the Hip-Joint." Dr. Owensread a paper on "Complications of Fractures involving the Hip-Joint," for which see page Dr. Ochsnersaid there was one complication in fractures of the hip-joint which he believed was accountable for a great many of the failures following their treatment. He re ferred to the possibility of the fractured end turning. If in a fracture of the neck of the femur the teres ligament was torn at the same time, there was nothing which would keep the head in its position. If the head turned so that its articular surface was opposed to the fractured surface of the neck, there was absolutely no chance for union to take place. This complication he believed occurred much more frequently than was generally supposed. If statistics could be relied on, it was known that so-called short fractures of the neck of the femur occurred most frequently in the aged. Furthermore, non-union was more common in the aged than in the young. The common cause for non-union of hip fracture in the aged had been ascribed to age. It was known that age did not prevent union from taking place anywhere else, and why should it here? According to statistics and personal experi ence, all other bones of a woman of seventy healed just as readily as the broken bone of a child of five. Why, therefore, should fail ure of union be ascribed to age in this particular fracture ? Would it not be more reasonable to suppose that non-union in the aged was caused by the fact that the fracture was more often near the head of the bone, so-called short fracture, and that the head rotated, making union impossible.
Four years ago he assisted his brother (Dr. A. J. Ochsner) in an operation where this pathological condition was found. The patient, a man, had been treated by an expert surgeon by the ordinary methods, but even after several years there was no union. All of the symptoms of fracture except crepitus existed. The fracture was cut down upon, and it was found that the teres liga ment had been torn, that the fractured surface of the head was opposed to the acetabulum, and the articular surface pointed out ward, so that there was no possibility of union, no matter what treatment might have been instituted. The head of the femur was removed and, considering the condition, the man made an excellent recovery, being able to walk with crutches.
The statement of Hoffa, that chloroform or any anmsthetic should not be administered in a case of fracture of the hip-joint or of the femur, was very dangerous teaching to follow, for any one who has seen a single undiagnosed dislocation and the un happy results that occur after it, will probably never follow such directions. Any surgeon who is competent to treat a fracture of the hip at all must have enough judgment not to undo an im pacted fracture. In a case of fracture of the hip, the administra tion of an anwsthetic was indicated, in spite of what Hoffa had said on the subject.
He was inclined to think that surgeons in the past ascribed altogether too much to immobilization. From his experience and the results he had seen in treating fractures of the femur, it was not absolutely necessary to resort to immobilization to the extent that it had heretofore been practised and advocated by some sur geons. He had treated three fractures of the neck of the femur, and he had seen eight other cases treated by his brother. In ten cases out of eleven the results were very good. He had not at tempted exact immobilization. With such good results without perfect immobilization, no one could make the statement that im mobilization was one of the essential features in treating fractures of the neck of the femur. The eleventh case died from hypostatic pneumonia on the fifth or sixth day. The method of treatment which he had used was a combination of the modified Hodge's splint and the Buck's extension. (Here Dr. Ochsner exhibited a model of the modified splint which he used in cases of fracture of the femur, and demonstrated its application.) Of the eleven cases reported by him, all of the cases, with the exception of three, were over fifty years of age. Any splint which caused discomfort and pain was a bad splint, in his opinion. If any splint caused pain, it simply showed that the surgeon had not mastered the par ticular fracture, and any splint applied in a case of fracture of the femur which caused discomfort and pain should be discarded. The modified splint described by him did not cause discomfort or pain, providing it be properly applied. It must be so applied that the limb swings perfectly free from the bed, the weight must be distributed evenly, the foot must extend vertically, i.e., eversion must be guarded against above all things, and the proper amount of weight must be applied to the Buck's extension, so that the limb is the proper length and the contraction of the muscles is just overcome. This will require the weight to be from one-fifteenth to one-tenth the weight of the patient's body, according to the degree of muscular development.
He emphasized the point that absolutely immobilization was not necessary, as had been conclusively demonstrated in the eleven cases previously referred to.
DR. ARTHUR DEAN BEVAN made a plea for the old and time honored division of fractures into intra- and extracapsular. If we examine the neck of the femur and the attachment of the cap sular ligament to it, it will be found that anteriorly it is attached to a spiral line which runs down from the great trochanter into the linea aspera. Almost the entire anterior surface of the neck was within the capsule. In the posterior portion of the neck the attachment of the capsule is at a point corresponding to a line of division about midway between the intertrochanteric line and the articular surface of the femur. The old division of fractures into intra- and extracapsular was a good one, because as a matter of fact union does not follow in a fracture within the capsule the same as in a fracture of the shaft of the femur, because the amount of blood supply furnished by the ligamentum teres to the upper fragment is not sufficient to establish union. In fracture of the neck of the femur we must accept that the all-important factor which prevents union is the lack of blood supply in the small fragment which is found, to all intents and purposes, intracap sular, and almost entirely cut off from blood supply.
The statements made by Drs. Ridlon and Ochsner in regard to treatment were too enthusiastic. When Dr. Ochsner made the statement that he had ten good results out of twelve, he could not have meant that union had taken place, but that they were to his mind good functional results. What would satisfy one surgeon in the matter of a good functional result would not please another, and how many patients out of the ten would be satisfied with the result? In making such enthusiastic statements, they should be qualified. He asked whether Dr. Ochsner had obtained any bony union in his cases, to which Dr. Ochsner replied that he did not know. How could bony union be obtained in a case where the X-ray picture showed that the articular portion of the bone was cut off from all of the rest of the bone? The speaker did not believe bony union could be obtained in such a even if the fragments were nailed or wired together, let alone by ap plying any method of conservative treatment whatsoever.
The X-ray had thrown a great deal of light on the class of fractures under discussion.
He reported a case which he had diagnosticated as one of traumatic neurosis. A woman fell, and her case pursued the clin ical course of a fracture of the neck of the femur. He examined her carefully and could not make out any shortening under an anmsthetic, and he could not elicit any evidence of fracture under chloroform. Within a short time thereafter an X-ray picture was obtained and an impacted fracture found. He was never able to obtain any motion. The amount of shortening was slight. The woman was very stout. She was probably five feet six inches in height, and weighed 200 pounds. Functionally the result was bad.
He mentioned another case which he thought was an old fracture of the neck of the femur at first, but which, after an ex amination by the X-ray, proved to be a fracture just below the great trochanter. In operating and removing a V-shaped section in order to correct deformity he found a thin shell of bone, and in the centre of that bone was a mass of fibrous tissue which he at first thought was possibly an osteosarcoma, but which proved to be granulation tissue. The value of the X-ray was shown in this as without its use it would have been impossible to have made a diagnosis. Since the days of Hamilton we have advanced in our ability to diagnose these cases, but he could not see any advance that had been made in treatment.
DR. RimoN, in closing the discussion, said the fact that there is union shows there is blood supply to the part, or else that there can be union without blood supply. As to what is a good result, each surgeon has his own standard. If a man, eighty-two years of age, recovers with no more than five degrees of outward rota tion, with no flexion or deformity, with only three-quarters of an inch shortening, is able to walk without a cane or crutch, and without much limp, he considers the result good. If a woman, who weighs zio pounds, recovers with one-half-inch shortening, with fifteen degrees outward rotation, and walks without a cane, but with a slight limp, the result is good.