Manual of Surgery Volume II Part 13

FRACTURES OF PELVIS: _Varieties_--INJURIES IN REGION OF HIP: Surgical anatomy; _Fracture of head of femur_; _Fracture of neck of femur_; _Fracture below lesser trochanter_--DISLOCATION OF HIP: _Varieties_--Sprains--Contusions--FRACTURE OF SHAFT OF FEMUR.

FRACTURE OF THE PELVIS

For descriptive as well as for practical purposes, it is useful to divide fractures of the pelvis into those that involve the integrity of the pelvic girdle as a whole, and those confined to individual bones.

In all, the prognosis depends upon the severity of the visceral lesions which so frequently complicate these injuries, rather than upon the fractures themselves.

#Fractures implicating the pelvic girdle as a whole# usually result from severe crus.h.i.+ng forms of violence, such as the fall of a ma.s.s of coal or a pile of timber, or the pa.s.sage of a heavy wheel over the pelvis. The force may act in the transverse axis of the pelvis, or in its antero-posterior axis. The pelvic viscera may be lacerated by the tearing asunder of the bones, or perforated by sharp fragments, or they may be ruptured by the same violence as that causing the fracture.

As a rule, more than one part of the pelvis is broken, the situation of the lesions varying in different cases.

_Separation of the pubic symphysis_ may result from violence inflicted on the fork, as in coming down forcibly on the pommel of a saddle; from forcible abduction of the thighs; or it may happen during child-birth. In some cases the two pubic bones at once come into apposition again, and there is no permanent displacement, the only evidence of the injury being localised pain in the region of the symphysis elicited on making pressure over any part of the pelvis. In other cases the pubic bones overlap one another, and the membranous portion of the urethra, or the bladder wall, is liable to be torn. The displaced bones may be palpated through the skin, or by v.a.g.i.n.al or rectal examination.

The _pubic portion_ of the pelvic ring is the most common seat of fracture. The bone gives way at its weakest points--namely, through the superior (horizontal) ramus of the p.u.b.es just in front of the ilio-pectineal eminence, and at the lower part of the inferior (descending) ramus (Fig. 55). The intervening fragment of bone is isolated, and may be displaced. These fractures are frequently bilateral, and are often a.s.sociated with separation of the sacro-iliac joint, with longitudinal fracture of the sacrum (Fig. 55), or with other fractures of the pelvic-bones.

[Ill.u.s.tration: FIG. 55.--Multiple Fracture of Pelvis through Horizontal and Descending Rami of both p.u.b.es, and Longitudinal Fracture of left side of Sacrum.]

Injuries of the membranous urethra and bladder are frequent complications, less commonly the r.e.c.t.u.m, the v.a.g.i.n.a, or the iliac blood vessels are damaged.

Localised tenderness at the seat of fracture, pain referred to that point on pressing together or separating the iliac crests, and mobility of the fragments with crepitus, are usually present. The fragments may sometimes be felt on rectal or v.a.g.i.n.al examination. In all cases shock is a prominent feature.

_The lateral and posterior aspects_ of the pelvic ring may be implicated either in a.s.sociation with pubic fractures or independently. Thus a fracture of the iliac bone may run into the greater sciatic notch; or a vertical fracture of the sacrum or separation of the sacro-iliac joint may break the continuity of the pelvic brim. In rare cases these injuries are accompanied by damage to the intestine, the r.e.c.t.u.m, the sacral nerves, or the iliac blood vessels.

[Ill.u.s.tration: FIG. 56.--Fracture of left Iliac Bone; and of both Pubic Arches.]

_Treatment._--It is of importance that the patient be moved and handled with care lest fragments become displaced and injure the viscera. He should be put to bed on a firm mattress, which may be made in three pieces, for convenience in using the bed-pan and for the prevention of bed-sores.

Before the treatment of the fracture is commenced, the surgeon must satisfy himself, by the use of the catheter and by other means, that the urethra and bladder are intact. Should these or any other of the pelvic viscera be damaged, such injuries must first receive attention.

The treatment of the fracture itself consists in adjusting the fragments, as far as possible by manipulation, applying a firm binder or many-tailed bandage round the pelvis, and fixing the knees together by a bandage (Fig. 57).

[Ill.u.s.tration: FIG. 57.--Many-tailed Bandage and Binder for Fracture of Pelvic Girdle.]

When there is displacement of fragments extension should be applied to both legs, with the limbs abducted and steadied by sand-bags.

Compound fractures, being commonly a.s.sociated with extravasation of urine, are liable to infective complications. Loose fragments should be removed, as they are p.r.o.ne to undergo necrosis.

The patient is confined to bed for six or eight weeks, and it may be several weeks more before he is able to resume active employment.

The #acetabulum# may be fractured by force transmitted through the femur, usually from a fall on the great trochanter, less frequently from a fall on the feet or other form of violence. It may merely be fissured, or the head of the femur may be forcibly driven through its floor into the pelvic cavity, either by fracturing the bone or, in young subjects, by bursting asunder the cartilaginous junction of the const.i.tuent bones. When the femoral head penetrates into the pelvis--the _central dislocation of the hip_ of German writers--the condition simulates a fracture of the neck of the femur, but the trochanteric region is more depressed and the trochanter lies nearer the middle line. The limb is shortened, and movements of the joint are painful and restricted, especially medial rotation. In some cases there is pain along the course of the obturator nerve.

On rectal or v.a.g.i.n.al examination there is localised tenderness over the pelvic aspect of the acetabulum, and in some cases a convex projection, or even crepitating fragments can be detected. The diagnosis is completed by an X-ray picture.

When the head of the femur penetrates the acetabulum, reduction should be attempted by traction and manipulation. The pelvis is held rigid, and the thigh is flexed and forcibly adducted, while the medial side of the thigh rests against a firm sand-bag; the femoral head is thus lifted out of the pelvis. In a recent injury the amount of force required is relatively slight. The head is kept in its corrected position by extension.

Fracture of the _upper and back part of the rim_ of the acetabulum may accompany or simulate dorsal dislocation of the hip. Crepitus may be present in addition to the symptoms of dislocation, and after reduction the displacement is easily reproduced. The treatment is by extension with the limb adducted.

#Fracture of Individual Bones of the Pelvis.#--_Ilium._--The expanded portion of the iliac bone is often broken by direct violence, the detached fragments varying greatly in size and position (Fig. 56).

The whole or part of the _crest_ may be separated by similar forms of violence.

When the fracture implicates the _ala_ of the bone, it usually starts at the triangular prominence near the middle of the crest, and runs backwards or forwards, pa.s.sing for a variable distance into the iliac fossa. The displaced fragment can sometimes be palpated and made to move when the muscles attached to it are relaxed. This is done by flexing the thighs and bending the body forward and towards the affected side. Pain and crepitus may be elicited on making this examination.

These fractures are treated by applying a roller bandage or broad strips of adhesive plaster over the seat of fracture, and by placing the patient in such a position as will relax the muscles attached to the displaced fragment--in the case of the iliac spine by flexing the thigh upon the pelvis; in the case of the crest or ala by raising the shoulders. Union takes place in three or four weeks.

In young persons, the _anterior superior spine_ has been torn off and displaced downwards by powerful contraction of the sartorius muscle; and the _anterior inferior spine_ by strong traction on the ilio-femoral or [inverted Y]-shaped ligament. These injuries are best treated by fixing the displaced fragment in position by a peg or silver wire sutures and relaxing the muscles acting on it.

Fracture of the _ischium_ alone is rare. It results from a fall on the b.u.t.tocks, the entire bone or only the tuberosity being broken. There is little or no displacement, and the diagnosis is made by external manipulation and by examination through the r.e.c.t.u.m or v.a.g.i.n.a.

A longitudinal fracture of the _sacrum_ may implicate the posterior part of the pelvic ring, as has already been mentioned. In rare cases the lower half of the bone is broken _transversely_ from a fall or blow, and the lower fragment is bent forward so that it projects into the pelvis and may press upon or tear the r.e.c.t.u.m, or the sacral nerves may be damaged, and partial paralysis of the lower limbs, bladder, or r.e.c.t.u.m result. These fractures are frequently comminuted and compound, and the soft parts may be so severely bruised and lacerated that sloughing follows. On rectal examination the lower segment of the bone can be felt, and on manipulating it pain and crepitus may be elicited.

Fracture of the _coccyx_ may be due to a direct blow, or may occur during parturition. As a result of this injury the patient may have severe pain on sitting or walking, and during defecation. The loose fragment can be palpated on rectal examination. There is considerable difficulty in keeping the fragment in position, and if it projects towards the r.e.c.t.u.m it should be removed. If the lower fragment unites at an angle so as to cause pressure on the r.e.c.t.u.m, it gives rise to the symptoms of _coccydynia_, which may call for excision.

INJURIES IN THE REGION OF THE HIP

These include the various fractures of the upper end of the femur; dislocation and sprain of the hip-joint; and contusion of the hip.

#Surgical Anatomy.#--The strength of the hip-joint depends primarily on its osseous elements--the rounded head of the femur filling the deep socket of the acetabulum, to the bottom of which it is attached through the medium of the ligamentum teres. The edge of the acetabulum is specially strong above and behind, while at its lower margin there is a gap, bridged over by the labrum glenoidale (cotyloid ligament).

In relation to fractures of the upper end of the femur, it is to be borne in mind that as the antero-posterior diameter of the neck is less than that of the shaft, and as a considerable portion of the great trochanter lies behind the junction of the neck with the shaft, the greater part of any strain put upon the upper end of the femur is borne by the neck of the bone and not by the trochanter. The head and neck of the femur are nourished chiefly by the thick, vascular periosteum, and through certain strong fibrous bands reflected from the attachment of the capsule--the retinacular or cervical ligaments of Stanley. The integrity of these ligaments plays an important part in determining union in fractures of the neck of the femur, both by keeping the fragments in position and by maintaining the blood-supply to the short fragment. Whether it be true or not that an alteration in the angle of the femoral neck takes place with advancing years, it is generally recognised that this change is of no importance in relation to fractures in this region.

The articular capsule of the hip is of exceptional strength. It is attached above to the entire circ.u.mference of the acetabulum, and below to the neck of the femur in such a way that while the whole of the anterior and inferior aspects of the neck lies within its attachment, only the inner half of the posterior and superior aspects is intra-capsular. The capsule is augmented by several accessory bands, the most important of which is the _ilio-femoral or [inverted Y]-shaped ligament_ of Bigelow, which pa.s.ses from the anterior inferior iliac spine to the anterior inter-trochanteric line, its fasciculi being specially thick towards the upper and lower ends of this ridge. The medial limb of this ligament limits extension of the thigh, while the lateral limits eversion and adduction. The weakest part of the capsular ligament lies opposite the lower and back part of the joint.

The hip-joint is surrounded by muscles which contribute to its strength, the most important from the surgical point of view being the obturator internus, which plays an important part in certain dislocations, and the ilio-psoas, which influences the att.i.tude of the limb in various lesions in this region.

Except in thin subjects, the const.i.tuent elements of the hip-joint cannot be palpated through the skin. A line drawn vertically downwards from the middle of Poupart's ligament pa.s.ses over the centre of the joint, which in adults lies on the same level as the tip of the great trochanter. In children it is somewhat higher.

For purposes of clinical diagnosis it is necessary to locate certain bony prominences, the most important being--(1) The _anterior superior iliac spine_, which is most readily recognised by running the fingers along Poupart's ligament towards it. (2) The _ischial tuberosity_, which in the extended position of the limb is overlapped by the lower margin of the gluteus maximus muscle, and is therefore not easily located with precision. By flexing the limb and making pressure from below upwards in the gluteal fold, the smooth, rounded prominence can usually be detected. (3) The quadrilateral _great trochanter_ is readily recognised on the lateral aspect of the hip. Its highest point or _tip_ can best be felt by pressing over the gluteal muscles from above downwards.

_Clinical Tests._--If a line is drawn from the anterior superior iliac spine to the most prominent part of the ischial tuberosity, it just touches the tip of the great trochanter. This is known as _Nelaton's line_ (Fig. 58).

[Ill.u.s.tration: FIG. 58.--Nelaton's Line.]

_Bryant's test_ (Fig. 59) is applied with the patient lying on his back, and consists in dropping a perpendicular AB from the anterior superior iliac spine, and drawing a line CD from the tip of the great trochanter to intersect the perpendicular at right angles. This is done on both sides of the body, and the length of the lines CD compared. Shortening on one side indicates an upward displacement of the trochanter, lengthening a downward displacement. The third side AC of the triangle indicates the distance between the anterior spine and the tip of the trochanter.

[Ill.u.s.tration: FIG. 59.--Bryant's Line.]

_Chiene's test_, which is simpler than either of these, consists in applying a strip of lead or tape across the front of the body at the level of the anterior superior iliac spines, and another touching the tips of the two trochanters. Any want of parallelism in these lines indicates a change in the position of one or other trochanter.

FRACTURE OF THE UPPER END OF THE FEMUR

The fractures of the upper end of the femur that are liable to be confused with one another and with dislocations of the hip, include fractures of the head, the neck, the trochanters, and separation of the upper epiphyses, and fracture of the shaft just below the trochanters.

Fracture of the #head of the femur# is rare, and is usually a complication of backward dislocation of the hip. It takes the form of a split of the articular surface caused by impact against the edge of the acetabulum, and is a.n.a.logous to the indentation fracture of the head of the humerus, which may accompany dislocation of the shoulder.

The #epiphysis of the head#, which lies entirely within the capsule of the joint (Fig. 60), is occasionally separated, and the symptoms closely simulate those of fracture of the narrow part of the neck. If the condition is overlooked or imperfectly treated, it may in course of time be followed by c.o.xa vara.