The insertion of the capsular ligament of the hip-joint, and its relation to intra-capsular fracture / by Geo. K. Smith.

  • Smith, George K.
Date:
1862
Catalogue details

Licence: Public Domain Mark

Credit: The insertion of the capsular ligament of the hip-joint, and its relation to intra-capsular fracture / by Geo. K. Smith. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    affected by the slow decay; and it has been no- ticed that, for some reason which has not yet been fully explained, the neck of the femur is more seriously affected by this process than other parts of the skeleton. In this fact we see the reason why a fracture of the neck of the femur which is the result of a severe injury, and is of the rarest occurrence in youth, is frequently met with in old age, and often as the result of a most tri- vial injury. This atrophy or absorption of the neck is, then, the exciting cause of the fracture, and its progress, after the fracture, is seldom, if ever, arrested until a great part or even the whole of the neck has been removed. Malgaigne holds that the destructive absorption of the neck, which follows a fracture within the capsule, is incompatible with bony union. After a careful review of the reports of post mortem exami- nations of fractures within the capsule, it ap- pears to me that the materials provided by nature for the uniting callus in this situation are in many cases entirely removed by absorption, leaving no appearance of an attempt at union; and that in those cases in which the callus is not thus removed, it is arrested in its development, forming, in some instances, a kind of semi-carti- laginous material, rounding off the extremities of the fragments, and in others, a firm fibrous union which does not become fully developed into bone. Sir Astley Cooper states that, in recent cases, the capsule is found to be distended with a mix- ture of serum, synovial fluid, and blood, which— “ Is produced by the inflammatory process, and becomes absorbed when the irritation in the part subsides. I do not know the exact period at which this change takes place, but L have seen it in the recent state of the injury.”* With regard to the new classification of frac- tures of the neck proposed by Professor Post, it seems to me that it will render the “vexed ques- tion of osseous union within the capsule” more difficult of solution than it will be with the classi- fication now in use. He proposes— “To make a new classification of fractures of the cervix femoris, dividing them into two classes, viz.: fractures between the caput femoris and the inter-trochanteric lines, and fractures at the inter- trochanteric lines extending more or less into the shaft of the bone. 1 propose to call the fractures of the first class intra-cervical, and those of the second class extra-cervical. I think that these two classes of fractures will be found to corre- spond very nearly with those which have hitherto * Cooper on Dislocations and Fractures of the Joints, p. 145. been described as intra-capsular and cxtra-cap- sular.” He divides “fractures of the cervix into two classes ;” but the class of intra-cervical fractures, representing fractures at any point between the head of the bone and the inter-trochanteric lines, includes all possible fractures of the cervix, and ( hence his extra-cervical fractures cannot properly be spoken of as fractures of the cervix, anc] do not, therefore, correspond in any degree with frac- [ tures hitherto described as extra-capsular, in which the line of fracture traverses the portion of the . cervix included between the insertion of the cap- ; sule and the inter-trochanteric lines. The greatest * objection to the classification is found in the fact ' that an intra-cervical fracture, which Professor E Post thinks will be found to correspond very j nearly with an intra-capsular fracture, may be 11 either an intra-capsular fracture, an extra-cap-s sular fracture, or a fracture partly within and partly without the capsule. This fact is import- j ant when we consider that these several fractures 11 included under the name of intra-cervical differ Ji: widely from each other, bony union being of fre- ™ queut occurrence in a fracture external to the ft capsule, occasionally seen in a fracture partly fa within and partly without the capsule, while it f has not yet been satisfactorily demonstrated that bony union has ever occurred entirely within the j. capsule. It is highly important, both in a scien-11 tific and a medico-legal point of view, to know whether we can ever expect bony union of a If fracture entirely within the capsule. If not, the |s surgeon who faithfully performs his duty, andjn fails to secure bony union of this fracture, canv summon to his defense, when unjustly arraigned for malpractice, the scientific fact that a fracture within the capsule is never united by bone. pei Professor Post states that “in intra-cervical nil fractures bony union very rarely occurs,” and he® tells us that an intra-cervical fracture w.ll bejj*1 found to correspond very nearly with an intra- L capsular fracture. If from this we are to under- ific stand that bony union of an intra-capsular frac-»b ture does occasionally occur, we think that he requires us to admit as a fact that which surgeons ... have labored for fifty or a hundred years, and failed to prove. I do not deny the possibility ol St bony union within the capsule, but simply think ‘jj that the evidence furnished in proof of sucl 1 union is not sufficient to establish it as a fact i(| and that further investigation is needed in this ll direction.