FRACTURE OF THE NECK OF THE FEMUR.—The division of these fractures into intracapsular and extracapsular has no clinical value and is not borne out by post-mortem findings. The more accu rate classification is: (1)fractures through the (narrow part of the) neck, and (2) fractures at the base of the neck. Clin ically, it is often impossible and never necessary to distinguish between the two.
Symptoms. — The chief deformity is shortening of the limb with eversion. The eversion is usually slight, often ab sent, and rarely exchanged for inversion. The shortening may appear at once or may only come on gradually. In the latter case, under appropriate treatment the shortening may never appear at all. In measuring for shortening the greatest care must be taken to compare the limbs when placed in exactly similar positions. There is also a fullness in the outer part of Searpa's triangle, and the fascia lata above the great trochanter is relaxed, as compared with the other side, on account of the elevation of the trochanter. Nor mally the upper border of the great tro chanter just touches Nelaton's line drawn from the anterior superior spine of the ilium to the tuberosity of the ischium Fig. 8). In fracture of the neck, with shortening, the trochanter rises above this line, and the amount of dis placement may be measured by means of Bryant's ilio-femoral triangle, variations in the length of the line (which is at right angles to a perpendicular dropped from the anterior superior spine of the ilium) indicating the displacement of the trochanter. If the trochanter is split, it is broadened in comparison with its fellow.
Crepitus can rarely be obtained. Pain may be diffuse, but pressure over the neck of the femur js likely to be painful, as is upward pressure of the femur. A few cases are reported in which the patient has walked on the limb, but usually loss of function is complete and all the move ments of the joint restricted.
The history of a typical case is as fol lows: An elderly person, preferably a woman, while walking about, stumbles and falls to the floor, with perhaps little violence. She cannot rise, and com plains that every movement of the hip is painful. Examination will reveal symp
toms as indicated above.
Diagnosis. — The diagnosis between the fractures through the neck and those at the base is often impossible. Splitting of the trochanter is a sure sign of the latter, while after the former it is be lieved that shortening is more likely to be secondary.
In dislocation the motions of the limb are restricted in certain definite direc tions and the head can be felt while in the usual dorsal dislocation; the empti ness of the acetabulum may be deter mined by pressure on Scarpa's triangle.
In subtrochanterie fractures the tro chanter does not share in gentle rotation imparted to the shaft.
In old persons it is not rarely an abso lute impossibility to differentiate con tusion of the hip from fracture of the neck of the femur. In such a case, when the sole symptoms are pain and disabil ity, treatment for fracture should be in stituted without the slightest hesitation, the patient being bedridden in any event, and this treatment should be continued for at least three weeks and until all pain and soreness have disappeared. Thus, if it turns out to be a contused hip, the patient has not been unduly inconven ienced, while if it be a fracture, he has been given the best chances of recovery and the surgeon has, perhaps, avoided a suit for malpractice.
Etiology.—As has already been indi cated, fractures of the neck of the femur is usually caused by a comparatively slight injury to an old person, usually a woman. In the young a much greater amount of violence is required to break the bone.
Pathology.—In fractures through the neck the cancellous tissue is crushed, but impaction is rare. The head of the bone may be splintered. As a portion of the periosteum habitually remains un torn, the vitality of the head is insured thereby, and union, fibrous at least, may be expected. Fractures at the base are likely to be impacted and the line of fracture may split the great trochanter. The greatest impaction is usually behind; hence the thigh tends to rotate outward. The callus is often excessive.