after several months confinement to move about with crutches, the nature of the union and the support given to the joint by bone between the trochanters, produces a more useful limb, and is preferable to those where the fracture is so closely united as to be nearly anchylosed.

A BRIEF NOTICE

OF

SOME CASES OF INJURY

ΤΟ

THE HIP-JOINT.

BY

EDWARD STANLEY,

LECTURER ON ANATOMY, AND ASSISTANT-SURGEON TO ST. BARTHOLOMEW'S

HOSPITAL.

Read June 5, 1827.

Fracture of the Trochanter Major, which may be mistaken for Dislocation of the Head of the Fe

mur.

AMONG the more complicated injuries to which the hip-joint is exposed, that of fracture of the trochanter major, combined with fracture of the neck of the femur, has, under certain circumstances, a strong resemblance to a dislocation of the head of the bone. Whenever the fractured portions of the trochanter can be brought into contact, a crepitus will be produced which may enable the surgeon to ascertain the precise nature of the injury. But when, from the direction of the fracture, one por

tion of the trochanter has been drawn by the action of the muscles towards the great ischiatic notch, no crepitus may then be discoverable, a direct source of mistake will then arise from the positive resemblance of the fractured portion of the trochanter to the head of the femur, the former occupying the same place which the latter would do in dislocation; and if, with these circumstances, there should happen to be an inversion of the injured limb, the difficulty of the diagnosis must be considerably increased. This obscurity, while it affords a strong motive for extreme caution in such cases in our own practice, should at the same time teach us to be slow in citing a mistake in the practice of others, as proving either ignorance or inattention. In this view the following cases may have some claim to the attention of the Society.

A woman, in her sixtieth year, fell in the street and injured her right hip. On examination, the limb was found slightly everted and shortened to the extent of three quarters of an inch, but moveable in every direction. The extremity of the shaft of the femur was in its natural situation, but behind the femur and at a little distance from it a bony prominence was discovered resting upon the ilium, towards the great ischiatic notch, strongly resembling the head of the femur. Various opinions were entertained as to the nature of

the injury, some believing it to be dislocation, and others, fracture. After a confinement of several months to her bed, the woman was sufficiently recovered to walk with the assistance of a crutch, and in this state she continued till her death, which took place about three years from the date of the accident, during the whole of which period I had watched the progress of the case. Having obtained permission to examine the seat of the injury, I ascertained that there had been a fracture extending obliquely through the trochanter major, and through the basis of the neck into the shaft of the femur, and that the prominence which had been mistaken for the head of the bone, was occasioned by the posterior and larger portion of the trochanter drawn backwards towards the ischiatic notch.

The next case is of a man aged sixty-five, who had been knocked down in the street. His skull was severely injured, and he had likewise sustained an injury in the right hip. His death took place on the tenth day from the time of the accident. The particulars of the injury sustained by the hip were as follow:-The limb was shortened and everted. Behind and at a considerable distance from the extremity of the shaft of the femur, a distinct prominence was discovered, so nearly resembling the head of the bone that it was presumed, a dislocation had occurred. On this pre

sumption forcible extension of the limb was made, which shifted the prominence that had been mistaken for the head of the bone. On examination of the hip after death, a fracture was found extending through the trochanter major and through the basis of the neck of the femur. One portion of the trochanter had been drawn backwards into the situation which the head of the bone would occupy in dislocation; but it still retained sufficient connexion, by periosteum, with the shaft of the femur, to explain the change in its situation during the extension of the limb.

In Sir Astley Cooper's work on Dislocations, &c., the fracture of the trochanter major is noticed, but without intimation of any difficulty in the diagnosis.

Mr. Swan has related a case of injury to the hip followed by inversion of the limb, in which a tumour was felt behind the trochanter major, resembling the head of the bone. On dissection, a fracture was discovered extending through the basis of the neck and into the shaft of the femur. A portion of the shaft had been separated, and was found behind the trochanter major; but here, the crepitus produced on examining the limb precluded any mistake respecting the nature of the injury. Other cases have been stated to me in which even experienced surgeons have found it difficult to decide whether they were cases of fracture or dislo