Clinical surgical diagnosis for students and practitioners / by F. de Quervain ; translated from the 4th ed. by J. Snowman.

Quervain, F. de (Fritz), 1868-1940.

Date:: 1913

Credit: Clinical surgical diagnosis for students and practitioners / by F. de Quervain ; translated from the 4th ed. by J. Snowman. Source: Wellcome Collection.

Provider: This material has been provided by the Augustus C. Long Health Sciences Library at Columbia University and Columbia University Libraries/Information Services, through the Medical Heritage Library. The original may be consulted at the the Augustus C. Long Health Sciences Library at Columbia University and Columbia University.

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$We may also derive important information by exaniiuing the inovc- ments. If crepitus is felt, impaction is excluded. It is also excluded if the thigh can be moved backwards and forwards on the pelvis— obviously without using force (the va et vient movement of French authors). If we find on rotating the limb that the tip of the trochanter turns on its own axis and does not describe any definite curve, a loose inter- trochanteric fracture must be present. If the trochanter describes a definite curve when the limb is rotated —a curve which is always smaller than normal in the case of fractures —there are two possibilities present. If the signs previously mentioned enable us to exclude impaction, the neck of the femur, which repre- sents the radius of the curve described by the trochanter, must still be attached to it. In other words, a non-impacted subcapital fracture is certainly present. If, on the other hand, we must assume that there is impaction, we can only suspect the exact situation of the fracture by localizing the direct pain on pressure and the thickening of the bone. If there is too much swelling to permit of this, it does not prejudice the question of treatment. Every impacted fracture which is suspicious of a subcapital fracture must be handled with due attention to the impaction, because this offers the safest guarantee for bony union. It is better to do without a definite diagnosis than to disengage the impaction. Only an X-ray examination can define the line of fracture and enable us to disengage the impaction, when the fracture is not directly at the head, and the eversion of the limb renders it desir- able to improve its position. In some cases the etiology assists in the forming of a diagnosis, but very often the patient himself does not know the details of the accident, and his statements are quite indefinite and useless. If he has fallen on his feet and the blow has thus been imparted from below, a subcapital fracture is the most likely result. A fall on the region of the trochanter is the most frequent cause of intertrochanteric fracture. Extreme external rotation is just as likely to be due to pertrochanteric or to subtrochanteric fracture as to subcapital fracture, but does not suggest intertrochanteric fracture. So far we have purposely not laid any stress on the age of the patient. Too much importance has hitherto been attached to the statement that fracture of the neck of the femur is the prerogative of old people. There is no doubt that old age predisposes to it, but fracture of the neck of the femur is by no means a rarity in young persons. The patients, after a slight injury, remain in bed for a few days, sometimes even for two or three weeks, with the diagnosis of contusion of the hip, or with no diagnosis at all, and then begin to resume their occupation. After a few months have elapsed, they consult their doctor because of pains in the hip and slight lameness. Examination then reveals a shortening of i to 2 cm., a corresponding elevation of the level of the trochanter, diminution of the power of abduction and$