PRACTICAL CONSIDERATIONS : THE FIBULA. 



395 



ligament or a fracture of the malleolus ; and (c) over the fibula from two to four 

 inches above the tip of the malleolus, — i.e., over the fibular fracture. 



The lower epiphysis of the fibula is an exception to the rule that the epiphyses 

 of long bones appear first at the end from which the nutrient artery is directed, and 

 to the more important rule that the chief growth of the long bones takes place at 

 the end where the epiphysis is last united to the shaft ; in the other long bones this 

 is also the ^nd from which the nutrient artery is directed. We have seen that in 

 the upper extremity, the nutrient canals being directed towards the elbow, the epiph- 

 yses at the upper end of the humerus and the lower ends of the radius and ulna appear 

 earlier and join the shaft later than those at the elbow, and that thus it is from the 

 shoulder and wrist that the chief growth of the upper limb takes place. In the lower 

 extremity, the nutrient canals being directed towards the hip and the ankle, the lower 

 epiphysis of the femur and the upper epiphysis of the tibia appear first and are joined 

 on last, and the chief growth of the lower limb takes place at the knee. 



Fig. 410. 



D 



Showing four types of fracture of lower end of fibula according to classification of Rose and Carless. 



In the case of the fibula — the upper part of which is in man in a comparatively- 

 rudimentary condition (Poland) — the exception is noted to avoid confusion in the 

 mind of the student. The nutrient artery runs downward, but the lower epiphysis 

 is both the first to appear and the first to consolidate, and is the chief seat of 

 growth. It is not of great practical importance, although it is probable that in most 

 so-called fractures of the extreme lower end of the fibula occurring between the 

 twelfth and nineteenth vears there has been a disjunction of this epiphysis. _ The so- 

 lution of continuity would then be below instead of above the tibio- fibular ligaments. 



The synovial membrane of the ankle-joint is attached above the epiphyseal line, 

 and that articulation is therefore likely to be involved more frequently than in 

 fractures of the diaphysis. This fact, together with the importance of the epiphysis 

 in its relation to growth of the bone, should cause the possibility of its disjunction to 

 be borne in mind. If arrest of growth does ensue, a condition of talipes valgus may 

 result from the relative overgrowth of the tibia. For the relief of this the operation 

 of " conjugal chondrectomy"'— removal of the lower epiphyseal cartilage of the tibia 

 — has been suggested. This at twelve years of age is seventeen millimetres from the 

 tip of the malleolus. It is subcutaneous. 



