THE THIGH. 



53i 



Plantaris 



Two heads 

 of the 

 gastrocnemius 



Mode of Injury. In old people the bone is weakened by atrophy and the neck 

 is often fractured by indirect violence, as by twisting, etc. Then the fracture is a 

 high one; if, however, the fracture is by direct violence, as by falling and striking 

 the hip, then the fracture is apt to be close to the trochanters and the prognosis 

 better. Hence the importance of ascertaining the history of the injury. Fracture 

 also occurs in young adults and children, usually from direct injury. 



Treatment. The injury is treated (i) by widely abducting the thigh, which ele- 

 vates the lower fragment to the upper; (2) by adhesive plaster extension combined 

 with lateral weight traction pulling the upper part of the thigh out, which renders tense 

 the capsule and so brings the fractured surfaces in apposition; or (3) by Thomas's 

 splint which is of metal and extends from the level of the axilla to below the knee; 

 this ensures immobility and facilitates 

 handling of the patient. 



Fracture through the Tro- 

 chanters. This is almost always 

 the result of a direct injury or blow 

 on the hip. Impaction is almost the 

 rule, the upper fragment being driven 

 into the lower. Shortening and other 

 symptoms are usually not so marked 

 as in the other fractures and almost 

 any method of treatment is followed 

 by good results. 



Fractures of the Shaft. 

 These may be in the upper, middle, or 

 lower third. They all have a common 

 displacement. The upper fragment is 

 displaced forward and outward and 

 the lower fragment backward and 

 usually inward. The foot is usually 

 everted. ^ 



fractures of the Upper Third. 

 The displacement of the upper frag- 

 ment forward and outward is usually 

 marked. It is caused by the iliacus, 

 psoas, and pectineus pulling it for- 

 ward and rotating it out and the 

 gluteus minimus and medius abduct- 

 ing it. The lower fragment is pulled 

 in by the adductors and posteriorly 

 by the gastrocnemius and plantaris 

 (Fig. 540). This is a troublesome 

 fracture and is treated either by a 

 double inclined plane or anterior 

 wire splint with the limb in a flexed 

 and abducted position or else the fragments are to be wired or pinned together. 



Fracture of the Middle Third. The displacement is the same as in the upper 

 third but to a less extent. It is usually treated by adhesive plaster extension with 

 the leg abducted. 



Fractures of tJie Loive'r Third Supracondylar. This is a particularly danger- 

 ous fracture because the lower fragment is drawn backward by the gastrocnemius and 

 plantaris, and the popliteal vessels and internal popliteal nerve may either be wounded 

 primarily or stretched over its sharp upper edge (Fig. 541). The artery lying deepest 

 is the most liable to injury, then the vein, and finally the nerve. Gangrene necessi- 

 tating amputation has occurred. Of course in attempting to replace the fragments 

 the knee should be flexed to relax the gastrocnemius and plantaris. Some cases can 

 be treated by ordinary extension with the knee straight, others with the knee flexed, 

 but others may require operation and fixing by pins or wiring. William Bryant 

 divided the tendo Achillis for the purpose of relaxing the pull of the gastrocnemius. 



FIG. 541. Supracondylar fracture of the femur. The 

 lower fragment is seen to be drawn back into the popliteal 

 space by the gastrocnemius and plantaris. The vessels are 

 stretched over the sharp edge of the lower fragment. 



