FBACTUKES OF THE FEMUE. 95 



immediately below the lesser trochanter, a characteristic displace- 

 ment of the proximal fragment is induced by the action of the 

 ilio-psoas. The fragment is flexed, so that its lower end tends to 

 project forwards, sometimes against the vessels, and in thin 

 persons it may almost appear as if it intended to perforate the 

 integument. Associated with the flexion will be found some 

 amount of external rotation and abduction, caused by the 

 pull of the obdurator muscles and the quadratus femoris. 

 The distal fragment at the same time will be drawn somewhat 

 upwards, backwards and towards the middle line, chiefly by the 

 action of the hamstrings aided by the quadriceps and the adductors, 

 thus inducing an angular deformity in two directions, that is, 

 with the apex of the angle both outwards and forwards. 



It is obvious from this description of the deformity that there 

 will be considerable difficulty in getting the two fragments into a 

 proper line of apposition, unless the knee is raised by flexion, and 

 traction is made upon the distal fragment to overcome its 

 upward displacement. 



Fractures of the middle of the shaft by indirect violence as a 

 rule are oblique, and the displacement may be considerable. 

 Again the muscles passing from the pelvis to the femur, such as 

 the ilio-psoas, pectineus, adductor brevis and adductor longus, 

 tend to flex the upper fragment and externally rotate it, but in 

 contradistinction to the abduction of the proximal fragment as 

 seen in the previous fracture, there is a tendency in fractures of 

 the middle of the shaft for the lower end of the proximal frag- 

 ment to be drawn somewhat inwards, that is, adducted. The 

 lower fragment is drawn upwards, backwards, and inwards, 

 chiefly by the hamstrings and the great adductor, and its upper 

 end may tend to push outwards the lower end of the upper 

 fragment, thus counteracting the tendency to adduction just 

 mentioned. In addition to the upward, backward and inward dis- 

 placement, the lower fragment is markedly rotated outwards 

 by the weight of the limb. There may also be, from powerful 

 action of the adductor magnus, some adduction of the lower 

 fragment and the leg, with the result that an angular deformity 



