96 CLINICAL APPLIED ANATOMY. 



with the apex outwards may occur at the seat of the fracture. 

 One of the nutrient vessels of the femur may be torn, and the 

 amount of extravasation of blood is often very great. 



In the treatment of such fractures the shortening may be over- 

 come by the application of an extension apparatus, which, whilst 

 acting by a distinct drag upon the lower fragment in a distal 

 direction, will also tire out the muscles and so bring about their 

 relaxation. The outward rotation is easy to correct, but it is diffi- 

 cult to prevent its recurrence owing to the weight of the limb. 



Transverse fracture of the middle of the shaft of the femur is 

 not uncommon in children, particularly in those who are the sub- 

 jects of rickets, but in these fractures the displacement as a rule 

 is but slight. 



Fractures close above the condyles are not infrequently caused 

 by falls upon the front of the lower end of the thigh, in which case 

 an oblique fracture occurs, running from behind downwards and 

 forwards. The lower end of the upper fragment in such a case, 

 being sharp and at the same time forced forwards and downwards, 

 may penetrate the lower end of the quadriceps and skin render- 

 ing the fracture an open one. The upper end of the lower frag- 

 ment at the same time may be somewhat flexed by the gastrocne- 

 mius and plantaris and carried upwards by the hamstrings, so as 

 possibly to press upon or even seriously damage the popliteal 

 vessels. The same effect upon the vessels may occur in cases of 

 simple transverse fracture above the condyles ; hence it is always 

 wise to feel for the pulse in the dorsalis pedis and posterior tibial 

 near the ankle. 



The flexion of the distal fragment is difficult to overcome, so it 

 is usual to put the limb up on a double inclined plane or an 

 anterior angular wire splint, and thus to obtain flexion of the 

 proximal fragment and bring it into line with the distal. The 

 objection to this method of treatment is chiefly to be found in the 

 fact that whilst pressure upon the vessels by the lower fragment 

 is relieved, the angle of the double plane may itself cause pressure 

 on them from behind and at a slightly lower level. 



In separation of the lower epiphysis of the femur the line of 



