chap, xxi.] THE REGION OF THE KNEE. 447 



applied in a lateral direction, is best calculated to pro- 

 duce a separation of the epiphysis. Hamilton reports 

 a strange case in a man aged 21, whose outer condyle 

 was fractured by the twist of the leg, which happened 

 while he was undressing himself to bathe. The only 

 fracture that requires special notice in this place is the 

 fracture of the shaft just above the condyles. The 

 lesion is situated generally about two inches above the 

 line of the epiphysis, and corresponds to the spot 

 where the compact shaft joins the softer and more 

 cancellous tissue of the lower end of the bone. It is 

 near the place, also, where the femoral artery crosses 

 the bone to reach the ham, and it has thus happened 

 that the vessel has been wounded by splinters in this 

 particular injury. The fracture is usually oblique, 

 from behind, downwards, and forwards. The lower 

 fragment will be drawn upwards by the same muscles 

 that produce shortening in other fractures of the shaft 

 (page 422), and its sharp upper end is very apt to be 

 pulled forcibly into the popliteal space by the gastroc- 

 nemius muscle. This latter displacement is difficult to 

 remedy. If the limb be extended, the fragment is 

 only drawn the more into the ham, and it is therefore 

 possible for the limb to appear straight, and yet have 

 the knee-joint much bent. In three cases of this 

 injury I divided the tendo Achillis, and then placed 

 the limb upon a straight splint, following a practice 

 suggested by Mr. Bryant. The effect upon the posi- 

 tion of the fragments was in each case very good 

 (Brit. Med. Jour., 1883). 



The upper end of the tibia is sometimes the 

 seat of fracture, although of all parts of this bone 

 the upper third is the part least often broken. One 

 or other of the tuberosities may be broken off, or 

 there may be a transverse or oblique fracture of the 

 upper end of the shaft associated with a vertical 

 one running up into the joint between the two 



