190 THE SKELETON. 



the Vastus externus, Gluteus maximus, short head of the Biceps, Vastus internus, 

 Adductor magnus, Pectineus, Adductor brevis, Adductor longus, Crureus, and 

 Subcrureus. To the condyles : the Gastrocnemius, Plantaris, and Popliteus. 



Surface Form. The femur is covered with muscles, so that in fairly muscular subjects the 

 shaft is not to be detected through its fleshy covering, and the only parts accessible to the touch 

 are the outer surface of the great trochanter and the lower expanded end of the bone. The 

 external surface of the great trochanter is to be felt, especially in certain positions of the limb. Its 

 position is generally indicated by a depression, owing to the thickness of the Gluteus medius and 

 minimus, which project above it. When, however, the thigh is flexed, and especially if 

 crossed over the opposite one, the trochanter produces a blunt eminence on the surface: The 

 upper border is about on a line with the spine of the os pubis, and its exact level is indicated by 

 a line drawn from the anterior superior spinous process of the ilium, over the outer side of the 

 hip, to the most prominent point of the tuberosity of the ischium. This is known as Nelaton's 

 line. The outer and inner condyles of the lower extremity are easily to be felt. The outer one 

 is more subcutaneous than the inner one, and readily felt. The tuberosity on it is comparatively 

 little developed, but can be more or less easily recognized. The inner condyle is more thickly 

 covered, and this gives a general convex outline to this part, especially when the knee is 

 flexed. The tuberosity on it is easily i'elt, and at the upper part of the condyle the sharp 

 tubercle for the insertion of the tendon of the Adductor magnus can be recognized without 

 difficulty. When the knee is flexed, and the patella situated in the interval between the con- 

 dyles and the upper end of the tibia, a part of the trochlear surface of the femur can be made 

 out above the patella. 



Surgical Anatomy. There are one or two points about the ossification of the femur 

 bearing on practice to which allusion must be made. It has been stated above that the 

 lower end of the femur is the only epiphysis in which ossification has commenced at the time of 

 birth. The presence of this ossific centre is, therefore, a proof, in newly-born children found 

 dead, that the child has arrived at the full period of utero-gestation, and is always relied upon in 

 medico-legal investigations. The position of the epiphysial line should be carefully noted. It 

 is on a level with the adductor tubercle, and the epiphysis does not, therefore, form the whole 

 of the cartilage-clad portion of the lower end of the bone. It is essential to bear this point in 

 mind in performing excision of the knee, since growth in length of the femur takes place chiefly 

 from the lower epiphysis, and any interference with the epiphysial cartilage in a young child 

 would involve such ultimate shortening of the limb, from want of growth, as to render it 

 almost useless. Separation of the lower epiphysis may take place up to the age of twenty, at 

 which time it becomes completely joined to the shaft of the bone ; but. as a matter of fact, few 

 cases occur after the age of sixteen or seventeen. The epiphysis of the head of the femur is of 

 interest principally on account of its being the seat of origin of a large number of cases of 

 tuberculous disease of the hip-joint. The disease commences in the majority of cases in the 

 highly vascular and growing tissue in the neighborhood of the epiphysis, and from here extends 

 into the joint. 



Fractures of the femur are divided, like those of the other long bones, into fractures of the 

 upper end ; of the shaft ; and of the lower end. The fractures of the upper end may be 

 classified into (1) fracture of the neck; (2) fracture at the junction of the neck with the great 

 trochanter; (3) fracture of the great trochanter; and (4) separation of the epiphysis, either 

 of the head or of the great trochanter. The first of these, fracture of the neck, is usually 

 termed intracapsular fracture, but this is scarcely a correct designation, as, owing to the attach- 

 ment of the capsular ligament, the fracture may be partly within and partly without the cap- 

 sule, when the fracture occurs at the lower part of the neck. It generally occurs in old people, 

 principally women, and usually from a very slight degree of indirect violence. Probably 

 the main cause of the fracture taking place in old people is in consequence of the degenerative 

 changes which the bone has undergone. Merkel believes that it is mainly due to the absorp- 

 tion of the calcar femorale. These fractures are occasionally impacted. As a rule they unite by 

 fibrous tissue, and frequently no union takes place, and the surfaces of the fracture become 

 smooth and eburnated. 



Fractures at the junction of the neck with the great trochanter are usually termed extra- 

 capsular, but this designation is also incorrect, as the fracture is partly within the capsule, 

 owing to its attachment in front to the anterior intertrochanteric line, which is situated below 

 the line of fracture. These fractures are produced by direct violence to the great trochanter, as 

 from a blow or fall laterally on the hip. From the manner in which the accident is caused, the 

 neck of the bone is driven into the trochanter, where it may remain impacted, or the trochanter 

 may be split up into two or more fragments, and thus no fixation takes place. 



Fractures of the great trochanter may be either "oblique fracture through the trochanter 

 major, without implicating the neck of the bone" (Astley Cooper), or separation of the great 

 trochanter. Most of the recorded cases of this latter injury occurred in young persons, and were 

 probably cases of separation of the epiphysis of the great trochanter. Separation of the epiphysis 

 of the head of the femur has been said to occur, but has probably never been verified by post- 

 mortem examination. 



Fractures of the shaft may occur at any part, but the most usual situation is at or near the 

 centre of the bone. They may be caused by direct or indirect violence or by muscular action. 



