464 



The Femur 



violence which causes it may be trifling, for the bone is weak and the 

 shock of an unexpected step, or of a jarring, comes vertically across it. 

 The limb is at once everted, shortened, and useless, and swelling and 

 pain are at the hip. With such signs it is superfluous and unkind to 

 try to elicit crepitus. 



The fracture may be within or outside of the capsule. In 

 the former case the shaft-fragment is tethered by the 

 ligament, and the shortening may not amount to more 

 than half an inch or so, but when the break is outside 

 the capsule there is, practically, no limit to the amount 

 of shortening, which may then amount to several 

 inches. 



Union after intra-capsular fracture very rarely 

 occurs by bone, probably because, the fracture being in 

 the joint, the surfaces are constantly bathed in sero- 

 synovial fluid, instead of being wrapped in blood-clot, 

 as happens in fracture in any other part of the body, 

 with the exception of the patella, the olecnmon, and 

 the coronoid, which are all, be it noticed, instances of fracture into a 

 synovial membrane. To explain the failure of bony union by reference 

 to the age of the patient (upwards of fifty years) is incorrect, for if a 

 man of one hundred years break the shaft of his femur firm union 

 would be expected. To say, also, that the cause of non-union may be 

 want of apposition of the surfaces is wrong ; for months or years after 

 the injury we may find the surfaces closely applied, polished by friction 

 against each other, or closely connected by fibrous tissue. Neither is 

 the theory of imperfect blood-supply to the parts valid. 



Extra-capsular 

 fracture. 



Fracture below lesser trochanter ; upper fragment lilted forwards by psoas and iliacus. 



(After HJND.) 



Xn fracture below the lesser trochanter the lower fragment 

 the chief part of the bone drops by its own weight, and is pulled 

 upwards, as explained above, and rolled outwards ; the upper fragment 

 is tilted forwards by the psoas, iliacus, pectineus, adductor brevis, and 

 gluteus minimus ; thus there is often considerable overlapping, defor- 

 mity, and shortening. The injury cannot then be satisfactorily treated 



