438 THE INFERIOR EXTREMITY 



the lateral superior genicular artery (p. 445) may be seen on 

 the bone. 



The distal part of this incision may be employed in performing 

 cuneiform osteotomy for genu varum (p. 465). 



In Operations for Genu Valgum the distal portion of 

 the shaft is approached from the medial side. The centre of 

 the incision lies one finger's breadth anterior and one finger's 

 breadth proximal to the adductor tubercle, and the wound is 

 directed distally and forwards, parallel to the fibres of the 

 vastus medialis. It thus lies anterior to the articular branch 

 of the arteria genu suprema (anastomotica) and proximal to the 

 distal epiphyseal cartilage, which corresponds in level to a 

 horizontal line drawn through the adductor tubercle. After 

 division of the skin and fascise, the vastus medialis is split 

 and the bone is exposed. The periosteum is incised vertically 

 for about one inch, and transverse cuts are made at each end of 

 this incision so that two small periosteal flaps may be elevated. 

 Cuneiform osteotomy or partial division of the femur may then 

 be carried out. 



Fractures of the Proximal Extremity of the 

 Femur. The neck of the femur may be fractured (i) at its 

 proximal end, close to the head, or (2) at its distal end, close to 

 the greater trochanter. 



i. This fracture is common in elderly people and is generally 

 due to indirect violence, but the force required is not great 

 owing to the rarefied condition of the bone. In healthy adults 

 the injury may result from a fall on the greater trochanter and, 

 in this case, the neck may be impacted into the cancellous tissue 

 of the head. 



The fracture is entirely intra-capsular and the fragments may 

 be completely separated or they may be retained in more or less 

 accurate apposition by the periosteum and synovial membrane 

 (Fig. 125). In old people non-union of the fragments is very 

 common. It is due partly to the reduced vitality, but especially 

 to the fact that the blood-supply to the head from the neck is 

 damaged and the supply via the ligamentum teres (Fig. 125) is 

 insufficient. 



If the neck is impacted into the head the amount of 

 shortening is usually small and special treatment is not called 

 for. When shortening and eversion are pronounced, active 

 measures must be taken to obtain good alignment, unless the 

 patient is advanced in years. The older methods Liston's 



