440 THE INFERIOR EXTREMITY 



and adductors, passes behind the proximal fragment and tilts 

 it forwards. In addition the distal fragment becomes laterally 

 rotated owing to the weight of the foot and the action of the 

 adductors. 



As the proximal fragment is so short and so deeply placed, 

 it cannot be controlled easily, and the fracture is, therefore, 

 very difficult to treat satisfactorily. The distal fragment may 

 be brought into line with the proximal fragment by putting the 

 limb up, flexed and abducted, on a double-inclined plane. In 

 this position the knee is passively flexed and the hamstrings 

 are relaxed. The application of extension by weight and pulley 

 helps to counteract the overlapping of the fragments. 



Fractures in the Middle Third of the Shaft are more 

 easily dealt with on account of the greater length of the proximal 

 fragment. The displacements are due to the same forces as 

 have been described for fracture in the proximal third. Ex- 

 tension by weight and pulley is employed to counteract the 

 shortening, and eversion of the limb is prevented by maintaining 

 the foot at right angles to the bed. 



When the fracture is due to indirect violence, the extremities 

 of the fragments are sometimes sharp and pointed. They may 

 become embedded in the muscles, and so give rise to difficulty 

 in reduction. 



In infants this fracture is best treated in the following way. 

 A gallows is placed across the bed immediately above the child's 

 pelvis. The thighs are flexed at right angles to the pelvis and 

 the legs are extended by weights and extension, acting over 

 pulleys which are fixed to the gallows. The weights used are 

 just sufficient to counterbalance the weight of the pelvis and 

 lower limbs, which act as the counterpoise. 



In Fractures of the Distal Tljird of the Shaft (Supra- 

 condylar) the distal fragment is rotated backwards by the 

 gastrocnemius. At the same time it is drawn proximally by 

 the quadriceps and hamstrings, and, owing to the first dis- 

 placement, it is drawn up behind the proximal fragment. A 

 double-inclined plane is used to relax the gastrocnemius, and 

 extension is applied to counteract the shortening, which con- 

 stitutes the chief deformity. Owing to the small size of the 

 distal fragment, the application of extension may be a matter 

 of difficulty. A horse-shoe shaped stirrup, which is attached 

 to the distal fragment by sharp screws, maintains satisfactory 

 extension and has been used with success. 



