Fractures of the Lower End of the Femur.
—Fractures of the lower end of the femur are usually the result of extreme violence, and may be classified as were those of the lower end of the humerus. When there is a supracondyloid fracture the two heads of the gastrocnemius will help to displace backward the upper end of the lower fragment to an extent permitting injury to the bloodvessels, while there is always marked shortening. Here the patella will be made unduly prominent, and there will be depression above it. Either condyle may be broken loose alone, or there may be intercondyloid or T-fractures which are serious because the amount of force required to produce them may have played serious havoc with the soft tissues. The joint capsule will probably be filled with blood, the ligaments rent, and perhaps the blood supply of the limb compromised. In such a case as this the joint may be opened, the contents turned out, and the fragments readjusted and wired or fastened in place ([Fig. 318]). Epiphyseal separations, which may occur up to the twentieth year, are not essentially different, although lateral displacement is perhaps more common, while they are often compound.
Treatment.
—Oblique fractures of the femoral shaft can be more easily adjusted under the influence of powerful and continuous traction than the transverse, where lateral displacement and overlapping tend to occur. A more general application can be made of the method described above when dealing with fractures at the upper end of the shaft, i. e., when the upper fragment cannot be controlled the balance of the limb must be adjusted to it in whatever position it may be required to maintain. By the use of sufficient traction, combined with molded or other splints, a fair result may usually be obtained. In stout individuals it is by no means easy to determine just how the fragments lie, save by the use of the x-rays. If traction be so adjusted as to maintain the limb at equal length with the other the surgeon may feel that, with certain coaptation splints, he is doing the best he can. Application of the same rule given above would lead him to place the limb on a double inclined plane, in case of fracture near the knee-joint, in order that in this position the sural muscles (the calf) may be relaxed and backward displacement of the lower fragment be adjusted. If the apex of this plane be arranged sufficiently high, so that the patient’s knee is practically hung over it, and that the weight of the body makes sufficient countertraction, then the use of weight and pulley may not be necessary. Here, however, pressure which will be efficient may produce numbness, as will any long-continued pressure in the popliteal space, and after a few days it may be necessary to assume some other position. Fractures which loosen the condyles will need lateral pressure, while the position of each condyle may be controlled by the position of the leg, through the medium of the corresponding lateral ligament.
Fig. 319
Extension band and foot-piece.
Fig. 320
Same, folded and ready for use.