FRACTURES OF THE GREAT TROCHAN TER.—The trochanter alone may be sepa rated by direct violence, or the line of fracture may pass through the neck above the lesser trochanter and thence through the lower part of the great trochanter. In such cases there are the usual signs of angle is made by the posterior fragments being drawn up behind it. The upper fragment is often rotated outward. In fractures of the upper third the upper fragment is usually abducted. In those of the lower third its sharp point is liable to pierce the quadriceps and even the skin. The shortening may be deter mined by measurement, the abnormal mobility by gently elevating the limb beneath the point of fracture. The tro chanter is not displaced upward. A coin plicating synovitis of the knee is mon, laceration of the great vessels rare.
Prognosis.—Shortening of about an inch should he expected.
Treatment.—Reduction is to be made gently. In fractures of the lower third if the upper fragment has pierced the quadriceps and cannot be disengaged by traction with the knee and hip strongly flexed, reduction must be made through a free incision.
Immobilization is best made by Hod gcn's splint, which, while it does not im mobilize quite as fully as Buck's, per mits much more liberty to the patient, and can be adjusted in such a position as to avoid deformity more surely, namely: flexion and abduction of the hip for high in a plaster splint should be beneficial, but great care must be taken to avoid angular deformity.
Ambulatory treatment as for fractures of the neck of the femur has proved satis factory. Children under 10 are best treated by vertical suspension of both legs. The pelvis should rest lightly on the bed, thus making counter-extension.
For compound fractures the double inclined plane (Fig. 14) is often most convenient. It affords no traction, but the loss of bone-substance by comminu tion usually renders traction unneces sary. In other cases Smith's anterior splint, which acts like a suspended double-inclined plane, is more appropri -Ln fractures and flexion of the knee for low ones. With Buck's extension it is par ticularly essential that the bed should be made flat by a "fracture-board" placed under the mattress. If the fracture is near the centre of the shaft coaptation splints may he used with advantage. In England a long side-splint with trac tion is a favorite dressing. It is very in convenient. The tendency to outward rotation in the upper fragment is best opposed by a hard cushion under the great trochanter. Traction should be maintained for six weeks, the patient being kept under constant observation. Then lie should be kept on crutches with a plaster-of-Paris splint from waist to ankle for about three weeks longer. If union is fibrous the irritation of walking