9. Fractures of the Femur Fractures of the femur are very frequent in children and comprise about 30 per cent, of all fractures. They are usually oblique fractures in the middle of the diaphysis. Through falls from great heights, but still more frequently in sport, especially coasting in winter, we will see them caused either by direct or by indirect force. Transverse fractures will prevail over the spiral ones in small children, especially those with rickets, and also the nearer the fracture comes to the end of the femur (Fig. 161, Plate 17; Fig. 107, Plate 20). Infractions are here more rarely observed, partly on account of the strength of the causative force, partly on account of the strong muscles which will here soon cause a total dis location (Fig. 152, Plate 14).
Fracture of the femur is one of the most frequent fractures in the new-born. In breech-presentations and in difficult or unskilful obstet rical operations it is frequently a direct consequence of labor and is generally a complete fracture.
The dislocation corresponds to the height of the fracture; in the upper third abduction of the upper end, adduction of the lower one; in the lower third the dislocation wit. be very slight, especially in trans verse fractures. Only in the very rare supracondylar fractures will the traction of the gastrocnemic cause a rotation of the peripheral piece around its frontal axis, and by its pushing against the popliteal space it may either tear or compress the popliteal artery, which here lies close to the bone (see epiphyseolysis) (Fig. 162, Plate 1s). We should always think of these fractures when we apply a short plaster cast to the hip which does not quite reach to the knee; should the patient fall, he will be liable to break the hone against the hard edge of the cast. For this reason every splint should reach down to the condyles and the parents should be warned to be careful when the child begins to walk.
10. Fractures in the Neck of the Femur Formerly these were considered to be extremely rare in children, but the study of coxa vara traumatica has shown their frequency (Hen, Whitman, Sprengel). Partial epiphyseolysis is also said to occur and to cause dislocation of the neck of t he femur later. They are most fre quent in the first part of the second decade; at t hi: time the epiphyseal line is very narrow, and we will be more liable to have an interosseal fracture than a separation of the bone in the epiphysis. In four cases
in all we saw only one ease of interosseal separation of the neck of the femur (Fig. 163, Plate is).
The diagnosis of fracture of the diaphvsis of the femur can usually be made by inspection. Shortening of the limb, change of its shape, dislocation, and crepitation will make it positive.
In fractures of the neck the sudden beginning of the symptoms, the lack of motion of the head, the ascending of the trochantcr, the out ward rotation of the foot, and perhaps crepitation may be used in the differential diagnosis against other affections of the hip. Incomplete infractions may be ascertained on the skiagram.
11. Fractures of the Bones of the Leg and Foot [Fractures of the upper end of the tibia and interartieular fractures and dislocations in the knee-joint are very rare in children. As the patella remains cartilaginous for a long time, we will not observe frac tures of the patella in children and their place is taken by the separation of the apophysis tibia' (baseball).—THE TRANSLATOR.] Hemorrhages and incomplete fractures at the apophysis tibia' are relatively frequent. This serves for the insertion of the tendon of the patella and is ossified from its own centre; these may lead us to suspect an osteomyelitie process. They cause the child severe and long-con tinued pain when extending the leg (Alsbcrg, Schlattcr).
The isolated fractures of the tibia are rarer in children than in adults. The fractures of the ankle are almost entirely lacking (see Sub periosteal Fractures) (Fig. 151b, Plate 14).
Only from strong impact do we observe fracture of both bones (Fig. 164, Plate 1S) (from being run over by a rig or automobile, falling after one leg had been caught, blow); sometimes the very elastic fibula will escape, and the tibia will then show a subperiosteal oblique frac ture, which we can only find, even on the skiagram, after we have taken it in different planes. Slight pe•iosteal swelling, local tenderness, and the impossibility of stepping upon the leg must make us suspect this condition.
Isolated fractures of the fibula are so rare in children as to deserve hardly any mention. The sante may be said of the fractures and the luxations of the bones of the foot. Of fractures of the metatarsi we have only seen those in the first one from direct force, also in one case from an involuntary jump from a considerable height.