manipulations necessary for eliciting it might be apt to separate the impaction-an event which would at least make a bad matter worse. And even in cases in which shortening and rotation were well marked, dislocation instead of fracture has been diagnosticated. It is true that a certain similarity to iliac dislocation exists, but the latter can be always excluded, for the reason that the femoral head can not be found outside of the acetabulum. It should furthermore be considered that in a fracture of this kind the patient is unable to elevate his leg by active flexion; while in dislocation passive motion would be arrested to a much higher degree than in fracture.

In summing up the main points of differentiation it should be considered that in dislocation the femoral head can be palpated in the buttocks. In dislocation. there is also a moderate amount of resistance when motion is made, while in fracture there is little or none. In dislocation the upper portion of the hip-joint is flattened, while in fracture there is no change of the normal contours. If the trochanter appears widened and enlarged, the chances are that the patient fell upon the trochanter, which fact would point to a fracture. In old age fracture is the rule.

Bony union, while exceptional in the intracapsular type, is the rule in the extracapsular variety, callus proliferation generally being abundant. Sometimes

the callus is so rich that free articular motion becomes impeded. (Fig. 107.)

Union generally becomes perfect in six weeks, after which the function of the extremity is seldom found to be disturbed, even if shortening to the extent of an inch has occurred.

Fig. 107.-Impacted extracapsular fracture of the neck of the femur in a man fifty-eight years of age (three years after the injury), causing considerable functional disturbance on account of the excessive callus proliferation around the seat of the fracture, especially around the major trochanter.

The principles of treatment are the same as those for the intracapsular fracture of the neck of the femur.

III. Isolated fracture of the trochanter major (Fig. 108 a and b) is always produced by direct violence, and is of rare occurrence. By being pulled backward and upward by the gluteal medius and minimus muscles the trochanter appears considerably displaced. The trochanter major is also sometimes separated in persons under the age of seventeen years.

The signs are sometimes insignificant, and may

Fig. 108.-Isolated fracture of trochanter major. a. Exterior view; b, showing diastasis (after Hoffa).

point to a contusion, since the function of the leg is little, if at all, disturbed; inward rotation of the leg being possible by the action of the tensor fascia latæ muscle, and outward rotation by that of the obturatores, gemelli, and quadratus femoris. There is, of course, no shortening such as occurs in fracture of the femoral neck. Flattening of the trochanteric area is often noticed. The displaced fragments being nearly always palpable, differentiation from simple contusion should be easy.

The treatment consists in immobilization of the leg between two sand-bags in outward rotation and abduc

Fig. 109.-Spiral infratrochanteric fracture in a boy of twelve years (fourteen hours after the injury), showing but little sideward displacement.

tion, while the hip and knee are slightly flexed. In this position reduction of the displaced fragment is

accomplished to the nearest extent possible. An adhesive plaster compress, to be kept in situ by an adhesive plaster strip, should be applied above and behind the fragments.

In children a large abdominofemoral dressing, consisting of plaster-of-Paris, is recommended. (Fig. 115.)

IV. Infratrochanteric fracture (Fig. 109)—that is, fracture just below the trochanter-is caused either by indirect violence (torsion of the body while falling down), causing a spiral-shaped line (Fig. 109), or by direct violence (blow or fall), which would cause a transverse line. It is prevalent among the hard-working classes, and generally concerns adults.

The signs, besides those found in ordinary fractures, are the tilting upward of the upper fragments by the ileopsoas and glutei muscles, which are inserted below the trochanter. This characteristic phenomenon explains why the upper fragment is sometimes put into a right angle to the femoral axis. In rotating the femur it will be found that the trochanter does not go along with the motion, abnormal mobility being found only below the trochanter.

The treatment requires reposition and extension in a flexed position; otherwise it is treated after the same principles as the fractures of the neck of the femur.

Fracture of the Diaphysis of the Femur.— Fractures of the diaphysis of the femur are far more frequent than those of the neck. Of all femoral fractures, which figure at six per cent, among all fractures, they represent seventy-one per cent., while those of the neck amount to twenty-nine per cent. only. They are caused either by direct or indirect violence or by mus