Union may be exceedingly slow in fracture of the femur, and may even be delayed for months. Mal-union sometimes occurs, the fracture uniting with an angular deformity outward and forward. Re-fracture is liable to occur if the patient falls or twists the limb within a few months of the original injury. It has happened not infrequently just after the retentive apparatus has been removed from the nurse raising the limb by the foot in order to wash it. _Liston's long splint_ is only employed as a temporary expedient for immobilising the fragments during transport; a Thomas' splint, if available, is better for this purpose. [Illustration: FIG. 78.--Long Splint with Perineal Band.] _Operative treatment_ is sometimes called for when simpler measures fail to reduce the displacement, and in cases of un-united fracture or of vicious union. The incision, which must be free, is preferably placed in the line of the lateral intermuscular septum; the periosteum is interfered with as little as possible. The application of extension by the calliper method is often of great service, during the operation, in enabling the operator to get the fragments into position; sometimes no fixation is required, but, if necessary, recourse is had to plating or pegging, or an intra-medullary pin. The extension apparatus is retained for three or four weeks. The after-treatment is carried out on the same lines as for simple fracture, but the retentive apparatus must be worn for a considerably longer period. [Illustration: FIG. 79.--Fracture of Thigh treated by Vertical Extension.] #Fracture of the Femur in Children.#--In children, especially below the age of ten, this fracture is quite common. It is often of the greenstick variety, or, if complete, is transverse and sub-periosteal, and as it is accompanied by few symptoms and but little deformity, is liable to be overlooked. When there is displacement, the deformity is similar to that in adults, and the treatment is carried out on the same lines. In young children the nursing is greatly facilitated by applying vertical extension to one or both lower extremities (Fig. 79). If the fracture is transverse and shows little tendency to displacement, the local Gooch splints may be dispensed with; in any case, massage should be employed from the first. The patient may be allowed out of bed in from three to four weeks, wearing a retentive apparatus. The shaft of the femur is sometimes fractured _during delivery_, particularly in breech cases. The simplest and most efficient means of controlling the fracture is by extension strapping fixed to the lower end of a Thomas' knee splint. CHAPTER VII INJURIES IN THE REGION OF THE KNEE AND LEG