eans of
combating the backward tilting of the distal fragment.

In all cases the retentive apparatus must be worn for about four
weeks, after which the limb is flexed over a pillow; but massage and
movement should be employed as soon as possible, as persistent
stiffness of the knee is one of the most troublesome sequelae of these
injuries.

Compound and complicated fractures are dealt with on the general
principles governing the treatment of such injuries. Amputation may
become necessary should gangrene ensue from injury to the popliteal
vessels, or if infective complications threaten the life of the
patient.

Operative interference may be called for to rectify deformities
resulting from mal-union.

The #T- or Y-shaped fracture# is, as a rule, produced by direct
violence, the force first breaking the bone above the condyles and
then causing the proximal fragment to penetrate the distal and split
it up into two or more pieces. The fracture implicates the articular
surface, and the main fissure is usually through the inter-condylar
notch; the lower end of the bone is sometimes severely comminuted.

The knee is broadened, and pain and crepitus are readily elicited on
moving the condyles upon one another or on pressing them together. On
moving the patella transversely, it may be felt to hitch against the
edge of one or other of the fragments. The shortening may amount to
one or two inches.

The treatment is carried out on the same lines as in supra-condylar
fracture, but as the joint is implicated there is greater risk of
subsequent impairment of its functions.

#Separation of the lower epiphysis# is a comparatively common injury.
It is seldom pure, a portion of the diaphysis usually being broken
off and remaining attached to the epiphysis. It occurs usually in boys
between the ages of thirteen and eighteen, from severe violence such
as results from the limb being caught between the spokes of a
revolving wheel, or from hyper-extension of the knee. It has also been
produced in attempting forcibly to rectify knock-knee and other
deformities in this region, and in making traction on the limb to
correct deformities following recovery from tuberculous disease of the
knee. As a rule, there is little displacement of the loose epiphysis,
but it may pass in any direction, forward being much the most common
(Fig. 82), and when displaced it is difficult to reduce and to
maintain in position. The age of the patient, the mode