A Case of Separation of the Lower Femoral Epiphysis

in the maternity department of this hospital, a primi-gravida, aged 30, having been in labour for two days, gave birth to a female child. 'The child was born by the breech, and the delivery was extremely difficult. I cannot ascertairn just how the baby was delivered, but it is undouibted that extreme force was required to extricate the infant from its unasked-for position. After birth it was discovered that the infant's right clavicle was fractured in its middle part, and a peculiar deformity of the right knee-joint was noticed. Three days after birth I 'was asked to see the case. The toes of the right foot were found to be blue, and colder than the opposite side, and'ulceration on the dorsum of the foot had commenced. On examination of the knee it became evident that the lower epiphysis'of the femur had separated and was pressing backwards in the popliteal fossa, Fine, silky crepitus was obtained on attempting to move the knee, and the child resented any such attempt in the usual way. It was also noticed that the child did not move the right leg freely. Pulsation in the popliteal artery was good, but none could be felt round the ankle-joint. An X-ray examination of the right knee-joint showed a displacement of the lower epiphysis of the femur backwards and slightly to the lateral side. The bony nucleus of the epiphysis was well developed. On the day of examination, i.e., three days after the injury, the epiphysis was replaced and the leg suspended from the end of the bed by strapping. X-ray examination showed perfect reduction of the separation. Unfortunately, the gangrene of the toes, which was showing its early presence on the first examination, progressed, and some ten days afterwards the toes sloughed off at the metatarso-phalangeal joints. Within two weeks of this occurrence a healthy granulating surface presented, and this was skin-grafted, using the inner lining of the prepuce from three circumcised male infants. The child is now six months of age, and is healthy in every other way. The foot has completely healed up, movements of the knee and ankle-joint are normal, and the foot is half an inch to three-quarters of an inch shorter than its fellow. The fractured clavicle has uniteed without deformity. Further X-ray examination shows a fair amount of subperiosteal new bone formation at the lower end of the femur', extending upwards from …