out with crutches.
As osseous union of the fragments is not essential to a good
functional result, and as fibrous union does not necessarily entail
any material interference with the usefulness of the limb, no attempt
need be made to approximate the fragments, but every effort must be
made to maintain the function of the quadriceps muscle and the
mobility of the joint.

If it is desired to bring the fragments into contact and to secure
osseous union, the limb should be placed upon an inclined plane to
relax the quadriceps muscle, and means taken to arrest effusion and to
diminish the swelling by systematic massage and a supporting bandage.
When, in the course of a few days, this has been accomplished, the
attempt is made to approximate the fragments, by fixing a large
horseshoe-shaped piece of adhesive plaster to the front of the thigh,
embracing the proximal fragment. Extension is made upon this by means
of rubber tubing, which is fixed to the foot-piece of the splint. The
bandage which binds the limb to the splint should make upward pressure
on the distal fragment, or this may be done by a special piece of
adhesive plaster with elastic tubing pulling in an upward direction.

The retentive apparatus is kept on for about three weeks, and a rigid,
but easily removable, apparatus is thereafter applied, and the patient
allowed up on crutches, the limb being massaged and exercised daily to
improve the tone of the muscles.

When the fracture is caused by _direct violence_, such as a fall on
the knee or the kick of a horse, it may be transverse, oblique, or
vertical, but in many cases it is stellate, the bone being broken into
several irregular pieces. These comminuted fractures are frequently
compound. In transverse and oblique fractures, the displacement
depends upon the same causes as in fracture by muscular action. In
vertical and stellate fractures, unless the knee has been forcibly
flexed after the bone has been broken, there is little or no
displacement. The treatment is governed by the same considerations as
in fractures by muscular action.

_Old-standing Fracture._--As fibrous union, even with an interval of
several inches between the fragments, is not incompatible with a
useful limb, it is not often necessary to operate for this condition,
but when the usefulness of the limb is seriously impaired, operative
treatment is indicated. The operation is carried out on the same lines
as for recent fracture, the ends o