Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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On the 6th of December he was discharged from the hospital, and
in February following he was walking without any support, and with
the free use of the joint.^

Case. — A gentleman living about eighty miles from town was
thrown from his carriage, breaking the left femur just above the con-
dyles into many fragments, so that when I saw him on the following

> Ai Cooper on Disloc, &c., op. cit., p. 289.



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PRACTUBES OP THE CONDYLES. 438

day, the attending physician showed me about four or five inches of
the entire thickness of the shaft which he had removed. The external
condyle was completely separated from the internal, and was quite
movable.

In this case the attempt to save the limb resulted in the loss of the
patient's life on the sixth or seventh day.

(d.) Separation of the Lower Epiphysia.

M. Coural relates the case of a boy 11 years old, who, while his
leg was buried in a hole up to his knee, fell forwards, separating the
lower epiphysis from the shaft, and at the same time driving the shaft
behind the condyles into the popliteal space. The epiphysis also
became tilted in such a manner that its lower extremity was directed
forwards. The limb was amputated.

Madame Lachapelle mentions a case in which traction at the foot of
a child in the act of birth caused at the same time a separation of the
lower epiphysis of the femur and the upper epiphysis of the tibia.
The child was born dead.^

Dr. Little presented to the New York Pathological Society. May 24,
1865, a specimen obtained from his own practice. A boy, aet. 11,
while hanging on to the back of a wagon, had his right leg caught
between the spokes of the wheel while it was in rapid motion. A few
hours after the accident. Dr. Little found the upper fragment of the
femur projecting through an opening in the upper and outer part of
the popliteal space. On examination, the wound did not appear to
communicate with the knee-joint. Under the influence of an anaes-
thetic the fragments were reduced ; the reduction occasioning a dull
cartilaginous crepitus. There was at the time no pulsation in the
posterior tibial artery, and the limb was cold. The limb was laid
over a double-inclined plane. The following day the upper fragment
was again displaced, and it was found that it could only be kept in
place by extreme flexion of the leg. This position was therefore
adopted and maintained ; considerable traumatic fever followed, with
swelling, and on the thirteenth day a secondary hemorrhage occurred
from the anterior tibial urtery near its origin, and it beca^ie necessary
to amputate. The boy made a good recovery. The specimen showed
that the line of separation had not followed the cartilage throughout,
but had at one point traversed the bony structure.

Dr. Yoss at the same meeting remarked that he had met with the
same accident. There was no protrusion of bone, but an abscess
formed, and it became necessary to amputate.

Dr. Buck saw a case which occurred in the practice of Dr. Hugh
"Walsh, of Fordham. The subject was a boy 14 years old, and it hap-
pened in the same manner as with Dr. Little's patient.' I know of
no other cases of this accident.

» Malgalgne, op. cit., t. i. p. 69.

« Little, Voss, Buck, N.Y. Journ. Med., Nov. 1865.



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484 FRACTURES OP THE PATELLA.



CHAPTER XXIX.

FRACTURES OP THE PATELLA.

Causes. — Of twenty-nine fractures of the patella which have been
recorded by me, twenty-seven were the result of direct blows or of
falls upon the knee. In the remaining examples the fracture was due
solely to muscular action ; one, a sailor, aged about thirty years, had
caught the heel of his boot in a knot-hole in the floor, which threw
him backwards, and in the effort to sustain himself the patella was
broken transversely. Dr. Kirkbride has reported a case in which both
patellaB were broken in a similar manner, bi^t at different periods. The
patient was a girl, set 29, who was admitted into the Pennsylvania Hos-
pital, Oct. 16, 1888. " In falling backwards, and making an effort to
save herself," the right patella had been fractured. She was dismissed
cured on the 2d of December, and on the 20th of April following she j
was readmitted, with a fracture of the left patella, produced ia the )
same manner as before ; but in her effort to save the right limb, the \
left received all the strain, and the patella gave way.^ Dr. Kirkbride
records another instance of fractare from muscular exertion in amUn
»t. 82, who attempted to jump into a cart, by raising his body with
his hands resting upon the bottom of the vehicle;' and Dr. Hay ward,
of Boston, saw a case in the Massachusetts General Hospital, in a man
8dt. 67, which occurred in consequence of a false step in descending
a flight of stairs.*

Pathology. — All the fractures produced by muscular action have
been found to be transverse, and the same is true generally of fractures

Fig. 185. Fig. 186.



produced by direct blows ; occasionally, however, we meet with lon-
gitudinal fractures, or with fractures more or less oblique and com-
minuted. Twenty-three of the fractures seen by me were simple and

1 Kirkbride, Amer. Joum. Med. Sci., Aug. 1835, vol. xvi. p. 880.
' Hay ward, Amer. Joum. Med. Sd., vol. xxx., from New £ng. Qaart. Jonrn.,
July, 1843.



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FBACTURES OP THE PATELLA. 485

'i^ransverse, two were simple and oblique, two were pomminuted, and
one was compound. Dupuytren, A. Cooper, and others, have also
xnentioned cases of longitudinal fracture.

Fig. 187.



I have seen a double transverse fracture, or a fracture of both
patellae, in a man aet. 22, who fell from a third-story window, striking,
he says, upon his knees. He was taken to the Hospital of the Sisters
of Charity, in Bu&lo, and, after a few weeks, made an excellent
recovery.

Symptoms, — The symptoms which characterize a transverse fracture
of the patella are sufficiently diagnostic. The fragments are separated
from each other, the superior fragment
being drawn upwards more or less, ac- Fig. 188.

cording to the power and activity of the
muscles or the degree to which the liga-
mentous coverings and attachments of the
patella have been torn. Seldom, however,
is the interval of separation greater than
Iialf an inch. But in a few cases the vio-
lent flexion of the knee has been known
to draw the upper fragment quite three
inches from the lower. By passing the
finger along the anterior surface of the

limb with a moderate degree of firmness, Fragments Mpamted by nexion of
the depression between the fragments '^eknee.
will be made manifest.

No crepitus can be expected unless the fragments remain in contact,
a condition which is unusual. The patient is unable to stand, and es-
pecially is the power of extending the leg upon the thigh completely
lost. Usually a good deal of swelling immediately succeeds the acci-
dent^ and after a time the skin becomes more or less discolored from
effusions of blood. If the fracture is longitudinal or oblique, a slight
separation is usually present, but not always very easily detected.

Prognosis. — One of my patients, who had a comminuted fracture,
with other serious injuries, died, but not as a consequence of the frac-
ture. In the following case the fragments appear never to have united,
although the patient recovered : —



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436 FRACTURES OF THE PATELLA.

John Sharkie, ddt 24, a soldier in the British service, while serving
in the East Indies, was struck on the right knee while he was in a
sitting posture, with his leg bent under him.

He was immediately placed under the charge of the surgeon of the
89th regiment of infantry. During the first eleven days no splints or
bandages were applied, on account of the severe inflammation and
swelling. A compress was then placed over both fragments, and
they were bound together by rollers, &c. The whole limb was sus-
pended on an inclined plane, the foot being made fast to a foot-board.
This treatment was continued four months. When the bandages were
removed, the limb was badly swollen, and immediately the upper
fragment was drawn up toward the body. Eighteen months elapsed
before he could walk, even with the aid of a cane.

March 27, 1855, twenty-nine years after the injury was received, he
was an inmate of the Buffalo Hospital, and I was permitted to ex-
amine his knee carefully.

The lower fragment is not displaced, but when the leg is straight
upon the thigh the upper fragment lies two and a half inches from

the lower, and when it is flexed upon the
Fig- 189. thigh the upper fragment is removed

five inches from the lower.

There is no ligament or other bond of
union, so far as I can discover. He walks
with very little or no halt, but be cannot
walk fast.

At my Bellevue Hospital clinic, Janu-
ary 8, 1866, I presented a man, jet. 38,
who had fractured his left patella trans-
versely, four years before. The frag-
ments had united, when he ruptured the
ligament again by a fall. I found a sepa-
ration of three and a half inches, and the
patient unable to walk except with the
aid of a leather splint.

In the case of a man, mt. 40, the liga-
mentous union, at first complete, seems to have subsequently given
way in part. He called upon me for advice nine weeks after the
fracture had occurred. The patella was surrounded with bony callus,
so that it was considerably wider than the other. The fragments
appeared to be united by a short ligament, except on the inner side,
where there was a separation or rupture of the ligament to the extent
of one-quarter of an inch. The patient explained this by saying
that the splint was removed at the end of four weeks, and that after
a week more he Began to walk, but that he almost immediately felt
it tear or give way on the inner side.

During the autumn of 1865 I examined the leg of Dr. B.. a graduate
of Bellevue Medical College, and found a transverse fracture of the
right patella with great displacement of the upper fragment. He in-
formed me that he had fallen six years before, when nineteen years
old, upon a stone, striking upon the patella. The fracture was recog-



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FRACTURES OF THE PATELLA. 437

nized, and the limb was laid upon a straight splint. At the end of
three months the limb was removed from the splint, and the union was
foand to be complete, with a separation of the fragments to the extent
of half or three-quarters of an inch. The knee was much anchylosed.
Soon after this the upper fragment began to draw up, and at the end of
a year was as much displaced as it is now. At this moment it is dis-
placed three inches, and seems to be held to the lower fragment only
by a narrow ligament attached to their inner margins. He extends
and flexes the leg perfectly, and walks without the least halt, but this
limb wearies sooner than the other.

February 16, 1866, John Donahue, aet. 50, was admitted into my
wards at Bellevue, with a refracture of the right patella. He stated
that it was first broken eight weeks before, and that it had united, but
that the day before his admission, while seated on the ground, he
attempted to rise, and that the ligament suddenly gave.. I found the
fragments separated one inch, and by pressing the upper fragment
against the lower a slight crepitus was occasioned. His limb was
placed upon a single-inclined plane, and union soon occurred.

Dr. Kirkbride has reported a case of ligamentous union of the
patella, in which the ligament was two and a half inches long, and
was attached only to the inner margins of the fracture. "He was able
to walk as rapidly as ever, and without perceptible limping."* A
similar case is reported by Dr. Watson, of New York, in which XhQ
fragments became separated three and a half inches.^ In both instances
the fragments were supposed to have united by a short ligament,
which had become lengthened by premature use of the limb; in the
case reported by Kirkbride, the ligament seemed to have partly torn,
as in the case reported by myself. Dr. Coale presented to the Boston
Society for Medical Improvement, at its April meeting in 1856, a
specimen of a fractured patella taken from a man sixty -five years old,
the fracture having occurred ten years before. The fragments were
at first so closely united that no division between them could be dis-
covered, but subsequently they became separated at their outer edges
one inch, and at their inner edges one-eighth of an inch.'

I have seen one more case in a woman at Bellevue Hospital, who
was laboring under tertiary lues at the time of the original accident.
She says the bone never united, and at this time the fragments are
separated about three inches. She can only walk with the aid of a
splint.

In every instance in which a fracture of the patella has been treated
by myself, union has taken place at periods varying from twenty-
four to fifty-eight days, the average being about thirty-eight days.
Twenty-one cases have united by ligaments, varying in length from
one-quarter to one-half an inch. These measurements, made upon
the living subject, may not be mathematically accurate, but they
cannot be far from the truth. In no case has the function of the
limb been in any degree impaired by this ligamentous union; from

1 Kirkbride, Amer. Joum. of Med. Sciences, yol. xyi. p. 83.

« Watson, N. Y. Joum. of Med. and Surgery, vol. ill., first series, p. 866.

> Coale, Boston Med. and Surg. Journal, vol. liv. p. 402.



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438 FRACTURES OF THE PATELLA.

which it must be inferred that a short ligamentous union is as iiselbl
as a bony union. Practically speaking, my results have been perfect.

Twice, I believe, I have seen a bony union of the patella. The first
instance is that to which I have already referred as an obliqae or
longitudinal fracture across one corner of the patella; and in the other
example the action of the muscles upon the upper fragment was pre-
vented by the occurrence of a'fracture of the shaft of the femur at the
same time, which permitted the thigh to shorten upon itaelf. The
man was about twenty-five years old, and in a fall from a sca£fold bad
broken his left femur, and also the patella. The patella was broken
transversely near its middle, and also longitudinally near its inner
margin. The fragments were all distinctly made out. Drs. Lewis and
Dayton, of Buffalo, were in attendance, and on the fifth day I was
called in consultation. We dressed the limb with a long straight
splint, employing moderate extension and counter-extension. The
patella was covered with strips o£ adhesive plaster. On the fifty-
eighth day I found the fragments of the patella united. June 8, 18o4y
five months after the accident, I examined the limb carefully. The
femur was shortened half an inch, and, although the two main frag-
ments of the patella were separated half an inch, the bond of union
seemed to be bone. It was hard, and allowed of no motion in the
upper fragment separate from the lower. The lateral fragment was
also apparently united by bone and in place. He had but little motion
in the knee-joint^ yet he walked very well, and was able to pursue his
trade, as a carpenter, without much inconvenience.

Sir Astley Cooper succeeded in obtaining a bony union in some
longitudinal fractures, but in a majority of cases it &iled, owing to the
want of apposition in the fragments. It might seem that it would be
easy to accomplish apposition in all longitudinal fractures, but expe-
rience has shown that it is not always, the fragments being kept
asunder partly by the action of the oblique fibres of the vasti and
partly by the pressure of the condyles of the femur, especially when
the leg is slightly fiexed.

Whether the fracture is transverse or longitudinal, a bony union
may occasionally be obtained when the fragments are retained in
absolute contact for a sufficient length of time ; but the failure to
procure a bony union is not a matter of consequence, since a short
ligament is equally useful.

Post, of New York, has reported three cases of compound fracture
of the patella extending into the knee-joint, brought to a successful
termination.^ I have myself met with one or more similar results.
. In a case mentioned by Eve, of Augusta, occasioned by the kick
of a horse, and in which amputation became necessary on the tenth
day, '' the knee-joint was found filled with dark grumous blood ; a
portion of the cartilage of the internal condyle of the os femoris was
chipped off, and the patella broken into a number of fragments."'

Lewitt, of Michigan, has related a case of fracture in a lad est. 16,

* Post, New York Joum. of Med., vol. ii., first stries, p. 867.
s Eve, Southern Med. and Surg. Joum., 1848 ; also Bost. Med. Joum., yol. xxxriL
p. 427.



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FRACTURES OF THE PATELLA. 439

procluced by striking his knee against a piece of timber, which re-
sulted in suppuration of the knee-joint, but from which he finally
reoovered with the perfect use of the limb. The fracture of the patella
>AraA oblique, traversing only its upper and outer margin, and it was
never much displaced.*

Dr. Levergood, of Pennsylvania, has reported a similar case, in which
it l>ecame necessary to open the joint freely, yet it was followed by
an excellent recovery, only a slight anchylosis remaining at the knee-
joint.*

Treatment. — The dressing which I prefer in the treatment of this
fracture consists of a single inclined plane, of sufficient length to sup-
port the thigh and leg, and about six inches wider than the limb at
tlie knee. This plane rises from a horizontal floor of the same length
and breadth, and is supported at its distal end by an upright piece of
"board, which serves both to lift the plane and to support and steady
the foot. The distal end of the ipclined plane may be elevated from
six to twelve inches, according to the length of the limb and other
circumstances. Upon either side, about four inches below the knee,
is cut a deep notch. The foot-piece stands at right angles with the
inclined plane, and not at right angles with the horizontal floor.

Having covered the apparatus with a thick and soft cushion care-
fall j adapted to all the irregularities of the thigh and leg, especial
care being taken to fill completely the space under the knee,. the
whole limb is now laid upon it, and the foot gently secured to the
foot-board, between which and the foot another cushion is placed.

The body of the patient should also be flexed upon the thigh, so as
the more effectually to relax the quadriceps femoris muscle.

Fig. 190.



The aathor'8 mode of dreeeing a fractured patella.

A roller is now applied to the knee by oblique and circular turns ;
commencing above the patella, and traversing the notch in the splint;
each successive turn covering more of the front of the knee until the

" Lewitt, Medical Independent, Sept. 1856.

* Levergood, Amer. Joum. Med. Sci., Jan. 1860.



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uo



FRACTURES OF THE PATELLA.



whole is inclosed. With a second roller the entire limb must then be
secured to the splint, this roller extending from the ankle to the groin.

The great advantage which this mode of dressing possesses is, that
it does not ligate the leg or thigh completely, since, on either side,
between the broad margins of the splint and the points where the
bandages touch the limb, there is a space, more or less considerable,
against which no pressure is made, ana through which the circulation
may go on without impediment; so that, however firmly the bands
are drawn across the knee, no swelling occurs in the foot.

The plan adopted by M. Gama, of Val de Grace,* is similar to that
which I have now described, but the splint upon which the limb
reposes is not so wide, while width is an essential point in the attain-
ment of the objects which I propose.

The dressing and apparatus employed by Wood, of King's College
Hospital, are very similar to my own, but, as will be seen by the acconfi-
panying drawing, the splint is only five or six inches wide. Dr.
Wood has substituted hooks for the notches."

Fig. 191.



Wood's appantas.



Dr. Dorsey, of Philadelphia, employed a very simple apparatus
which .will serve to illustrate the general plan adopted by many sur-
geons, both at home and abroad. It is liable, however, to the objec-

Fig. 192.




John SjDf Dorsej'a patella upliot.

tion already stated, namely, that it interrupts too much the circula-
tion of the limb. His apparatus consists of a piece of wood half an

> Malgaigne, Traits des Fractures, etc., op. cit., p. 764.
« Fergusson's Surgery, p. 807.



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PRACTURES OF THE PATELLA. 441

incli tbick and two or three inches wide, and long enough to extend
TroTn the buttock to the heel ; near the middle of this splint, and six
incbes apart, two bands of strong doubled muslin, a yard long, are
Tiailed. The splint is then cushioned, and the limb laid upon it, a
roller being first applied from the ankle to the groin, encompassing
the knee in the form of the figure-of-8; after which the two muslin
l^ands are secured across the knee in such a manner as that the lower
one shall draw down the upper fragment, and the upper one elevate
the lower fragment.

A single instance will explain the danger of ligation to which I
ha^e alluded, and which, although it may be greater in case a starch
or dextrine bandage is used, exists in some degree, whatever material
for bandaging is employed, if it is applied to the whole circumference
of the limb, and constant attention is not paid to the progress of the
si^elling.

"A vine-dresser, 8Bt. 40, of a good constitution, fell and received a
simple transverse fracturo of the patella on the 15th of January. The
medical officer called upon to attend him applied first a bandage for
the purpose of drawing together the fragments, and afterwards a
starched bandage extending from the toes to the upper part of the
thigh; the limb was then put upon an inclined plane. The patient
-was visited a few times, but, as he scarcely suffered, the apparatus
was in no way disturbed. On the first of March (sixteenth day) the
attendant returned to remove the bandage, when the odor arising from
the limb led him to believe that gangrene had taken place, and Dr.
Defer was sent for. Dr. Defer found the limb in the following state:
The toes, which were not covered by the bandage, were completely
insensible and mummified. The bandage being removed, the gan-
grene was perceived to extend within seven inches of the knee, and
was arrested in its progress. The foot was cold, and was totally in-
sensible ; the epidermis was raised up, and was beginning to be sepa-
rated from the skin. The articulation of the ankle was exposed, and
the ligaments destroyed. The bones of the leg were also exposed in

Fig. 193.




81r A. Cooper's method by elrealar Upei.

their lower third, and the tendons were in a sloughy state. Amputa*
tiou was performed, and the patient recovered."^

Very little better than the starch bandage, and exposing the patient

1 Amer. Joum. Med. Sci., vol. xxiv. p. 462, from Gazette M^dicale, No. 28.
29



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442 FRACTURES OF THE PATELLA.

in a still greater degree to the dangers of ligation and strangulation,
are either of the methods recommended by Sir Astley Cooper.

Fig. 194.




Sir A. Cooper's method hj a lefttber ooanter-ttrap.



Mr. Lonsdale's instrument is ingenious, but complicated. It is also
liable to the serious objection that it forbids almost entirely the use

Pig. 195.



LoiniDALB*8 Apparatdb for Fragturbd Patblla.^A B. Two vertioal Iron bars, eaeh svpportiBf a
horiiontal one ; these horizontal arms slide upon the vertical bars, bat can be secured at anj* point by
the screws C D. To the horizontal beams are attached other vertical rods, which are movable, and jH
flzable bj screws, as at E. Finally, to esch of these last upright pieces is fixed an iron plate, F F. by
means of a hinge-Joint, wbich keeps the patella in place. The foot-piece is movable np and down npoa
the main body of the apparatus, and can be made fast at any point, so as to adapt the splint to limbs of
different lengths.

of bandages, v^hich, while they are capable of doing great mischief
when they bind the limb too closely, are capable also of proving
eminently serviceable when they press upon certain portions of the *
limb, and not with too much force.

Malgaigne's hooks or clamps I regard as liable to more serious
objections, and, notwithstanding considerable testimony in their favor,



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 51 of 100)