where it rests upon the knee-cap so that it may not press it severely; the inner splint should extend from the perineum, and the outer from the great trochanter to the sole of the foot, and a large hole made in each corresponding to the ankle. All the splints should be thickly padded and have their ends well defended with the pads. A SCULTETUS's bandage of sufficient length to cover the whole limb and foot having then been laid upon the padded hind splint, the limb is to be gently lifted, and the splint having been put behind it up to the tuberosity of the haunch-bone, the limb is placed upon it, gentle extension made, the bandage and side splints applied, and then the front one, after which all the splints are tied together with three bands upon the thigh and two upon the leg. If there be any disposition to spasm or dragging up the lower part of the fracture, a sand-bag may be attached for two or three days to the foot; after which it is rarely needed. I prefer this to most other apparatus, because the patient is generally very easy with it, and is capable of moving about a little in the bed without disturbing the fracture. (2) The plan here proposed of replacing the splints after every six days is faulty, a being liable to produce disturbance of the fracture. They are best left alone as long as possible, except so far as merely tightening the bandages when they become loose. If the case do well, it is rare that the splints need reapplication more than once or twice during the cure. It must be remembered, however, that, under these circumstances, the fracture has not been set till after the subsidence of all swelling, during which time the limb is merely laid upon a pillow.—J. F. S.] 2. The Apparatus with splints, with the limb bent, and lying on the side or on the back. The bent position of the limb was proposed by POTT, for the purpose of relaxing the muscles of the thigh. The ailing thigh is to be laid on its outer side, with the knee-joint half bent; the whole of the patient's body should be inclined to the side. The setting is perfected in this half bent position. The apparatus consists of two splints, placed on the hinder and fore part of the thigh, and attached with the eighteen-tailed bandage. The whole limb rests on a pillow. As with this apparatus the motions of the knee are not interfered with, the position does not tend to the perfect relaxation of the muscles, and imperceptibly the upper part of the body sinks down in the bed straight by which displacement of the broken ends is favoured, the bent position has been changed, and, as in fracture of the neck of the thigh-bone, (par. 677,) the limb is put on a wooden stage formed of two boards, connected at an obtuse angle, and of which the oblique surfaces require a suitable bending of the limb. These are covered with pillows and provided with pegs on the sides, to prevent the displacement of the limb. When the limb is placed on this stage, the setting is to be completed, the thigh surrounded with compresses, and SCULTETUS's, bandage, and steadied with three splints on the outer, inner, and fore part. (C. BELL, A. COOPER.) 3. The permanent extension may be employed either on the plan of Dr SAULT, as in fractured neck of the thigh-bone; or after BRUNNINGHAUSEN, also as in fracture of the neck of the thigh-bone, except that together with the outer splint, a second is to be applied on the inner, a third on the front, and a fourth on the back of the thigh. If both extremities be connected at the foot and knee, according to BOYER and HAGEDORN, as in fractured neck of the thigh-bone; or according to SATER, in which case the permanent extension is made whilst the limb is bent, and the limb kept suspended. Here also EARLE's bed (par. 677) is suitable, and the apparatus proposed by GRANGER (a), for the purpose of connected permanent extension with a double inclined board. For the same purpose is MossIsovic's (b) equilibrium plan. (a) Edinburgh Medical and Surgical Journal, April, 1821. p. 194. f. i. ii. (b) Darstellung der æquilibrial-Methode zur sicheren Heilung der Oberschenkelbrüche oline Verkurzung. Wien., 1842. BLUME, Einfache Beinbruchmaschine zur Heilung der Schenkelbrüche in gebogener Lage. Warsburg, 1831; with one plate. The permanent apparatus is put on by SEUTIN in the following manner:-After the bed has been properly arranged, bandages, a straw cloth, SCULTETUS's bandage in three or four layers of strips sufficiently long to reach once and a-half round the limb, are to be laid upon it. The swathing of the foot is now to be commenced with the stirrup bandage from the root of the toes, which remain uncovered, and at the same time serve as an index to determinine the position of the bone. The first layer of bandages is then as usual to be applied from below upwards, and then plaster of Paris spread over it. This acts merely for the gluing of the second layer, without by its hardness injuring the skin. The second layer is to be applied in a similar manner, and an assistant smears it over with plaster with a large brush. The pasteboard splints are then cut to fit, broadest at the back part of the thigh and calf. At the edges of the foot they are to be cut with two broad pieces, which, connected in the middle, form a sole, and reach only to the lateral projections of the head of the first and fifth mid-foot-bones. A single sole does not give sufficient firmness, though one sole may be put on, and the ends of the pasteboard splints made to overlap it. The pasteboard splint must not press the edge of the shin-bone, and should be sufficiently wide that there may remain behind and before a finger's breadth between their edges. In the edges of the splints, notches should be made with the shears, or indents, which are still better, whereby they stick closely to the underlying parts. The pasteboard splints should be soaked in water, spread with plaster, applied, and at once overspread on both sides with a thick layer of plaister, so that in drying they form as firm a substance as a wooden splint; and now the third layer of bands is applied. The foot is then to be somewhat raised, and a conical pillow stuffed with tow, placed between the heel and calf, to keep the hind part of the apparatus perfectly horizontal, and to diminish the dropping through of the heel and calf. The heel-pad is also to be spread with plaster, and fixed in the fourth layer of bandage; or it may be applied earlier between the bandage straps, so that subsequently it is not necessary to raise the limb higher. As it is important that the ACHILLES' tendon should not be compressed, two pieces of the same compress should therefore be previously laid on both sides of it. The lower part of the splint, which bends over the sole of the foot, is fixed within a circular bandage. As till the complete drying of the apparatus, displacements easily occur, straw splints are usually applied by means of straw splint cloth, and the whole firmly bound with rollers, as in the common contentive apparatus. The assistants, who have hitherto kept up extension and counter-extension may now let go the limb. If the fracture be very oblique and the fractured ends easily separate, a sling must be applied at the lower part of the limb by means of a double bandage, fastened on both sides of the foot and leg, and connected at its end with bags, more or less full of sand, which are allowed to hang down over the foot of the bed, in order that in the perfectly horizontal position of the patient, a continued extension may be kept up, by which necessarily the counter-extension can be made to operate, not merely by the simple weight of the body, but also by a cloth folded longitudinally, carried between the thighs, and fixed to the bed's head. On the day after the drying of the apparatus, the straw splint-cloth and the straw splints are to be removed, and a circular bandage applied from the foot to the hip. Two or three days after the patient may be allowed to go with crutches, in which case the foot should be supported by a bandage slung round the neck. 685. In transverse fractures in the middle of the thigh a simple appatus with splints and the limb put straight are sufficient. In fractures of the upper and lower third, the half-bent position is preferable on account of the special displacement of the broken ends (par. 682); and in fracture in the upper third immediately under the great trochanter, a position approaching the sitting posture is preferable, because thereby only can the lower end be kept in corresponding position with the upper end of the fracture. But it must be here observed whether the fracture be not so near the joint and connected with such injury that stiffness will ensue, in which case the straight position with or without tension according to circumstances must be employed. The half-bent position of BELL and COOPER is preferable to POTT's posture on the side. 686. In oblique fracture this treatment is rarely sufficient, as the broken surfaces after having been apposed cannot be kept in contact. In these cases the permanent extension is necessary, and in fractures in the middle of the thigh, is best effected by the machines of BOYER and HAGEDORN; but in fractures of the lower and upper third, the machine of SAUTER or the double inclined plane are especially serviceable on account of the advantages connected with the half-bent posture. If the fracture be complicated with wound, one or other position may be advantageous as may best suit the care of the wound. 687. In children, after properly setting the fracture, it is usual to swathe the whole limb up to the hip in a circular bandage, several turns being made round the seat of fracture. Pasteboard splints are then to be applied on the outer, inner, fore and back part of the limb from the groin to the foot, swathed in a roller, and the whole wrapped in a cloth to protect the apparatus against displacement. The application of the common contentive bandage is, however, more suitable, because it can be more easily renewed and without changing the position of the limb. 688. If much inflammation and swelling have set in, they must be treated according to the rules laid down, (par. 587.) 689. The management of the patient during the cure of the fracture is directed by the general rules. Stiffness of the joint after the cure, especially if the fracture be near the knee joint, is often of long continuance, but gradually subsides with motion and with volatile rubbings-in. 690. In rare cases, the outer or inner condyle of the thigh-bone may be broken obliquely, or it may be separated by a vertical cleft which descends from a fracture. This is distinguished by the great swelling of the kneejoint, by the deformity, and by the crepitation observed in the movements of the condyles. It is difficult in these cases to prevent deformity, and great interference with the motions of the joint. The limb is to be put straight on a pillow and the inflammation sought to be repressed with leeches and cold applications. This done, a simple contentive bandage is to be applied. If in an oblique fracture with separation of the condyles, the upper end of the fracture be driven out through the coverings, amputation of the thigh is indicated. XVI.-OF FRACTURE OF THE KNEE-CAP. (Fractura Patellæ, Lat.; Bruch der Knieschiebe, Germ.; Fracture de la Rotule, Fr.) MEIBOM, Dissert. de patellâ ejusque læsionibus. Francf., 1697. BÜCKING'S Abhandlung von Kniescheibenbruche nebst der Beschreibung einer neuen Maschine. Stendal, 1789. SHELDON, On Fracture of the Patella and Olechranon. London, 1789. DESAULT, above cited, vol. i. CAMPER, P., De fracturâ patellæ et olechrani. Cum fig. Haag. 1790. 4to. BOYER, above cited, vol. iii. p. 291. COOPER, A., above cited, p. 200. ALCOCK, Observations on the Fracture of the Patella and Olechranon. London, 1823. ORTELLI, Dissert. de fracturâ patella. Berol., 1827. FEST, Dissert. de fracturâ patella. Berol., 1827. LACHMUND, Inaug. Abhandl. über den Bruch der Kniescheibe und die Zerreissung des Knieschiebenbandes. Würzb., 1838. DUPUYTREN; in Leçons Orales de Clinique Chirurgicale, vol. ii. p. 297. 691. Fracture of the Knee-cap, has most usually a transverse, rarely a longitudinal, and often a more or less oblique direction; or the bone is split to pieces. In the former case it may be consequent on violent contraction of the muscles attached to the knee-cap in violent bending of the leg; in other cases it is always produced by direct external violence and is accompanied with great contusion, with effusion of blood into the joint, or with wound. 692. The diagnosis is easy. There has been previous violent tension whilst the knee was bent, to preserve the equilibrium of the body, or a fall upon the knee whilst the leg was bent; the patient feels severe pain, often hears a crack, and can neither stand up nor stretch out his foot after the fall. In transverse fracture a space is distinctly felt between the two ends of the bone, which are separated, the upper piece being drawn upwards. This separation is the greater, the more the fibrous covering of the knee-cap is torn, and may extend to four or five inches; but it is lessened when the leg is straightened. Crepitation is not observed because the broken ends cannot be brought into immediate contact. In vertical, oblique, or splintered fractures of the knee-cap, the separation and mobility of the broken ends and crepitation are felt on examination. 693. The union of the fractured pieces is effected by means of a fibrous intersubstance, the cause of which does not depend on the sponginess and isolation of the bone, nor on the want of blood between the fractured surfaces, nor on the intrusion of the synovia, and paucity of vessels in the bone and surrounding parts, but on the difficulty of retaining the fractured ends in sufficiently close contact. The opinion, however, that in transverse fracture the consolidation does not depend on callus, is unfounded and disproved by experience (a). In splintering of the knee-cap, the broken ends are usually connected by callus. If the intersubstance which effects the union be not very broad, the motions of the joint are scarcely hindered, but under contrary circumstances the gait is more unsteady. If with fracture of the knee-cap there be severe bruising or a wound of the joint, the injury is always important, as anchylosis or suppuration of the joint with fatal consequences may ensue. Even in simple fracture, by the use of unsuitable and especially of too tight bandages, destruction of motion, union of the upper part of the knee-cap with the front of the thigh-bone, with atrophy of the ligaments and extending muscles may occur, which is worse than if a broad intersubstance had been formed. From GULLIVER's observations (b), it appears, 1. That if the aponeurosis be completely divided as is the case in fracture from muscular contraction, a bony union is not to be expected; 2. In transverse fractures in which bony union is deficient, the fragments and the interposed fibrous tissue are well provided with vessels; the want of union, therefore, is not to be ascribed to imperfect nourishment; 3. If the union in transverse fractures be effected by fibrous substance, there is often a bony deposit on the ends of the bone, so that the fragments have the appearance of two symmetrical bones; 4. Bony union is simply the result of immovable adjustment of the fragments which, in many cases of fracture, the uninjured state of the aponeurosis on the fore part effects; 5. New bones, which in fracture of the knee-cap seem to be formed of the broken pieces. The surrounding cellular tissue rarely or never becomes converted into bone; the fibrous tissue goes directly to the production of new bone. No cartilaginoid substance appears during the ossification. (a) DUPUYTREN; in AMMON Parallele der französischen und deutscher Chirurgie, p. 151. LANGENBECK, neue Bibliothek für Chirurgie und Ophthalmologie, vol. iii. pt. i. p. 49. (b) Edinburgh Medical and Surgical Journal, 1837. No. 130. VOL. I. 2 P 694. In transverse fracture, the two broken ends are in general easily brought into perfect contact, if the joint be completely straightened, the hip bent, so that the thigh forms an obtuse angle with the axis of the body, and the broken ends pressed together with both hands. If the broken ends be not far apart, that position of the limb is favourable to the cure, in which it is supported on a pillow laid beneath it, upon which it is to be closely pressed with a cross cloth carried round over the lower part of the thigh and fastened on both sides to the bed; or the whole limb is put upon a machine in which the foot is fixed to a footboard, and motion at the hip-joint can be restricted at pleasure. This is even to be considered as the most proper mode of treatment, as after it less stiffness of the knee is to be expected than after the use of bandages (a). The close union of the fractured ends may also in this position be further assisted by properly applied strips of adhesive plaster (b). 695. In considerable separation of the broken pieces, a special bandaging is, however, necessary, which should counteract the contraction of the muscles, and press together the two ends of the fracture, in order to produce union with the smallest possible interspace. After the coaptation of the fractured ends, as already directed, two long pads are to be applied above and below the knee-cap, so that their ends may cross in the ham. By means of a single or double-headed roller they are to be so fastened that a figure of is formed around the knee-joint. On the front of the limb is put a strip of linen, four fingers wide, somewhat longer than the limb, with two clefts in its middle, corresponding to the seat of fracture. This is to be fixed, its lower end being somewhat enveloped by spiral turns from the ankle to the knee. The remainder of the roller, with the loose strip of linen, is to be given to an assistant, and a second strip of linen, split to its middle into two heads, applied upon the front of the thigh, and fastened with another roller carried in spiral turns from the groin to the upper part of the knee-cap. The circular bandage is then given to an assistant, and the head of one strip of linen brought through the cleft of the other, both drawn in opposite directions, and their two ends turned in and fixed with the continuation of the spiral turns. The extremity thus placed has a splint laid behind the ham, in order to prevent the motion of the joint. LANGENBECK (c) puts the extremity in a horizontal posture, allows the patient to sit, and envelops the leg with ascending, and the thigh with descending spiral turns, to the two fragments of the knee-cap. I cannot agree with CHELIUS in the use of this bandage, for the pressure necessarily made upon the front of the broken knee-cap will be very irksome, if not painful to the patient. It is far better, after fixing the circular pads above and below the knee-cap, to draw them together on each side with a tape; by doing which, as the pads are brought together, so is also the upper part of the knee-cap brought down to the lower without any pressure being made on the front of the bone.-J. F. S.] 696. Besides the apparatus mentioned, which best serves the purpose, numerous bandages and apparatus have been proposed, but which for the most part have the objection that they do not counteract the muscles, which draw up the upper fractured piece, nor press equally strongly upon both upper and lower broken end, in consequence of which the (a) FLAJANI, Medicinisch-chirurgische Beobachtungen, Nürnberg, 1799, vol. ii. p. 151. RICHERAND, Histoire des Progrès récents de la Chirurgie, p. 142. DUPUYTREN; in AMMON. (b) ALCOCK, Practical Observations on Fracture of the Patella and of the Olechranon. London, 1823. (c) Above cited. |