In a considerable number of cases these means of retaining the fragments in apposition prove ineffectual, and it is necessary to have recourse to operative measures for mechanical fixation. Division of the tendo calcaneus (Achillis) is not to be recommended as a means 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 sequelæ 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 of injury, the finding of the smooth broad end of the diaphysis in the popliteal space or on the front of the thigh, according to the displacement, usually serve to establish the diagnosis. The X-rays afford reliable information as to the position of the fragments. Pressure on the popliteal vessels is a serious aggravation of the injury, and adds greatly to the difficulties of treatment.
