Elements of Surgery

by Robert Liston

The application of force may, in young persons, detach the epiphysis of the lower end of the femur, and displace it to a greater or less extent; and if the accident be not detected, the epiphysis will become consolidated with the shaft in this unnatural position, impairing the usefulness of the member, and probably laying the foundation for disease in or around the articulation. Reduction is easy, and the retentive treatment is the same as that recommended generally

for fracture of the thigh near the knee-joint. I have met with one well-marked case of this form of diastasis. A girl sustained an injury of the knee when fourteen years of age, in consequence of the limb having been entangled amongst the spokes of a carriage-wheel in motion; the knee continued painful and swollen, and she had a halt in walking. After the lapse of about three years, extensive suppuration occurred in the lower part of the thigh and round the knee-joint, and amputation very soon became indispensable for the preservation of life. The synovial apparatus was much diseased, and the epiphysis of the lower end of the femur was found displaced forwards and upwards, so that only the posterior part rested on the tibia; in fact, it was turned, as here shown, almost half round on the shaft: firm union by bone had taken place.

Fracture of the Patella is generally simple. It is occasioned either by great force applied to the bone directly, or by the action of the strong extensor muscles—the knee being suddenly bent, and the bone snapped across over the end of the femur. The degree of immediate swelling, and of incited action, will vary according to the mode of infliction. When the injury is caused by a blow upon the part, the bone may be broken either transversely or vertically, or both; either the upper or the lower portion may be vertically split, usually the upper; sometimes there is considerable comminution. Muscular action produces transverse fracture only.

The nature and extent of the injury is readily ascertained. The patient is unable to extend the limb, and cannot support weight on it; in the bent position, a space is felt in the situation of the patella, the lower portion is found nearly in its place, but the other is drawn upwards on the fore part of the thigh; by extension of the limb and flexure of the thigh the portions are approximated, and crepitus is perceived when they are brought in contact. These symptoms are perceptible through any quantity of bloody effusion. By attentive manipulation, comminution and vertical splitting may also be detected. The circumstances attending the accident will, in most instances, lead to a tolerably accurate expectation of the state of parts.

The ligament of the patella does not often give way from muscular action; it is much stronger than the bone, and the latter consequently snaps. It may be, and has been, divided, along with the superimposed integument, by a fall on a sharp substance. This accident is followed by lameness, the ligamentous tissue does not soon unite, and the limb is long in regaining its usefulness; sometimes the union is imperfect, and the member remains weak.

Division of the integuments over a fractured patella is a very serious accident. The joint is opened, and such a state both of the limb and of the constitution must in general sooner or later occur as to cause necessity for amputation. Cases have, however, occurred, in which compound fracture of the patella has been cured.

The bone unites, under favourable circumstances, in the same way as any other. In longitudinal fracture there is almost always bony union. In transverse, the obstacles to correct apposition are great; the upper portion is acted on by the muscles on the fore part of the thigh, to a greater or less degree, in almost any position; there is increase and vitiation of the synovial secretion, and when the bones are approximated, this fluid is interposed. The union is therefore almost uniformly ligamentous, and, fortunately, this is as strong and as rapidly effected as that by bone. When the treatment is not of the most approved kind, a long portion of ligament is produced, and the limb remains weak. But union by a short ligament is undoubtedly the most desirable result, the member is as useful as when bone is the uniting medium, and ligament is less subject to disruption; bony union is, for a long time, apt to give way on the application of even slight force.

The fragments are to be approximated, and brought nearly into contact, by placing the limb, with the knee extended, and the thigh slightly bent on the pelvis. The limb is retained in this position by the application of a straight splint behind, hollowed at the extremities, extending from a little below the tuberosity of the ischium to below the middle of the leg, and retained by a roller, not at all tight; the foot and lower part of the limb must be previously bandaged to prevent infiltration. All apparatus with straps, buckles, and apertures to receive the portions of the bone, are worse than useless. The splint requires to be worn for some time after the patient gets into the erect position, which ought not to be before six weeks after the accident.

Fracture may occur at any part of the leg. One or both bones may give way, either transversely or obliquely, according to the application of the force. The transverse fracture is produced by a direct blow, by a heavy body striking or falling on the limb, or by the lower part of the limb being fixed whilst the body is in rapid motion; the oblique is caused by force applied in the direction of the bones—as when a person falls or leaps from a height, and alights on one foot, the limb being extended and the body erect. In the latter description of accident, it is frequently supposed, erroneously, that but one bone has given way; fracture of the tibia perhaps is perceived some few inches from the distal end, whilst the fibula at that part is entire; but, by attentive manipulation, it will often be found that the fibula has sustained fracture, within a short space of its upper extremity; the force was applied to the ends of the bones, and they gave way, each at the weakest part.