Fig. 328
Comminuted fracture.
Stellate fracture of the patella. (Erichsen.)
Fracture of patella, united by ligamentous tissue. (Erichsen.)
Side view of same.
The more completely mechanical method, partaking of the operative, is afforded by the use of certain hooks, whose points are permitted to pass through the skin above and below the fragments and to engage in the bone. By a screw mechanism these points are drawn toward each other, and thus approximation is effected. This method was first devised by Malgaigne and is usually known under his name, although his device has been much improved. This is far from ideal, and yet has given good results in some cases. The surgeon should constantly guard against infection through the punctures.
By far the most ideal method, when it can be suitably carried out, is the open operation, a transverse incision being made across the front of the joint, which is completely opened; this affords an opportunity to empty out clots and to thoroughly cleanse it, which of itself is a great advantage, since these clots often produce subsequent adhesions. The exposed surfaces may now be freed from clot and all soft tissue, or they may be neatly sawed as near to the fractured surfaces as possible, the intent being to permit them to come into absolute and complete contact, and to hold them there by wire or other sutures, for a length of time sufficient for absolute bony union. When properly performed this operation gives ideal results; it, of course, exposes to great danger if improperly done.
Treatment by non-operative method rarely affords a useful member under an average period of from thirteen to fourteen weeks, while the operative method permits a reduction of this time to less than half. It, therefore, has obvious advantages for those (e. g., laboring men) to whom time is of great importance. The operation, however, is not to be practised as a rude emergency affair, but only when we may be absolutely certain of everything pertaining to aseptic technique. After operation it is rarely necessary to use a drain, and such a limb can usually be dressed in a plaster-of-Paris splint. Compound fractures, however, will probably need drainage at least for a day or two, and because of this need may as well be operated at once. In comminuted fractures the method is desirable, since by a loop or by some other expedient fragments can be held together as in no other way ([Figs. 329] and [330]).