Fig. 329
Fig. 330
Wiring patella. (Lejars.)
Injuries to the patellar region, equivalent to fractures, are separations, either of the tendon from the bone, or of the bone from the ligament which holds it to the tibia. Such injuries can be recognized by the fact that the contour of the bone itself is preserved; in the former case it is not drawn up, although the extensor muscles have lost their power while in the latter it is drawn up, leaving a well-marked gap below it.
Remarks concerning the treatment of fractures apply equally here. Choice can be made between the operative and the non-operative treatment. In well-selected cases the former seems much the more desirable, the fibrous end of the tendon or ligament being held to the bone by strong sutures of silk or wire.
THE LEG; FRACTURES OF THE TIBIA.
The head of the tibia is occasionally broken as the result of extreme violence, the fragment being usually held reasonably in place by one or other of the lateral ligaments. Hemorrhage into the joint will be profuse, with swelling extreme, while disability will be complete. Not a few of these cases justify operation, directed toward opening the joint, removing all clot, and fastening the fragment in place with suitable sutures ([Figs. 331] and [332]).
Transverse fracture below the tubercle is less rare. The insertion of the terminal ligament of the quadriceps extensor group will, in all of these injuries to the upper portion of the tibia, tend to pull up the upper fragment and make it project beneath, even protrude through the skin. Fractures of the lower part of the tibia are freer from such distorting influences. [Fig. 333] illustrates the distortion produced as above, while [Fig. 335] shows one of the tendencies in fracture of the lower end of the tibial shaft, which has to be overcome by correct emplacement of the foot within the dressing. [Fig. 334] illustrates synostosis as the result of fracture of both bones at about the same level. Torsion is a factor of no small importance in the production of most of the fractures of the leg, to such an extent as sometimes to make a completely spiral fracture, a condition generally held to be more serious than fracture of the ordinary type. The line of fracture often extends in such a direction as to leave a sharp spicule of bone close beneath the skin; here rough handling, or carelessly made pressure in the dressing, may cause a perforation within a few hours or days after the injury, by which a simple is converted into a compound fracture. Such a complication should always be avoided.