70 



ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



patella backwards, and it breaks transversely, 

 according to Boyer and Malgaigne, " par la 

 meme mecanisme que nous cassons un baton 

 place en travers le genou ; en agissant avec les 

 deux mains sur ses deux extremites." In 

 transverse, oblique, and comminuted fractures of 

 the patella there is almost always more or less 

 separation of the fragments, and the signs of 

 the accident are easily recognized. In some 

 cases of fracture of the patella the fibrous and 

 aponeurotic layer which immediately invests it 

 anteriorly is broken ; in other cases, particularly 

 those from external violence, the fibrous layer 

 remains entire ; it is in these latter cases, as 

 the fragments are preserved in complete appo- 

 sition, that bony consolidation may be ex- 

 pected. The following case, which it lately 

 fell to our lot to attend in the Richmond Hos- 

 pital, appears to possess some interest as a fact, 

 tending to throw light on some of the disputed 

 questions here adverted to relative to this ac- 

 cident. 



A man, a;t. 18, on the evening of 16th Fe- 

 bruary, 1839, fell from the height of twenty 

 feet to the ground, and fractured two of the 

 cervical vertebrae, of which injury and its con- 

 sequences on the spinal marrow he died in 

 forty hours. His lower limbs were paralyzed. 

 It was noticed that the integuments over the 

 patella were much bruised, and that there was 

 some effusion into the cavity of the knee- 

 joint. On the post-mortem investigation, the 

 patella was found traversed by a perfect frac- 

 ture of the bone ; but the fragments were not 

 separated from each other. On examining the 

 patella anteriorly, its fibrous and aponeurotic 

 coverings were in a perfect condition. Upon 

 looking at the posterior articular surface of the 

 patella, the cartilage was broken correspond- 

 ing to the line of the transverse fracture of 

 the patella, but only half-way across the trans- 

 verse extent of the fracture was entirely through 

 the bone. We regarded this accident to the 

 patella to be the result of direct violence, com- 

 plete paralysis of the lower limb having oc- 

 curred as the immediate effect of the lesion of 

 the spinal marrow ; the usual source of dis- 

 placement arising from muscular contraction 

 was here destroyed. When we bear in mind 

 the complete apposition existing in the frag- 

 ments of this patella, we cannot for our parts 

 question but that if life had been preserved, 

 complete consolidation should have taken place. 

 Although but few doubts are now entertained 

 that the transverse fracture of the patella is in 

 general a real rupture of the bone transversely, 

 owing to the powerful action of muscles, it 

 may not perhaps be amiss to adduce as an ex- 

 ample of it, the following case of a patient 

 who many years ago was under the care of the 

 late Mr. Todd in the Richmond Hospital. A 

 remarkably muscular man, a lamp-lighter in 

 this city (Dublin), was on the top of his ladder 

 when it slipped from the lamp-post, and he fell 

 with it to the ground, making at the moment 

 vain but violent efforts to save himself. The 

 whole muscular system, according to his 

 own account, seemed to be suddenly thrown 

 into energetic and involuntary effort, to resist 



the fall ; when he was lifted up, he was unable 

 to stand. Mr. Todd, having examined him, 

 found both olecrana and both patellae broken 

 transversely. We have often heard the above- 

 named professor mention this case in his lec- 

 tures, and the treatment of the accident was 

 also witnessed by Dr. Hutton. 



It was for a long time greatly doubted that 

 bony union of the broken pieces of the pa- 

 tella could occur, but it is now fully proved 

 that the fractured patella does not want really 

 any of the conditions necessary to the reunion 

 and consolidation of broken bones. The spongy 

 structure of the patella and the great number 

 of bloodvessels entering into its structure 

 ought to favour the inflammatory turgescence 

 (Boyer) which seems necessary in the early 

 stage of ossification, and would do so but that 

 the continual contraction of the muscles feebly 

 resisted by the bandages suggested by surgery, 

 keeps the fragments separated from each other, 

 and hence union has been so rare in those 

 cases that the possibility of it under any cir- 

 cumstances was for a long time questioned. 

 Pibrac, one of the most distinguished members 

 of the ancient Academy of Surgery of France, 

 defied all the surgeons of Europe to shew a 

 specimen of the fracture of the patella united 

 solidly by bone, and no example was at that 

 time produced. Among many cases published 

 since that time in various works, proving the 

 possibility of bony consolidation of the broken 

 patella, we adduce the following.* 



Louis Manilla, aged 36 years, of a most 

 vigorous constitution, being a veteran soldier in 

 the Salpetriere, on the 7th of April, 1797, was 

 thrown down by a comrade, with whom he was 

 struggling. One of his knees supported all the 

 effect of this fall, and the patient suffered in this 

 part a sensation of crackling and laceration, 

 and a pain which was extremely severe. He 

 could not rise without assistance, and M. Lal- 

 lement recognised a transverse fracture of the 

 patella. The interval between the two frag- 

 ments was very perceptible, but approximation 

 of the two pieces was easily accomplished when 

 the leg was extended. The patient having been 

 brought to the infirmary, the fracture was re- 

 duced by M. Lallement, and retained by means 

 of the apparatus of Desault. This bandage 

 was kept on for two months, at the end of which 

 time the fracture appeared to be united. Dur- 

 ing one year the patient walked with the assist- 

 ance of a cane and then returned to his duty. 

 The movements of the knee were nearly perfect, 

 witli the exception of flexion of the leg, which 

 was still alittle confined on the 18th Aug. 1810. 

 Manilla died of an attack of apoplexy, and 

 M. Lallement having examined the knee be- 

 came satisfied that the two fragments of the 

 patella were solidly united. This bone being 

 submitted to ebullition for ten hours was de- 

 prived of the articular cartilage which covered its 

 posterior surface, and of the tendinous and 

 aponeurotic fibres which enveloped it. It was 

 now evident that the total height of the patella 



* See Beyer's Surgery, vol. iii. p. 353. Edit. 

 Paris, 1818. 



