76 



ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



to form an obstuse angle internally, and it is 

 not improbable, that by the sprain the internal 

 lateral ligament or other structures in the in- 

 terior of the joint were injured. The sprain 

 was followed by swelling, &c., and it was six 

 weeks before he recovered so as to be able 

 to walk. Mr. L. remained well for eight 

 months, when, in crossing over a ditch, the 

 sudden derangement recurred. The moment 

 the displacement of some part of the interior 

 of the joint occurred, he dropped suddenly to 

 the ground. Another day, while practising 

 some gymnastic exercise, it occurred. Again, 

 it happened while in bed, the bed-clothes em- 

 barrassing the motion of the foot while he was 

 turning his body round. On the last occasion 

 on which the displacement happened, he was 

 on horseback ; he had just mounted, and was, 

 while his knee was flexed, seeking with the in- 

 verted foot for the off-stirrup, when the dis- 

 placement happened. On all these occasions 

 he has without loss of time sought to replace 

 the deranged parts, and sometimes has suc- 

 ceeded instantaneously, and sometimes weeks 

 have passed without the adjustment of the 

 parts in the interior of the joint occurring. 

 The restoration of the use of the joint has al- 

 ways been as sudden as the derangement, and 

 the replacement has invariably been accom- 

 panied by a sudden snap, as if something at 

 that moment changed its place, and this to him 

 was always the signal of recovery of the uses 

 of the joint. When the extension and flexion 

 of the limb in the manner recommended by 

 Hey has been the means of restoration, he has 

 on some occasions not only felt the sudden 

 movement of what he considers the dislocated 

 part in the interior of the joint, but he thinks 

 he could distinctly hear the crack the part 

 gave in resuming its ordinary place. The writer 

 of this has lately seen and examined Mr. 

 L.'s knee-joint, and compared it with the 

 opposite one, and cannot perceive the slightest 

 difference on a simple inspection of both arti- 

 culations either before or behind. The patella 

 and the ligament which connects it to the tibia 

 are just as firmly applied in front of the joint 

 as usual, and there is now no effusion into the 

 joint of any unnatural quantity of synovial 

 fluid. He habitually wears a laced knee-cap, 

 and finds only a difficulty in flexing as fully 

 the affected knee-joint as the other, and he has 

 an habitual fear of any movement of the leg in 

 which this is at the same time flexed, and the 

 foot inverted. This is a well-marked example 

 of the internal derangement of the knee de- 

 scribed by Hey ; but what are the true ana- 

 tomical characters of the accident, or what 

 really is the structure, whether normal or ab- 

 normal, which slips in and out with a noise ? 

 Nothing positive, in our opinion, has been added 

 to the knowledge of the nature of the accident 

 given to us by Hey, who has the merit not only 

 of first describing the injury, but of also 

 pointing out a simple and generally successful 

 remedy. 



Many surgeons have considered that the in- 

 ternal derangement of the knee described by 

 Hey, and considered by Sir A. Cooper as a 



" partial luxation of the femur from the semi- 

 lunar cartilages," is a dislocation of these fibro- 

 cartilages. Malgaigne justly criticises the vague- 

 ness of the language used by authors relative to 

 this matter. M. Velpeau, according to Mal- 

 gaigne, in one place treats of this luxation as a 

 luxation of thesemilunarfibro-cartilages,and in 

 another work he seems so uncertain of the na- 

 ture of the accident as to demand whether 

 the phenomena may not be owing to the ex- 

 istence, in the interior of the joint, of some of 

 those cartilages which we call foreign bodies. 

 Malgaigne himself seems to fall into the opi- 

 nion of Sir A. Cooper upon this subject, al- 

 though he does not use the same terms, and 

 considers the accident to be a simple and par- 

 tial luxation of the femur from the tibia, the 

 consequence of the relaxation of all the liga- 

 ments, but adduces no anatomical evidence of 

 the truth of his hypothesis. He considers the 

 accident, " Une simple luxation incomplete du 

 femur sur le tibia, produite par un relachement 

 de tous les ligamens, et tout-a-fait analogue 

 aux deplacemens occasioned par la meme cause 

 dans les autres articulations." Sir A. Cooper 

 is of opinion that Mr. Key's plan is generally, 

 but not invariably successful, and adduces the 

 case of a lieutenant in the army who suffered 

 this accident repeatedly, and the limb was 

 often reduced by the above-mentioned means ; 

 but at length, turning in bed, from the pres- 

 sure of the bed-clothes on his foot, the accident 

 recurred. He came to London, but bending 

 the limb had now no effect in enabling him to 

 extend the joint. Sir A. Cooper, therefore, ad- 

 vised him to visit Mr. Hey, but he learned 

 that in this case the dislocation was never re- 

 duced. In an obstinate case of this internal 

 derangement of the knee-joint, which resisted 

 all the ordinary means of surgical treatment, 

 the writer succeeded (in Jervis-street Hospital) 

 by using the pulleys. Under exactly simi- 

 lar circumstances, his lamented friend, Dr. 

 M'Dowel, subsequently succeeded by having 

 recourse to the pulleys when all other means 

 had failed. 



The knee-joint is seldom affected by sprains. 

 When, however, there is an undue inclination 

 of the knee inwards, the internal lateral liga- 

 ment is occasionally, by an accidental false 

 step or twist, sprained, and sudden lameness 

 comes on followed by swelling, and more or 

 less inflammation of the synovial membrane of 

 the articulation. It has not been ascertained 

 whether in such cases the fibres of the internal 

 lateral ligament have given way, or whether 

 they are detached from the bone or not; but it 

 is not improbable that some such lesion has 

 occurred as that we have already noticed under 

 the head of Sprains in another articulation : 

 (see ANKLE.) When sprains of the knee take 

 place, it is almost invariably the inner side of the 

 joint to which the patient refers as the prin- 

 cipal seat of tenderness and pain. The joint 

 admitting of motion unaccompanied by any 

 crepitation (although the act may be painful), 

 readily distinguishes a sprain from any frac- 

 ture of the bones of the articulation. It is 

 not improbable that in sprains of the knee- 



