68 



ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



does so, whilst the patella, tibia, and condyles 

 of the femur sink towards the ham, and are 

 drawn upwards behind the broken extremity 

 of the shaft of the os femoris, which is thrown 

 forwards." He adds that falls from a great 

 height on the feet or knees have been the usual 

 sources of this accident.* In most of the cases 

 already met with, and described, of oblique 

 fracture of the lower extremity of the shaft of 

 the femur, the direction of the obliquity was 

 from above downwards, and from behind for- 

 wards, and the pointed extremity of the broken 

 bone was consequently directed downwards and 

 forwards ; but the pointed extremity has been 

 seen towards the popliteal space. In Sir 

 Charles Bell's lectures on the thigh-bone which 

 he has published, there is an engraving of a 

 very remarkable case, which appears to us to 

 have been an oblique facture of the femur near 

 the knee-joint, in which the pointed extremity 

 of the superior fragment presented towards the 

 popliteal space.f About twenty years after the 

 bone had been fractured, the patient, in jump- 

 ing down from a chair, felt something snap, 

 and very soon after a pulsating tumour formed, 

 which was discovered to be a popliteal aneurism. 

 The direction of the course of an oblique frac- 

 ture may be various ; that downwards and out- 

 wards is the least likely to be followed by 

 dangerous consequences. 



3. Oblique fruc tures of the os femoris into the 

 knee-joint, detaching laterally the condyles, are 

 not very uncommon accidents ; they may be 

 known by the great and sudden swelling of the 

 joint by which they are accompanied, by the 

 great degree of lateral motion which can be 

 communicated to the limb, by the crepitus 

 which can be felt, and by the obvious deformity 

 with which they are attended. 



It is sometimes the inner condyle, and some- 

 times the outer, which is detached from the 

 shaft; and in these cases the cavity of the 

 synovial membrane of the knee-joint is always 

 opened into by the fracture. The following 

 case presents a good example of an oblique 

 simple fracture, which detached the outer con- 

 dyle of the femur from the shaft of this bone. 



Ganet Doyle, a-t. 45, was admitted into the 

 Richmond Hospital under the care of Dr. Hut- 

 ton on the 27th March, 1839. He stated that 

 about ten minutes before his admission he was 

 standing on a double ladder about four feet from 

 the ground ; the ladder gave way under him 

 suddenly, and he fell with it, the right limb 

 having been engaged between two of the steps. 

 During the fall he was sensible of being bruised 

 below the knee by the steps, and of something 

 " cringing" in the lower part of the thigh ; im- 

 mediately after the fall he found the limb quite 

 powerless and was unable to put it under him. 

 Tumefaction of the knee and lower part of the 

 thigh took place instantly and to a great extent. 

 On examination the outer condyle was found 

 to move and grate against the inner through the 

 centre of the joint ; no breach of continuity 



* Sir A. Cooper on Dislocations, 8th edition, 

 plate xv. 



f Fig. 3, plate iv. 



could be detected between the inner condyle 

 and shaft of the bone. The femur, as the pa- 

 tient endeavoured to stand, was directed down- 

 wards and inwards, and the tibia downwards 

 and outwards, so that the junction of these 

 two bones at the knee-joint formed an obtuse 

 angle salient internally. There was considerable 

 enlargement of the femur in the situation of 

 the fracture for several inches above the knee- 

 joint, and on measurement there was shortening 

 of the injured limb for half an inch. By making 

 extension, and by pressing the condyles towards 

 each other, the natural form of the limb was 

 restored. No fever nor constitutional disturb- 

 ance arose, and at the end of the fifth week 

 passive motion was recommended. When the 

 man left the hospital the external appearance 

 of the joint was very nearly natural, except 

 that the patella had been elevated at its outer 

 edge obliquely by the callus which had united 

 the fracture. When this bone was moved across 

 the trochlea of the femur, a roughness was per- 

 ceived to exist on the corresponding surface, 

 and a sensation of something grating was con- 

 veyed to the fingers of the examiner. There 

 was some shortening of the limb, which also 

 still remained more inclined inwards towards 

 the knee-joint than natural, and the movement 

 of flexion was limited. 



Sometimes an oblique fracture occurs 

 through the lower part of the femur into the 

 joint, which detaches the inner condyle. The 

 prognosis in these cases of simple oblique 

 fractures of the inner and of the outer con- 

 dyle of the femur, so far as life is concerned, 

 does not appear, from what we have seen of 

 them, unfavourable ; but we have known some 

 examples of what may be designated as T 

 fractures of the lower extremity of the femur 

 that is to say, a transverse fracture of the lower 

 extremity of this bone, combined with a ver- 

 tical split from the transverse fracture down 

 through thetrochleainto the outercondyloid fossa 

 of the femur, in which the prognosis is generally 

 unfavourable, even when the fracture is uncom- 

 bined with any wound in the integuments. 

 Mr. Chelius, of Heidelberg, shewed Mr. 

 Smith and the writer, in August 1837, two 

 specimens of T fracture of the lower extremity 

 of the femur. In the first case, the exact 

 nature of the accident was unknown to Mr. Che- 

 lius. Violent inflammation set in in the knee- 

 joint and the whole limb, causing the death of 

 the patient. In the second case he recognized 

 the nature of the injury early, and amputation 

 in the thigh saved the patient In such cases, 

 to decide at once whether amputation shall be 

 immediately resorted to or not, becomes a very 

 critical and often a very urgent question. If 

 the first opportunity be lost, the constitutional 

 symptoms attendant on the local inflammation 

 set in so speedily, and run to such a height, 

 that a second seldom offers ; the two following 

 examples, however, should caution us against 

 deciding hastily on immediate amputation in 

 cases of simple fracture, in which the cavity of 

 the knee-joint is implicated, because, although 

 in the first case the femur was broken into a 

 great number of fragments, the inflammation 



