ABNORMAL CONDITIONS OF THE KNEE-JOINT. 



77 



J oint, the interior of the articulation is occa- 

 sionally injured ; that the crucial ligaments are 

 stretched ; and that some of their fibres give 

 way occasionally, breaking in their centres, or 

 detached by their extremities from the bone. 

 "We lately had an example of a severe injury 

 of the knee-joint, in which the anterior crucial 

 ligament must have suffered great violence. 

 The fibres of this structure did not give way, 

 but the portion of the tibia to which they were 

 naturally connected was torn up with the cru- 

 cial ligament. We are not aware that such an 

 accident as this has been before noticed, al- 

 though it is probable that all complete luxa- 

 tions of the knee-joint must be preceded by 

 such a lesion. 



A young man, aged 25, was admitted into 

 the Richmond Hospital under the care of Dr. 

 Hutton, on the llth of December, 1837, with 

 an injury of the left knee-joint, which occurred 

 when wrestling. Being intoxicated at the time 

 his account of the manner in which the acci- 

 dent occurred could not be depended upon. 

 The joint was much swollen, very tense, and 

 painful ; no fracture, and no other deformity 

 than that occasioned by the general swelling of 

 the joint could be detected. The limb was 

 maintained in the semiflexed position and on 

 the outside. Inflammation and symptomatic 

 fever ran very high, and the pain was excessive, 

 especially on the least motion of the joint. 

 On the eleventh day the pain and swelling had 

 diminished. He could then raise the limb 

 from the bed, but could not increase the 

 amount of flexion. On the seventeenth day 

 symptoms of diffuse inflammation set in ; these 

 rapidly increased, and on the twenty-fourth 

 day from the receipt of the injury he died. 

 The knee-joint was found to contain eight 

 ounces of purulent matter, in which flakes of 

 lymph floated ; the synovial membrane was 

 soft, pulpy, and vascular ; the circumference of 

 the cartilages covering the condyles of the femur 

 was in a slight degree absorbed. On flexing 

 the joint, the spine and central portion of the 

 head of the tibia, with a considerable portion 

 of its left articulating surface, were found torn 

 up from the rest of the bone in one piece, 

 (Jig. \Q,) and remained attached to the ante- 

 rior crucial ligament. 



Rupture of the quadriceps extensor tendon 

 from its attachment to the superior border of 

 the. patella. The muscles and tendons around 

 the knee-joint are very seldom the subject of 

 accident. We have never heard of any acci- 

 dental rupture of the tendons of the hamstring 

 muscles ; we have, however, known some in- 

 stances of rupture from the upper edge of the 

 patella of the muscular and tendinous structure 

 attached to the superior edge of this bone, con- 

 sisting of the combined muscular and tendinous 

 attachments, of the rectus, cruraeus, and vasti 

 muscles. A person who has met with this 

 accident cannot rise from the ground, nor can 

 he stand when raised without being sustained 

 by two persons; when he attempts to lean his 

 weight on the affected limb, it yields and 

 bends forwards. On examining the knee we 

 observe between the superior border of the 



Fig. 10. 



Anterior crucial ligament torn up with portion of tibia. 



patella and broken tendon a separation of one 

 inch, which is diminished when we extend the 

 leg, and increased much when we flex it. If 

 we introduce our fingers into the bottom of 

 this depression, we feel plainly the trochlea of 

 the femur. In this case, as may be expected 

 in all analogous accidents, there is much effu- 

 sion of synovial fluid, which distends the inte- 

 rior of the joint ; and it is probable that the 

 synovial membrane does not escape laceration. 

 Patrick Dignam, set. 69, was admitted into 

 the Richmond Surgical Hospital on the 15th 

 of December, 1839, for a rupture of the tendon 

 of the rectus cruris. He stated that about a 

 week previously, while carrying on his back a 

 load of about two hundred weight, he slipped 

 and fell backwards, and in making a violent 

 muscular effort to recover himself, he felt some- 

 thing snap about his knee. He fell backwards, 

 and was unable to rise without assistance. 

 When placed on his sound limb, he found he 

 could not elevate the affected one ; he could 

 only flex it. Whenever he attempted to put 

 the limb under him, it quite failed him, his 

 knee giving way and becoming instantly flexed 

 against his will. It was found that consider- 

 able effusion had taken place into the knee- 

 joint : the patella was raised up and seemed to 

 float as it were on the synovial fluid and was 

 very moveable ; its entire outline could be 

 easily ascertained ; and when the leg was fully 

 flexed, the patella was still quite moveable in 

 the lateral directions. Above the margin of 

 the patella a considerable depression existed 



