THE PATELLA OF LONG STANDING 



473 



consisting, of course, only of skin and fat, as the muscle was absent at that part. 

 Then passing a strong pair of forceps from the lower incision under the skin till 

 their blades appeared in the upper incision, I seized the ends of the wire and 

 drew them down into the lower incision. I then drilled two holes in the lower 

 fragment and passed the ends of the wire through them from within outwards, 

 and, after drawing the upper fragment well down, secured them in the usual 

 way and cut the ends short. The immediate result, so far as the fragments 

 were concerned, is indicated in this diagram (Fig. 3). The incisions in the skin 



L o wer Fraarrwn t 



Uppef^ Fraament 



Fig. 



were then brought together by sutures, and a dressing (the double-cyanide gauze) 

 applied. 



In drawing down the upper fragment I found a great advantage from the 

 use of a very strong sharp hook (Fig. 4), the point of which was inserted in the 

 tendon of the quadriceps at its attachment. By this means I was able to exert 

 much greater traction upon the bone than can be done by simpl}- pulling upon 

 the wire ; and, in order to relax the quadriceps as much as possible, the limb 



Fig 4. 



was placed in the vertical position before the fragment was pulled down. The 

 dressing having been put on, a trough of Gooch's splint was applied to the limb 

 still in the elevated position, and the same attitude was maintained as the patient 

 was removed to the ward, and continued by attaching the end of the splint 

 to a rope connected with the tripod and pulley used in applying Sayre's plaster- 

 of-Paris jacket. This ])osition of the limb tlicl not cause the patient material 

 inconvenience, and after two or three days the rojie \\a> slackened a little so 

 as to allow the end of the splint to come down an inch or two. and the same 



LISTER U II 



