followed was inconsiderable, and in the 
dan opporiunity for “secondary ampu- 
tion” was afforded even after acute inflam- 
ation of the joint had taken place. 
A healthy labourer, about 30 years of age, 
admitted into Jervis-street Hospital about 
ght years ago, under the care of the late Mr. 
llace, for a comminuted, but still a simple 
re of the lower extremity of the femur, 
ere it entered into the formation of the 
ee-joint. The accident was attended with 
rmous effusion, and there was a degree of 
dbility of the limb in the seat of the commi- 
fracture truly astonishing ; but little in- 
gation followed, and under the simplest 
ent the man ultimately recovered with a 
knee-joint. The second case was that of 
ged 13 years, who had received a simple 
ure of the lowest part of the shaft of the 
The condyles of this bone were de- 
id at their normal line of junction with the 
ft, and where they are covered with syno- 
| membrane ; the posterior and anterior cru- 
cial ligaments were separated from the femur, 
[had carried with them small portions of 
is bone. The result of the operation is not 
ded, but the specimen, preserved in our 
um at the Richmond School of Medicine, 
its, besides the injury the bones received, 
s of the very acute inflammation which 
wed, particularly on the surface of the sy- 
] membrane, which is covered with lymph. 
periosteum of the femur in the vicinity of 
fracture is much thickened and detached all 
nd from the femur. 
ong the valuable preparations presented 
Mr. Kirby to the College of Surgeons in 
lin is a specimen of one of these transverse 
res of the lower extremity of the femur, 
h was combined with a vertical split of 
bone down through the trochlea and outer 
yloid fossa. Although the fracture was a 
le one, it was followed by enormous effu- 
1, succeeded hy acute inflammation of the 
tructures of the joint; and Mr. Kirby in- 
ms me that amputation was successfully re- 
sorted to. The synovial membrane was much 
hickened, and evidences of acute inflammation 
if the structures of the knee-joint are still to be 
een in the preparation. 
Fractures of the tibia close to the knee-joint 
| may be transverse, or through the line of junc- 
tion of the epiphysis with the rest of the tibia 
€ young subject, or in the situation and 
ion of this line in the adult. In this case 
broad surfaces of the broken tibia nearly 
haintain their relations with each other. If 
there be any displacement, it will be that of 
the superior fragment, which will be drawn 
backwards towards the popliteal space, as the 
inner hamstring muscles will draw the bone in 
this direction. 
Oblique fractures of the upper extremity of 
the tibia which run into the knee-joint are 
‘accompanied with symptoms not very dissi- 
} milar from those belonging to oblique fractures 
of the internal condyle of the femur, except 
€ situation of the pain, and the crepitus which 
ean be elicited on motion being communicated 
eli ee elie el 
ey Te er ee le res 
a a 
ABNORMAL CONDITIONS OF THE KNEE-JOINT. 
69 
to the broken portion of bone. There is the 
same sudden effusion into the knee-joint, and 
a very great degree of lateral motion is allowed, 
which is a movement the knee-joint does not 
normally possess. 
We learn from Blandin that Beclard had 
very frequently observed elderly females to be 
the subjects of fractures of the upper portion 
of the tibia, produced by the contraction of 
the flexor muscles of the leg, which muscles 
also he observed uniformly pulled the supe- 
rior fragment into the hollow of the ham. The 
explanation of the fracture occurring from such 
a cause must be referred to the atrophy which 
the head of the tibia undergoes in elderly 
people, in consequence of which the tibia he- 
comes thin in its shell, and the interior os- 
seous structure reduced to a thin reticular 
tissue, which in the dead subject we notice to 
yield to the slightest pressure of the fingers. 
We have known this,atrophy of the tibia to 
exist in adults as well ‘as in old subjects, and 
when present, it of course renders the bone 
liable to be broken by slight causes. More- 
over, we have usually found the species of 
reunion of the broken bone which can be 
effected under such circumstances to have been 
very imperfect; the patient after a long period 
endeavours to move about with the assistance 
of crutches; and effusion takes place into the 
knee-joint, the functions of which hecome 
greatly impaired for the rest of life. 
Fracture of the patella— This fracture oc- 
curs almost always in the transverse direction ; 
it is rarely oblique, and still more rarely longi- 
tudinal ; sometimes a fracture divides this bone 
into three or four pieces, or is what is called 
comminuted. The longitudinal fracture is rare, 
and this and the comminuted are generally the 
result of direct violence; and, although the 
transverse fracture may depend on a similar 
cause, still the violent contraction of the ex- 
tensor muscles of the leg is the most frequent 
source of this accident. When a fall occurs 
directly on the front of the knee, this joint 
being at the moment in a state of semiflexion, 
if a fracture take place it will no doubt be 
considered as the result of the fall directly on 
the bone, by which it is broken; certainly 
muscular action may lend its assistance to the 
external violence even in producing the frac- 
ture, and after this has occurred, to cause the 
separation of the fragments. 
This fracture cannot so readily be effected 
by muscular action when the limb is in a state 
of complete extension as when it is in a com- 
mencing state of flexion, because in complete 
extension the muscles act in the direction of the 
long axis of the bone; but in flexion at the 
knee to the first degree the patella is in a par- 
ticular condition, which is favourable to the 
production of fracture; it only applies itself 
to the condyles of the femur by its middle 
point. The base and summit of this bone are 
unsupported ; the extensor muscles of the leg 
.on one side, and the tendon or ligament of the 
patella on the other, are; in this position of 
the joint, oblique with relation to the long 
axis of the patella; the muscles then bend the 
