70 
patella backwards, and it breaks Schelpe 
—according to Boyer and Malgaigne, “ a 
méme mecanisme que nous cassons un baton 
placé en travers le genou ; en agissant avec les 
deux mains sur ses deux extremités.” In 
transverse, oblique, and comminuted fractures of 
the patella there is almost always more or less 
separation of the fragments, and the signs of 
the accident are easily recognized. In some 
cases of fracture of the patella the fibrous and 
aponeurotic layer which immediately invests it 
anteriorly is broken ; in other cases, eed 
those from external violence, the fibrous layer 
remains entire; it is in these latter cases, as 
the fragments are preserved in complete appo- 
sition, that bony consolidation may be ex- 
ted. The following case, which it lately 
ll to our lot to attend in the Richmond Hos- 
pital, appears to possess some interest as a fact, 
tending to throw light on some of the disputed 
questions here adverted to relative to this ac- 
cident. 
A man, xt. 18, on the evening of 16th Fe- 
bruary, 1839, fell from the height of twenty 
feet to the ground, and fractured two of the 
cervical vertebre, of which injury and its con- 
sequences on the spinal marrow he died in 
forty hours. His lower limbs were paralyzed. 
It was noticed that the integuments over the 
patella were much bruised, and that there was 
some effusion into the cavity of the knee- 
joint. On the post-mortem investigation, the 
patella was found traversed by a perfect frac- 
ture of the bone; but the fragments were not 
separated from each other. On examining the 
patella anteriorly, its fibrous and aponeurotic 
coverings were in a perfect condition. Upon 
looking at the posterior articular surface of the 
patella, the cartilage was broken correspond- 
ing to the line of the transverse fracture of 
the patella, but only half-way across the trans- 
verse extent of the fracture was entirely through 
the bone. We regarded this accident to the 
patella to be the result of direct violence, com- 
plete paralysis of the lower limb having oc- 
curred as the immediate effect of the lesion of 
the spinal marrow; the usual source of dis- 
placement arising from muscular contraction 
was here destroyed. When we bear in mind 
the complete apposition existing in the frag- 
ments of this patella, we cannot for our parts 
question but that if life had been preserved, 
complete consolidation should have taken place. 
Although but few doubts are now entertained 
that the transverse fracture of the patella is in 
general a real rupture of the bone transversely, 
owing to the powerful action of muscles, it 
may not perhaps be amiss to adduce as an ex- 
ample of it, the following case of a patient 
who many years ago was under the care of the 
late Mr. Todd in the Richmond Hospital. A 
remarkably muscular man, a lamp-lighter in 
this city (Dublin), was on the top of his ladder 
when it slipped from the lamp-post, and he fell 
with it to the ground, making at the moment 
vain but violent efforts to save himself. The 
whole muscular system, according to his 
own account, seemed to be suddenly thrown 
into energetic and involuntary effort, to resist 
ABNORMAL CONDITIONS OF THE KNEE-JOINT, 
the fall; when he was lifted up, he was ung 
to stand. Mr. Todd, having examined I 
found both olecrana and both patelle 
transversely. We have often heard the 
named professor mention this case in his” 
tures, and the treatment of the 
also witnessed by Dr, Hutton. sa 
It was for a long time greatly doubted 
bony union of the broken pieces of the 
tella could occur, but it is now fully pr 
that the fractured patella does not want te 
any of the conditions necessary to the r 
and consolidation of broken bones. The sp 
structure of the patella and the 
of bloodvessels entering into its 
ought to favour the inflammatory turgese 
(Boyer) which seems necessary in = 
stage of ossification, and would do so but 
the continual contraction of the muscles fee 
resisted by the bandages s ed by surge 
keeps the fragments from each o 
and hence union has been so rare in th 
cases that the possibility of it under any 
cumstances was for a long time question 
Pibrae, one of the most distingui mem! 
of the ancient Academy of Surgery of Fra 
defied all the surgeons of to 
specimen of the fracture of the i 
solidly by bone, and no example was at | 
time produced. Among many cases pub 
since that time in various works, proving 
possibility of bony consolidation of the bro! 
patella, we adduce the following.* 
Louis Manilla, aged 36 years, of a 
vigorous constitution, being a veteran soldie 
the Salpetritre, on the 7th of April, 1797, 
thrown down by a comrade, with whom he’ 
struggling. One of his knees su i 
effect of this fall, and the patient suffered in 
part a sensation of crackling and 
and a pain which was extremely severe. 
could not rise without assistance, and M.1] 
lement recognised a transverse fracture of | 
patella. The interval between the two ff 
ments was very perceptible, but at 
of the two pieces was easily accomplished w 
the leg wasextended. The patient having 6 
brought to the infirmary, the fracture was 
duced by M. Lallement, and retained by mi 
of the apparatus of Desault. This bane 
was kept on for two months, at the end of wi 
time the fracture appeared to be united. 1 
ing one year the patient walked with the as 
ance of a cane and then returned to his 4 
The movements of the knee were nearly pe’ 
with the exception of flexion of the leg, w 
was still a little confined on the 18th Aug. 1f 
Manilla died of an attack of apoplexy, 
M. Lallement having examined the knee 
came satisfied that the two fragments of 
patella were solidly united. This bone b 
submitted to ebullition for ten hours was 
prived of the articular cartilage which covered 
posterior surface, and of the tendinous 
aponeurotic fibres which enveloped it. It) 
now evident that the total height of the p 
' 
. 
aCccid 
* See Boyer’s Surgery, vol. iii. p. 358. E 
Paris, 1818. ‘ . 
