754 
SURGERY. 
or nails, are arranged, the use of which is for fixing the 
straps, which serve for holding the fragments of the bone in 
a state of approximation. These straps are two in number, 
rather more than an inch wide, and about seven inches long. 
Their middle portions are quilted with wool, covered with 
chamois, and made of softer leather than their extremities, 
which are of calf-leather, and furnished with holes placed at 
the distance of about a quarter of an inch from each other. 
The limb is to be placed in the concavity of the splint, the 
ham occupying its middle; and the empty spaces, left be¬ 
tween the limb and the apparatus, are to be nicely filled up 
with soft tow. Then, while an assistant, presses the pieces 
of bone together, the straps are to be applied in such a way, 
that the one which lies above the upper fragment of bone, is 
to be fastened to two of the pegs lower down; and that 
which crosses immediately under the lower fragment is to be 
fastened to two pegs situated higher up. By this contriv¬ 
ance, the straps, the ends of which cross each other, leave 
between them a transverse space, in which is compre¬ 
hended the broken patella. Any resolvent lotion may now 
be applied to the injured part; and, lastly, the limb is secured 
in the splint by means of a roller, or four or five pieces of 
broad tape, doubled, and tied over one side of the wood. 
Boyer generally enjoins his patients not to begin to bend 
their knees earlier than two months after the accident. 
Dislocations of the patella happen either upwards, when 
the ligament that attaches this bone to the tibia, is ruptured, 
or to the side; the second kind of dislocations are far more 
frequent than the first, and the displacement is oftener to the 
outer than to the inner side of the limbs. External force is 
a common cause of all these accidents; but the bone is 
often displaced outwards, by the action of the muscles in 
bandy-legged people. 
In the dislocation outwards, which is the most common, 
the leg is extended, and cannot be bent without seriously in¬ 
creasing the pain, which the patient already suffers; the 
inner margin of the articular pulley, off which the patella 
has slipped, can be plainly felt under the skin; over the 
outer part of the same pulley, the patella itself forms a re¬ 
markable swelling, and the outer edge of this bone is quite 
perceptible. Were the luxation complete, the extended po¬ 
sition of the leg, the depression in the natural situation of the 
bone, the facility of distinguishing the articular pulley, and 
the tumour caused by the luxated bone itself upon the side of 
the outer condyle, would leave no chance of mistaking the 
nature of the accident. 
A dislocation inwards may happen, when an external 
force propels the outer edge of the patella in this direction : 
but, the case is hardly ever complete. The patella forms a 
considerable prominence upon the internal condyle; its 
front surface is inclined outwards, and its posterior one in¬ 
wards; while its outer edge is turned backwards, and its 
inner one forwards. In the depression observable in the 
situation, from which the patella is removed, the outer con¬ 
dyle may be plainly felt with the finger. The leg is extend¬ 
ed, and an attempt to bend the knee produces a great 
increase of pain. To reduce these dislocations, the surgeon 
having fully relaxed the exterior of the leg, by raising the 
1 heel until it forms a right angle with the pelvis, presses down 
that edge of the patella which is most remote from the joint, 
whether the luxation be outwards, or inwards. This pressure 
raises the inner edge of the bone over the condyle of the 
femur, and the patella is immediately drawn into its natural 
situation by the muscles. 
Of fractures of the leg.—The cases in which both bones of 
the leg are broken together, are more frequent than those, in 
which only one of them is fractured. When the two bones 
are broken, the solutions of continuity are sometimes parallel; 
sometimes at different heights. The direction of the fracture 
of each bone is also subject to variety, in some cases being 
transverse, which is most common in children; in other 
instances, being oblique; and, what is remarkable, the 
obliquity of fractures of the tibia has something determinate 
about it, usually extending from below upwards, and from 
within outwards, so that the end of the upper fragment is 
generally manifest below the integuments at the front and 
internal part of the leg. Lastly, either of the bones may be 
broken in several places, and the soft parts more or less con¬ 
tused, or lacerated, either by the ends of the broken bone, 
or the same force which occasioned the fracture itself. 
Cases in which the two bones are broken, are frequently 
the consequence of falls upon the feet, and then the fracture 
is mostly oblique, and that of the tibia happens alittle below 
its middle portion. However, when the tibia gives way 
at this point, it often happens, that the fibula breaks towards 
one of its extremities. As the tibia alone sustains the weight 
of the body, it is evident, that when both bones are broken 
by a force, which acts perpendicularly, the tibia gives way 
first, its fragments are displaced, and the force continuing 
to operate, then bends the fibula, the fracture of which is 
subsequent to that of the other bone. Both bones of the leg 
may also be fractured by violence applied directly to the seat 
of the injury, as when the wheel of a carriage passes over 
the limb, while this is extended on the ground, or a heavy 
body falls upon the member. 
In fractures of the leg, the displacement of the fragments 
depends upon the direction of the division of the bones, and 
the nature of the cause of the injury. When the fracture is 
transverse, the displacement can only take place in the 
diameter of the fragments, particularly when the injury is 
situated high up, where the surfaces of the broken part of the 
tibia, which are applied together, are large. In fractures 
of both bones of the leg, however, it is remarked, that the 
ends of the bone seldom remain long in their natural situa¬ 
tion, even when their surfaces are broad, and the solution of 
continuity is transverse, because every movement of the 
limb has a tendency to produce displacement. When the 
fracture is oblique, and has been produced by a fall on the 
foot, the ends of the fracture must inevitably pass beyond 
each other. In the majority of instances, the end of the 
upper piece of bone presents under the integuments of the 
shin a sharpish point directed downwards and inwards; while 
the extremity of i the lower portion is drawn backwards and 
outwards by the muscles of the calf. However, notwithstand¬ 
ing the obliquity of the surfaces of the fracture, and the 
tendency to displacement necessarily resulting from it, ex¬ 
perience proves, that these cases are never followed, as 
broken thighs are, by any subsequent increased shortening of 
the member, excepting where the tibia has been driven out 
through the skin. 
The lower portions of the broken bones are also liable to 
a rotatory displacement; an inconvenience faciliated by the 
foot being naturally turned outwards, and the greater 
portion of its mass and weight being external to the axis of 
the limb. 
Fractures of both bones of the leg are readily ascertained; 
for the slightest deformity is obvious along the sharp ridge 
termed the spine of the tibia, as well as upon its anterior flat 
surface, usually called the shin. The gentlest movement of 
the member will also produce a very plain crepitus. 
Dislocations of the tibia happen either forwards, backward s 
or to one side. In the first case, according to Sir A. Cooper, 
while the tibia projects forwards, the thigh-bone is depressed 
and thrown somewhat laterally as well as backwards; the 
pulsation of the popliteal artery is stopped by the pressure of 
the condyles of the femur, and the tibia and patella are both 
turned forwards.—The dislocation backwards (a rare accident) 
is marked by depression of the patella, projection of the 
condyles of the femur and flexion of the leg forwards, ac¬ 
cording to Sir A. Cooper; backwards according to Heister — 
Lateral dislocations, though commoner than thepreceding,are 
nevertheless rare, and they are always incomplete; for in the 
dislocation inwards, the inner condyle of the femur is merely 
thrown into the external articular cartilage, so as to leave the 
the head of the tibia projected half way towards its fellow; 
and in the dislocation outwards, the outer condyle is thro%vn 
on the inner cartilage: in both these cases, according to 
Sir A. Cooper, the femur is somewhat twisted on the tibia, so 
that 
