CHAPTER XLI. (Part 2)

accident. Note silver wire which crosses line of fracture twice but does not enter joint. Accident in 1905; wire in place at the present time. Fig. 667. — Wired fracture of the patella two years following accident. Patient failed to follow instructions, got out of bed and walked about shortly after operation with the result that the wire was broken. It held, however, sufficiently well to secure a functionally perfect result. This case demonstrates the advisability of using heavy wire which is as well tolerated by the tissues as lighter material. Compare this case with the one shown in Figs. 665 and note the size of the wire. fractured surfaces are opposite the corresponding openings of the holes on the other fragment. A heavy silver wire is then threaded through these holes so that the two ends are above the line of frac- ture (see Fig. 662). The fragments are then drawn together until they are in firm apposition and then the ends of the wire are twisted together, cut off, and turned in toward the bone. This mattress suture will securely hold the fragments in simple transverse 604 FRACTURES AND DISLOCATIONS fracture of the patella and in addition may be made to work well when three fragments are present instead of two. In the presence of comminution it may be impossible to make the mattress suture hold because of the breaking up of the compact tissue, and when such is the case a circular wire surrounding the comminuted bone may serve the purpose. A specially formed Lane plate has been devised to be used on the patella but the nature of the bone and the difficulty of making the screws hold, results in wire being the material of choice in the open treatment of this fracture. When the wire is placed there should be no motion in the fragments nor in the wire: in other words the fixation should be as secure as possible, to obtain the best results. ' The knee should be flexed and extended before the wound is closed to see that the action of the joint does not disturb the fixation. The skin incision is then closed and a few strands of silk-worm are left in the lower angle of the wound to allow the escape of fluids following operation. If the vertical incision is employed directly over the fracture, a subcutaneous running suture should be so placed that it will bring as much of the soft tissues between the fracture and the skin as possible. Fracture of the patella is sometimes compound from the first, with the joint exposed and infected at the time of the accident. When such is the case, the condition of greatest importance is in- fection of the knee-joint. This is a serious matter and if not prop- erly controlled may necessitate amputation, or may even result in death from a general sepsis. The opening of the joint should be increased in size if not already sufficiently large, and the edges of the wound should be trimmed away until all traces of crushed and devitalized tissue are removed. The joint should then be irrigated with a few gallons of warm physiologic salt solution. In irrigat- ing the wound a soft rubber catheter should be used, and carried to the innermost recesses of the articulation so that the flow will be directed from the interior of the joint to the surface. After the articulation has been thoroughl}^ washed out, the soft tissue should be accurately approximated and the joint closed as tightly as pos- sible with the idea of preventing subsequent leakage. The cavity of the knee is then injected with Murphy's Formalin Glycerine solution, the patient put to bed, the lower extremity elevated. Buck's extension applied and an ice cap kept on the knee. Sub- sequent injections of the formalin glycerine solution are made FRACTURES OF THE PATELLA 605 according to the amount of leakage through the incision and the reaction occurring in the articulation. This method of treating infected joints, devised by IMurphy, is productive of such vastly better results that no other form of treatment should be considered until after this has been tried. If suppuration of the joint can be avoided in this way, suturing the patella may be done at the end of two or two and a half weeks Avhen the dangers of articular infection have passed. Suturing of the patella immediately following the accident should not be done in compound cases. The joint infection should be treated first and the fracture reduced in a secondary operation. If infection of the joint cannot be controlled by the initial irriga- tion and subsequent injection, it should be opened and freely drained, and under such circumstances approximation of the patella will be of little importance, since ankylosis of the knee-joint will, in all probability, be the result. If the accident occurs in a region of the country in which tetanus prevails, the patient should receive a prophylactic dose of anti-tetanic serum. AYhen operation is done for the secondary separation which sometimes follows fibrous union the method of procedure is similar to that already described. The fibrous tissue between the frag- ments should be excised and the fractured surfaces freshened and approximated. It may occasionally be necessary to lengthen the quadriceps above the patella to bring the fragments together. When the patella is attached to the trochlear surface by -adhesions it may be possible to free it by forced passive motion under anes- thesia. If the adhesions are too firm to be broken up in this man- ner it may be necessary to open the joint and divide them with the scalpel. If the adhesions are extensive and show a tendency to reform, a transplanted layer of fascia lata may be sutured in position to cover the articular surface of the patella. Early passive motion, repeated at regular intervals, will then, as a rule, result in a freely movable patella and good articular function. After-Treatment. — The length of the after-treatment will vary according to whether or not the open method has been employed. If expectant treatment has been followed immobilization of the knee is required for from six weeks to two months, after which guarded passive motion is indicated. During the use of the splint the dressings should be carefully watched and tightened to keep them in proper position. The diagonal straps which tend to pull 606 FRACTURES AND DISLOCxVTIONS the fragments together are likety to become lax, especially as the joint distention subsides. During the first two or three weeks, pads should be kept on either side of the quadriceps and firmly bandaged in position to prevent contraction of this muscle. During the stage of articular inflammation the local application of the ice-cap will be found of service in controlling the reaction. The lower extremity should be elevated on an inclined plane to favor the cir- culation of the parts and relax the extensor thigh muscles. Accu- rate approximation of the fragments is practically impossible in the non-operative treatment, as previously stated, and during the Fig. 668. — Method of performing passive motion in the treatment of fracture of the patella. The left hand bears down on the ankle thus flexing the knee Avhile the right hand pushes downward on the patella to relieve the fracture of the pull of the quad- riceps. time the joint is distended it will be useless to even attempt dimin- ishing the degree of separation; when the fluid has left the joint the distance between them may be somewhat decreased by the proper application of straps. At the end of two months the splint may be discarded and the patient allowed to get about on crutches with some more convenient form of joint immobilization. A cast of the leg may be made, split up the front before thoroughly dried and removed. After the plaster is set the cast may be covered with some durable material and strips of leather with hooks, applied to the edges on either side of the opening. In this way the cast may FRACTURES OF THE PATELLA 607 be removed at night for the purpose of massage and motion of the joint. During the day it is worn and when snugly laced immo- bilizes the knee and protects the patella from strain. Motion of the knee involving strain, such as walking without splint or cast, should be prohibited inside of from six to eight months. Excep- tional muscular strain should be avoided for a year. If fibrous union is heavy and short, the time may be considerably shortened. If it is weak and shows a tendency to stretch, the period of fixation and protection of the knee should be increased. The period of disability following the open treatment is strik- ingly shorter than that just described. The limb should be kept on a posterior splint as described in the after-treatment of un- operated cases. The dressings should be removed at the end of two weeks from the time of operation, and passive motion insti- tuted, provided the internal fixation was properly and securely accomplished at the time the joint was opened. The manner of performing passive motion is of considerable im- portance: the knee may be so flexed that the entire strain of the thigh muscles is thrown on the patella, or it may be so accomplished that the fracture is entirely relieved of the pull of the quadriceps. "When the knee-joint has been fixed for a period of two or three weeks and the joint has suffered the inflammatory reaction incident to traumatic arthritis, it will be impossible to accomplish passive motion without producing spasm in the quadriceps, and it is this spasm which should be guarded against. If the surgeon places the lower extremity across his knee while one hand grasps the ankle and the opposite index finger and thumb are pressed into the thigh just above the upper border of the patella, he will be in a position to perform passive motion and still protect the patella from the spasmodic action of the quadriceps (see Fig. 668). As the ankle is depressed, thus flexing the knee, the opposite hand forces the patella downward towards the knee and takes up the strain of the contracting extensors of the thigh. This is the only way in which early passive motion can be perform.ed without risk. Slight, snapping sensations are sometimes felt by the hand which forces the patella downward, but there is no cause for alarm since they are produced by the breaking up of adhesions in the joint which at this time are too imperfectly organized to act as serious obstacles to motion. At the end of eight or ten weeks, the patient is allowed to get 608 FRACTURES AND DISLOCATIONS about without any fixation apparatus. It is well for him to carry a cane, and favor the injured knee for another two or three weeks, and he should be especially cautioned against unusual and excessive strains until four or five months have elapsed from the time of the injury. It is well to have another X-ray taken at the end of three months to determine the presence of bony union. The heavier the union, the less caution is necessary. Prognosis. — The restoration of function following fracture of the patella is a variable quantity. Fibrous union, even to the extent of two or three inches, does not necessarily indicate that the pa- tient may not enjoy most excellent function. On the other hand, accurate reduction and firm union does not necessarily indicate that the knee will be restored to its original usefulness. The percentage of functionally perfect results, however, is much higher in cases in which bony union is present. In the ordinary fractured patella we can hardly expect complete restoration of function with any form of non-operative treatment. The power of extension is likely to be decreased, and the action of the joint impaired, although it is not uncommon to find complete flexion possible. "When fibrous union occurs, it will be impossible to state whether this union will be heavy, strong and efficient, or, on the other hand, thin, weak and permitting of subsequent separation of the fragments. Weak- ness and painful joint are common sequelse. The results following the open treatment are vastly better, pro- vided the three requisites previously mentioned, are observed, namely : avoidance of infection, secure internal fixation of the frag- ments and early and persistent passive motion. Under such cir- cumstances the usual result is complete and permanent restoration of function, together with absence of pain in the articulation.