CHAPTER XLIV. (Part 2)

adhesive above the patella to prevent upward displace- ment, and bandages about the upper part of the leg to force the fragment home are, as a rule, only partially successful. If there has been little or no upward displacement of the fragment non- operative measures will probably produce the desired result. Starting of the tubercle as an epiphysis is usually not attended by much displacement and the treatment will consist of fixation and rest until the loosened portion of the epiphysis has become firmly fixed again. In luxations of the head of the fibula, pads may be so placed, and held in position by straps of adhesive plaster, as to prevent recur- rence of deformity. The lower extremity should be immobilized for three or four weeks, and in backward luxations the condition should be treated with the knee semiflexed to relax the pull of the biceps. If these measures are not etfective in maintaining reduc- tion, or if evidences of nerve laceration are present, operation is indicated. Operation is also indicated in fractures of the fibular head with upward displacement of the fragment. Operative Treatment. — In cases of simple transverse fracture of the tibia below the knee, with good reduction, operative interven- tion offers nothing, but when the fracture enters the joint cavity it may become necessary to cut down on the fragments to restore the articular surfaces of the knee-joint to their normal relations. Cases in which the tuberosities cannot otherwise be brought back into proper relation, or in which recurrence of deformitv takes 630 FRACTURES AND DISLOCATIONS place, should be operated upon. If two longitudinal incisions are made, one on the inner and the other on the outer side of the joint, the fragments may be directly manipulated and reduction effected. If a solid engagement can be obtained between them, the incisions may be closed and splints applied. If a tendency toward the recurrence of deformity is manifest the fragments should be secured by some method of internal fixation. Non-absorbable materials should not be used if the fracture is compound. In a number of cases of T-fractures the author has found the following procedure satisfactory: two holes are drilled transversely through the tuberosities after they have been forced together, and a heavy silver wire is threaded through the holes and the ends tightly twisted together, thus maintaining the fragments in proper position and restoring the intra-articular surfaces .in their normal relations. This method is equally efficient in instances in which one of the condyles is broken off' and displaced. The principle is the same as that already described as ''transverse wiring" under the heading of '^Operative Treatment of the Lower End of the Femur." Nails, screws, and the Lane plate are at a discount in this region because of the internal structure of the upper end of the tibia which is composed of a loose cancellous tissue. Compound fractures of the upper end of the tibia should be treated according to the principles laid down under the heading of '"The Treatment of Compound Fractures" on page 789. Avulsion of the tibial tubercle with displacement of the frag- ment can seldom be reduced and maintained in proper position without operation. The fragment may be secured in place by means of a small nail or it may be sutured to the adjacent peri- osteum and surrounding soft tissues with absorbable suture material. Probably the best method in the adult, is to secure it to the shaft by means of a loop of silver wire. The scale of bone torn away may be too small to fix in this manner, or instead of an avulsion there may be a rupture of the patellar ligament, and when either of these conditions is encountered, the operation must consist of suturing of the soft tissues to properly anchor the ligament. When the tubercle is a\ailsed as an epiphysis it should not be sutured in position with anything except absorbable material. An occasion calling for open reduction of a complete separation of the upper tibial epiphysis almost never arises. In fractures or dislocations of the upper end of the fibula, the condition most often INJURIES JUST BELOW THE KNEE 631 rendering operation necessary, is injury to the peroneal nerve as it winds around the neck of the bone. When a portion of the fibular head has been displaced upward by the pull of the biceps, the fragment should be exposed, replaced and sutured in position. Non-operative methods of correcting this displacement are usually not successful. In dislocations of the head of the fibula the most prompt recovery and complete restoration of function follow open reduction, with fixation of the head in proper position against the external tibial tuberosity. This may be accomplished by suturing the soft tissues about the head or by means of a single loop of wire passed through the adjacent portion of the tuberosity. After-Treatment. — The first portion of the after-treatment will depend largely on the intensity of the traumatic reaction following the injury and whether or not the knee-joint is involved. When the reaction is severe it is often best to postpone manipulation of the parts until it has subsided. The lower extremity should be treated on a pillow-splint and the member elevated to favor circu- lation. The ice cap will aid materially in controlling the swelling. Undue constriction of the member should be avoided. With the subsidence of swelling, reduction should be accomplished by non- operative methods, if possible, or with operation if necessary. At the end of ten days or two weeks a permanent dressing should be applied. The plaster cast or plaster splints will be found quite satisfactory in this respect. If the plaster cast is used it should be split up the front before the plaster has set so that it may be removed during the after-treatment for inspection, massage and passive motion of the leg. Repeated adjustments will be found necessary during the after-treatment to keep the patient comfort- able. Frequent inspection of the leg is necessary to recognize and treat pressure points on the skin, should they develop. In the healthy adult union is to be expected in an uncomplicated case at the end of six weeks, but the callus at this time is too soft to with- stand any considerable strain. The full weight should not be borne on the leg for another month. Gratifying results have been obtained by use of the ambulatory pneumatic splint in simple frac- tures of this region. When this splint is employed it is often possible to begin the ambulatory treatment as soon as the acute swelling has subsided. In compound fractures of the upper end of the tibia recovery may be much delayed by the development of 632 FRACTURES AND DISLOCATIONS necrotic bone or arthritis of the knee. Persistent discharging sinuses call for operation to remove the dead bone. Early guarded passive motion will accomplish a great deal in the prevention of permanent adhesions within the joint cavity. Anesthesia and forcible passive motion may be indicated to break up organized adhesions within the knee. Even arthrotomy may be called for in instances in which the adhesions are unusually strong. Early passive motion is called for to restore the function of the knee but the greatest care should be exercised to avoid refracture during the time the callus is friable. If a firm grasp be taken of the upper end of the tibia, force may be applied with much less risk than is the case when the leg is moved by the- usual grip above the ankle. The lower the leg is grasped, in performing passive motion, the less the surgeon appreciates the leverage he is exerting against the upper end of the bone and the articulation. The dress- ing should be renewed from time to time to accommodate the changes which occur with the onset and subsidence of swelling. The older the patient the longer the time required for firm union to take place and the more imperfect recovery will be in the end. In avulsion of the tubercle of the tibia union may be expected within six weeks and the member may be actively used at the end of two and a half months. If the condition has been treated by non-operative methods the parts should be frequently inspected to see that the strappings are properly performing their function in holding the fragment in reduction. In separation of the upper tibial epiphysis the knee should be immobilized for a period of six weeks during the latter half of which time passive motion should be performed at intervals of four or five days. In dislocations of the upper end of the fibula retentive apparatus should be kept in place for about a month, provided the luxation has not been secured in position by operation and internal fixation. During this time undue strain should be avoided, especially activ- ities which involve forceful contraction of the flexors of the leg of which the biceps is one. Prognosis. — The prognosis of fractures of the upper end of the tibia is very variable according to the extent and severity of the lesion. Simple fractures not produced hy severe trauma are usually followed by complete restoration of function. On the other hand, a severe compound fracture entering the knee-joint may be INJURIES JUST BELOW THE KNEE 633 followed by infection of the knee-joint with septicemia and death. Restoration of function in severe cases is usually prolonged and seldom complete. The development of septic arthritis renders the fracture itself only of secondary importance. The prognosis fol- lowing operative cases is better than those treated by non-operative methods. Union often takes place with permanent thickening below the knee and the motion in the articulation is not infrequently restricted. The prognosis of avulsion of the tubercle of the tibia in the adult is good with proper treatment; when separated as an epiphysis the prognosis is equally good. The prognosis of fractures and dislocations of the upper end of the fibula is good, aside from the injuries sustained by the peroneal nerve. When the nerve is injured the outlook varies with the degree of the injury and the completeness of repair which is pos- sible at operation.