Part 40

121. But whatever may be the precise form and figure of the fracture, its signs are easily comprehended: a very perceptible separation oftentimes exists between the two condyls, increasing the transverse diameter of the knee. The rotula, sinking into this chasm between the condyls, renders the part more flat from before backwards, than it is in its natural state. If the rotula be pressed in a backward direction, the condyls are separated still further from each other. If, on the other hand, pressure be made on each side of the lower part of the os femoris, the condyls are brought together, and the knee resumes its usual shape. If we take hold of a condyl in each hand, it will be easy, by moving them alternately backward and forward, to make them rub against each other, and produce a crepitation which characterizes the fracture beyond a doubt.

122. If the upper fracture be oblique, a shortening of the limb more or less perceptible is always the effect of it: this appears to be principally owing to the weight of the body which pushes the upper fragment down, and to the action of the muscles which draws the lower ones up (10 ... 14). In this case, the superior fragment, being forcibly pushed against the integuments, has sometimes lacerated, and even passed through them, giving rise to consequences of a serious nature. Desault has published a case of this kind. A similar effect has been produced, though more rarely, by the inferior fragment, in which case much mischief has arisen from the admission of air into the joint.

123. Sometimes when the upper fracture extends through the whole thickness of the os femoris, the extremity of the bone is turned round, so that the external condyl lies behind, the internal before, and the rotula on the outside, while the foot points in the same direction. A case of this kind is recorded in the Journal of Surgery. The body of the bone, being pressed into the chasm or interval between the two condyls, may prevent their reunion, by pushing them asunder, and thus give rise to various accidents.

124. Most of these phenomena will fail to occur, if the upper division, passing only half way through the bone, break off but one of the condyls, or if, passing through even the whole of the bone, it be perfectly transverse; but cases of this description are seldom met with.

§ XX.

OF THE PROGNOSIS.

125. I have little to add to the observations already made on the prognosis in fractures of the condyls of the os humeri. All that I have there said is applicable to the os femoris. As is the case with regard to the former fractures, so also here, the apprehensions of authors have been greatly exaggerated by their visionary doctrine respecting injuries of the joints: both reason and experience unite in showing such apprehensions to be unfounded.

I shall only observe, that in the present case, even more particularly than in fractures of the condyls of the os humeri, most of the unfortunate events that take place, are owing to the insufficiency of the means employed for effecting a cure. Indeed, as I have already observed (45), all those means can have no effect in opposing the continual tendency of the fragments to become displaced, if the upper fracture of the os femoris be oblique. And in most cases, this fracture is oblique: hence it follows, 1st, that the bony points of the fragments being constantly pushed, during their displacement, against the ligaments that surround the joint, will perpetuate in them the irritation first produced by the fracture, and thus give rise to swelling, inflammation, and all the other morbid affections of the part, so much dreaded by authors, and attributed by them to the mere communication of the fracture with the joint: 2dly, that the best expedient to prevent such affections, is an apparatus that shall retain the divided surfaces in perfect contact with each other by means of permanent extension.

That which forms the superior boundary of the longitudinal fracture by which the condyls are separated from each other. TRANS.

126. It is obvious that this extension will be less necessary, if the upper division of the os femoris be transverse, because, then, the condyls and the body of the bone will find a mutual point of support against each other.

§ XXI.

OF THE MEANS OF CONTACT BETWEEN THE FRAGMENTS.

127. Since the same causes, as in the preceding cases, tend here to destroy this contact, when the superior fracture is oblique (122), the apparatus ought, therefore, to be so constructed as to counteract these causes, that is, it ought, 1st, to draw the two condyls down; 2dly, to retain the pelvis up, and with it the superior fragment. This twofold indication relates only to the upper division of the bone, without any reference to that which separates the condyls; 3dly, it is necessary to counteract the tendency which the condyls may have to separate from each other.

128. Permanent extension, made in the manner already mentioned (60 ... 63), fulfils the two first indications; while two lateral splints, and the bandage of strips fulfils the third. Desault, therefore, applied to this particular case his apparatus for permanent extension, modified only in such a way, that, instead of terminating at the knee, the bandage of strips was continued to a distance down the leg, in order that its action might be the more efficacious. For, it is well known, that it is at its middle part that the firmness and retentive power of a bandage are greatest, because the casts of the roller at the upper and lower ends, serve to secure those in the middle. The upper splint being altogether useless, was not employed.

129. If the superior fracture be transverse, the condyls, as I have already said, meet with resistance against the body of the bone, while they, on the other hand, support it in such a manner, as to prevent it from descending, though pushed by the weight of the body along the inclined plain made by the pressure of the nates. Here, then, permanent extension is generally useless, and all that is necessary is, to retain the condyls and prevent their separation by means of lateral pressure. The same apparatus may still be employed, provided the two rollers for extension be laid aside.

130. If a wound in the soft parts accompany the fracture, whether it be produced by the same cause, or by the subsequent passage of the fragments through the integuments, and whether it communicate with the articulation or not, it is necessary, as soon as suppuration has taken place, to renew the dressings every day or every other day, taking care, in the mean time, to supply, by the hands of an assistant, the want of extension by means of the apparatus. The following case, extracted from the Journal, exhibits a specimen of the treatment that ought to be adopted in similar cases.

CASE XI. Claudius Legrange, aged thirty-one, and of a sound constitution, was wounded by the kick of a horse, on the internal condyl of the left os femoris. The violence of the pain obliged him to throw himself on a heap of straw, that lay at a little distance, and which he reached by hopping on his right foot. The pains were augmented by this, for at each step, the thigh being alternately bent or extended at the injured part, was moved sometimes backward and sometimes forward. The patient was brought to the Hotel-Dieu, a few hours after the accident.

The signs already specified (121 and 122) announced to Desault, a longitudinal fracture separating the two condyls, and terminated above by another fracture of the body of the bone, which descended obliquely from about five inches above the external condyl, to within two inches of the internal one.

The muscles of the thigh, by means of violent contraction, had drawn that portion of the os femoris attached to the external condyl upwards, and the superior fragment downwards. The sharp point of the latter had passed through the skin, and produced a wound of an inch and a half in extent, on the inside of the thigh, and a little above the condyl.

The patient being undressed, was placed on a bed nearly horizontal, on which had been previously spread the necessary pieces of apparatus, disposed in proper order. Desault then examined the wound, extracted a splinter of the bone, covered the wound with lint, and then proceeded to the application of the apparatus which he usually employed in such cases (128).

The extension was accompanied by no pain: on the other hand, it gave immediate relief: diluting drinks were prescribed. Next day, no pain; pulse a little raised; no dryness, nor any alteration of the skin; diet the same as on the preceding day; the apparatus wet with vegeto-mineral water. Fourth day, a new application of the apparatus, which had become relaxed; appearances of suppuration.

From this time the dressing was renewed every other day, till the sixteenth, when the wound was cicatrized. After this the apparatus was not touched except when deranged; it was only wet from time to time with vegeto-mineral water, and great pains were taken to keep up the extension. The apparatus was not laid aside till the sixty-fourth day, although the callus appeared to have acquired a state of solidity somewhat sooner.

The patient was soon in a situation to take exercise. The stiffness then disappeared rapidly, and, in about three weeks, he left the hospital, able to bend the leg to a right angle with the thigh, and under a full confidence that he would in a short time regain all the motions of the limb.

§ XXII.

OF THE SUBSEQUENT TREATMENT.

131. As soon as the consolidation is complete, the motions of the limb must commence. These, at first gentle and confined, must be afterwards, increased in extent, and more frequently repeated, till, at length, the limb should be exercised every day for two or three hours without intermission. The position and direction of the leg ought to be constantly changed. One while, the thigh should be elevated by a bolster, so as to flex the leg; at another time, the bolster should be fixed under the leg to keep it extended. The rotula must be moved in every direction, and, as soon as the patient can leave his bed, he should take exercise himself. These precautions are more necessary here than in any other fracture, because a stiffness of the parts adjacent to the joint, is always the inevitable consequence of a long state of rest. Certainly writers would not have considered anchylosis as the most favourable termination of such fractures, had they been acquainted with the effect of exercise and rest in that now under consideration.

132. Provided the mode of treatment here laid down be faithfully pursued, the affection is seldom accompanied by those numerous accidents, of which so much has been said. The callus is formed in the usual manner: and, on some occasions, where the patients have died at the Hotel-Dieu, in consequence of some affection not connected with the fracture, the two condyls have been found perfectly united together and to the body of the bone. An instance of this kind is recorded in the Journal of Surgery.

133. Let us, in the mean time, not speak too favourably of that, respecting which the ancients were accustomed to speak too unfavourably. Even the practice of Desault would expose our error. Sometimes the most assiduous attention, and the most careful application of the apparatus, have not been sufficient to prevent abscesses around the knee, and an anchylosis of the joint. Desault related a case where even a caries of the articulating surfaces occurred. But some extraneous circumstances appeared to have an influence in these instances: and it may be laid down as a general rule, that fractures of the lower extremity of the os femoris, require the same treatment with fractures of its other parts.