Part 44

19. M. Valentin, believing that position alone was sufficient to retain the fragments in contact, neglected the application of apparatus entirely, which he even considered as hurtful, in consequence of the swelling it produced; but experience soon proved the insufficiency of this method. The slightest movement, or the least effort on the part of the patient, made the extensor muscles contract, which, drawing the superior fragment upwards, separated it from the lower one; and, as the time of reunion is in direct proportion to the distance of the fragments from each other, it must, under such treatment, have been necessarily tedious, and sometimes must have even failed altogether.

20. As to a swelling being produced by the bandage, this never occurs, unless when some openings are left, through which the integuments protruding become tumefied: but, when the pressure is uniform throughout, when the fluids find throughout an equal resistance, this accident is not to be apprehended, as is proved by the practice of Desault, who never met with it; on the contrary, a bandage properly constructed and applied, is calculated to prevent swelling (16).

Mere position, then, though always of service in this affection, is not alone sufficient, because it fulfils only the first of the indications or principles laid down with respect to every form of apparatus for transverse fractures (18), namely, that which relates only to the lower fragment; while those that relate to the upper one, remain still to be fulfilled.

21. Most authors have employed, with a view to these, a kind of figure of 8 bandage, known in art by the name of Kiastre, and approved of by Petit, Heister, &c. This is made of a roller formed into two balls, which are brought across each other alternately under the ham, passing over two hollow or forked compresses, that enclose the two fragments of the rotula.

I know not of any English term equivalent to this. T.

But the unequal pressure which this makes on the unequally projecting parts of the knee, renders its application extremely painful, particularly below, where the pasteboard covering applied by Louis, immediately on the skin, afforded but a feeble protection to the tendons of the flexors. Besides, it did not prevent the swelling, which is indeed a necessary consequence both of this unequal pressure, and of the openings left between the casts of the bandage. This swelling is taken notice of by all writers, and is, according to them, one of the troublesome circumstances attending the fracture. The third indication is not all fulfilled (18).

22. The extensor muscles, not being at all compressed, will act with their whole force on the upper fragment, and, on the slightest effort of the patient, overcome the resistance of the bandage, the action of which, being oblique with respect to the fragment, is inconsiderable, unless it be drawn very tight, and thus a displacement will again occur. This obliquity of the turns of the roller obliges the surgeon, either to draw it very tight, in which case a swelling is inevitable, or to make it but moderately tight, and then the apparatus will be insufficient to resist the action of the muscles.

23. Most of the objections to the ancient apparatus for fractures of the rotula, apply also both to that proposed by Ravaton in his surgery, and to that which Bell employs in his practice. Both of these, while they fail in making sufficient resistance to muscular action, as well as in fulfilling the third condition laid down as necessary to every bandage (18), contribute to the swelling, and can rarely produce a perfect contact between the fragments. Thus Bell has well observed, that the reunion is rarely perfect, and that there is always a separation more or less perceptible.

24. The complication, the intricacy, the expense, and other more weighty inconveniences of the machine described by Garengeot in his treatise on instruments, and employed, for the first time, by Arnaud, and also of that which was proposed and used by Solingen, have, long since, entirely banished them from among the means of reduction.

25. Some practitioners have advised the uniting bandage used in cases of transverse wounds, which is formed, as is well known, of two small rollers or strips placed in the longitudinal direction of the limb, one of them having holes in it, to which the divisions of the other are fastened. Both of these are first secured by circular turns; being then drawn in opposite directions so as to meet, they draw the parts on which they are applied in the same directions. But the action of this bandage is confined to the integuments, and would have of course but a feeble influence on the fragments beneath. It is also attended with this further inconvenience, that by wrinkling the integuments, and throwing them into folds, it might press them down between the fragments, and thus prevent their contact. Besides, it is liable to most of the objections urged against the preceding one.

26. This view of the means employed by different practitioners, to counteract the causes of displacement in this fracture, are sufficient to convince us, that the difficulties hitherto experienced in the treatment of it, have arisen from the feebleness of the former, and the strength of the latter. So great indeed have been these difficulties, that some authors, conceiving a reunion impossible, have, in conformity to such an opinion, though contrary to all the rules and principles of the profession, advised us to abandon the patient to himself. But I have already exposed the fallacy of that opinion, respecting the want of a healing power in the rotula (12), an opinion which, if generally adopted, would give rise to consequences of the most serious nature. In the present case, as in all other fractures, the contact of the fragments ought to be the chief object of the surgeon’s efforts.

27. But ought this contact to be perfect and exact? Several authors, particularly Bell, have conceived, that the motions of the limb can be performed as well with a slight separation of the fragments. Pott even declares that such a separation will enable the patient, after his recovery, to walk with more ease. Flajani advances the same opinion in a dissertation on the subject.

From this doctrine arose a new mode of treatment, which consisted in not suffering the fragments to be at rest. They were accordingly, during the cure, put frequently in motion, the more effectually to prevent an anchylosis, which is sometimes the consequence of this fracture.

28. But, on the one hand, it is difficult to conceive, on what this opinion of these authors can be founded; while, on the other, reason declares, in the plainest and most forcible terms, that the more the state of a bone, after it has been broken, differs from its natural state, the less free will be the exercise of its functions, and, that the perfection of the treatment of fractures consists, in leaving behind it no vestige of the accident.

29. This truth was frequently confirmed in the experience of Desault, who had an opportunity of seeing numerous fractures of the rotula, both in the Hotel-Dieu, and in his private practice. He always observed, that, when the separation of the fragments was considerable, and the ligamento-cartilaginous substance uniting them was of some extent, standing and walking were performed with much difficulty; that the patient was exposed to frequent falls, from the want of a proper correspondence, in point of strength and motion, between the two limbs; and that, on the contrary, the less extensive the separation and the substance that filled it up were, the more free and easy were the motions of the part, which still remained, however, somewhat defective and imperfect, unless every vestige of the division was obliterated.

Paul of Egina long since observed, that, when no means of reduction were employed, though the patient might walk tolerably well on a level surface, he could not, without difficulty go up an ascent.

30. From what has been said, it follows, 1st, that in the treatment of this fracture, the perfect contact of the fragments ought to be the principal object of the practitioner; 2dly, that the kinds of apparatus employed by different authors, are but ill calculated for the attainment of this end, because they fulfil but imperfectly the indications formerly laid down (18). Let us see whether or not the apparatus of Desault be any better suited to this purpose.

31. The bandage, which he employed in this case, analogous to that for fractures of the olecranon, is composed, 1st, of one splint, two inches broad, and long enough to reach from the tuberosity of the ischium, to a little above the heel; 2dly, of two rollers, five or six yards long, and nearly three inches wide; 3dly, of another single roller, with two holes about the middle of it, a little longer than the injured limb of the patient, along the fore part of which it must be extended.

32. Every thing being arranged for the application of the apparatus,

1st, One assistant secures the pelvis, in the same manner as in fractures of the lower extremities; while another keeps the leg in a state of perfect extension on the thigh, and the thigh on the pelvis.

2dly, The surgeon, then, standing by the side of the fractured limb, extends along the anterior part of the leg and thigh the roller with holes in it, having previously wet it with vegeto-mineral water, taking care to make the two openings correspond to the lateral parts of the rotula, that, by being thus better adapted to its shape, it may not be thrown into wrinkles.

3dly, He then secures it on the top of the foot, by three circular casts of a roller placed one over the other, three or four inches above its lower end which must next be turned up over the three first casts, and made fast by two other ones. Then, while the compress roller is secured above by an assistant, he passes up along the leg by oblique and reverse turns, according to the inequalities of the limb.

The roller or strip with holes in it, which is extended along the fore part of the limb, serving, in some measure, the purpose of a compress. TRANS.

4thly, Having arrived at the lower part of the knee, he pushes the lower fragment upwards, and makes below it two or three circular turns to secure it. He then gives the roller into the hands of an assistant, and directing him who holds the long compress roller, to draw it forcibly upwards, pushes the integuments of the knee in the same direction, lest, by becoming interposed between the fragments, they might prove an obstacle to their reunion. Passing then the fingers of his left hand through the holes in the compress-roller he places them behind the superior fragment and pushes it forcibly downwards.

5thly, When the reunion of the fragments is exact, without any space intervening, he resumes the roller, and passing it obliquely under the ham, and bringing it up again behind the superior fragment, withdraws his fingers which held this fragment down. In place of his fingers, he then applies two or three tight circular casts, covers the knee with several oblique casts in form of the figure of 8, so as to leave no opening between them, and, then, continues the bandage up along the thigh, securing by it the compress-roller extended along the fore part of the limb.

6thly, When he has arrived at the upper part of the limb, the assistant who holds the compress-roller, drawing it forcibly upwards, doubles down its end over the circular casts. The surgeon next fixing this end by several additional casts, descends again along the thigh, covers the knee by a few more oblique turns, and finishes with the roller on the leg.

33. This first part of the bandage evidently fulfils the third and fourth indications (18). The compression of the roller on the muscles weakening their action and impeding their motions prevents their tendency to draw the superior fragment upwards: while the circular casts passed behind this fragment, acting in opposition to the muscular contractions, prevents it from moving upwards in obedience to them. The long compress-roller, stretched on the fore part of the limb, being first secured below, and then drawn forcibly upwards, presses the casts of the roller against each other, and prevents those that correspond to the thigh from slipping upwards, and thus abandoning the superior fragment, and prevents also those on the leg from slipping down and withdrawing their support from the inferior fragment. As there remains no vacant space between the circular turns, their pressure is uniform throughout: no swelling can consequently supervene (20).

34. But the first and second indications remain still to be fulfilled (18): it is necessary to prevent the separation of the lower fragment, by the extension of the leg on the thigh, and to throw the muscles into a state of relaxation by extending the thigh on the pelvis, and to maintain permanently, by the apparatus, that double position, which the assistant maintains only during the operation.