15. I have already observed (7), that the causes of the separation of
the fragments are, as far as respects the upper one, the contraction of
the extensor muscles; and, in relation to the lower one, the flexion
of the leg; whence it follows, that the means of preserving contact
between these fragments are 1st, all those that are calculated for the
prevention of muscular action; 2dly, such as may keep the limb in a
state of permanent extension. Hence two leading curative indications
must be fulfilled by the bandage constructed for fractures of the
rotula: the last of these indications presents in general but little
difficulty; but, with regard to the other, the case is different. To
fulfil the latter, it is necessary first, to weaken the contractile
force of the muscles, and by that means diminish the effort which they
make to draw the superior fragment upwards; and then, to oppose to
them a proper mechanical resistance, which, by acting in a direction
the very reverse of that in which they act, may countervail their
efforts.
16. But the force of contraction is diminished, 1st, by throwing the
muscular fibres into a state of relaxation; this end is best attained
by bending the thigh on the pelvis: 2dly, by making compression over
the whole limb, by means of a circular bandage, which, by confining the
muscles, tends to restrain and weaken their action. Thus it is known
that the advantage of the bandage employed to unite transverse wounds,
consists chiefly in that compression which, by diminishing muscular
action, prevents the retraction of their edges. Another advantage
resulting from the bandage in this case is, that it prevents the
swelling of the limb.
17. As to the mechanical resistance, which must act in a direction
opposite to that of the contraction of the muscles, and, by that means,
prevent the displacement of the superior fragment, it cannot, in the
present case, be of the same nature as in fractures of the thigh, the
clavicle, &c. where permanent extension is practised. The superior
fragment offers too small a purchase for any extending forces to act
on. This resistance must be made, then, by placing some body above this
fragment, and retaining it in that situation with a force sufficient
to hinder the fragment from rising upwards: such as a few turns of a
roller drawn tight, a bit of leather, some hollow compresses, &c.
18. It is evident from the foregoing principles, that every bandage
intended to retain a transverse fracture of the rotula, ought to
be calculated to maintain the following state of things: 1st, the
extension of the leg on the thigh; 2dly, the flexion of the thigh on
the pelvis; 3dly, a uniform compression over the whole limb; and,
4thly, some mechanical resistance properly secured above the superior
fragment: the three last expedients relate to the displacement of that
fragment alone; while the first has a relation to that of the lower
one. Let us examine whether or not the bandages, hitherto employed by
different authors, be calculated for these purposes.
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_,[32] 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.
[32] 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.