Manual of Surgery Volume II Part 16

In many fractures of the thigh, and especially in those produced by indirect violence, the knee is sprained, and there is a considerable effusion into the joint, and this may lead to stiffness unless ma.s.sage is employed from the outset.

_Treatment._--Fracture of the shaft of the femur is one of the most difficult fractures in the body to treat successfully. In cases of oblique fracture, the patient should be warned that shortening to the extent of from 3/4 to 1 inch is liable to result, however carefully the treatment may be carried out. This does not necessarily imply a permanent limp, as by tilting the pelvis he may be enabled to walk quite well; if this is not sufficient to equalise the length of the limbs, the sole of the boot may be raised. A general anaesthetic is necessary to ensure accurate reduction, and extension must be applied to maintain the fragments in apposition and prevent shortening. The splint which has been found most generally useful is the Thomas' knee splint, the ring of which rests against the ischial tuberosity. To admit of flexion at the knee the Thomas' splint should have a hinged attachment on which the leg is supported. This leaves the knee free and allows of movement being made to prevent stiffness. The limb is suspended by broad strips of flannel or linen, fixed to the side bars of the splint by means of safety pins or strong spring paper clips.

In simple fractures extension may be obtained by means of broad strips of adhesive plaster applied to each side of the thigh and reaching well above its middle. The plaster is secured by a bandage, and to its lower ends are attached broad tapes which are buckled to a stirrup through which traction is made by means of a cord pa.s.sing over a pulley fixed to an upright at the foot of the bed.

The lower end of the splint is suspended, and the counter-extension is obtained by pressing the ring against the ischial tuberosity. To prevent the ring overriding the tuberosity and pressing on the soft tissues of the b.u.t.tock, it is slung by the rope to a cross-bar above the bed, _e.g._ the Balkan frame (Fig. 81).

In compound fractures the presence of a wound may prevent adhesive plaster being used, and it is necessary to take the extension directly through the bone. A posterior gutter splint is applied to prevent sagging. After pulling the skin upward, a small incision is made over the upper expanded border of each condyle, and the points of an ice-tong calliper are made to grip the bone without penetrating into the cancellous tissue. A cord attached to the handles of the calliper pa.s.ses over a pulley and supports the weight necessary to give the desired amount of traction (Fig. 81).

An alternative method of exerting traction directly through the bone is by means of Steinmann's apparatus (Fig. 76). In a moderately muscular adult, a weight of from 12 to 15 pounds by means of strips of plaster applied to the skin, or 10 to 25 pounds by direct traction on the bone, should be applied in the first instance. The correct weight to employ is that which maintains the length of the limb at its normal, and is therefore liable to revision from time to time.

[Ill.u.s.tration: FIG. 76.--Radiogram of Steinmann's Apparatus applied for Direct Extension to the Femur.]

_Hodgen's splint_ is a comfortable and efficient means of treating these fractures, as it allows the patient a certain amount of movement, admits of the part being ma.s.saged, and facilitates nursing.

It consists of a wire frame (Fig. 77) to one side of which a series of strips of flannel about 4 inches wide are attached. Extension strapping is first applied, and then the frame, which extends from the level of Poupart's ligament to well beyond the sole, is placed over the front of the limb, and the loose ends of the flannel strips brought round behind the limb, and fixed to the other side of the frame, convert it into a sling. The tapes attached to the extension strapping are now tied to the end of the frame. By suspending the limb in this splint by means of cords pa.s.sing obliquely over a pulley attached to an upright at the foot of the bed, the weight of the limb is made to act as the extending force.

[Ill.u.s.tration: FIG. 77.--Hodgen's Splint.]

The retentive apparatus should be worn for from six to eight weeks, after which the patient is allowed up with crutches, which he usually requires to use for three or four weeks longer, before he can bear his weight upon the limb. The old dictum of Nelaton, that the treatment of fracture of the thigh should last for a hundred days, is a safe working-rule. In fractures of the shaft an ordinary Thomas' knee splint, or a "walking calliper splint" which is fixed to the heel of the boot, may be worn when the patient gets up.

Union may be exceedingly slow in fracture of the femur, and may even be delayed for months. Mal-union sometimes occurs, the fracture uniting with an angular deformity outward and forward.

Re-fracture is liable to occur if the patient falls or twists the limb within a few months of the original injury. It has happened not infrequently just after the retentive apparatus has been removed from the nurse raising the limb by the foot in order to wash it.

_Liston's long splint_ is only employed as a temporary expedient for immobilising the fragments during transport; a Thomas' splint, if available, is better for this purpose.

[Ill.u.s.tration: FIG. 78.--Long Splint with Perineal Band.]

_Operative treatment_ is sometimes called for when simpler measures fail to reduce the displacement, and in cases of un-united fracture or of vicious union. The incision, which must be free, is preferably placed in the line of the lateral intermuscular septum; the periosteum is interfered with as little as possible. The application of extension by the calliper method is often of great service, during the operation, in enabling the operator to get the fragments into position; sometimes no fixation is required, but, if necessary, recourse is had to plating or pegging, or an intra-medullary pin. The extension apparatus is retained for three or four weeks. The after-treatment is carried out on the same lines as for simple fracture, but the retentive apparatus must be worn for a considerably longer period.

[Ill.u.s.tration: FIG. 79.--Fracture of Thigh treated by Vertical Extension.]

#Fracture of the Femur in Children.#--In children, especially below the age of ten, this fracture is quite common. It is often of the greenstick variety, or, if complete, is transverse and sub-periosteal, and as it is accompanied by few symptoms and but little deformity, is liable to be overlooked.

When there is displacement, the deformity is similar to that in adults, and the treatment is carried out on the same lines.

In young children the nursing is greatly facilitated by applying vertical extension to one or both lower extremities (Fig. 79). If the fracture is transverse and shows little tendency to displacement, the local Gooch splints may be dispensed with; in any case, ma.s.sage should be employed from the first.

The patient may be allowed out of bed in from three to four weeks, wearing a retentive apparatus.

The shaft of the femur is sometimes fractured _during delivery_, particularly in breech cases. The simplest and most efficient means of controlling the fracture is by extension strapping fixed to the lower end of a Thomas' knee splint.

CHAPTER VII

INJURIES IN THE REGION OF THE KNEE AND LEG

_Surgical Anatomy_--FRACTURE OF LOWER END OF FEMUR: _Supra-condylar_; _T- or Y-shaped_; _Separation of epiphysis_; _Either condyle_--FRACTURE OF UPPER END OF TIBIA: _Of head_; _Separation of epiphysis_; _Avulsion of tubercle_--DISLOCATIONS OF KNEE: _Dislocations of superior tibio-fibular joint_--INTERNAL DERANGEMENTS OF KNEE--INJURIES OF PATELLA: _Fractures_; _Dislocations_--INJURIES OF LEG: _Fracture of both bones_; _Fracture of tibia alone_; _Fracture of fibula alone_.

INJURIES IN THE REGION OF THE KNEE

These include the supra-condylar fracture of the femur, the T- or Y-shaped fracture opening into the joint, separation of the lower femoral epiphysis; fracture of the head of the tibia, and separation of its upper epiphysis; the various sprains and dislocations of the knee, as well as its internal derangements; and fractures and dislocations of the patella.

#Surgical Anatomy.#--Of the two epicondyles the medial is the more prominent and palpable. The adductor tubercle, which is situated on the upper and back part of the medial epicondyle, gives attachment to the round tendon of the adductor magnus, and marks the level of the epiphysial line and of the upper limit of the trochlear surface of the femur. Between the medial condyle of the femur and the medial condyle (tuberosity) of the tibia, when the limb is in the flexed position, the line of the joint can be recognised as a groove or cleft, and this is made use of in measuring the length of the tibia. The lateral condyle (tuberosity) of the tibia can also be palpated, and must not be mistaken for the head of the fibula, which lies farther back and at a slightly lower level, and can readily be identified by tracing to it the tendon of the biceps. The tuberosity of the tibia, into which the quadriceps extensor tendon is inserted, lies on the same level as the head of the fibula. In the extended position of the limb, the patella is loose and movable on the front of the trochlear surface of the femur, while in the flexed position it sinks between the condyles, resting chiefly on the lateral one and becoming fixed.

The popliteal artery and vein and the tibial (internal popliteal) nerve lie in close relation to the posterior aspect of the joint; and the common peroneal (external popliteal) nerve pa.s.ses behind and to the medial side of the biceps tendon.

The knee is an example of a joint which depends for its strength chiefly on its ligaments. Not only are the tibial and fibular collateral (external and internal lateral) ligaments and the posterior part of the capsular ligament particularly strong, but the cruciate ligaments and the menisci (semilunar cartilages) inside the cavity of the joint further add to its stability. The powerful tendon of the quadriceps extensor muscle, in which the patella is developed as a sesamoid bone, protects and strengthens the front of the joint and functionates as the anterior ligament of the joint. In the att.i.tude of complete extension in which the joint is locked, no demand is made on the quadriceps apparatus; with the commencement of flexion, the stability of the joint, and the weight-bearing capacity of the limb as a whole, depend largely on the controlling influence of the quadriceps muscle; this becomes evident on going down an incline and more markedly on going down stairs. Hence it is, that in recurrent sprains of the knee, including under this term the various forms of internal derangement of the joint, the wasting with loss of tone of the quadriceps is an important factor in aggravating the disability of the limb and in r.e.t.a.r.ding and preventing recovery. In the treatment of recurrent sprains of the knee, therefore, special attention must be directed towards the wasting of the quadriceps by means of ma.s.sage and appropriate exercises.

The synovial cavity extends from the level of the head of the tibia to an inch or more above the trochlear surface of the femur, pa.s.sing slightly higher on the medial aspect of the joint than on the lateral (Fig. 80). The large bursa between the quadriceps muscle and the femur (_sub-crural bursa_) generally communicates with the cavity of the joint. The synovial cavity of the superior tibio-fibular articulation is usually distinct from that of the knee-joint, but may communicate with it through the popliteal bursa.

[Ill.u.s.tration: FIG. 80.--Section of Knee-joint showing extent of Synovial Cavity.

_a_, Pre-patellar bursa.

_b_, Infra-patellar bursa.

_c_, Ligamentum mucosum.

_d_, Ligamentum patellae.

_e_, Posterior cruciate ligament.

_f_, Medial semilunar meniscus.

(After Braune.)]

A large bursa (_pre-patellar_) lies over the lower part of the patella and upper part of the ligamentum patellae; and a smaller one separates the ligamentum patellae from the tuberosity of the tibia. Several important bursae are found in the popliteal s.p.a.ce, one of which--the semi-membranosus bursa--sometimes communicates with the knee-joint.

FRACTURE OF THE LOWER END OF THE FEMUR

Fractures involving the lower end of the femur, especially the supra-condylar and T-shaped fractures, are to be looked upon as serious injuries, on account of the difficulties attending their treatment, and the risk of damage to the popliteal vessels and of impairment of the usefulness of the knee-joint.

#Supra-condylar# fracture is usually the result of a fall on the feet or knees, or of direct violence, and is most common in adult males.

The line of fracture is generally irregularly transverse, or it may be slightly oblique from above downwards and forwards, so that the proximal fragment pa.s.ses forward towards the patella, while the distal is rotated backward on its transverse axis by the gastrocnemius muscle.

_Clinical features._--Soon after the accident a copious effusion of blood and synovia takes place into the cavity of the knee-joint, adding to the swelling caused by the displaced bones, and rendering it difficult to recognise the precise nature of the lesion. As it is important to make an accurate diagnosis, the X-rays should be employed if possible, and a general anaesthetic should be given when necessary.

The proximal end of the distal fragment is usually palpable in the popliteal s.p.a.ce, while the proximal fragment is unduly prominent in front. By flexing the knee the fragments may be brought into apposition and crepitus elicited. In oblique fractures, the pointed lower end of the proximal fragment may transfix the quadriceps extensor muscle and may be felt under the skin, or it may perforate the skin and thus render the fracture compound. It should be disengaged by fully flexing and making traction on the knee. The thigh is shortened to the extent of from 1/2 to 1 inch.

The popliteal vessels lie so close to the bone that they are liable to be torn by the displaced distal fragment, giving rise to the usual signs of ruptured artery. Sometimes, owing to the feeble state of the circulation from shock, the bleeding does not take place at the time of the accident, but ensues some hours later. The vessels may merely be pressed upon by the displaced bone, but the nutrition of the limb beyond is endangered and gangrene may ensue if early reduction be not effected.

_Treatment._--The small size of the distal fragment, its depth from the surface, and the accompanying effusion into and around the joint, render its control difficult. In the majority of cases the two fragments can only be brought into apposition when the knee is flexed on the thigh and the thigh on the pelvis, and it is almost always necessary to carry out the reduction under anaesthesia.

In the few cases in which the fragments can be accurately approximated in the extended position of the limb, retention may be effected by means of a box splint reaching well up the thigh (p. 180).

In the majority, however, flexion is necessary, and a Thomas' knee splint with flexion attachment bent to an angle of 30 (Fig. 81) and extension by means of ice-tong callipers secures the best apposition.