A STUDYOF

TRANSVERSE FRACTURE pF the PATELLA,BY

H. Augustus Wtusdn. M. D..Lecturer on Fracture Dressings and Microscopical Anatomy in the Philadelphia School of A natomy.

Ophthalmic and Aural Surgeon to St. Mary's Hospital, Philadelphia.

Transverse fracture of the patellawould seem to be of comparativelymodern recognition for Hippocrates,Celsus and Galen are absolutely silentupon the subject, Sorannus being thefirst to give a description of it. Whetherthe occurrence of fracture of the pa-tella at the present day is owing toadvance in civilization or deteriorationof the human economy, or both, willnot be discussed in this paper. Evenat the present time, however, fracturesof the patella from whatever causesare not very common, for they com-prised only 45 of the 2,328 cases of frac-tures treated in the Hotel Dieu, Paris;at most one in fifty, or an average of 4yearly.

Anatomy. The patella is a sesamoidbone situated in the anterior part ofthe femoro-tibial articulation. It isenveloped in the substance of the ten-don common to the extensor musclesof the thigh. It is cellular within andcovered by very thin but firm plates,so that in proportion to its bulk thereis scarcely a stronger bone in the body.(Anat. Phys. and Diseases of Bonesand Joints, S. D. Gross, M.D., p. 137.)

The anterior surface is convex and isperforated by small apertures for thepassage of the nutrient vessels andmarked by rough vertical striae, which

give the fibres of the tendon of thequadriceps a remarkably firm hold.

The posterior surface is divided by aridge into two facets united angularly,each of which articulates by a trochlearsurface with one of the condyles of thefemur. The outer one for articulationwith the outer condyle being broaderand deeper serves to indicate the legto which the bone belongs.

The patella is held firmly in placeby the quadriceps tendon from aboveand the ligamentum patellae from below,and in the act of flexion and extensionthe patella glides over the condyles ofthe femur, giving an example of a leverofthe first order. The extensor musclesare the power, the leg the weight, andthe patella resting on the condyles ofthe femur the fulcrum placed betweenthe power and the weight.

The predisposing causes of this lesionmay be age, sex, scurvy, gout, cancer,syphilis, rachitis, occupation, attemptsat muscular feats. The study of ageand sex and their influence in thecausation of any disease or deformityis always of interest, and I think itparticularly so in fractures of thepatella.

In the following table I have collatedfrom the annual reports all the cases oftransverse fractures of the patella from

TRANSVERSE FRACTURE OF THE PATELLA.

whatever cause, that were treated inSt. Bartholomew’s Hospital, London,during a period of eleven years, from

1866 to 1877, inclusive, omitting 1869,for which year I was unable to find areport:

Between the ages of 15 and 25 there were 20, or one-fourth of the total number.“ “ “ “25 and 35 “ “ 70,

“ one-fourth “ “

“ “ “ “35 and 45 “ “ 98, “one-third ““ “

“ “ “ “45 and 55 “ “ 63, “ one-fourth “ “ “

“ “ “ “55 and 65 “ “ 22, “ one-fourth “ “* “

“ “ “ “65 and 75 “ “ 9, “ one-thirtieth “

“ “ “ “75 and 85 “ “ 2, “ one-i4oth “ “ “

Thus it will be seen that 98 cases, orabout one-third of entire number, oc-curred in persons between the ages of35 and 45.

The study of sex is likewise of con-siderable importance and none the lessinteresting. From the same source Ifound that

Between 15 and 25 there were 16 males and 4 females, the proportion being as 4 to 1.“ 25 and 35 “ “ 54 “ “ t6 “ “ “ “ 3a to 1.“ 35 and 45 “ “ C 2 “ “36 “ “ “ “ if to 1.“

45 and 55 “ “ 36 “ “27 “ “ “ “ to 1.“ 55 and 65 “ “ 13 “ “ 9 “ to 1." 65 and 75 “ “ 7 " “ 2 “ 3? to 1.“ 75 and 85 “ “ 2 “ “ “ “

Total, 188 “ “96 “ “ “ “ 2to 1.

Transverse fracture when due alone .to muscular action takes place alwayswhen the leg is flexed upon the thighand sudden muscular contraction takesplace.

To illustrate The first, suppose that Ishould wish to break a pen holder, Icertainly would not direct my force inthe line of the fibres of the wood, butwould place my thumb near the middle(a fulcrum) and apply the force requiredto break the stick at the two ends,using the force against the fulcrum,thus illustrating power and resist-ance.

So it is with the patella, which wouldrequire an immense force to break ifthe leg was extended and the powerwas exerted in a line with fulcrum andresistance, but when the patella is heldagainst the condyles of the femur andthe leg is flexed a tremendous force,the character of which is a cross break-ing strain is being exerted upon thepatella.

The second element required is sud-den muscular contraction. A delicate

silk cord may be made to sustain acertain weight if the power is exertedgradually, but if the same cord and theweight are submitted to elevation sud-denly applied the cord will break.

A few cases due entirely to muscularaction may be studied with benefit.

Cases 1, 2.—Bichat (Packard’s Mai-gaigne, p. 602), and Sir A. Cooper(Cooper’s Surg. Essays , Part 11, p. 85),each saw a case where the fracture tookplace in aiming a kick, the motion ofthe foot being suddenly impeded, frac-ture took place.

Case 3.—Hevin saw the case of adancer who received a fracture in mak-ing a great effort in leaping. (Pack-ard’s Malgaigne, p. 602.)

Case 4.—In the operating theatre ofthe Hotel Dieu both patellae of apatient were broken by the violentspasms of the muscles which followedan operation for stone. (Cooper’s Surg.Diet., p. 752.

Case 5.-Bichat (Packard’s Malgaigne,p. 602) mentions the case of a man whowas cut for stone and who in a subse-

TRANSVERSE FRACTURE OF THE PATELLA. 3

quent convulsion broke both patelke atthe same time.

Case 6.-Desault (Gross System Surg.,sth Edit., Vol. I, p. 1,001) met a casein which a man broke both patellae sim-ultaneously by a violent effort of themuscles to disengage the limbs from theconstrained position in which they wereplaced during the operation of lithoto-my. Before the use of anaesthetics, thepatients who were to undergo this op-eration wr ere placed upon their backsand the wrists and ankles of corres-ponding sides were securely fastenedtogether.

Case 7.—Boyer {London Med. Repos.,1823, Vol. XIX, p. 174) speaks of acoachman who, being in danger of fall-ing from his box, made an effort to savehimself and heard the crack producedby the fracture.

Case 8.—Dr. Kirkbride {Am. JournalMed. Sci., Aug., 1835, Vol. XVI., p.330) records an instance in a man whoattempted to jump into a cart andbroke his patella.

Case 9.—Fielding {London Med. Re-pos., Vol. XIX., 1823, p. 174) met acase in a woman caused by attemptingto lift a heavy basket.

Case io.-A sailor (Hamilton, Fract-ures and Disloc., Ed ? p. 434) caughtthe heel of his boot in a knot hole,in the floor, which threw him backward,and in the effort to save himself fromfalling the patella was fractured.

Case 11.—Jno. C k was admittedto Dr. R. J. Levis’ ward at the Penn-sylvania Hospital January 7th, 1878,and said that he had slipped upon theice, and in the effort to save himselffrom falling felt the patella snap.There had been a fracture of a similarnature of the opposite patella sevenyears before. The fragments on theside of the old fracture were separatedfour inches. The patient stated thatthere had been close apposition when

he was discharged, but that the sepa-ration had gradually taken place.

Case 12.—About the same time MaryMe was admitted into the sameHospital and under the care of Dr.Levis. The fracture was also causedby a slip upon the ice and an attemptto prevent falling.

Case 13.—Sands {Med. Rec., Feb. 2,1878, p. 87) reports a case where thefracture was caused by the effort toprevent falling on being roughly as-saulted.

Case 14.—A gentleman (Sir A. Coop-er, Surg. Essays, vol. I, p. 350) injumping a ditch fractured his patellain his effort to prevent falling uponreaching the opposite side.

Case 15.—Sir Wm. Blizard (Lancet,Aug. 17, 1833, p. 673) reports the caseof Wm. A , who, while walking onthe curbstone slipped off, and in theeffort to prevent falling, fractured hispatella.

Case 16.—A man {Am. Journal Med.Sci., July, 1848, p. 220) was tripped bythe rope of a canal boat, and beforereaching the ground felt the snap ac-companying the fracture.

Case 17.—M. Sallemont {Cyclopad.Anat. and Phys., Todd, vol. hi., p. 70;Boyer s Surg., vol. hi., p. 358) reportsthe case of Louis M , who wasthrown by a comrade with whom hewas struggling, and in the effort toprevent falling broke his patella.

Case 18.—Mr. Liston (Lancet , Oct.14, 1873, p. 81) reports the case ofEliz S , who fractured her rightpatella in leaping from an embank-ment.

Case 20.—Dr. Kirkbride {Am. Jnl.Med. Sci., Aug., 1835, vdl. xvi., p. 330)has reported a case in which bothpatellae were broken in a similar man-ner, but at different periods. The girl,aged 29, was admitted into the Penna.Hospital, Oct. 16, 1833. In falling

4 TRANSVERSE FRACTURE OF THE PATELLA.

backwards and in making an effort tosave herself the right patella gave way.She was dismissed on Dec. 2d.

On April 20th following she was re-admitted with a fracture of the leftpatella, produced in the same manneras before.

Case 21.—M. De Beauvois {Med.Times and Gazette, Oct. 9, 1880, andMed. News, Jan., 1881) related at theParis Society de M6decine an exampleof this rare occurrence. A man, thirtyyears of age, and apparently in goodhealth, was engaged in the game ofleap-frog, and having struck the groundwith his feet, when on the point ofspringing forwards he felt as if he hadreceived a blow on the legs and hearda crackling sound. He fell on theground, believing that some one hadstruck him. On his being carried tothe hospital, a transverse fracture ofeach patella, with a separation of notmore than two centimetres, was foundto exist.

9 Cases.—There are nine cases wherethe fracture was caused by a mis-stepin going down-stairs, and falling back-wards, the patients made powerfulefforts to prevent falling :

Lancet, Feb. 15, 1840, p. 770.St. George Hosp. Reports for 1870.Am. Jnl. Med. Sci., July, 1848, p. 220.Lancet, Sept. 5, 1835, P- 74-8.Am. Jnl. Med. Sci., vol. xxx. (Hay-

wood).New Eng. Quart. Journal, July, 1842.Packard’s Malgaigne, p. 600.Hamilton Fracts. and Disk,4th Edit.

P- 434-ANALYSIS OF THIRTY CASES.

In aiming a kick, 2In leaping, 3In leaping (double), 1During lithotomy (double), . . 1In convulsions subsequent to lith-

otomy (double), 2Effort to prevent falling, ... n

Lifting heavy weights, 1Efforts to prevent falling, threat-

ened by a misstep in goingdown-stairs, 9

30I believe that muscular exertion is

the cause of the vast majority of thecases that are set down as due to trau-matism. When a person falls on hisknees, the patellae very rarely touch theground, the force of the fall is receivedby the tuberosities of the tibia, and if afracture of the patella should takeplace it would be undoubtedly due tomuscular action alone. That this mustbe the case is abundantly proved bythe fact that there is, as a rule, noabrasion or contusion of the skin overthe patella.

In cases where the fracture is due todirect violence and no muscular forceis exerted, the fracture is apt to be inany other than a transverse direction,the skin in many cases being severelypulpefied. I have, upon several occa-sions, in the anatomical rooms of thePhiladelphia School of Anatomy, triedto produce a transverse fracture of thepatella upon the cadaver. I have com-minuted it, but I have never withoutusing a chisel or similar instrument,been able, to produce a transversefracture of the patella, because theessential of that fracture the muscularexertion was absent.

Transverse fractures of the patellaare very rarely united by osseous tissue,and the reasons for this are sufficientlysimple, and may be briefly stated asfollows :

a. The intervention oftynovial fluidbetween the fragments.

b. The blood supply of one or bothfragments being cut off.

c. Muscular action prevents perfectcoaptation.

a. The synovial fluid, when exces-

TRANSVERSE FRACTURE OF THE PATELLA. 5

sive, may be drawn off by an aspirator,or its absorption may be promoted bystimulating lotions applied externally,but if complete coaptation is accom-plished and maintained this will notinterfere to a very marked extent.

b. The blood supply of the upperfragment is largely cut off, owing tothe rupture of the nutrient arterieswhich come from the anastomoses ofthe internal and external articularbranches of the popliteal artery. Theprincipal blood supply of the upperfragment is derived from the perios-teum and from the lower fragment, ifit is kept firmly in apposition. Asstrange as it may seem, this fact isoften ignored by surgeons who arecalled to treat such cases, for by theirvery treatment they frequently tendstill further to diminish the blood sup-ply, by tight bandages, adhesive strips,in fact by nearly all the applianceswhich make pressure upon the skinover the bone. Thus they defeat thevery object which they are endeavor-ing to bring about.

c. The principal cause in the preven-tion of ossific union in transverse frac-ture of the patella is the muscularaction. If this be properly overcomeand the bone held firmly in position, Icannot understand why the transversefracture should not unite by bone justas well as the vertical fracture, for thelatter certainly must contend againstthe presence of the synovial fluid, andthe probable ruptured nutrient artery,but it has in its favor the absence ofmuscular action.

I believe it is now an undisputed factthat in transverse fractures uniting byligamentous bands, the ends of bothfragments are very often covered by abony deposit.—Edinburg Med. andSnrg. JuL, 1837, No. 130, Chelius’s Sur-gery, p. 630, vol. 1.

This ossific deposit would in most

cases have been sufficient to hold thefragments firmly together. This seemsto me to indicate that the method oftreatment to be adopted is that whichholds the fragments in perfect apposi-tion, and, therefore, excludes all syno-vial fluid from between the fragments,and does not interfere with the bloodsupply of the affected part.

Some surgeons raise the very seriousobjection to bony union, that it willform a ridge of callus on the articu-lating surface, which will be sure tocause serious impediment to the use ofthe limb. I have been unable to findauthentic records of a single patholog-ical specimen of transverse fracturewhere bony union was claimed by theoriginators of the various appliancesfor the treatment of this lesion. Theirclaims are based upon the examinationof living specimens, and it thereforeseems to me as though the theory ofthe ridge of callus was raising an ob-jection not founded upon fact, butmerely a possibility.

The same may be said of the sur-geons who claim that ligamentousis far superior to any other union afterthis fracture. The fact that the ex-tensor quadriceps muscle has the bonypatella to glide over the condyles ofthefemur, seems to me to indicate thatbone is the correct substance for thepurpose and in case of fracture to se-cure bony union if possible, and I be-lieve it possible. I can not say that Iever saw bony union, because I didnot see the cases after death, but I cer-tainly have seen cases under the careof Dr. R. J. Levis, of this city, thatwere treated by his modification ofMal-gaigne’s hooks, that so simulated os-seous union that no one seemed able todefine any separation, and the twopatellae measured very nearly the same.

It is certainly remarkable that pa-tients seem to be able to walk quite

TRANSVERSE FRACTURE OF THE PATELLA.

\vell when there is a separation of aconsiderable distance between thefragments. Benj. Bell makes one inchthe limit of separation, allowing offirmness of the knee. Velpeau as-serts that he has seen the functions ofthe joint completely re-established withan interval of two or three inchesbetween the fragments. Malgaignesays that such assertions are in hisopinion only accounted for by some in-accuracy in examination. He said henever saw the function of the limb com-pletely restored even when the separa-tion was limited to one-third of aninch.

Among the many disadvantages ofligamentous union is its tendency tostretch, an elongation is most certainto follow the fibrous union, and espec-ially is this the case if the patient is al-lowed to use his limb too soon.

There isa case quoted by Hamilton inhis excellent work on Fractures and Dis-locations, in whom after three months’treatment by splint the separation wasone-half to three-quarters of an inch.The knee was much ankylosed. Soonafter this the upper fragment began todraw up and at the end of a year theseparation was three inches.

Kirkbride {American Journal Medi-cal Sciences, Vol. XVI), has reported acase in which the ligament had stretch-ed two and a half inches.

Dr. Watson ( Watson Jour. Med. andSurg., Vol. 111, p. 366), refers to a casein which the ligamentous band of unionmeasured three and a half inches.

In case No. u, of the 30 previouslymentioned the ligamentous band mea-sured four inches after seven years. Itwas supposed to be a case of bonyunion and the case was noted as suchupon the books.

The liability of the new formed liga-ment to rupture, is a serious objectionro this form of union.

Hamilton speaks of two cases (Ham-ilton, Fracts. and Dislocations 4thEdit., p. 436).

Morgagni saw two cases, and othershave been recorded by Richter, Ortalli,Dupuytren, Roux, Velpeau and others.I have seen out one case.

Sir Chas. Bell saw a case where theskin gave way at the same time thatthe ligamentruptured, thus laying openthe joint. Subsequently it becamenecessary to amputate the limb.

The most serious sequella of liga-mentous union is the great liability toa fracture of a similar nature of theopposite patella. This is occasionedby the increased strain placed upon thesound side by the presence of defectiveunion of the side first fractured.

In case No. 11 the second fractureoccurred seven years after the firstone.

In case No. 20 the left patella wasfractured six months after the right one.

The great necessity of striving, by allhonest means, after bony union in casesof this kind of fracture is evident, foreven though osseous union be not at-tained, the shorter the bond of unionthe better. “For it is found that the“joint will always be weak and unpro-“ tected precisely in proportion to its“ length and thinness.”— Gross , SystemSurgery , sth Edit., p. 946.

As I have previously said the reasonswhy this fracture does not unite byosseous tissue are :

a. Presence of synovial fluid betweenthe fragments.

b. Faulty nutrition, due to rupture ofthe nutrient vessels or compression.

c. Difficulty of maintaining completecoaptation.

It therefore follows that the treat-ment to be adopted is that which over-comes these difficulties best, and at thesame time does not endanger the pa-tient’s life.

TRANSVERSE FRACTURE OF THE PATELLA. 7

It is stated (Med. andSurg. Reporter,Nov., 1874), that at the Hospital Lari-bosiere, the surgeons becoming con-vinced that bony union cannot be at-tained, “ dispense with all apparatus“ to coaptate the fragments, which is“ perfectly useless, as whatever is done“the surgeon can hardly expect any“ thing more than a fibrous union which“ after all does not interfere with loco-“ motion.”

“ Dr. R. J. Levis, of Philadelphia,“ (Med, Times, Dec. 5, 1874), says he“ has seen three instances in which frac-“ ture of the patella was left without“ further treatment than a state of rest,“no attempt being made to secure“mechanically the coaptation of the“fragments. In one case the fracture“ was associated with other injuries al-“ most necessarily of a fatal character,“but the patient survived for nearly“ three months. In another instance“ the fracture was complicated with“ severe injuries of the limb which“ were attended with such great swel-“ ling that the fracture was not recog-“ nized until after the lapse of more“ than two months.“ In the third case the fracture was

“treated as a simple sprain with rest“ alone by a Homoeopathic surgeon and“ the patient came ultimately under my“ care on account of permanent disa-“ bility of the limb, due to a separation“ of the fragments of not less thanfive“ inches. In each of these cases the“ separation of the fragments remained“far greater than I have ever seen it“ as the result of ordinary treatment, in“ which approximation is effected as“ thoroughly as possible.”

The serious objection to the variousappliances which aim to maintain co-aption through the medium of the skinis that they tend still further to reducethe blood supply of the fragments, anddo not keep the fragments in that per-

feet state of approximation which isabsolutely essential for the productionof osseous union—therefore it seems tome that they should be discontinued asunscientific.

The above objections cannot be rais-ed against those appliances which actdirectly upon the bone, and theseappliances are hooks originated byMalgaigne and modified by Levis andMorton, and the wiring together ofthe fragments.

Malgaigne was the first to use thepatella hooks, and his uniform goodresults caused other surgeons to resortto this form of apparatus.

About 1877 (Med. and Surg. Reporter ,

Aug. 31st, 1878), Dr. R. J. Levis ofPhiladelphia, while using Malgaigne’sdouble hooks in a case of fracture ofthe patella was impressed by the factthat the double hooks implied that thepatella was a symmetrical bone, but asit was known not to be so, it occurredto him that single hooks would bemuch preferable, and he had made aninstrument with two hooks instead offour. The general principle of thehooks has remained the same, but theattachments have been somewhatchanged, until now the hooks are heldtogether with a rachet on a pinion,greatly facilitating the application, andremoval.

M. Nelaton (Clin. Surg., Translatedby Atlee, p. 171), used the hooks a“ number of times, but never found any“ of those inconveniences to result from“ its use which have been so singularly“ exaggerated.”

Campbell De Morgan (Am. Jnl. Med.Sci., July, 1863, Brit. Med. Journ., May24th, 1862), mentions the fact that alarge number of cases have been treat-ed by means of Malgaigne hooks in theMiddlesex Hospital and the resultswere most satisfactory.

Mr. Mitchell Henry, (Lancet, Aug.,

TRANSVERSE FRACTURE OF THE PATELLA.8

iB6O, p. 146), saw the hooks in use formany years in Malgaigne’s wards inParis without any serious incon-veniences.

I have had opportunities of seeingquite a large number of cases in thePennsylvania Hospital treated in Dr.Levis’ wards by his modified hooks, andam convinced that if bony union wasnot attained, it was impossible to deter-mine the space between the fragments,and I cannot remember one instance ofserious difficultyarising from the hooks.

Cases when admitted to that insti-tution are usually allowed to remainquietly in bed for a week, the leg andthigh being bandaged to control mus-cular action. Attention is paid to theinflammatory condition of the parts,which is reduced as speedily as possi-ble with solutions of acetate of lead,etc.

The hooks are applied generallyabout one week after the receipt of theinjury, and are permitted to remain forabout four weeks, when very gentlepassive motion is indulged in. Thepatient is not allowed to rest hisweight on the affected side for at leasttwo months after the accident.

Sir Astley Cooper, (Sir A. Cooper,Surg.EssaysPJol. 11., p. 350),performeda series of experiments upon rabbitswith reference to the solution of thequestion,—Why does not the patellaunite by bone? In experiment VI,having divided the bone by means ofa chisel, he sewed the two portionstogether, the suture being passedthrough the tendinous covering of thebone, but the ligatures separated andthe bone united by ligament.

It is quite evident that Sir AstleyCooper had grasped the thought ofwiring the fracture in the human sub-ject, but it does not seem to have mademuch impression, either because of itsfailure in the experiment or because his

mind was occupied in watching intentlythe phenomena of repair. lam notaware of any application of this princi-pal to the human subject made byCooper.

But Mr. Lister Med. and Surg. Re-porter, Jan. 12, 1878), cut down uponthe fragments in a case and drilled thetwo portions of the patella and tiedthem together with silver wire. Sixweeks after the operation the woundwas completely healed, the ends of thewire projecting through the scar.There was in this case no constitutionaldisturbance and the patient obtainedexcellent use of his limb. Dr. JohnRhea Barton performed a similar opera-tion, but lost his patient—Gross,SystemSurgery, sth Edit., vol. I, p. 1,004.

Dr. T. M. Logan performed this ope-ration once. {Pac. Med. and Surg.Journ., Dec., 1866), {Agnew's Surgery,Vol. 1., p. 781). The fracture had ex-isted for nine weeks when the wiringwas done. The wire remained sixweeks, the patient being kept undertreatment for four months and a cureis recorded.

Dr. J. E.Van der Meulin, of the Uni-versity of Utrecht Cameron of Glasgow(-Hamilton Tracts, and Dislocations,Edit. 1880, p. 516), Mr. Rose of Lon-don {N. V. Med. Journal, May, 1876,page 463, Med. Rec., April 3, 1880, p.384), G. McClelland (W. V. Med.Journal, May, 1876) have recordedcases, but I believe the procedure to besuch a dangerous one, presenting nosuperiority over the hooks when pro-perly applied, that I believe it shouldbe resorted to only after every otherknown method ||as failed ; and eventhen only after a deliberate study ofthe cases previously operated upon.

In closing I would say that it is myconviction that the hooks are the onlyscientific method of treating transversefracture of the patella.