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Fracture of the Patella Dr Howard Lilienthal

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FRACTURE OF THE PATELLA.

DR. HOWARD LILIENTHAL presented a man, twenty-eight years old, who on the 24th of March, 1896, fractured his right patella by muscular strain. When Dr. Lilienthal saw him, five days later, there was a transverse fracture, with a single small comminution in the lower fragment. The case was treated by massage, as follows: Twice each day the bandage covering the joint was removed, and the parts thoroughly massaged for half an hour. This treatment was continued for six weeks. After the eighth day the patient was allowed to walk about, the joint being confined by a stiff splint. The patient made a good recovery and was able to resume his occupation as a dancing-master. The union obtained was ligamentous, and there is a certain degree of separation between the fragments, but the functional result is all that could be desired.

A second patient was a married woman, who fractured her patella about five weeks ago, and on the day following the acci dent gave birth to a child. On this account it was deemed inad visable to remove her to the hospital, in spite of the fact that her sanitary surroundings were very unfavorable. The fracture was a transverse one, and the massage treatment was carried out as thoroughly as was possible under the circumstances. While the cure is not yet complete, there is some ligamentous union, and since the eighth day the patient has been walking about and at tending to her household work.

Dr. Lilienthal said that wiring the patella was attended by some danger, even under the most favorable circumstances. In some instances, of course, there are particular reasons for resort ing to it. In a case of fractured patella in a demented woman, who continuallly tore off her bandages, he was compelled to wire the bone, but, in the usual run of cases, massage gives admirable results. The speaker said it had been asserted that massage really had nothing to do with it ; that it was a treatment by means of splints, with early motion. It is a fact, however, that massage of the quadriceps has an important bearing on these cases, as it prevents the muscles from becoming atrophied. This atrophy of the quadriceps has been shown by Raymond, a French pathologist, to depend upon a reflex neuropathy of some sort. He has shown by animal experimentation that there is a trophic relationship between the joint and muscles through the sensory tract.

DR. JOHN F. ERDMANN presented a young man who had been shown about two years ago before the Surgical Section of the New York Academy of Medicine. He had had a fracture of the patella, followed by a refracture, and subsequently by a refracture of the refracture. The original fracture occurred on March 31, 1896, and was treated by massage. About two months later there was a refracture, as the result of a fall. The fragments were then wired, but, as rather a light grade of wire was employed, a second refracture soon occurred. The patient refused to submit to another operation until October, 1896, when he returned to the hospital with an ankylosed knee and three inches of separation be tween the fragments. A rather long incision was made over the joint. This showed that the upper fragment of the patella was strongly adherent to the condyles of the femur, and the quadri ceps muscle had contracted to such a degree that it was impos sible to bring the two fragments into apposition. After making a liberal inverted V-shaped incision through the tendon of the quadriceps, and liberating the attachment of the vastus exter nus and internus, it was possible to bring the two fragments together. They were then united with very heavy wire, and after sewing up the gap made in the quadriceps tendon the wound was closed and the limb encased in plaster of Paris. Subsequent to the operation the man developed a very peculiar temperature range, for which no satisfactory explanation could be found. His tem perature was usually normal during the day and ran up to 103° F. at night. He was discharged from the hospital in four weeks. At present the limb has practically a normal range of motion and firm bony union between the fragments.

fragments, massage, refracture, patient, day, quadriceps and joint