A METHOD OF TREATING TRANSVERSE FRACTURE 
OF THE PATELLA. 
BY JOHN C. SCHAPPS, M.D., 
Brooklyn, N. Y., 
Surgeon to Department of Orthopedic Surgery and Diseases of Joints, St. Mary’s Hospital. 
After MacEwen’s investigations,1 had shown that the cause 
of non-union in transverse fracture of the patella is the pres- 
ence of soft tissues between the fragments, and that these 
tissues are commonly so entangled in the osseous irregularities 
of the fractured surfaces as to require, for their removal, careful 
scraping* or dissection, surgical opinion rapidly accumulated in 
favor of the treatment of this fracture by open incision, clearing 
of the bony surfaces, and securing their apposition by means of 
suture of some kind. And brilliant successes were frequently so 
obtained. But the repeated occurrence of serious mishaps due to 
the operation, and the excellence of the functional results obtain- 
able by non-operative methods eventually caused the backward 
swing of the pendulum, and now it is not expressing it too 
strongly to say that the operative method of treating recent fract- 
ure is generally regarded as unjustifiable. Various substitutes, 
such as tying the fragments together subcutaneously, or bolting 
them together by means of screws or drills subcutaneously intro- 
duced have been advanced. These and similar propositions 
necessitate invading the joint and leaving in it foreign bodies. 
For the crevice between the fragments is clinically a part of the 
joint cavity. Thus, while involving all or nearly all the risks of 
the operation they are intended to supersede, they do not attempt 
the only procedure which makes the latter justifiable—that of 
clearing the fractured surfaces This not being attempted, there 
remains to be secured such more or less complete approximation 
of the bony surfaces as the absence or presence of tendinous 
structure may permit. To accomplish this it is not necessary to 
'Annals of Surgery, March, 1887. JOHN C. SCHAPPS, M.D. 
enter the joint nor even to puncture the skin, except to relieve 
joint effusion when present. 
Without enumerating the various external methods commonly 
used for treating this fracture, and criticising them in detail, it 
may be stated that they appear generally defective in one or 
more of the following respects : 
1. They do not utilize all available surface in the application 
of approximating force. Not only is the force thus restricted to 
what a limited area will bear, but the means of applying the force 
is very liable to become displaced from its limited attachment. 
2. They make no provision for adjustment to the varying 
conditions, atrophy, absorption, etc., of the parts which are acted 
upon. 
3. The coapting force does not oppose in the most direct 
manner distracting force, but acts through the intervention of ob- 
jects whose relations to the fragments to be approximated are vari- 
able and uncertain. Such objects are the foot and ankle joint, the 
splint which is applied to the limb, or even the bedstead upon 
which the patient lies. 
The method here described was used in a case treated during 
the summer of 1885. The ultimate result was a separation of 
about 3/4 inch and a practically perfect limb. The procedure was 
simply a combination of the expedients which constitute to great 
extent the orthopedic surgeon’s, mechanical pharmacopoeia— 
removal of effusion, traction, fixation, and limitation of articular 
motion. 
Two pieces of stout extension plaster were cut into right- 
angled triangles, ABC and A ' B ' C so that the warp ran in 
Fig. i 
the direction of the hypothenuse, B C, B ' C The distance A B, 
A ' B ' is about one-third of the upper circumference of the thigh, 
and AC, A ' C ' is the length of the inner aspect of the thigh. 
The plaster was cut three inches longer than it appears in the 
figure, in order, by doubling it twice, to strengthen it sufficiently to 
hold the buckle sewn in. In cases of doubt it is safer to reinforce 
by the folding in of an additional piece. The triangles were 
divided longitudinally, as shown by the dotted lines, into three 
tongues, and were applied so that the buckles were situated over 
the condyles, while the two sets of tongues interlaced on the front TRANSVERSE FRACTURE OF THE PATELLA. 
of the thigh (Fig. 3). A bandage of firm muslin served to main- 
tain the necessary pressure to keep the plaster adhering. The 
buckles were left uncovered. 
Fig. 2. 
To the leg was applied the arrangement of adhesive straps 
commonly used for producing traction on the knee, but in a 
reversed direction. Four central strips of plaster, one and one- 
half inches wide, and long enough to extend from condyle to 
malleolus, and four side strips, one-half inch wide and one and one- 
half as long as the preceding, were cut. They are arranged in 
Fig. 3. 
two sets as shown in Fig-. 2, with the adhesive surfaces all facing JOHN C. S CHAFFS, M.D. 
the same direction. One end of each pair of strips was folded 
over those of two smaller strips, and all were sewn to a short piece 
(about six inches), of 7/g inch surgical webbing. The two sets of 
plasters were applied to the leg as follows : The pieces of web- 
bing were secured in the buckles, so that the pull came squarely 
on the latter. The junctions of the webbings and plasters were 
located on the side of the leg about three inches from the 
buckles in order that the slack might subsequently be taken in. 
The first broad strips of plaster were placed down the leg, the 
narrow strips were wound in spiral turns around the leg and the 
plaster, and the remaining broad strips placed on top of them 
all. (Fig- 3-) The whole was secured by a bandage, which 
passed over as well as under the thick end where the webbing 
was sewn. A firm base for counter traction was thus secured, 
and as the straps were drawn through the buckles, traction 
was exerted upon the whole surface of the quadriceps. Before the 
plaster was applied the jqint had been punctured by a tenotome in- 
troduced as recommended by Barwell, in a direction oblique to the 
skin, for the purpose of producing a valve-like opening, and a clot 
having been extruded, a very perfect approximation was attained. 
It was easily possible even to cause the fragments to overlap. 
Fixation was provided by the use of the knee splint of Dr. Jud- 
son, and the limb was slung in a slightly elevated position. This 
instrument (Fig. 4) affords a very simple and perfect means of 
fixing a knee in any desired position for any purpose whatever. It* 
is made of mild steel or iron. It is bandaged on or secured by 
straps and buckles. For an adult the stem should be one by one- 
eighth inch, and the cross pieces which are riveted to it should be 
Fig. 4. 
three-quarters by one-sixteenth. The foot piece, which is shown 
as detached, I have subsequently added for cases where support 
for the foot is desired. It is fastened to the brace by two screws 
and may be removed when the limb is used in walking. The 
surface of the knee was open at all times to inspection and adjust- 
ment. At the end of ten weeks the patient was allowed to walk, 
the joint being still immobilized by the Judson brace. Three TRANSVERSE ERACTORE OF THE PATELLA. 
weeks later an instrument (Fig. 5), designed to accomplish the fol- 
lowing ends, was applied : (1) To relieve the quadriceps muscle 
and therefore the patella from the strain involved in the act of 
extension. (2) To permit a regulated arc of motion. (3) To pro- 
vide a safety check against any sudden and extreme flexion, such 
as might be produced by the patient’s weight unexpectedly com- 
ing upon the not fully extended limb. The brace was attached to 
the shoe, the stiff spiral spring acted as an extensor. The 
strong steel discs shown at each side of the knee-joint, were cen- 
trally attached by the steel rivets of the joint, and each disc was 
provided with a circular slot, and a number of circularly arranged 
holes. By screwing the disc through one of these holes to the 
Fig. 5. 
thigh-upright the slot could be brought to move as desired past a 
screw in the leg-upright. And the impingement of the end of the 
slot on the screw afforded the desired check. Motion was gradu- 
ally increased. This apparatus was worn with perfect comfort, 
and the patient was able to walk and dance in it with ease. It 
gave her such a feeling of security that at the end of one and a 
half years she relinquished it with reluctance.