FRACTURE OF THE PATELLA TREATED BA 
CONTINUOUS EXTENSION; PATIENTS 
NOT CONFINED TO BED. 
BY 
y 
JOSEPH D. BRYANT, M.D., 
OF NEW YORK. 
FROM 
THE MEDICAL NEWS, 
January 7, 1893. [Reprinted from The Medical News, January 7, 1893.] 
FRACTURE OF THE PATELLA TREATED BY 
CONTINUOUS EXTENSION; PATIENTS 
NOT CONFINED TO BED. 
By JOSEPH D. BRYANT, M.D., 
OP NEW YORK. 
Two varieties of treatment of fractured patella 
are generally recognized, the mechanical and the 
operative. It is not my intention to allude to the 
latter method, except in a general way; nor, in 
fact, to the devices of the former plan except as they 
may be employed to illustrate the method of treat- 
ment that I present. The indications to be met in 
the treatment of this fracture are the stereotyped 
ones that are applicable to all fractures, namely, the 
reduction of the fragments and the holding of them 
in place until a proper degree of union ensues to 
permit of the removal of the retaining forces. In 
fracture of the patella the uppermost fragment is 
drawn upward by the influence of the quadriceps 
extensor muscle, while the lower is somewhat dis- 
placed downward by means of the non-muscular 
tissues attached to it. Ordinarily, crepitus can be 
easily elicited between the fragments, provided 
the attempt be made before the formation of the 
firm blood-clots that become closely connected 
with the broken surfaces of the bone within a 
few hours after fracture. The failure of the medi- 2 
cal attendant to obtain crepitus at this time 
should be attributed to the presence of these 
clots rather than to the influence of the stretched 
aponeurotic tissues connected with the upper surface 
of the patella. The presence of these clots and 
their influence in separating the fragments are fre- 
quently and easily demonstrated during the opera- 
tive technique of wiring the patella for fracture. 
The steps necessary for the reduction are, first, 
the extension of the leg and elevation of the limb 
to secure complete relaxation of the quadriceps ex- 
tensor muscle; second, the drawing together and 
retention of the fragments in position until some 
form of union insures sufficient strength to prop- 
erly maintain them in place. It is hardly necessary 
for me to describe the various instrumental means 
heretofore employed to effect the reduction and 
retention of the fragments in this fracture. It is 
sufficient to say, however, that their basis-action 
consists in extension applied directly or indirectly to 
the upper fragment and the holding of the lower 
fragment upward in position. The extension is re- 
presented in these cases as applied to the upper frag- 
ment and to the thigh, and also to both of these 
parts simultaneously. It is manifest to one familiar 
with the relationship of the tissues composing the 
thigh that extension applied to the thigh alone 
can exercise but little other restraining influence 
on muscular contraction than that dependent on 
coaptation pressure, because ,the dense fascia lata 
intervenes between the muscles of the thigh and 
the integument to which the extension is applied. 
However, when extension-apparatus is applied to 3 
the upper fragment of the patella with sufficient 
firmness to meet the indication, then, indeed, some 
command of the quadriceps muscle is secured. 
But even in this instance the inequality, severity, 
and direction of the pressure necessarily brought 
against this fragment, together with the absorption 
of the surrounding soft parts incident to the press- 
ure, quickly render its influence insecure and migra- 
tory, unless constant and tedious, not to say painful 
attention be given to the case. 
In my judgment, the feature most commendable 
in the wiring method is this: It permits patients to 
move around on crutches within a few days, thereby 
relieving them of the tedium and depression of long 
confinement. 
Of the mechanical appliances permitting patients 
to be at once about on crutches, plaster-of-Paris, 
applied in the form of a thigh or hip spica, extend- 
ing down to cover the foot, with an oblique patella- 
traction arrangement of the bandage at the knee, is 
most often selected. With this method, even in a 
very few days, the limited direct-extension influence 
that the splint exercises on the upper fragment dis- 
appears, owing to the shrinkage of the limb, and in 
part to the pressure of the splint itself. The coap- 
tation-influence on the tissues of the thigh, exercised 
by the splint at the time of its application, is soon 
much lessened on account of the same shrinkage. 
I have quite often witnessed the treatment of this 
fracture with the plaster-of-Paris splint when little 
attention was paid to the tissue-changes following 
its application, even up to final recovery; and 
candor compels me to State that in these cases the 4 
results were quite as satisfactory in all respects as 
in cases treated more actively and with seemingly 
better philosophy. I have often remarked that the 
results of the treatment of fracture of the patella 
with a plaster-of-Paris spica were much more con- 
vincing of the fact of how little treatment the frac- 
ture required than of the efficiency of this particular 
method. However this may be, it is surely a great 
desideratum to employ a means that, while it holds 
the fragments as well as possible by mechanical 
measures, still subjects the patient to as little con- 
finement as if wiring of the patella had been done. 
The plan that I have employed, with some interrup- 
tions, for a number of years past can be divided for 
the sake of simple elucidation into five separate 
steps. 
First step (Fig. i). The first step consists in the 
application to the leg of a plaster-of-Paris splint, 
extending from the base of the toes up to and 
partly around the lower fragment (3). The splint 
is firmly applied to the limb a sufficient time in 
advance of the succeeding steps to permit of its 
becoming thoroughly hardened. It is carefully 
rounded at the lower extremity (2), so as to press 
into position and hold there the lower fragment (3). 
Its functions can be said to be threefold: 1st. It 
serves to protect the foot of the patient from the 
pressure of the rubber extension, which acts from 
this part of the limb. 2d. It confines in place the 
lower fragment, and the pressure upward of the 
splint, due to the elastic force of the extension 
transmitted through it to the foot, retains the upper 
border of the splint in proper relationship to the 5 
lower fragment. At all events, any diminution of 
pressure on the part of the splint in this situation 
can be readily supplemented by the introduction of 
Fig. i. 
Fig. 2. 
Fig. i.—i, i. Plaster splint as applied to leg. 2. Upper border 
of splint pressing lower fragment into position. 3. Lower frag- 
ment with line of fracture above. 
Fig. 2.—1,1. Extension as applied to thigh. 2, 2. Front view 
of extension straps. 3. Adhesive straps retaining fragments in 
position. 4, 4. Rubber extension made taut while adhesive straps 
are being applied. 6 
suitable pads between it and the lower fragment of 
the patella. 3d. It affords attachment to the lower 
end of the supporting rod or brace, intended to 
maintain complete extension of the limb while 
acting as a posterior support. 
Second step (Fig. 2). The features of the second 
step are quite as strongly expressed by the illustra- 
tion representing it as words can define them. This 
step consists in the application to the thigh of an 
extension-apparatus fashioned after the manner of 
the well-known Buck’s extension, which reaches 
from the perineum to the upper border of the 
upper fragment (1, 1). 
It is confined in position by the ordinary muslin 
roller. The adhesive element of this appliance 
terminates a little below the knee in a loop (2, 2) 
at either side, through which may be passed the 
rubber extending cord (4, 4), or to which may be 
connected hooks for the convenient attachment of 
the rubber cords or bands that are to pass around 
the bottom of the splint, and by means of which 
the extension is made and maintained. The broad 
triangular adhesive strips to which the extension 
loops are sewed are confined in position at the sides 
of the thigh by means of simple roller bandages. 
Moderate extension is then made on the loops by 
means of the rubber cords, in order to draw as far 
as possible downward the soft tissues of the thigh 
and the upper fragment of the patella. While the 
extension is thus being made, the roller bandage 
intended to hold the adhesive-plaster strips in place 
is covered by plaster-of-Paris rollers from the upper 
to the lower limits of the adhesive-plaster extension, 7 
and so fashioned as to control the upper fragment 
in the most serviceable manner while extension is 
in action. The object of this plaster-of-Paris ad- 
dendum is, first, to aid in holding the primary- 
dressing of the thigh in a firm position ; second, 
and principally, to afford an upper support for the 
extending rod or splint to be placed behind the 
limb, and to aid, also, in confining the upper frag- 
ment of the bone in proper relationship to its fellow, 
as will appear in the succeeding step. 
The second step meets the following indications : 
First, it coaptates the tissues of the thigh, thereby 
exercising a controlling influence over muscular con- 
traction, and is the agent causing extension of the 
integument and the subcutaneous tissue. Second, 
it makes direct extension of the quadriceps through 
its firm application to the upper fragment of the 
fractured'bone and the tissues immediately above 
and around it. 
Third step. This step consists in strapping the 
fragments of the patella in such a manner as to 
draw them well together and properly maintain 
them in position. These strips of plaster (3, Fig. 2) 
are fastened in position behind to a wooden sup- 
port or brace, about two inches in width, one inch 
in thickness, and extending from near the upper 
border of the thigh portion of the splint to the 
lower part of the splint surrounding the leg. These 
adhesive strips should be applied cautiously, so as 
not to irritate the integument, and also to prevent 
either of them from being drawn downward between 
the fragments of the broken bone. If this accident 
happens, greater separation of the fragments ensues, 8 
and union of a serviceable kind is much delayed, 
and may be defeated. These strips can be applied 
with greater care, convenience, and effectiveness, if 
traction be made away from the median line of the 
thigh, as represented in Fig. 2 (4, 4). 
Fourth step (Fig. 4). This consists in fastening 
the posterior support or brace (2) in proper posi- 
tion, and fixing it there by means of plaster-of-Paris 
rollers carried around it and the upper and lower 
segments of the splint where they lie in contact 
with each other. These bandages harden quickly, 
and thus incorporate the posterior support firmly 
with their structure, forming an interrupted plaster- 
of-Paris splint, with a posterior connecting brace 
(1, 1, 2). The interval at 2 shows this brace with 
the patellar adhesive straps attached, by means of 
which the strips are retained in position. 
Fifth step (Fig. 4). The posterior support in this 
illustration is unusually thick (2), being composed 
of wood. A small iron rod on each side of the 
posterior surface of the limb will answer much 
better for many reasons, and is less cumbersome. 
However, this one illustrates sufficiently well the 
importance of the posterior support, and better, 
perhaps, than a less conspicuous object. Fig. 4 
shows the posterior support as placed against the 
posterior surfaces of the plaster splints previously 
described, and confined there by fresh plaster rollers. 
This should be accomplished while the extension 
force is in action. These bandages are represented 
as carried around the limb from the extremities of 
the support to the contiguous borders of the under- 
lying plaster splints. As already mentioned, the 9 
hardening of these newly applied bandages incor- 
porates the posterior support with the plaster-of-Paris 
structure so firmly that an unyielding common ap- 
Fig. 3. 
Fig. 4. 
Fig. 3.—i, 1. Plaster bandage applied around thigh extension. 
2, 2. Rubber extension in position and action. 3. Patella-retain- 
ing straps. 4, 4. Hooks for rubber extension bands. 
Fig. 4.—1, 1. Upper and lower segments of interrupted splint. 
2. Posterior support of splint covered by retaining straps. 3. Side 
view of extension strap. IO 
paratus is formed. The object of this support is 
obvious to anyone. It serves to keep the limb 
extended, thus preventing undue traction on the 
fragment of the quadriceps muscle, and it affords 
attachment to the adhesive plasters that confine the 
fragments of the patella in proper position. Leather 
collars, properly fashioned and padded, passing 
around the limb above and below the patella, and 
drawn firmly toward each other by means of leather 
straps, as figured in the text-books, may be em- 
ployed instead of this method of strapping. In 
either instance the hamstring tendons should be 
carefully protected from undue pressure by the in- 
terposition of some soft suitable material. After 
the apparatus is completely and suitably applied, 
the patient may be permitted to walk around, but 
the limb during this time should be flexed some- 
what on the trunk by means of a long sling extend- 
ing from the foot, which it supports, and carried 
over the neck of the patient. The employment of 
this expedient will flex the entire limb considerably 
on the trunk, and thereby cause greater relaxation 
of the quadriceps extensor muscle, and also obviate 
the influence on the upper fragment of the involun- 
tary contraction of the muscles that are associated 
in the effort of locomotion. 
THE ADVANTAGES OF THIS APPLIANCE. 
The following advantages appear to me to be 
quite clearly defined : 
i. It apposes the fragments of the patella from 
the first as well as any other non-operative appli- 
ance can accomplish this purpose. 11 
2. It maintains them in position better than any 
mechanical means yet employed, unless the patient 
be confined in bed and a constant and tedious 
scrutiny be exercised by the physic'an in charge. 
3. It permits the patient to be up and around 
sooner and more comfortably than any non-opera- 
tive method of treatment yet employed. 
I have thus far treated nine cases by this method, 
with results equal to those of any other non-opera- 
tive method, and with much more comfort to the 
patients. Like all methods, this one, too, has its 
fallacies. It is important to regulate the degree of 
elastic extension in accordance with the require- 
ments of each particular case. If greater extension 
be employed than is essential, the straps by means 
of which the extension is secured may be torn or 
drawn away from their fastenings. At all events, 
great discomfort will be caused. It is proper to 
say, however, that a degree of extension may be 
employed which will be readily withstood by the 
straps at the earlier period of their application, 
which is out of all proportion to the requirements 
of the case, and at a later period would promptly 
cause slipping of the adhesive straps. In one in- 
stance, as a matter of experiment alone, I applied 
a degree of elastic traction to a case equivalent to 
forty pounds. It may be thought, perhaps, that 
the application around the thigh of the plaster- 
of-Paris casing, and introduction of the posterior 
support connecting the two portions of the splint, 
will interfere with the extension influence applied 
to the thigh itself. This, however, is not the case, 
as the extension acts independently of the incasing 12 
plaster, while at the same time the incasing plaster 
serves to confine the adhesive strips properly in 
position. If the interval between the plaster splints 
corresponding to the knee and popliteal space be 
not thoroughly and carefully covered, either with 
straps, cotton, or bandages, pain and edema will, 
for obvious reasons, take place there. 
After the adhesive strips are properly applied 
to the patella, the intervals between the splints, 
behind and in front, should be filled in with 
layers of absorbent or other kind of cotton, 
and bandaged closely in place. At the time the 
posterior support is placed in position, cotton or 
other suitable material for exercising moderate 
pressure should be interposed between it and the 
posterior surface of the knee, already the patella- 
retaining straps are applied, as then this material 
can be drawn firmly into place. As before re- 
marked, the fragments should be carefully and 
properly strapped, and great care exercised in the 
application of the straps, else one of them may be 
drawn between the fragments, and before its dis- 
covery may cause greater separation and interfere 
with the union. 
Finally, it is necessary that the plaster splints 
should be kept firmly apposed to the underlying 
surfaces, which, of course necessitates their being 
cut up quite soon after their application. The 
cutting up can be easily done by means of an ordi- 
nary knife after the manner usually employed in 
other forms of splints of a similar nature. If a 
proper portion of the splint be removed in the line 
of incision, the splint can then be firmly drawn in 13 
place around the limb by means of an ordinary 
muslin roller. 
In presenting to your consideration this method 
of treatment of fractures of the patella, I do not 
claim any originality as to the application of ex- 
tending force in this manner to the thigh, as I re- 
call distinctly having seen, while an interne in Belle- 
vue Hospital in 1870, a similar extension applied to 
the thigh for fracture of the patella by Dr. Stephen 
Smith. However, in that instance the patient was 
kept in bed, and no effort was made to control the 
lower fragment by means of a plaster splint or by 
the influence of the extension employed in making 
traction upon the upper fragment. I have not, 
however, as yet seen or learned of the treatment of 
fracture of the patella by a method in any way con- 
templating the use of extending influence associated 
only with the limb itself, the introduction of a pos- 
terior stiffening support, and non-confinement of 
the patient in bed. The Medical News. 
Established in 1843. 
A WEEKLY MEDICAL NEWSPAPER. 
Subscription, $4.00 per Annum. 
The American Journal 
OF THE 
Medical Sciences. 
Established in 1820. 
A MONTHLY MEDICAL MAGAZINE. 
Subscription, $4.00per Annum. 
COMMUTA TION RA TE, $7.50 PER ANNUM. 
LEA BROTHERS dr* CO. 
PHILADELPHIA.