[WITH TH®/COMPLIMENTS OF THE AUTHOR.] 
FRACTURE OP THE PATELLA 
AND 
TREATMENT BY A NEW METHOD. 
BY 
HENRY O. MARCY, A. M., M. D., 
CAMBRIDGE, MASS. 
[Reprinted rkom The Boston Medical and Surgical, Journal, December 7, 1876.] 
CAMBRIDGE : 
srintcfc at tfoc 
1876. FRACTURE OF THE PATELLA AND TREATMENT 
BY A NEW METHOD.1 
BT HENRY O. MARCY, M. D. HART. 
It may be accepted as a rule in medical or surgical practice, that the 
treatment of diseases or injuries, which have many remedies, is unsat- 
isfactory. This pertains in no small degree to the treatment of fracture of 
the patella. There is no fracture to which a greater variety of appara- 
tus has been applied, and yet the results attained are by no means sat- 
isfactory ; bony union rarely occurs, and the affected limb is seldom as 
strong as before the injury. 
It is well to remember that the patella resembles the sesamoid bones 
in its development in the tendon of the quadriceps extensor, that it con- 
sists of loose cancellous tissue covered by a thin, compact lamina, and 
that it is this kind of osseous structure, moderately supplied with nu- 
trient vessels, which, when injured, undergoes slow and imperfect rep- 
arative processes. From the exposed position of the patella it is sub- 
ject to accidents of great variety; yet the large majority of fractures 
are transverse, and are caused by the enormous muscular force ex- 
ercised by the extensor group acting in a spasmodic way, usually to 
prevent the body from falling backward. When we reflect that the full 
power of these muscles is probably expended in a great variety of the 
ordinary avocations of life, it is worth while to inquire how the patella 
can be fractured by muscular effort. This I believe to occur only when 
the muscular tension is at an angle with the long axis of the bone, produc- 
ing a leverage effect over the condyle of the femur, and this is precisely 
the position of the body, when an individual makes a sudden effort to 
save himself from falling backward. Soon after the injury there is 
usually developed a more or less severe synovitis, with effusion. This 
is a far more important factor in the injury and its results than is usu- 
ally believed. It is generally supposed that the extensor group is in a 
state of contraction after the injury, and that, owing to this, the upper 
1 Read before the Suffolk District Medical Society, October 28, 1876. 2 
Fracture of the Patella. 
fragment is carried away from its fellow a considerable distance. If I 
may judge from my own observations this is not generally true, and in 
the patient seen immediately after the injury, when the limb is placed at 
rest in a state of extension, the fragments adjust themselves nearly in 
apposition, and remain so until separated by the effused fluid. 
We should remember that the patella is firmly attached by its entire 
circumference to strong fibrous structures; and, when the bone is 
broken, many of the fibres may escape injury, and are usually amply 
sufficient to retain the fractured portions in place the limb being ex- 
tended and at rest —so long as there is no distending force exerting 
pressure from within. Soon, however, fluid is effused, and though at 
first only a slight separation existed between them, the fragments are now 
removed a considerable distance from each other. Not only does fluid 
occupy the space between the fragments, but these are tilted upward at 
a considerable angle. There are rare cases where very little effusion 
occurs, and it is, as I believe, precisely these cases in which the frag- 
ments are little separated and the best results are obtained. I think I 
have seen one case of true bony union, and, as I remember it, although 
it was some years ago, and before I recognized the clinical importance of 
the effused fluid, there was little or no distension of the joint. 
‘ A good practical rule might be deduced, that the results will depend 
largely upon the amount and duration of the fluid. The farther apart 
the fragments are, the greater the difficulty of apposition, and if sep- 
arated for any considerable period they cannot unite by bone. 
Mr. William Adams has given us much valuable information in his 
careful study of the specimens of this fracture contained in the London 
museums. When the fragments are not separated more than an inch 
and a half, the interspace is usually filled by firm fibrous tissue. In 
some of these cases, however, and in those separated by a greater space, 
Mr. Adams finds that the fragments are not united by plastic matter, 
but are bound together by thickened fasciae which pass over the patella 
and incorporate themselves with the bursa patellae. This aponeurotic 
structure is arranged in different ways. It may be adherent to the 
periosteal surface of both fragments and pass between them ; it may 
be reflected over, and may be adherent to both fractured surfaces; or, 
as most frequently happens, the connecting aponeurosis may pass from 
the periosteal surface of the upper fragment to the fractured surface of 
the lower one, to wdiich it becomes firmly united. In the majority of 
cases, when thus united the fragments are tilted outward, being in closer Fracture of the Patella. 
3 
relationship upon the articular than upon the periosteal surface. Of 
thirty-one specimens examined, fifteen were thus united, twelve by lig- 
amentous and four by undetermined union. Union as thus described 
leaves a very imperfect result. The limb is weak, the joint is unpro- 
tected, the fragments are so widely separated that the articular surfaces 
may be felt between them, and the fasciae may be folded in or adherent 
to the capsule of the joint. 
This brief review of the injury, and of the character of the inflam- 
matory and reparative processes, brings us naturally to the consideration 
of its treatment. Much ingenuity has been expended in a great vari- 
ety of appliances, as every surgeon is aware, from Sir Astley Cooper’s 
bandage above and below and cross-ties between, and Malgaigne’s hooks 
variously modified, and especially made practicable by Spence of Edin- 
burgh, to the method of Eve of Tennessee, who surrounds the fragments 
with a ring. The fragments have even been cut down upon and wired, 
with bony union as a result; and as a believer in antiseptic surgery I 
trust it may not be too much to hope that the time will come when 
this may be adopted as the safest and best rule. 
Professor Wood’s method, modified by Hamilton, of a figure of eight 
bandage, the limb resting upon a wide inclined plane, is a favorite one 
in America, and I have used it in a number of cases with good results. 
It is open to two objections : first, it tilts the fragments forward and 
consequently places them in an unfavorable position for union ; secondly, 
the constrained position is a very painful one to the patient. A large, 
fleshy woman, who had sustained fracture of both patellae from muscu- 
lar action, was treated by me two years ago by this apparatus. It was 
midsummer, and the suffering from this unnatural and constrained posi- 
tion alone was most cruel and severe. 
Sanborn, of Lowell, has devised a very simple appliance which has 
given excellent results. It consists of a long piece of adhesive plaster 
extending from the thigh to the ankle, left in a loop over the knee ; this 
is twisted by an inserted stick until the desired approximation is at- 
tained. Of course the limb remains at rest on a splint. 
Mr. Teale, of Leeds, has treated a number of cases by the “ expect- 
ant method ” with success. He evidently recognizes the fact referred 
to earlier in this paper, that the muscles when at rest are not in a state 
of contraction, and gives the following reasons for the approximation of 
the fragments: “ First, at the time of injury the quadriceps extensor is 
thrown into a state of tonic contraction. After a few days this con- 4 
Fracture of the Patella, 
traction relaxes, and the muscle gradually regains its normal length, 
thus removing all traction on the broken bone. Second, the effusion, 
which always occurs at the time of the accident, is slowly absorbed, 
and by its removal allows the fragments to fall together. And third, the 
fibrinous band, which is formed between the opposing surfaces, has, like 
all cicatricial tissue, a tendency to contract, and thus to complete the 
approximation.” 
Much ingenuity has also been expended upon the construction of hos- 
pital appliances to bring, by means of weights and pulleys, the frag- 
ments into apposition, and good results have been obtained. 
A careful study of the pathological processes brings one to the deduc- 
tion of a few simple rules for treatment. 
The first, and as I believe one of the most important factors of all, 
is the effusion. This, if in large quantity, or if not rapidly absorbed, 
from my experience in aspiration in acute synovitis of idiopathic char- 
acter, I would unhesitatingly remove by the aspirator, and repeat the 
operation if necessary. The fracture cannot be treated in permanent 
apparatus until after the effusion has disappeared, but rest on pillows, 
cold applications locally, etc., answer very well. I have in several in- 
stances placed the limb in Hamilton’s splint for the first week. 
As soon as the traumatic inflammation has subsided, I have used in 
the last three cases the following, which so far as known to me is a new 
method of treatment. 
Adhesive plaster of good quality, upon strong cloth (I have found 
that of Maw & Sons, of London, prepared upon thick cloth, the best), 
cut in pieces of concentric shape, of considerable width, should be care- 
fully adjusted both above and belowr the patella. The inner edges are 
best turned slightly back upon themselves, or welted over a small cord, 
while the projecting points are doubled back for reinforcement as well 
as to prevent their adhesion to the skin. These pieces are perforated 
for the introduction of an elastic cord. 
The limb is carefully enveloped in a plaster bandage extending from 
the toes to the hip, and strengthened by inlaid pieces of tin. The same 
precautions are required in the application of the bandage as in fracture 
of the thigh, to secure rest and support, as well as disablement of the 
muscles. The best proof of its proper application is that the limb is 
perfectly comfortable, and at the same time voluntary muscular contrac- 
tion is reduced to the minimum. 
Tins are incorporated into the bandage each side of the knee, of suit- Fracture of the Patella. 
5 
able shape to reinforce the fenestra, which is at once cut in the bandage, 
of oval shape and sufficiently large to liberate the entire patella, with a 
free surrounding of nearly an inch. Loops of wire (one or better two on 
each side, above and below the knee) are also adjusted in the bandage at 
suitable distances for the tying of the elastic ligatures fixed in the ex- 
tremities of the adhesive plaster. The proper position of these loops is 
of some importance ; for if placed too low, the pressure is too great from 
above downward, which results, as in the figure of eight bandage, in tilt- 
ing forward of the fragments, thus causing the fractured surfaces to 
approach each other at a greater or less angle. 
Pressure is made upon the fragments by the adjustment of the cords. 
Much less force is required than would be supposed, the lower piece of 
plaster fixing the lower fragment, while the upper draws its fellow into 
apposition. The inclosed surface over the patella is easily rendered 
oedematous by interference with the capillary circulation, if too much 
tension is used. 
The patient may be at once allowed to walk with crutches, the foot 
being supported by a sling from the neck, as in fracture of the thigh. 
After the first week he may ride, and, in fact, attend to many light 
duties. 
In illustration of this treatment I will briefly report my last three 
cases treated by this method. 
Case I. April 21,1876. Mr. T. L., a strong, healthy man, in middle 
life, fractured the left patella transversely by muscular effort. The leg 
was kept at rest upon an inclined plane until the effusion, which was of 
considerable amount, subsided, and on April 27th was put up as above 
described. 
The splint was removed at the end of seven weeks, and a light splint 
was adjusted for a few'weeks longer. The patient was on crutches 
after the first few days, and busied himself most of the time correcting 
proof, as his business was that of a music printer. September Ist, he 
walked with only a slight halt, and chiefly complained that the limb 
became tired sooner than its fellow. The union is ligamentous, and 
does not exceed a quarter of an inch in length. 
Case 11. April 28th. Mr. F. L., aged twenty-nine, fractured the 
right patella transversely by muscular action. The synovitis was severe 
and the effusion was very marked, and in consequence I was unable to 
apply a permanent apparatus until the thirteenth day. The fragments 
came well into apposition and were easily retained. In a few days the 6 
Fracture of the Patella. 
patient walked with the aid of crutches, and enjoyed driving almost 
every pleasant day. The treatment in all respects was similar to that 
in the first case. September Ist the fragments were separated by about 
one third of an inch, and on the 25th by five eighths of an inch. The 
union now seems firm and the fragments freely movable, but the fract- 
ured edges are tilted forward at an angle, and the result is evidently 
modified and less successful on account of the great amount of effu- 
sion. In a similar case I would asph'ate the fluid. The patient wears 
a knee-cap, and walks easily with the aid of a cane. 
Case 111. Mrs. W., seen in consultation with Dr. Flowers, of 
Cambridge, fractured her right patella in April, six years ago, and was 
kept in bed nine weeks, the limb supported on a straight splint, and 
then had a plaster splint adjusted, which she continued to wear until 
the following January. The limb was almost entirely stiff for many 
months, yet the fragments were separated so that the finger could be 
laid between them. July 6, 1876, the ligamentous union was broken 
by a muscular effort to save herself from falling. There was a consid- 
erable amount of effusion and ecchymosis, which subsided in about ten 
days, when I applied the apparatus as above. She began to walk with 
crutches in a few days, and suffered very little during her treatment. 
The splint was removed in fifty days, a knee-cap was applied, and the 
patient now walks with the aid of a cane. The fragments are separated 
one fourth of an inch. The knee can be slightly flexed. 
New devices are likely to be overestimated. I would not claim too 
much for the above method. It has the advantage of being simple, 
keeps the injured parts open to inspection, saves the patient the irksome 
suffering of weeks in a constrained position, and maintains his general 
health by exercise and ability to be out of doors, which last is no minor 
factor in hastening the reparative processes. In the hands of any physi- 
cian of moderate mechanical genius it can scarcely fail of securing sat- 
isfactory results. As in cases treated by any other method, care should 
be exercised for a considerable period after the removal of the splint 
not to bring the limb into too free use, for not rarely will the tendon it- 
self lengthen after several weeks have elapsed, and what appeared to be 
a good result, months later makes a different exhibit. This is illustrated 
by the case of a physician in Cambridge, who remained in bed four 
months in order to be certain of a good result, but the tendon gradually 
lengthened for some months, until now it measures about two inches.