UPON 
THE DANGER FROM FRACTURES IN CLOSE 
PROXIMITY TO THE KNEE-JOINT. 
BY ( 
OSCAR H. ALLIS, M.D., 
SURGEON TO THE PRESBYTERIAN HOSPITAL IN PHILADELPHIA. 
EXTRACTED FROM THE TRANSACTIONS OF THE MEDICAL SOCIETY OF THE STATE 
OF PENNSYLVANIA FOR 1881. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1881. UPON 
THE DANGER FROM FRACTURES IN CLOSE 
PROXIMITY TO THE KNEE-JOINT. 
BT 
OSCAR H. ALLIS, M.D., 
SURGEON TO THE PRESBYTERIAN HOSPITAL IN PHILADELPHIA. 
EXTRACTED FROM THE TRANSACTIONS OF THE MEDICAL SOCIETY OF THE STATE 
OF PENNSYLVANIA FOR 1881. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1881. UPON THE DANGER FROM FRACTURES IN CLOSE 
PROXIMITY TO THE KNEE-JOINT.' 
Case I.—David H., 50, admitted to county hospital on account 
of fracture of the femur just above the condyles. There was some 
swelling and effusion into the knee-joint. The limb was dressed 
with long splints and extension. Two days later the patient com- 
plained of pain in the thigh, and an increase of swelling at the knee 
and seat of fracture. On the fourth day the pulse was 112; temp. 
103°; patient sleepless in spite of opiates; anterior and posterior 
tibial arteries can both be felt pulsating strongly at the ankle. Has 
vomited and refused food. Fifth day pulse 112, temp. 101°, S}rmp- 
toms no better. Death on sixth day. 
Autopsy.—On cutting into the thigh, blood poured out from the 
cellular tissue. No large collection of blood at any point, though 
generally diffused throughout the soft parts. The fracture was at 
the junction of the lower with the upper three-fourths. The autopsy 
was hurriedly made and the precise source of the hemorrhage not 
ascertained. Internal organs healthy. {Med. Times and Gazette, 
1871, vol. ii. p. 10.) 
Case II.—Man, jet. 46, while pulling on his right boot felt some- 
thing give way just above his knee. (This limb had been paralyzed 
for over a year, but was nearly restored at the time just referred to.) 
A surgeon was immediately summoned, who detected a fracture in 
the lower third of the femur. The limb was dressed in a long splint 
and left undisturbed for tlix-ee weeks. He suffered considerable pain 
immediately after the dressing and during the time the splint was on, 
when, owing to an increase of the pain, he was sent to the hospital. 
Condition on reaching the hospital.— Patient blanched ; lips, 
tongue, e3relids extremely pale ; pulse rapid and feeble; right limb 
enormously swollen throughout. Pain extreme, but greatest at the 
knee, from which it seemed to shoot. The knee was notably promi- 
1 For an exhaustive paper on this subject see 3d series, Guy’s Hosp. Reports. 
By Poland. 4 
nent, and above the knee a distinct depression was evident. The skin 
in front and to the inner side of the knee was reddened, and deep fluc- 
tuation could be obtained. Both tibial arteries could be felt. For 
the past week he has perspired profusely, but had no rigors. An ex- 
ploratory operation was made by Mr. Heath, and finding no pus, a 
consultation was called, the limb removed, and death followed in 
three days. 
Examination of the limb.—Fracture very oblique and extending 
from just above the inner condyle to a point five inches above. 
There was a large amount of laminated blood, the source of which 
was from the popliteal, the injury being the tearing off of one of the 
azygos arteries at its attachment to the main trunk. (Lancet, 1868, 
vol. ii. p. 246, University College Hospital.) 
Case III.—Benj. M., 18, was thrown from his horse and dragged 
some distance, injuring knee and shoulder. On examination the 
latter was found to be slight, while the injury to the knee was 
regarded as a complete lateral dislocation with four inches of short- 
ening. It was easily reduced, but would not remain in position until 
after the third reduction, wrhen it sta}7ed in place and was dressed on 
a long splint. 
For a few days the case did well, but then violent inflammatory 
symptoms set in, and, fearing gangrene, other advice was sought, and 
the limb amputated in the lower third of the femur. The boy made 
a good recovery. Six weeks later the amputated limb was exhumed, 
and the injury found to have been a separation at the lower epiphy- 
sis of the femur. A suit for malpractice was institu- 
ted, and damages to the amount of $750 and cost of suit adjudged. 
Case IV.—This remarkable case was furnished me by Dr. J. II. 
Fisliburne, of Lock Haven, Pa. 
John McV., 48, wood-chopper, injured by the falling of a tree. 
Sustained a transverse fracture of the femur just above the joint. 
Treated in the usual manner for twelve weeks, when the case came 
for the first time under the care of Dr. Fishburne, who found the 
entire limb below the fracture in a singularly abnormal condition. 
“The lower portion of the bone and the knee-joint was a crispy 
nodulated deadened mass ; the whole lower extremity was shrivelled, 
resembling a dried lifeless anatomical specimen.” Having satisfied 
himself that the limb was an incumbrance, and that there was no 
possibility of reclaiming it, amputation was resorted to and fol- 
lowed by a good recovery. 
Dissection of the limb.—The soft parts literally metamorphosed; 
no soft tissue left save the dried shrivelled parts. The bloodvessels 
were like so many brittle, or cheese-like strings. The bones were of 5 
a darkened, slightly brownish color, exceedingly brittle, with the 
medullary tissue all dried up. The arteries at the seat or point of 
fracture were torn or destroyed. The shrinking away began im- 
mediately below the line of fracture, and the flesh fell abruptly away 
from nearly normal fulness to a skeleton-like shrunken condition. 
Case V.—H. B., 48, slipped on an orange-peel and fractured the 
lower third of the femur. It was dressed upon an American swing 
splint. Ten days later he was attacked with pneumonia, and thir- 
teen days later (twrenty-three from the injury pus was discovered 
about the fracture. This was twice aspirated, and, collecting the 
third time, was laid open and a drainage tube inserted. The wound 
healed, and the man left his bed about three and a half months after 
the injury. 
About two weeks later he refractured the bone at the same point; 
a second abscess formed, which was freely opened and followed by a 
speedy cure. (Lancet, 1871, vol. i. p. 153, St. Bartholomew’s Hos- 
pital.) 
Case VI—James Bennett, R. R. engine driver; was precipitated 
with his engine down an embankment twenty feet. He was imme- 
diately removed to the Chesterfield Hospital, when upon examina- 
tion a simple comminuted fracture was detected in the lower third 
of the right thigh—and a long splint applied. 
A few hours later the surgeon of the R. R. visited the hospital 
and approved of the treatment. The limb swelled rapidly, and on 
the visit of the surgeons of the hospital, Drs. Jones and Black, on 
the following day, they found the dressing had been removed and 
the limb resting on a pillow. The swelling was below the knee, 
■while the toe, instep, and ankle were below the normal temperature. 
The skin presented patches of livid discoloration, particularly about 
the lower part of the calf, and several bullae had arisen on the 
dorsum of the foot and lower part of the leg. These symptoms 
suggested an below the knee, but, as in the original examina- 
tion none was found, the suspicion was laid at rest. The symp- 
toms, however, grew daily worse, and gangrene declared itself on the 
sixth da}'. On the seventh day, through the sloughing structures, a 
fracture of the tibia below the knee was noticed. On the ninth day 
the limb -was amputated, but death followed on the next day. 
Examination of the limb.—Fracture of the tibia two inches below 
the knee-joint, and a fracture of the fibula one inch lower. The 
posterior tibial artery and the venae comites were ruptured. (Lan- 
cet, 1861, vol. ii. p. 227.) 
Case VII.—W. J. W., 52, a carpenter, was knocked down, and 
the wheel of a brick cart passed over his left leg, fracturing both 6 
bones at the same level, a little below the tuberosities of the tibia. 
A good deal of blood was effused above and below the seat of the 
injury, and the limb was considerably swollen and bruised. 
The limb was put up in splints and evaporating lotions applied. 
The fragments were not easily kept in position, a tendency to over- 
lap being manifest at every movement of the patient. 
For about two weeks and a half everything proceeded favorably, 
but at this time pain and swelling took place at the seat of fracture 
and an abscess pointed. From this a large quantity of fetid blood- 
stained fluid was evacuated. This was followed by considerable 
sloughing of tissue, and five days later the limb was amputated just 
above the knee. A good recovery followed. On dissection of the 
limb, the femoral artery was found plugged with fibrine. (Lancet, 
1876, vol. ii. p. 638, London Hospital.) 
Case YIII.—As J. D., set. 15, was wheeling a heavy loaded 
wheel-barrow, it tilted suddenly, and the right handle struck him 
a severe blow below the right knee, producing a fracture of the 
upper epiphysis of the tibia simulating an internal lateral disloca- 
tion. The fracture was easily reduced, a bandage applied from the 
toes upward, and lateral splints adjusted. 
On completing the dressing the limb was found to be numb 
throughout its entire length, and much colder than its fellow. The 
dressings were therefore immediately removed and the limb placed 
upon cushions. The second day extensive vesications appeared all 
along the calf reaching to the popliteal space; the great toe and 
some of the small toes began to look livid. The foot and leg and 
especially the knee became swollen. On the third day the gangrene 
was more pronounced, and as the pain was excruciating, consent to 
amputation was given, which was followed by a good recovery. 
Examination of the limb.—The fracture was at the epiphysis of 
the bones, and the veins were so injured that phlebitis had been 
set up by pressure upon their coats. The veins were plugged and 
impervious: the condition of the arteries is not given. (Medical 
Times and Gazette, 1871, vol. ii. p. 74.) 
Case IX.—John A., 82, slipped off the edge of a step, fell about 
two feet, and coming down upon his left leg bent it under him. The 
joint and surrounding parts swelled rapidly. On examination an 
oblique fracture in the upper third of the tibia was detected, with 
some comminution of the fragments. The fibula was also broken a 
little higher up. 
Three days later the leg was blue and much swollen with many 
blisters upon it, though still warm even to the foot. The sjmovial 
cavit}f of the knee-joint was distended to its utmost capacity. He 
became delirious, and died on the twelfth day. 7 
At the autopsy blood was found in the joint cavity, and was sup- 
posed to have found its way through the superior tibio-fibular articu- 
lation, since the fibular fracture communicated with it. Neither 
fracture communicated with the knee-joint. The cause of the gan- 
grene is not stated. (Lancet, 1875, vol. i. p. 857, London Hospital.) 
The remaining eases are interesting as showing a result similar 
to those previously recorded, though not accompanied by fracture. 
Case X.—Man, 25, was engaged in raising a heavy truck by 
means of a crowbar, when the bar slipped and struck him a violent 
blow on the front of the right thigh. This was followed by sudden 
and intense pain in the popliteal space, which almost caused him to 
faint. The pain measurably abated, and he resumed his avocation. 
Six days later he walked several miles, but a sudden seizure of pain 
in the knee forced him to obtain conveyance home. There was a 
gradual increase in the limb for about two weeks longer, when it 
ceased to swell, and a point of fluctuation was noticed in the ham, 
and on being opened clotted blood was found. He was admitted, 
five weeks from the injury, into St. George’s Hospital, and, as the 
limb was cold, pale, and tensely swollen without pulsation below 
the knee, a large bleb existing on the heel, and a bloody fluid oozing 
from the popliteal region, amputation was resorted to above the 
knee, but death from pyaemia followed on the nineteenth day. 
Dissection of the limb showed an incomplete rupture of the popli- 
teal artery opposite the joint. The vein was uninjured. (Med. Times 
and Gazette, 1866, vol. i. p. 427.) 
Case XI W. W., 21, while walking down hill by the side of a 
loaded wagon, one wheel of which was locked, fell and the lower part 
of his right thigh was caught by this locked wheel. The wheel did 
not pass over the limb, but pushed it before it for some distance. 
He was taken to the Great Northern Hospital soon after in a 
state of collapse. The limb (on examination) was found colder 
than its fellow, swollen above the knee, and pulseless below the 
knee. The limb soon began to change color, first becoming livid 
in the foot, and amputation was resorted to forty-nine hours after 
the accident. The case recovered. 
On dissecting the limb, the popliteal was found ruptured just 
above the anterior tibial branch. (Lancet, 1876, vol. ii. p. 426.) 
Case XII—Leah A., 71, fell, doubling the left leg under her; was 
taken home, but not doing well was sent a week later to King’s 
College Hospital. Here the limb was found enlarged, painful, pulse- 
less, and with a tendency to gangrene, but with no distinct progress. 
She died four days later. 
Examination of limb—Rupture of the popliteal artery and vein 8 
opposite the joint, with effusion of blood into the popliteal space. 
(Med. Times and Gazette, 1868, vol. ii. p. 123.) 
Case XIII.—J. T., 40. While carrying a sack of wheat, he slip- 
ped and fell backwards, the sack falling upon his right thigh. He 
felt something give way just below the knee, and a swelling at once 
appeared behind the knee and in the upper part of the calf. He was 
unable to rise without assistance, but could straighten the leg. He 
was admitted the day of the injury to Guy’s Hospital. On his 
arrival the leg and popliteal region were very hard, tense, and some- 
what shiny. No pulsation could be felt below the knee; leg numb 
and temperature slightly elevated. The limb was dressed in cotton 
wadding. On the 7th day gangrene was declared, and the limb 
removed on the eleventh (he would not consent to it earlier). Re- 
covery, though after a long and tedious confinement. 
Dissection.—Anterior crucial ligament ruptured; popliteal artery 
and vein both torn across. {Med. Times and Gaz., 1866, vol. ii. p. 6.) 
The cases here represented are only a few typical ones from the 
multitude that could easily be collected. They have not been 
sought for, but merely noted in the pursuit of the general study of 
fractures. I have given them at some length, hoping thereby to 
arrest the attention of any who have hitherto given the subject no 
special attention. Not that I have anything new to offer, but rather 
because I feel satisfied that the danger in this class of injuries is 
greatly underrated. 
All writers upon fractures near the knee-joint have stated that 
the chief danger is from hemorrhage; but none of them have cared 
to hazard the assertion that it was physically impossible to have a 
fracture in close proximity to the joint without having hemorrhage, 
often dangerous if not fatal. 
The principle up(on which such a statement rests lies in the dis- 
position of the bloodvessels; and unless this is fully appreciated, a 
person might be led to make as favorable a prognosis in this class 
of injuries as in any other; while any one who had been fortunate 
in a single case thus injured would have little sympathy for others 
whose results were less favorable. 
To illustrate let me refer to a few anatomical points. The femoral 
artery on emerging from the canal of Hunter takes its course close 
to and behind the lower end of the femur and upper end of the tibia. 
The course and branches of this artery must be noted; it is placed 
behind the bend of the knee for protection and to accommodate 
itself to the motions of the limb. A glance at any anatomy will 
give the plan and number of the arteries. There are three pairs 9 
making six branches in all, three on each side. These branches pass 
off at nearly right angles to the main trunk and anastomose with 
each other on the front of the knee. It is evident that one function 
of these branches is to hold the main artery in its median course. 
Below the articulation a branch of considerable size, the anterior 
tibial, makes its way between the head of the fibula and tuberosity 
of the tibia to supply the soft structures upon the front of the leg, 
while the terminal branches are soon lost in the muscular structures 
of the calf and foot. It is plain from this arrangement, that, while 
the main artery is guarded against injury from the front, and 
securely stayed and held in the median course by its numerous 
branches at this point, yet it is also evident that it must be in great 
peril when the lower portion of the artery is carried suddenly and 
forcibly away from the upper portion, as must be the case in all 
fractures in this locality. 
As my main point is, not that hemorrhage, but that dangerous 
hemorrhage, is likely to follow injuries here; not that it may occa- 
sionally occur, but that it is always to he apprehended, I shall offer 
no apology for further illustrating it. In Fig. 1, I represent an 
Fig. 1. 
Diagrammatic—showing the arteries put upon the stretch when fracture with 
overlapping occurs above the joint. 
oblique fracture just above the knee. The upper fragment is below, 
and the lower above the normal attachment of the arteries; and 
when such a change in the relation of the bone takes place suddenly 
and forcibly, when the bone, so to speak, suddenly expands to 
twice or three times its normal diameter, when the distance between 
two branches is suddenly increased two, three, or four inches, is it 
not evident that such sudden, violent, forcible change must be at 
the expense of the vessels that surround the part? The rupture, if 
in the branches, may be at a distance from the main trunk, and in 
all such cases the hemorrhage will be trifling; but it will be noticed 10 
(Fig. 1) that not one but several branches are involved, and, if the 
rupture in a single branch occur close to the parent trunk, then the 
hemorrhage will be fatal to life or limb. 
When the fracture occurs just below the knee, the danger will be 
similar in nature but more inevitably serious. Here the sudden 
Fig. 2. 
Diagrammatic—showing the arteries put upon the stretch in fracture with 
overlapping below the joint. 
separation produces tension upon one of the terminal tibial arteries, 
and the anterior tibial, passing through as it does between the bones 
to the front of the leg, cannot accommodate itself to the sudden 
tension, and is therefore the more liable to rupture, and hemorrhage 
from an artery of this size would be as mischievous as from' the 
popliteal itself. 
Although the anterior tibial is in great jeopardy from fractures 
just below the knee, yet the overlapping of fragments, when the 
fracture is in the femur, may be just as trying to its integrity. In 
Fig. 3 I represent an epiphyseal separation possibly similar to the 
one described in Case III. 
Fig. 3. 
Diagrammatic—showing how a fragment of the femur may rupture 
arteries below the joint. 
There are still injuries, whose remarkable fatality every careful 
observer and reader has noticed, that must be included among those 11 
already described, viz., the epiphyseal disjunctions that are liable 
to occur at any time prior to mature life. I desire to call special 
attention to this injury, since authors have described it as one of no 
serious moment, and to the unwary it may seem not unlike the sepa- 
rations that safely occur in other parts of the skeleton. The facts 
of the case are directly opposed to so favorable a view. Hamilton 
gives half-a-dozen cases, and the case (III.) already reported shows 
that loss of limb is often the best compromise that can be made; 
and he who will take a growing bone, and note how the articular 
arteries lie parallel with and embrace the bones at these points, will 
not be at a loss for a solution of so grave a result. (See also Fig. 3.) 
Fig. 4. 
In the foregoing remarks I have taken but a few of the many in- 
juries that may occur here. To appreciate the full extent of the 
danger one must picture the veins as numerous as the arteries, and 
to these add the nerves, all in the narrow compass of the popliteal 
space, and then subject them to the violence, tension, and laceration 
that accompany injuries that break the bone, breaking it not 
smoothly across but always roughly, often with sharp-cutting edges; 
sometimes cutting both artery and vein across; sometimes piercing 
one with a sharp fragment, or tearing or bruising them so as to 
render them no longer capable of acting as blood channels. Such 
possibilities, such strong probabilities are well worthy the most 
serious contemplation, for upon the full appreciation of these cir- 
cumstances hangs the destiny of all thus injured. 
Treatment.—No positive rules can be laid down. Everything will 
depend upon the degree, the character, and the gravity of the injury. 
In all the cases to which I have referred it will be borne in mind 
that the skin was unbroken, and the fracture the so-called simple 
variety. It is plain then that no diagnosis that will embrace 
the details of the injury, the precise lesions of arteries, veins, and 
nerves, can be made, and yet the life of the patient will depend upon 
a wise and intelligent course. 
As soon as the patient has recovered from the shock the limb 12 
should be examined under an anaesthetic. No judicious surgeon 
would add to the shock by instituting a careful, deliberate examina- 
tion while the patient is still suffering from the depression of the 
injury. At the proper time, usually within twelve hours, this should 
be done, i. e., the examination under an anaesthetic. I would make 
this a positive condition, nor would I consent to take charge of a 
case unless this privilege was conceded. Before the anaesthetic is 
given, the patient if of suitable age, and the family if not, should 
consent to the conclusion that may be arrived at by the examination. 
Such an arrangement will be to the advantage of all concerned. 
In making the examination all unnecessary rudeness should, for 
obvious reasons, be especially guarded against; yet, the examina- 
tion should thoroughly map out the line of fracture. The mistake 
of calling an epiphyseal separation a dislocation has been made, 
and a fracture of the tibia two inches below the knee has been over- 
looked when it coexisted with a fracture above the knee. No 
reliable diagnostic signs can be laid down; they will all vary with 
the injury and the interval between it and the examination. For 
this reason the anaesthetic should never be omitted. Crepitus will 
always be present with fracture. If the fracture is just above the 
joint it may simulate a dislocation, and if there is much swelling, 
the contour of the whole region will be changed. Let the swelling 
be ever so great the condyles of the femur can be felt in the se'mi- 
flexed limb; and if the point of crepitus is above them a fracture 
must be present. Having ascertained the injury to the bones, the 
attention should be directed to the circulation ; this embraces (1) the 
arteries and (2) the veins. If the popliteal artery has been torn 
across, it is probable there will be no pulsation in the vessels below 
the knee. The popliteal may be uninjured, and the amount of blood 
effused within the popliteal space may so compress the artery as to 
render pulsation below too feeble for detection. It must thus be 
evident at the outset that nothing absolutely positive can be said of 
its condition. Some added information may be obtained by apply- 
ing a bandage tightly to the feet, so as to drive all the blood out of 
them. After a few moments remove both bandages simultaneously. 
If the feet redden with equal promptitude a point in favor of the 
circulation has been established, while if retarded in the injured limb 
it ma}r be from lesion or compression of the popliteal artery, or 
lesion or compression of the popliteal vein. The superficial veins 
of the lower extremity, and especially belowr the knee, are the main 
channels for the return current. If an occlusion in the popliteal 
vein occur below the knee-joint, the circulation will suffer no material 
loss, but if it become occluded above it the entire reflow must be 13 
through the internal saphenous, and when this the only avenue of 
escape is blocked by excessive swelling, the early onset of gangrene 
is inevitable. 
In estimating the gravity of the injury I should caeteris paribus 
deem a fracture just below the knee of graver import than one 
similarly situated above it. Again, if the original injury had been 
accomplished through great violence, as by a fall from a great height, 
or by being thrown from a rapidly moving carriage, so that the 
vulnerating force had not been expended in breaking the bone, but 
passed beyond to the soft parts, in all such injuries the prognosis 
must be far more unfavorable than when the injury was of a less 
violent order, even though the fracture in the bone be equally ex- 
tensive. Finally, if the swelling has been rapid and the temperature 
below the knee be below the standard, the indications are that the 
injury is of a different and more critical nature than when the 
swelling comes on slowly or after the lapse of days. 
It is highly probable that in the majority of such injuries the 
patient will not consent to the prompt removal of the limb, nor 
would the surgeon like to assume so great responsibility. Should 
conservative measures prevail—a term never used when the amputa- 
tion of a limb saves a life—the dressing is of the utmost importance. 
A fracture-box on the principle of the double inclined plane will 
serve as a retentive apparatus for a pillow upon which the limb may 
securely rest and receive without further disturbance the medicated 
applications that may be indicated. In the absence of such a frac- 
ture-box I would strongly urge (but only as a temporary expedient) 
the simple use of pillows, for the limb may be cold and livid before 
another day, and if splints and bandages have been applied, there 
are not a few medical men who will assert with the utmost con- 
fidence that it was a case of tight bandaging. In the fracture-box 
the semiflexed position is most favorable to fracture just above or 
below the knee, and as the entire box can be suspended, there is 
much more to commend it than at first appears. 
If swelling becomes excessive, the idea of punctures and free in- 
cisions might suggest themselves, but the probability is they would 
do no possible good. If there is good reason to think that the ten 
sion of the skin and underlying fasciae should be relieved, then one 
continuous incision the entire length of the swollen mass down to 
or even through the deep fascia will relieve it, and nothing else 
will. If the swelling be attended with grave constitutional symp- 
toms, then the question of immediate amputation assumes great 
magnitude. To delay for the line of demarcation should symptoms 
of gangrene arise, would be fatal to the case. Should symptoms of 14 
septicaemia declare themselves, delay will only diminish the chance 
of recovery. 
Not every form of swelling and pain should call for such extreme 
measures. The swelling may terminate in abscess and recovery 
follow, still what I urge is that if the injury is near the joint, this 
fact alone calls for unusual vigilance on the part of the medical 
attendant, who should be on the alert for every untoward symptom, 
give it its true value, and be prepared for extremest measures at a 
moment’s warning. 
On removing the limb, carefully examine and record the injury in 
detail; the character and position of the injury to the bone; the 
blood poured out; the injury to vessels and nerve; and injury to 
the tissues. As a further precaution, it would not be unwise to 
preserve the part removed or the injured specimens, as no one can 
foresee the amount of litigation that is in store for the surgeon. 
Before leaving the general subject, I have a word to offer that has 
been suggested by three cases of injury in this region, two of which 
found their wa}r into the courts, and the third was only saved there- 
from by the prompt and decided action of a distinguished hospital 
surgeon. In two of the cases heavy damages were awarded, in one 
case (III.) they were wholly unjust, for though it was treated by an 
eclectic, there is no reason to believe that the result would have 
been more favorable in the hands of the most skilful. In all three 
the cases passed from the care of the original medical attendants 
into that of other medical men. In the first, suit was threatened 
because the limb was not promptly removed. In the second, the 
main charge was that an epiphysial disjunction had been mistaken 
for a dislocation. There is no evidence tliat the peculiar danger 
of this class of injuries was dwelt upon, but the mere fact that an 
error in diagnosis, not in treatment, had been made rendered him 
liable, though the treatment adopted would have been judicious had 
he known the precise injury. In the third ease there was good 
reason to think from the character of the injury that amputation 
should have been resorted to at once. The fact that one is liable to 
be dismissed from a severe case at any time, should, especially in 
such an injury as this, prompt him to associate with him one who is 
both competent and willing to face the consequences either medical 
or judicial. 
In conclusion, I would say— 
1. Regard all fractures in the vicinity of the knee-joint as belong- 
ing to a class of special danger. 
2. Examine all such fractures under an anaesthetic. 15 
3. Amputate promptly if there is reason to believe the artery or 
vein is torn. 
4. Make no hasty or favorable prognosis. 
5. If an attempt is made to save the limb, place it in an easy, 
unconstrained but secure position. 
6. Visit the patient frequently, and record the change from day to 
day. 
7. If high constitutional symptoms arise, if gangrene or septi- 
caemia threaten, delay will add nothing to the chances of recovery. 
8. If the limb is removed, make a careful dissection of it in the 
presence of competent physicians, and record the result. 
Philadelphia, 1604 Spruce St.