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Fractures of the Knee-pan.When the muscle contracts the leg is straightened. The knee-pan is located at just that part of the muscle which is stretched over the end of the thigh-bone, when the leg is bent; the object of this little bone is, therefore, to endure the friction which is inevitable when the leg is bent. The muscle is attached to the upper edge of this bone, the lower edge being firmly bound by a ligament to the front of the leg-bone. It is necessary to understand the anatomy of this part in order to appreciate the ways in which it can be fractured as well as the difficulty in securing a union of the fragments. The bone is most frequently broken by direct violence such as occurs when a person falls forcibly upon the knee. In some cases, however, muscular contraction alone is sufficient to break the bone ; such instances occur usually during violent efforts, such as are made in jumping or in kicking. The usual fracture is a transverse one, running from side to side of the knee-pan. Sometimes the bone is broken vertically, and in some cases a blow upon it shatters the knee-pan into several pieces. Signs.-This fracture is usually recognized without difficulty ; one can almost always feel the fragments, unless the limb be much swollen. If the fracture be transverse, there can be felt a distinct crack or fissure, which may be half an inch wide, running across the front of the knee. In this case there will probably be no grating sensation. If the fracture be vertically, or if the bone be broken into several pieces, we can often detect a grating sensation when the leg is straightened and bent. A characteristic symptom of this fracture is the inability of the patient to straighten the leg ; if the leg be straightened for him by another person, he can easily bend it, but when it is bent he is unable to straighten it. The reason for this is evident when we remember what has been said about the anatomy of the parts. The leg is straightened by the contraction of the muscle which is attached to the upper edge of the knee-pan. If this bone be broken, the upper fragment is drawn away by the muscle of the thigh, without moving the lower fragment or the leg to which it is attached. Treatment.-The treatment of a fractured knee-pan is extremely troublesome, and the results are usually unsatisfactory. The difficulty lies in the fact that the two fragments are rarely united by bone, but are simply joined together by a band or ligament; the result is that the length of the limb is increased, and hence the leg can not be managed with the same accuracy and facility. The most favorable of these fractures for treatment is the vertical one. To treat this fracture, it is only necessary to keep the leg quiet and straight. During the first few days there will probably be some swelling of the knee-joint, which should be treated by the application of hot cloths. After this swelling has subsided, the limb should be placed upon a straight splint of wood which runs from the ankle to the middle of the thigh. After this is well padded it is attached to the under surface of the leg by means of bandages placed above and below the knee. The healing process requires six to eight weeks. If it be necessary that the patient be on his feet, the leg may be enveloped in a plaster of Paris dressing, which shall extend from the ankle to the middle of the thigh. This will serve to keep the knee at rest. The patient should not place the foot to the ground, but should use crutches. Transverse fracture of the knee-pan is an extremely troublesome one, because the fragments are separated and can be maintained in contact only with difficulty. Many dressings have been devised for the treatment of this fracture ; the simplest and one of the most effective is that of Dr. Hamilton. The difficulty in keeping the fragments together arises, as has been said, from the contraction of the large muscles at the front of the thigh Now, if we can relax these muscles, we can prevent, in a great measure, their effect in drawing the upper fragment of the knee-pan away from the lower. When the thigh is bent at an angle with the trunk, these muscles are relaxed. Dr Hamilton, therefore, advises that the patient's body be supported in bed by pillows placed behind the back, while the limb is rested upon an inclined plane, so that the foot is raised ten or twelve inches above the bed. He makes a splint composed of three pieces of board. The first of these pieces supports the leg, and is long enough to reach from the hip to the sole of the foot. This piece is ten inches wide at the knee. The upper end of this piece is connected by a hinge to a second piece of board, which rests upon the bed; this piece is as broad as the first and several inches longer. A third piece is joined by hinges with the second, and folds upward, so as to meet the first piece and extend above the toes of the foot. This third piece is provided with pegs, which project from the edges ; by means of these pegs and of hooks attached to the first piece, just under the foot, the limb can be rested at any desired height. The splint, therefore, when complete, makes a triangle, the base of which is prolonged so as to form a support for the foot. A deep notch is cut in either side of the first splint at a point four or five inches below the knee. This splint is then thickly padded with cotton, especially under the knee. The limb is then placed upon the inclined plane, and the foot is fastened to the splint by means of a bandage carried around the ankle. Another bandage is then applied in the notch, and is carried from this point above the upper fragment of the knee-pan ; it is then brought through the notch on the opposite side, under the splint, and through the first notch on the other side. The bandage is carried around the leg and through the notches five or six times, being brought lower upon the knee at each successive turn. After the entire knee is covered this bandage is pinned, and a second one is applied around the entire limb from the ankle up to the hip. Another dressing is made on essentially the same principle ; instead of the bandage, which encircles the limb through the notches, strong elastic bands are used. These are attached to pegs driven in the side of the splint. One of these bands is brought above the upper fragment, and the other below the lower fragment, the two bands crossing each other at the knee like a pair of suspenders on a man's back. The advantage of this dressing is that the fragments are constantly pressed together by the elasticity of the rubber, while the knee is exposed so that we may readily examine the injured knee-pan without removing the dressing or disturbing the limb. In Hamilton's dressing, on the other hand, the bandage which is passed through the notches does not bring the fragments together with the same certainty, and is apt to become loose in a few days ; moreover the condition of the kneepan cannot be examined without removing the bandage. The disadvantage of the rubber consists in the liability to chafing of the skin under the bands ; this can be avoided by placing cotton between the skin and the rubber. The fragments usually unite by the formation of a ligament between them. The result may be considered very good if the fragments are not separated more than a quarter or even half an inch. If this be the case, the patient will be able to walk without limping, though he will experience at first some awkwardness in advancing the foot in walking. After a fracture of the knee-pan the patient cannot be too careful in avoiding any strain upon the knee for months. It will be well for him to wear a firm elastic band, which shall encircle the leg for three inches above and below the knee, leaving a slit large enough for the knee-pan to project through it. There will be, of course, some stiffness of the knee, resulting from the enforced inactivity of the joint for six or eight weeks. This may be overcome by gently bending tbe leg, beginning with a little exercise for fifteen minutes every day and gradually increasing both the extent and duration of the motion. A star-shaped fracture of the knee-pan- usually the result of a blow or a fall upon the knee-requires special treatment in different cases. In general, it becomes necessary to place the leg upon a splint in the shape of the inclined plane already described. In fact, Dr. Hamilton's dressing for a transverse fracture of the knee-pan, which has been already described, answers very well for many cases of star-shaped fracture. But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy! Also, please consider sharing our helpful website with your online friends.
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