Fig. 10

Diagram showing the condition of the bones in a very difficult oblique fracture of the tibia and fibula six weeks after the accident, the immediate massage and early movement method having been used after operation had been negatived. During the first week much difficulty arose in maintaining anything like good position. The fracture of the fibula was almost at the same level as that of the tibia, but does not show in the skiagram. The patient was walking naturally at the end of six weeks with a limb perfect in its 'mechanics.' - From an article by the Author in the 'Practitioner,' August 1901.

Lecture II. The Use Of Massage And Early Movements In Recent Fractures And Other Common Injuries (continued)

In my previous lecture the expiration of the time at my disposal compelled me to omit any mention of two varieties of fractures of considerable importance from the point of view of the treatment by the use of immediate massage - viz. fracture of the patella and of the olecranon. Until recently, as you know, the classical method of treating these fractures was by long confinement in splints or fixed apparatus (the period in the case of fracture of the patella extending sometimes to as much as a year or even more), with the object of obtaining as firm a union between the fragments as possible. Under such circumstances it cannot be considered remarkable that in many cases the difficulty in obtaining free movement in the knee-joint at the end of the splinting period was extreme, and that in some cases, indeed, the pain and distress entailed in the necessary treatment were more than the patients could endure. So great, indeed, was the pain sometimes under these circumstances that a certain number of people who had sustained a fracture of the knee-cap, rather than bear the pain entailed in getting free movement, preferred to remain with the limb more or less stiff. Speaking generally, the stiffness that follows upon a fracture of the patella, treated upon the old lines, depends largely on the fixation of the upper fragment to the anterior aspect of the femur at the time when attempts at movement are commenced - not, of course, by bony ankylosis, but by adhesions which, forming around the margin of the knee-cap, so tighten the soft parts about it that it is for practical purposes sealed to the surface of the femur. In attempting to get movements in these cases when treated, as I have said, in the olden way, no really good result could be obtained until these adhesions, as well as those in the joint, were loosened - a difficult and painful process which was rendered necessary merely because the parts had been confined so long in splints without movement. Moreover, the strain put upon the parts under these circumstances frequently led to a great stretching and sometimes laceration of the uniting medium. The upper fragment of the patella remained, in fact, at first fixed, and before the exercises had resulted in the breaking down of the adhesions, movement was often obtained at the expense of the stretching of the union, the stretching in some cases being very great; but even in such cases, so long as the upper fragment ultimately became freely movable upon the femur, a fairly good limb resulted in the majority. In the absence of the treatment by suture now so commonly employed the final result is dependent mainly upon two points: (1) the amount of laceration of the lateral expansions about the knee at the time of the injury (the less the lateral expansions are ruptured the more strength is there left in the joint after the fracture);1 and (2) the amount of mobility finally retained by the upper fragment of the patella. If the fragment does not contract inveterate adhesions, and finally becomes freely movable upon the femur, a more or less useful limb follows, the strength of the limb, as a rule, then being in inverse ratio to the length of the uniting medium. If, on the other hand, fixation of this upper fragment occurs, then the interference with the mobility and strength of the joint is so great that the patient is much crippled.

1 See Present Position of the Treatment of Simple Fractures.

The first object, then, in a case of a fracture of the patella, whether wiring has been practised or not, is to prevent by constant manipulation any chance of adhesions forming around the upper fragment and fixing it to the femur - a treatment which excludes any form of splint which makes the patella inaccessible. This necessity for securing free mobility of the patella is not confined to cases of fracture, but if a rapid and perfect result is to be obtained it should be used in all cases of inflammation of the knee-joint, traumatic or otherwise, liable to be followed by stiffness. This is a point to which reference will again be made.

As I have already said, this method of treatment makes the use of fixed immovable apparatus impossible, such, for example, as plaster of Paris, silicate of potash and the like. I may at once state that I have no doubt that the sooner these stiff, immovable appliances become obsolete the better it will be in all cases of damage of joints and in the neighbourhood of joints. The stiffness and pain which so often followed in fracture of the patella when treated upon the old lines were much more frequently due to the treatment than to the injury. The best results which follow fracture of the patella when not subjected to the wiring treatment will be obtained by immediate smooth massage and patellar manipulation, followed in a fortnight or earlier by gentle passive movement of the knee, during which the upper fragment should be firmly fixed by the hand of the manipulator in order to prevent its being drawn up towards the thigh. By this means, if effectually managed, flexion to a right angle can generally be accomplished without increasing the separation. In this way, in the majority of instances, a useful limb may be expected in from three to six months, all splints being discarded at the end of the first month. It is remarkable how little, if any, stretching of the union occurs in cases treated in this manner when care is taken from the outset to secure free movement of the patella upon the femur.