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GLASGOW ROYAL INFIRMARY.
1761 be further flexed or extended. Two days after admission the patient was placed under chloroform and the knee-joint was examined. Dr. Newman:found that
GLASGOW ROYAL INFIRMARY. TWO CASES OF DISLOCATION OF THE PATELLA, ONE UPWARDS AND ONE DOWNWARDS.
(Under
the
care
FiG. 1.
of Dr. DAVID NEWMAN and Dr. HENRY
RUTHERFURD.)
of these forms of dislocation of the from the total absence of any description manifest is pa.tella of them from the text-books. Either form must require a direct blow on the patella, and this blow must probably be delivered in a nearly vertical direction, either upwards or downwards, according to the variety of dislocation proTHE
exceeding rarity
duced. CASE 1. IJislocation of the patella upwards by rotation on its horizontal axis, the articular surface presenting upwards. -A man, aged 24 years, was on Oct. 24th, 1900, admitted into the Glasgow Royal Infirmary under the care of Dr. David Newman complaining of an injury to the right kneejoint. The history of the accident given by the patient was that a few days prior to admission he fell and injured his right knee which he said had been weak as the result of an injury received six years ago. On examination the knee was seen to be swollen and the slightest pressure with the hand caused the patient great pain. The knee while at rest assumed a slightly flexed position and without the employment of an anaesthetic the joint could not
Section of the knee-joint, showing dislocation of the upwards in Case 1.
patella.
FIG. 2.
Skiagram (lateral) showing the dislocation of the patella
downwards in Case 2.
The upper border is engaged between the femur and the tibia.’
1762
the operation
there was a rise of temperature to 101° F. while the lower border of the patella was wedged in between the head of the tibia and the condyles of the Whether this was due to absorption of extravasated blood or femur there was an abrupt hollow immediately below the to a slight formation of stitch abscess is doubtful. Next dislocated bone, and the ligamentum patellae lay close to night the temperature was 100° and thereafter it was the head of the tibia, while the tendon of the quadriceps regularly below the normal. Remarks by Dr. RUTHEBFURD.-SO far as published extensor muscle was thrown forwards and rendered unduly prominent. On both sides of the tendon there was a deep records go this would seem to be a unique case. Apart from groove. Fig. 1 shows a section of the knee-joint in its compound injuries, I am inclined to think that engagement middle line. The condyles are not represented, being shown of the patella between the bones entering into the formation The apex of the knee is rare, yet it is only a few weeks since that as a section through the inter-condyloid notch. of the patella was wedged between the head of the tibia and I was told by my colleague, Dr. Newman, of the first case the adjacent surfaces of the internal and external condyles, which is described above, but the interest of the case which and was there firmly fixed. While the patient was under the I have described lies in its bearing on the generally accepted influence of the anaesthetic the dislocation was easily reduced view as to the classification of dislocations of the patella. by manipulation and the movements of the limb were com- This may be taken as expressed by Stimson: 1" Dislocations pletely restored. Probably a portion of the ligament of the [of the patella] upwards and downwards should not, I think, patella was separated from the bone, but this could not be have a place in the classification, since they are the secondary ascertained by palpation through the integuments ; there results of other lesions, rupture of the ligamentum patellae or was no evidence of rupture of the tendon of the quadriceps of the tendon of the quadriceps, which are to be deemed extensor muscle. the principal and controlling ones." The same view is set Remarks by Dr. NEWMAN.-The case above described is forth by Stephen Smith in his edition of "Hamilton on exactly the converse of the one now published by Dr. Henry Fractures and Dislocations "and by Bergers who quotes Rutherfurd. In the very idjteresting case brought forward Malgaigne, and before him Petit, as having enunciated the by him the apex of the bone was thrown forwards, so that doctrine. It may seem difficult to distinguish between a the articular surface looked downwards, while the base of tearing away of the patella from the insertion of the the patella was wedged between the head of the tibia and quadriceps and a rupture of the quadriceps itself, but the condyles of the femur. In my case it was the lower I think that the distinction is valid. In the case which border of the patella that was fixed in the knee-joint ; I describe the periosteum was stripped from the front the articular surface looked upwards while its base projected of the patella and remained connected with the quadri. forwards. ceps, so that the extensor apparatus of the knee was CASE 2. ])ownward dislocation of the patella.-A youth, virtually intact. Rupture of the quadriceps, even if it be aged 18 years, was admitted to Ward 25 of the Glasgow held to have occurred, was certainly not the principal and Royal Infirmary on Jan. 28th last with an injury to the controlling lesion." The lesion here was due to direct left knee, and in the absence of Mr. H. E. Clark came violence, and the difference between its results to the under the care of Dr. Henry Rutherfurd. The history was extensor function of the knee and that resulting from a that the night before the patient had struck his knee against true rupture of the quadriceps is analogous to the difference a bogey or low truck which was standing in his way and had in the functional results in fracture of the patella from been thrown down by the violence of the impact. Dr. direct and indirect violence. Judging from the statistics W. S. Findlay of Bellshill saw him and recognised the collected by Berger in the article referred to there are at existence of a dislocation of the patella; on admission the least three points wherein rupture of the quadriceps differs joint was painful, fixed, and its capsule was distended. Dr. from the injury which I have described-namely: (1) Rutherfurd examined the patient under chloroform, expect- rupture of the quadriceps is an accident of advanced lifeing to find rupture of the quadriceps or possibly fracture of more than two-thirds of the cases were over 50 years of the patella. No gap could be found in the continuity of age; (2) it is almost invariably due to muscular action-in the rectus tendon nor could any fragmentation of the the one case out of 28 where it was ascribed to direct patella be made out. A body apparently corresponding to violence the patient was the subjeet of locomotor ataxy; that bone could be felt impacted between the femur and the and (3) the recovery (apart from the results of suture) is tibia as if it had been turned through a right angle on its slow and in many cases markedly incomplete. transverse axis. On the presumption that it was the lower edge that was presenting forwards an attempt was made to reduce it, but this was not effected even after emptying the joint by an incision through the vastus externus. In view of the unusual nature of the injury Dr. Rutherfurd thought that it was advisable to have the parts skiagraphed before proceeding further. This was done the same day by Mr. OPHTHALMOLOGICAL SOCIETY. Brennan, electrician to the infirmary, and the print which he obtained confirmed the diagnosis (Fig. 2). The patella is turned downwards and seen with its articular surface ot Inflammatory Eaeudates into the Vitreous.engaged between the femur and the tibia. The ligamentum Study of the Third Nerve with Unusual Compliea. Paralysis patella is seen tightly stretched. tions.-.Double b’,ymmetrical Opacities of the Cornea.On Jan. 30th (two and a half days after the injury) the Erpthropsia.-4e Injury due to Lightning in South patient was again put under chloroform and Dr. Rutherfurd of Cases and Specimens. Africa.-Exhibition proceeded to operate for reduction of the displacement. It AN ordinary meeting of this society was held on being probable to his mind that there was a rupture of the quadriceps which would require suture he turned up a flap June 13th, Mr. G. ANDERSON CRITCHETT, the President, from below the anterior tubercle of the tibia, exposing the being in the chair. Dr. LESLIE BUCHANAN read a paper on Inflammatory front of thejoint to above the insertion of the rectus femoris. The tendon though ecchymosed presented no Exudates into the Vitreous which was illustrated by lantern rupture and he was still unable to pull up the patella from slides made from his preparations. He said that the its position between the bones. Accordingly the joint was exudation into the vitreous in cyclitis was, in the first cut into about a finger’s breadth from the outer side of instance, formed in the pars ciliaris retinas, and more the patella, and passing in the finger the bare anterior especially in the non-folded portion of it, but soon the folded surface of the patella could be felt and seen presenting portion, the fibrous atroma of the ciliary body, and the upwards ; with a hook it was now levered into place. The retina took part in the production of the inflammatory The exudate into the vitreous body was wound of the capsule was closed with a continuous suture of exudate. chromicised gut, and afterwards the skin flap was dealt with seen in the fresh specimen fixed in 5 per cent. It might in like manner. The joint was carefully emptied of blood by formalin as opaque white flocculent masses. pressure and a bulky dressing was applied; no splint was be divided into zones, which from the ciliary body employed. A fortnight later the dressing was removed, when inwards were as follows-namely: (1) a fibrous zone ;i the jjint was found to be of normal appearance ; there was (2) a fibrinous zone ;and (3) a fibrino-cellular zone. The no gap above the patella and there was no tilting forwards of 1 Fractures and Dislocations, 1899, page 772. its upper edge, as is typical in rupture of the quadriceps. 2 1891, page 760. the Within another week patient was walking about the 3 Article " Rotule," Dictionnaire Encyclopédique des Sciences ward and on Feb. 22nd he was sent out. On the day after Médicales, 1877.
Medical Societies.
GLASGOW ROYAL INFIRMARY. TWO CASES OF DISLOCATION OF THE PATELLA, ONE UPWARDS AND ONE DOWNWARDS.
(Under
the
care
FiG. 1.
of Dr. DAVID NEWMAN and Dr. HENRY
RUTHERFURD.)
of these forms of dislocation of the from the total absence of any description manifest is pa.tella of them from the text-books. Either form must require a direct blow on the patella, and this blow must probably be delivered in a nearly vertical direction, either upwards or downwards, according to the variety of dislocation proTHE
exceeding rarity
duced. CASE 1. IJislocation of the patella upwards by rotation on its horizontal axis, the articular surface presenting upwards. -A man, aged 24 years, was on Oct. 24th, 1900, admitted into the Glasgow Royal Infirmary under the care of Dr. David Newman complaining of an injury to the right kneejoint. The history of the accident given by the patient was that a few days prior to admission he fell and injured his right knee which he said had been weak as the result of an injury received six years ago. On examination the knee was seen to be swollen and the slightest pressure with the hand caused the patient great pain. The knee while at rest assumed a slightly flexed position and without the employment of an anaesthetic the joint could not
Section of the knee-joint, showing dislocation of the upwards in Case 1.
patella.
FIG. 2.
Skiagram (lateral) showing the dislocation of the patella
downwards in Case 2.
The upper border is engaged between the femur and the tibia.’
1762
the operation
there was a rise of temperature to 101° F. while the lower border of the patella was wedged in between the head of the tibia and the condyles of the Whether this was due to absorption of extravasated blood or femur there was an abrupt hollow immediately below the to a slight formation of stitch abscess is doubtful. Next dislocated bone, and the ligamentum patellae lay close to night the temperature was 100° and thereafter it was the head of the tibia, while the tendon of the quadriceps regularly below the normal. Remarks by Dr. RUTHEBFURD.-SO far as published extensor muscle was thrown forwards and rendered unduly prominent. On both sides of the tendon there was a deep records go this would seem to be a unique case. Apart from groove. Fig. 1 shows a section of the knee-joint in its compound injuries, I am inclined to think that engagement middle line. The condyles are not represented, being shown of the patella between the bones entering into the formation The apex of the knee is rare, yet it is only a few weeks since that as a section through the inter-condyloid notch. of the patella was wedged between the head of the tibia and I was told by my colleague, Dr. Newman, of the first case the adjacent surfaces of the internal and external condyles, which is described above, but the interest of the case which and was there firmly fixed. While the patient was under the I have described lies in its bearing on the generally accepted influence of the anaesthetic the dislocation was easily reduced view as to the classification of dislocations of the patella. by manipulation and the movements of the limb were com- This may be taken as expressed by Stimson: 1" Dislocations pletely restored. Probably a portion of the ligament of the [of the patella] upwards and downwards should not, I think, patella was separated from the bone, but this could not be have a place in the classification, since they are the secondary ascertained by palpation through the integuments ; there results of other lesions, rupture of the ligamentum patellae or was no evidence of rupture of the tendon of the quadriceps of the tendon of the quadriceps, which are to be deemed extensor muscle. the principal and controlling ones." The same view is set Remarks by Dr. NEWMAN.-The case above described is forth by Stephen Smith in his edition of "Hamilton on exactly the converse of the one now published by Dr. Henry Fractures and Dislocations "and by Bergers who quotes Rutherfurd. In the very idjteresting case brought forward Malgaigne, and before him Petit, as having enunciated the by him the apex of the bone was thrown forwards, so that doctrine. It may seem difficult to distinguish between a the articular surface looked downwards, while the base of tearing away of the patella from the insertion of the the patella was wedged between the head of the tibia and quadriceps and a rupture of the quadriceps itself, but the condyles of the femur. In my case it was the lower I think that the distinction is valid. In the case which border of the patella that was fixed in the knee-joint ; I describe the periosteum was stripped from the front the articular surface looked upwards while its base projected of the patella and remained connected with the quadri. forwards. ceps, so that the extensor apparatus of the knee was CASE 2. ])ownward dislocation of the patella.-A youth, virtually intact. Rupture of the quadriceps, even if it be aged 18 years, was admitted to Ward 25 of the Glasgow held to have occurred, was certainly not the principal and Royal Infirmary on Jan. 28th last with an injury to the controlling lesion." The lesion here was due to direct left knee, and in the absence of Mr. H. E. Clark came violence, and the difference between its results to the under the care of Dr. Henry Rutherfurd. The history was extensor function of the knee and that resulting from a that the night before the patient had struck his knee against true rupture of the quadriceps is analogous to the difference a bogey or low truck which was standing in his way and had in the functional results in fracture of the patella from been thrown down by the violence of the impact. Dr. direct and indirect violence. Judging from the statistics W. S. Findlay of Bellshill saw him and recognised the collected by Berger in the article referred to there are at existence of a dislocation of the patella; on admission the least three points wherein rupture of the quadriceps differs joint was painful, fixed, and its capsule was distended. Dr. from the injury which I have described-namely: (1) Rutherfurd examined the patient under chloroform, expect- rupture of the quadriceps is an accident of advanced lifeing to find rupture of the quadriceps or possibly fracture of more than two-thirds of the cases were over 50 years of the patella. No gap could be found in the continuity of age; (2) it is almost invariably due to muscular action-in the rectus tendon nor could any fragmentation of the the one case out of 28 where it was ascribed to direct patella be made out. A body apparently corresponding to violence the patient was the subjeet of locomotor ataxy; that bone could be felt impacted between the femur and the and (3) the recovery (apart from the results of suture) is tibia as if it had been turned through a right angle on its slow and in many cases markedly incomplete. transverse axis. On the presumption that it was the lower edge that was presenting forwards an attempt was made to reduce it, but this was not effected even after emptying the joint by an incision through the vastus externus. In view of the unusual nature of the injury Dr. Rutherfurd thought that it was advisable to have the parts skiagraphed before proceeding further. This was done the same day by Mr. OPHTHALMOLOGICAL SOCIETY. Brennan, electrician to the infirmary, and the print which he obtained confirmed the diagnosis (Fig. 2). The patella is turned downwards and seen with its articular surface ot Inflammatory Eaeudates into the Vitreous.engaged between the femur and the tibia. The ligamentum Study of the Third Nerve with Unusual Compliea. Paralysis patella is seen tightly stretched. tions.-.Double b’,ymmetrical Opacities of the Cornea.On Jan. 30th (two and a half days after the injury) the Erpthropsia.-4e Injury due to Lightning in South patient was again put under chloroform and Dr. Rutherfurd of Cases and Specimens. Africa.-Exhibition proceeded to operate for reduction of the displacement. It AN ordinary meeting of this society was held on being probable to his mind that there was a rupture of the quadriceps which would require suture he turned up a flap June 13th, Mr. G. ANDERSON CRITCHETT, the President, from below the anterior tubercle of the tibia, exposing the being in the chair. Dr. LESLIE BUCHANAN read a paper on Inflammatory front of thejoint to above the insertion of the rectus femoris. The tendon though ecchymosed presented no Exudates into the Vitreous which was illustrated by lantern rupture and he was still unable to pull up the patella from slides made from his preparations. He said that the its position between the bones. Accordingly the joint was exudation into the vitreous in cyclitis was, in the first cut into about a finger’s breadth from the outer side of instance, formed in the pars ciliaris retinas, and more the patella, and passing in the finger the bare anterior especially in the non-folded portion of it, but soon the folded surface of the patella could be felt and seen presenting portion, the fibrous atroma of the ciliary body, and the upwards ; with a hook it was now levered into place. The retina took part in the production of the inflammatory The exudate into the vitreous body was wound of the capsule was closed with a continuous suture of exudate. chromicised gut, and afterwards the skin flap was dealt with seen in the fresh specimen fixed in 5 per cent. It might in like manner. The joint was carefully emptied of blood by formalin as opaque white flocculent masses. pressure and a bulky dressing was applied; no splint was be divided into zones, which from the ciliary body employed. A fortnight later the dressing was removed, when inwards were as follows-namely: (1) a fibrous zone ;i the jjint was found to be of normal appearance ; there was (2) a fibrinous zone ;and (3) a fibrino-cellular zone. The no gap above the patella and there was no tilting forwards of 1 Fractures and Dislocations, 1899, page 772. its upper edge, as is typical in rupture of the quadriceps. 2 1891, page 760. the Within another week patient was walking about the 3 Article " Rotule," Dictionnaire Encyclopédique des Sciences ward and on Feb. 22nd he was sent out. On the day after Médicales, 1877.
Medical Societies.