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Osteochondral fracture of the knee-joint
558
American
Journal
of Surgery
Krida-Fracture
of the Knee-Joint
and did not wish her fiance to know that she was Iame. Shortly after the same miracIe took pIace in the case of the Austrian girl Her charitabIe uncIe got tired of supporting her in idIeness and she was forced to get a job. I think that is a point of great importance in the seIection of cases suitabIe for such operations, that the patients should have enough iron in their souIs to deveIop the quadriceps muscIe, which is, equaIIy with the ligaments, responsibIe for the stabiIity of the knee. DR. BENJAMIN: Dr. Krida spoke of the suc-
OSTEOCHONDRAL
cess of 6 out of 8 cases. I happen to know of one of these cases which was done some four or five years ago. After the operation this young feIIow had a job as a radio repair man, and he feI1 off a roof and had some injury to his knee. SubsequentIy he feI1 off a horse, and was again injured but was abIe to waIk after that. That seems to indicate that his knee was fairIy we11 stabiIized. DR. KRIDA, closing: It is very important to seIect the proper patients for these cases. They shouId be under thirty years of age.
FRACTURE
ARTHUR
KRIDA,
M.D.,
OF THE KNEE/JOINT* F.A.C.S.
NEW YORK
T
HE case here shown is one of a number of operated cases of fractures of the articuIating surface of the interna condyIe of the femur, commonIy entaiIing as a Iate resuIt the formation of free osteocartiIaginous bodies in the kneejoint. The condition is commonly caIIed osteochondritis dissecans. Since there is in these cases no clear evidence of osteochondritis, and since a11 those cases operated upon by myseIf were of definiteIy traumatic origin, I preferred the designation osteochondra1 fracture, as more cIearIy indicating their traumatic origin, and so described it in a previous paper.’ A. V., aged fifty, sea captain, U. S. Marine HospitaI, No. 21. History: Three months prior to operation, he feI1 from a height of 5 ft., striking on the extended right Iower extremity. The knee became painfu1 and swoIIen but he was abIe to hobble about. The pain and disabiIity became graduaIIy worse, so that his sIeep was disturbed, and he Iost 15 Ib. in weight. He compIains of a sensation of slipping on the inner side of the joint, and he refers his pain to that point. Examination: He walks with the aid of a 1KRIDA, A. Osteochondral fracture joint. Surg. Gynec. Obsr., 39: 791, 1924. * Presented
of
the
before the Section of Orthopedic
knee
stick, evidentIy in considerabIe pain. The quadriceps muscIe is greatIy atrophied, extension is limited at 165”, ffexion is possibIe to 80”. There is rather sIight infiItration and no effusion. There is marked tenderness over the articuIar surface of the interna condyIe when the knee is flexed. X-ray fiIms show an irreguIarIy ova1 fracture of the articuIating surface of the interna condyle. The fracture Iine is represented by a narrow area of rarefaction which has been accentuated artificiaIIy in the accompanying reproduction since it may be seen we11 onIy by transmitted Iight in the origina fiIms. Operation: December 14, 1927. The joint was opened by the genera1 utiIity incision. The middIe of the weight bearing surface of the internal condyIe presented a semi-detached fracture fragment 3~ X I in. in size, and including about SQ in. of the underIying bone. This was removed; the rough edges of the remaining crater were smoothed off as we11 as possible with a chisel. Result: His pain was reIieved by the remova of the fragment. February 1930; range of motion compIete. There is grating in the joint, and some discomfort after use, so that he has had to seek Iighter empIoyment. His symptoms have to a great extent been reIieved, but those which persist must be ascribed to the Iocation of the fracture directIy in the middIe of the weight bearing surface of the condyIe.
Surgery, New York Academy of Medicine, February,
1930.
NEW SERIES VOL. IX, No.
3
Krida-Fracture
DISCUSSION
DR. HENRY MILCH: I am of the opinion that the type of osteochondral fracture due to a severe trauma is 0nIy one form of osteochondritis dissecans. Within the past three months, I have operated on a case which I consider osteochondritis dissecans in which there was a history of repeated minimal traumata. On opening the joint, found two osteochondra1 masses, but no concavity on the surface of either condyIe from which they might have originated. The cartiIage covering the articuIar surface of the femur gave the impression of having been moth-eaten, either as a resuIt of the erosion caused by the joint mice, or as a result of the underlying pathoIogica1 process which resuIted in the formation of joint mice. I fee1 that this, too, is a case of osteochondritis dissecans, and that it shouId be incIuded in the Iarge group of osteochondritis dissecans which embraces as one type the osteochondral fracture which Dr. Krida has presented. DR. W. M. BRICKNER: On various occasions I have advocated the treatment by aspiration of so-caIIed traumatic synovitis. I have no doubt some of you have aIso used it instead of the time-honored strapping, bandaging and massage. I employ it in the smaIIer joints, e.g., the finger, the wrist; but, of course, especiaIIy in the knee. I have aIso emphasized the fact that the fluid at the outset of these cases is aIways bIood or bIoody, in other words, that we are dealing with an acute synovitis with a hemarthrosis; and, since there is bIood in the joint, we must postuIate a tear of the capsuIe to produce it, and some injury to a structure outside the capsuIe, Iigament, bone or cartiIage. Therefore one shouId have a more definite picture of traumatic synovitis in mind than that of a mere sprain. The injury is often an overIooked joint fracture that may not be seen even with ordinary x-ray examination. Sometimes, however, we will find a crack in the bone (femur or tibia) if the pictures are taken from various angIes and with particuIar care to get bone detai1. AIso productive of traumatic synovitis is the condition Dr. Krida has described, osteochondra1 fracture,. and this, too, occurs oftener than is generaIIy recognized. I have in mind a case I operated on some time ago, a young man with recurrent effusions in the knee-joint foIIowing an injury sustained some months previousIy and with an x-ray finding simiIar to that shown by Dr. Krida. He, too,
of the
Knee-Joint
A m&can Journnl of Surgery
559
had an osteochondra1 fracture of a condyIe of the femur. When I opened the knee-joint and removed this fragment of bone and carti-
FIG. I. Osteochondral
fracture.
Iage, I found another, unsuspected and very much Iarger fragment of partly attached condyIar cartiIage, a pure chondra1 fracture of the articuIar surface of the femur. There must often occur such chondral fractures or cartiIage tears, in connection with traumatic synovitis. We can see roentgenographicaIIy the osteochondra1 fracture, since it tears off a bit of bone; the pureIy chondra1 fracture, however, is not shown in the x-ray film. DR. KRIDA, closing: I agree with Dr. Brickner that some of the most striking cures can be made by aspirating the knee-joint in cases of hemarthrosis. On one occasion I was caIIed to see a big man who had been Iying in bed for three days unable to obtain reIief from mor-
560
American
Journal
of Surgery
Krida-Dislocation
of Vertebrae
phine; he had hurt his knee, and by having the joint aspirated of about 6o C.C. of blood, he was entirely relieved. As to Dr. MiIch’s remarks about these fractures, I did not mean to imply that there if no such condition as osteochondritis dis-
SEPTEMBER. ,930
secans; it must be very rare; in exploring kneejoints I have never seen one that I could not attribute to traumatism. I have never seen ostcochondritis dissecans non-traumatic. These fractures correspond in appearance to Koenig’s description of osteochondritis dissecans.
DISLOCATION BETWEEN FIFTH @ SIXTH CERVICAL VERTEBRAE DELAYED
OPERATIVE ARTHUR
REDUCTION
KRIDA, M.D., F.A.C.S. NEW
T
HE
which
case
a
here
reported
successful
is
outcome
& FUSION*
one
YORK
in
was
obtained by open reduction and fusion of a gros.sIy unstabIe fifth and sixth cervical dislocation, eleven weeks after injury. The possible failure to obtain and the obvious failure to maintain reduction are outlined in the recital of events
prior to the date of operation.
being fastened to a single foot stirrup, and counter traction by a surcingle over the iliac crests reinforced by manual traction on the Iower extremities. After fairly considerable traction had been apphed, there was a coarse bony click. The traction on the head was then maintained manually and a pIaster of Paris dressing was applied including the chin and occiput and extending to below the nipple line. The patient was not again seen until admission to Hospital for Ruptured and Crippled five weeks later, and details of his stay at the country hospital include an x-ray picture taken through the plaster collar which was reported upon as indicating that the dislocation had been reduced. Without advice the collar was removed at the end of three weeks since there was no evidence of paralysis at this time and patient ahowcd to sit up and move his neck about. At this time an x-ray- was made which, much to the astonishment of the attending surgeon, showed that the dislocation has either recurred or in the initial instance not been reduced. November g, 1928. Hospital for Ruptured and Crippled. There was no pain, paralysis, or gross external deformity. The x-rav sholvcd a rcmarkabIc degree of dislocation at the junction of the fifth and sixth cervical vertebrae. The dislocation of the fifth body was of a degree where its posterior border impinged just behind the anterior upper border of the sixth. There was aIso an angulation at this point in which the upper part of the spine was angulated forward on the lower. There was no evi-
History: A. H., aged forty-two, laborer. Forty-eight hours previously he was struck on the back of the head by a bale of hay falling from a Ioft in the barn. It was stated that he was immediately disabled and that he had paralysis of the extensors of the wrists and fingers, and of the biceps humeri on both sides, together with a feeling of heaviness in both Iower extremities. I was asked to see the patient at the request of an insurance company in consuItation with his attending physician at a hospital in the country. He had at this time no paralysis, but weakness of the extensors of the wrist and fingers, and a very much increased knee-jerk on the right side. He was in great pain and his neck was rigid. The x-ray showed a nearly complete forward dislocation of the fifth upon the sixth cervical vertebra. I. Closed manipulation. The Operation patient was removed to the operating room. Traction apparatus was improvised, and the patient was anesthetized with cthcr. Traction was applied to the head with an improvised portable Hawley apparatus, the head straps * Case reported and .x-rays shown before the Set tion of Orthopedic Surgery, New York Academy of Rlcdicine, February,
1930.
American
Journal
of Surgery
Krida-Fracture
of the Knee-Joint
and did not wish her fiance to know that she was Iame. Shortly after the same miracIe took pIace in the case of the Austrian girl Her charitabIe uncIe got tired of supporting her in idIeness and she was forced to get a job. I think that is a point of great importance in the seIection of cases suitabIe for such operations, that the patients should have enough iron in their souIs to deveIop the quadriceps muscIe, which is, equaIIy with the ligaments, responsibIe for the stabiIity of the knee. DR. BENJAMIN: Dr. Krida spoke of the suc-
OSTEOCHONDRAL
cess of 6 out of 8 cases. I happen to know of one of these cases which was done some four or five years ago. After the operation this young feIIow had a job as a radio repair man, and he feI1 off a roof and had some injury to his knee. SubsequentIy he feI1 off a horse, and was again injured but was abIe to waIk after that. That seems to indicate that his knee was fairIy we11 stabiIized. DR. KRIDA, closing: It is very important to seIect the proper patients for these cases. They shouId be under thirty years of age.
FRACTURE
ARTHUR
KRIDA,
M.D.,
OF THE KNEE/JOINT* F.A.C.S.
NEW YORK
T
HE case here shown is one of a number of operated cases of fractures of the articuIating surface of the interna condyIe of the femur, commonIy entaiIing as a Iate resuIt the formation of free osteocartiIaginous bodies in the kneejoint. The condition is commonly caIIed osteochondritis dissecans. Since there is in these cases no clear evidence of osteochondritis, and since a11 those cases operated upon by myseIf were of definiteIy traumatic origin, I preferred the designation osteochondra1 fracture, as more cIearIy indicating their traumatic origin, and so described it in a previous paper.’ A. V., aged fifty, sea captain, U. S. Marine HospitaI, No. 21. History: Three months prior to operation, he feI1 from a height of 5 ft., striking on the extended right Iower extremity. The knee became painfu1 and swoIIen but he was abIe to hobble about. The pain and disabiIity became graduaIIy worse, so that his sIeep was disturbed, and he Iost 15 Ib. in weight. He compIains of a sensation of slipping on the inner side of the joint, and he refers his pain to that point. Examination: He walks with the aid of a 1KRIDA, A. Osteochondral fracture joint. Surg. Gynec. Obsr., 39: 791, 1924. * Presented
of
the
before the Section of Orthopedic
knee
stick, evidentIy in considerabIe pain. The quadriceps muscIe is greatIy atrophied, extension is limited at 165”, ffexion is possibIe to 80”. There is rather sIight infiItration and no effusion. There is marked tenderness over the articuIar surface of the interna condyIe when the knee is flexed. X-ray fiIms show an irreguIarIy ova1 fracture of the articuIating surface of the interna condyle. The fracture Iine is represented by a narrow area of rarefaction which has been accentuated artificiaIIy in the accompanying reproduction since it may be seen we11 onIy by transmitted Iight in the origina fiIms. Operation: December 14, 1927. The joint was opened by the genera1 utiIity incision. The middIe of the weight bearing surface of the internal condyIe presented a semi-detached fracture fragment 3~ X I in. in size, and including about SQ in. of the underIying bone. This was removed; the rough edges of the remaining crater were smoothed off as we11 as possible with a chisel. Result: His pain was reIieved by the remova of the fragment. February 1930; range of motion compIete. There is grating in the joint, and some discomfort after use, so that he has had to seek Iighter empIoyment. His symptoms have to a great extent been reIieved, but those which persist must be ascribed to the Iocation of the fracture directIy in the middIe of the weight bearing surface of the condyIe.
Surgery, New York Academy of Medicine, February,
1930.
NEW SERIES VOL. IX, No.
3
Krida-Fracture
DISCUSSION
DR. HENRY MILCH: I am of the opinion that the type of osteochondral fracture due to a severe trauma is 0nIy one form of osteochondritis dissecans. Within the past three months, I have operated on a case which I consider osteochondritis dissecans in which there was a history of repeated minimal traumata. On opening the joint, found two osteochondra1 masses, but no concavity on the surface of either condyIe from which they might have originated. The cartiIage covering the articuIar surface of the femur gave the impression of having been moth-eaten, either as a resuIt of the erosion caused by the joint mice, or as a result of the underlying pathoIogica1 process which resuIted in the formation of joint mice. I fee1 that this, too, is a case of osteochondritis dissecans, and that it shouId be incIuded in the Iarge group of osteochondritis dissecans which embraces as one type the osteochondral fracture which Dr. Krida has presented. DR. W. M. BRICKNER: On various occasions I have advocated the treatment by aspiration of so-caIIed traumatic synovitis. I have no doubt some of you have aIso used it instead of the time-honored strapping, bandaging and massage. I employ it in the smaIIer joints, e.g., the finger, the wrist; but, of course, especiaIIy in the knee. I have aIso emphasized the fact that the fluid at the outset of these cases is aIways bIood or bIoody, in other words, that we are dealing with an acute synovitis with a hemarthrosis; and, since there is bIood in the joint, we must postuIate a tear of the capsuIe to produce it, and some injury to a structure outside the capsuIe, Iigament, bone or cartiIage. Therefore one shouId have a more definite picture of traumatic synovitis in mind than that of a mere sprain. The injury is often an overIooked joint fracture that may not be seen even with ordinary x-ray examination. Sometimes, however, we will find a crack in the bone (femur or tibia) if the pictures are taken from various angIes and with particuIar care to get bone detai1. AIso productive of traumatic synovitis is the condition Dr. Krida has described, osteochondra1 fracture,. and this, too, occurs oftener than is generaIIy recognized. I have in mind a case I operated on some time ago, a young man with recurrent effusions in the knee-joint foIIowing an injury sustained some months previousIy and with an x-ray finding simiIar to that shown by Dr. Krida. He, too,
of the
Knee-Joint
A m&can Journnl of Surgery
559
had an osteochondra1 fracture of a condyIe of the femur. When I opened the knee-joint and removed this fragment of bone and carti-
FIG. I. Osteochondral
fracture.
Iage, I found another, unsuspected and very much Iarger fragment of partly attached condyIar cartiIage, a pure chondra1 fracture of the articuIar surface of the femur. There must often occur such chondral fractures or cartiIage tears, in connection with traumatic synovitis. We can see roentgenographicaIIy the osteochondra1 fracture, since it tears off a bit of bone; the pureIy chondra1 fracture, however, is not shown in the x-ray film. DR. KRIDA, closing: I agree with Dr. Brickner that some of the most striking cures can be made by aspirating the knee-joint in cases of hemarthrosis. On one occasion I was caIIed to see a big man who had been Iying in bed for three days unable to obtain reIief from mor-
560
American
Journal
of Surgery
Krida-Dislocation
of Vertebrae
phine; he had hurt his knee, and by having the joint aspirated of about 6o C.C. of blood, he was entirely relieved. As to Dr. MiIch’s remarks about these fractures, I did not mean to imply that there if no such condition as osteochondritis dis-
SEPTEMBER. ,930
secans; it must be very rare; in exploring kneejoints I have never seen one that I could not attribute to traumatism. I have never seen ostcochondritis dissecans non-traumatic. These fractures correspond in appearance to Koenig’s description of osteochondritis dissecans.
DISLOCATION BETWEEN FIFTH @ SIXTH CERVICAL VERTEBRAE DELAYED
OPERATIVE ARTHUR
REDUCTION
KRIDA, M.D., F.A.C.S. NEW
T
HE
which
case
a
here
reported
successful
is
outcome
& FUSION*
one
YORK
in
was
obtained by open reduction and fusion of a gros.sIy unstabIe fifth and sixth cervical dislocation, eleven weeks after injury. The possible failure to obtain and the obvious failure to maintain reduction are outlined in the recital of events
prior to the date of operation.
being fastened to a single foot stirrup, and counter traction by a surcingle over the iliac crests reinforced by manual traction on the Iower extremities. After fairly considerable traction had been apphed, there was a coarse bony click. The traction on the head was then maintained manually and a pIaster of Paris dressing was applied including the chin and occiput and extending to below the nipple line. The patient was not again seen until admission to Hospital for Ruptured and Crippled five weeks later, and details of his stay at the country hospital include an x-ray picture taken through the plaster collar which was reported upon as indicating that the dislocation had been reduced. Without advice the collar was removed at the end of three weeks since there was no evidence of paralysis at this time and patient ahowcd to sit up and move his neck about. At this time an x-ray- was made which, much to the astonishment of the attending surgeon, showed that the dislocation has either recurred or in the initial instance not been reduced. November g, 1928. Hospital for Ruptured and Crippled. There was no pain, paralysis, or gross external deformity. The x-rav sholvcd a rcmarkabIc degree of dislocation at the junction of the fifth and sixth cervical vertebrae. The dislocation of the fifth body was of a degree where its posterior border impinged just behind the anterior upper border of the sixth. There was aIso an angulation at this point in which the upper part of the spine was angulated forward on the lower. There was no evi-
History: A. H., aged forty-two, laborer. Forty-eight hours previously he was struck on the back of the head by a bale of hay falling from a Ioft in the barn. It was stated that he was immediately disabled and that he had paralysis of the extensors of the wrists and fingers, and of the biceps humeri on both sides, together with a feeling of heaviness in both Iower extremities. I was asked to see the patient at the request of an insurance company in consuItation with his attending physician at a hospital in the country. He had at this time no paralysis, but weakness of the extensors of the wrist and fingers, and a very much increased knee-jerk on the right side. He was in great pain and his neck was rigid. The x-ray showed a nearly complete forward dislocation of the fifth upon the sixth cervical vertebra. I. Closed manipulation. The Operation patient was removed to the operating room. Traction apparatus was improvised, and the patient was anesthetized with cthcr. Traction was applied to the head with an improvised portable Hawley apparatus, the head straps * Case reported and .x-rays shown before the Set tion of Orthopedic Surgery, New York Academy of Rlcdicine, February,
1930.