Knee breeches

“ I prefer a compromise: the breeches made loose to the knee, as above described, but the leg of the breech below the knee carried on and down, in the same material and shaped to the calf, low enough to be easily covered at the end by a sock. To allow passage to the foot, the extension opens down the inside of the calf, and is secured there by a row of four small press springs. Buttons or buckles at the knees are always breaking on rocks, and can be painful. Lacing is better, but apt to be too tight. ”

“ The principle of breeches is a close fit for the inner surface of the knee and thigh, because with heavy material such as leather or cloth any wrinkles against the saddle will tear off one's skin and cause a deal of pain. With bent leg riding, the outer surface of the thighs had to be loosened, and this loosening has developed into monstrous puffed sleeves which expose the Englishman to ridicule on an irreverent stock-range. ”

“ Ossification in the crureus or vastus lateralis muscle has been frequently observed as a result of a kick from a horse. Within a week or two a swelling appears at the site of injury, and becomes progressively harder until its consistence is that of bone. If the mass of new bone moves with the affected muscle, it causes little inconvenience. If, as is commonly the case, it is fixed to the femur, the action of the muscle is impaired, and the patient complains of pain and difficulty in flexing the knee. ”

“ It is of the first importance that people should learn to abhor anything which is so awkward, perishable, and dirty as a hassock. They must not, however, forget, as some do, that the human body is so constituted that kneeling on the floor for any length of time is not the alternative. Such kneeling strains the joint between the foot and the leg at the point B B in the accompanying drawing. It is not a natural posture for that joint. To most people there would be the further objection that the floor must be dirty. The knee should be lifted about five inches above the floor in kneeling. ”

“ The configuration then of the articulations, and of the bones of the elbow, is such as I have described. Owing to their configuration, the bones at the knee are indeed frequently dislocated, but they are easily reduced, for no great inflammation follows, nor any constriction of the joint. They are displaced for the most part to the inside, sometimes to the outside, and occasionally into the ham. The reduction in all these cases is not difficult, but in the dislocations inward and outward, the patient should be placed on a low seat, and the thigh should be elevated, but not much. ”

“ Once the joint is flexed, the involuntary contraction of the flexor muscles maintains the attitude, and if the patient is able to use the limb in walking, the weight of the body is a powerful factor in increasing it. The eversion of the leg is probably associated with contraction of the biceps muscle. Backward displacement of the tibia is met with chiefly in neglected cases of chronic disease of the knee when the child has walked on the limb after it has become flexed. ”

“ It is obvious that, when the disease has proceeded thus far, the joint must become more or less deformed, and its motions considerably impeded. Accordingly, old men are often seen at work with much rigidity of the joints, particularly of the knee, which is frequently projected inwards, from absorption of the cartilage from the outer condyle of the femur and corresponding part of the tibia, with a thinning and degeneration of the inner-articular cartilage into a tissue resembling the cellular. ”

“ Conditions, Etc.—This condition, which may affect almost any freely movable joints, as the knee, elbow, ankle, and hip, is commonly caused by a wrench, blow, or fall. Occasionally it comes on without any apparent cause, in which case there is swelling and but slight pain or inflammation about the joint. We shall speak of synovitis of the knee ("water on the knee") , as that is the most common form, but these remarks will apply almost as well to the other joints. In severe cases there are considerable pain, redness and heat, and great swelling about the knee. ”

“ It more frequently occurs in young adults. Immediate pain is felt in the knee and walking becomes impossible; in fact, often the patient cannot rise from the ground after the acci [Pg 110] dent. Swelling at first is slight, but increases enormously within a few hours. Immediately after the injury it may be possible to feel the separate broken fragments of the kneepan and to recognize that they are separated by a considerable space if the break is horizontally across the bone.
Fig. 26. A BROKEN KNEEPAN (Scudder) .
A padded splint, supporting knee, is shown reaching from ankle to thigh. ”

“ The causes of this unsoundness are hereditary and accidental. Weak knees due to faulty conformation seldom escape becoming sprung in animals that are given hard work. Severe and continuous driving is a common factor in the production of this condition. Strains of the flexor muscles of the region may cause it. The retraction of the flexor muscles and their tendons and the aponeurosis of the antibrachial region occurs in this disorder and prevents the animal from extending the knee. ”

“ The result, then, is that the coronet bone forces the navicular hard against the flexor tendon, which, in turn, presses firmly against the navicular as the force of the contracting muscles lifts the tendon into place. It is self-evident, then, that the more rapid the pace and the greater the load, the greater must these contending forces be, and the greater the liability to injury. For the same reason horses with excessive knee action are more liable to suffer from this disease than others, concussion of the foot and intense pressure on the tendon being common among such horses. ”

“ The parts can be immobilised by the application of a vesicant or mild blister. A week or ten days later dry friction, muscular and periarticular massage are indicated, and gentle exercise should be commenced. The same treatment may be employed in strain of the elbow joint and in strains of muscles or tendons in the neighbourhood of joints. Such lesions are, however, very rare in the ox.
STRAIN OF THE KNEE. Strain of the knee is commoner in the ox than in the horse, because of the special conformation of the knee in the ox and the mode of working under a yoke. ”

“ That the patella and articular surface of the femur are healthy. These conditions at once exclude nearly every case of disease or accident. If the joint is diseased some amputation through the thigh must be attempted; if injured, and the front of the knee is safe, it may very likely be possible to amputate below the knee. Hence this operation may be useful in cases where, for malignant disease, the whole tibia requires removal, and yet the knee-joint is sound, or for gunshot injuries, in which the tibia is splintered but the soft tissues comparatively uninjured. ”

“ From one to two months are required to secure union in a broken leg in adults, and from three to five months elapse before the limb is completely serviceable. In children the time requisite for a cure is usually much shorter.
ANKLE-JOINT FRACTURE.
First Aid Rule.—One or both bones of leg may be broken just above ankle. Foot is generally pushed or bent outward. Prepare two pieces of thin wood, four inches wide and long enough to go from sole of foot to just below knee:—the splints. Pad them with folded towels or pieces of blanket. ”

“ This was the direct result of his previous inaction. He moved only with pain; and yet, by the stern north-country code, he made no complaint and moved as rapidly as possible. Each time he raised his knee a sharp pain stabbed his groin, as though he had been stuck by a penknife; each time he bent his ankle in the recover the mal de raquette twisted his calves, and stretched his ankle tendons until he felt that his very feet were insecurely attached and would drop off. ”

“ The Foot is very rarely dislocated from the leg without fracture of the malleoli. Its reduction requires simple extension of the foot on the leg, with the [Pg 111] knee bent; the surgeon grasps the heel in one hand, the foot in the other, while an assistant fixes the thigh in the half-bent position. The foot is first drawn downwards to disengage it from the tibia, and then directed into its place.
After reduction the limb should be put in a McIntyre’s splint, in the way described for fracture of the tibia near the ankle-joint. ”

“ He may fall to the ground and be unable to rise. On examination, the knee is found to be fixed in a slightly flexed position; and while the surgeon may be able to carry out movements of flexion to a considerable extent without increasing the pain, any attempt to extend the joint completely is extremely painful. Tenderness may be elicited on making pressure to the medial side of the ligamentum patellæ in the groove between the femur and the tibia, but the meniscus cannot be recognised by palpation. Considerable effusion rapidly takes place into the synovial cavity. ”

“ Hence any deviation from this line, one way or the other, indicates more or less dislocation of the tibia. There is a pellet of fat under the ligament, which answers a ‘packing’ purpose—sinking in when the knee is bent; rising when the knee is extended, and bulging on either side of the tendon, almost enough to give the feel of fluctuation.
In a well-formed leg the ligamentum patellæ, the tubercle [Pg 51] of the tibia, and the middle of the ankle should be in the same straight line. ”

“ In oblique fracture a gliding displacement is liable to occur and cause bow- or knock-knee. Transverse fracture of the head of the fibula sometimes accompanies fracture of the head of the tibia, and there is always considerable effusion into the knee-joint. One or other of the condyles may be chipped off by forcible adduction or abduction at the knee. ”

“ When the metal lever moves around the axis of the knee joint, its lower end and the pulleys at the upper end travel in opposite directions: in flexion the pulleys move downwards and forwards, the lower end upwards and backwards; in extension they move in the opposite direction. Therefore when the limb is swung and the knee bends (Fig. 71) , the thigh piece drops of its own weight, the braces tighten, raise the pulley and consequently make the lower end of the lever move downwards and forwards, thus extending the knee joint. ”

“ The shaft is prismoid and is more slender for the lower quarter, where fracture is consequently most frequent. The anterior border forms the crest or shin and can be felt for its upper two-thirds. The lower extremity, which is smaller than the upper, articulates with the astragalus bone of the ankle and with the fibula. Its head or upper extremity is expanded into two lateral tuberositis for articulation with the femur and for muscular attachment, both of which can easily be felt just below the bend of the knee. ”

“ The symptoms are swelling, heat, and proportionate degree of lameness. Bleeding and rest are absolutely necessary, assisted by an emollient poultice from the hoof to the knee. A flannel bag, or large woollen stocking, secured above the shoulder by a tape, is the best mode of applying the poultice. All movement of the knee should be avoided. ”

“ A swelling forms in the upper and medial part of the thigh, which becomes smaller and harder when the muscle is thrown into contraction.
The _quadriceps femoris_ is usually ruptured close to its insertion into the patella, in the attempt to avoid falling backwards. The injury is sometimes bilateral. The injured limb is rendered useless for progression, as it suddenly gives way whenever the knee is flexed. ”

“ Now, such is the mutual static interdependence of the component parts of the lower limb that this condition of flatfoot promotes or favours the incidence of villous overgrowths in the proximal joints, the knees. As to the modus operandi we have put forward the following explanation: “The everted foot, with its sunken arch, as before stated, determines an alteration in the normal coaptation of the articular surfaces in the knee, and this incongruence is revealed in skiagraphs by the marked prominence laterally of the external tibial tuberosity beneath the external femoral condyle. ”

“ If the leg stump is ten centimetres long, if the knee joint is freely mobile and capable of complete, or almost complete, active extension, and if there are no adherent scars around the tuberosities of the tibia, the American apparatus with free knee joint should be adopted. ”

“ If the fracture be simple, a bandage of strips previously applied round the limb from the ancle to the knee is highly useful. It secures the fragments more effectually from lateral displacement, and prevents the swelling of the leg. A simple roller applied with a moderate degree of tightness round the foot, is also of service in preventing a swelling in that part, as well as in removing it if it has already occurred. ”

“ They are subject to injury such as is occasioned by hard work and concussion and contract as a result; but, more frequently a congenital malformation of the leg is responsible for undue strain upon these parts. Horses that are "knee sprung" or that have a congenital condition where in the anterior line, as formed by the radius, carpal and metacarpal bones, is bent forward at the carpus, are subject to inflammation and contraction of the carpal flexors. When these flexors are contracted, the condition is commonly known among horsemen as "buck knee." ”

“ The McIntyre’s Splint may be used either bent or straight, whichever position of the knee most relaxes the tension of the muscles on the fragments. As a general rule the straight position is best if the fracture is high up, and the bent one, when near the ankle joint. ”

“ The man softly, yet awkwardly, lifted the robe, folded it back, and slowly uncovered the knee. The leg was worn away almost to skin and bone, but the knee itself was swollen with inflammation. He bathed it with some water, mixed with vinegar and herbs, then drew down the deer-skin shirt, and did the same with the child's shoulder. Both shoulder and knee bore the marks of teeth,—where a huge wildcat had made havoc—and the body had long red scratches. ”