Knee joint

“ In a knee hitter, also in an arm hitter, the bones of the foot and leg do not work true in their sockets, clear up to the knee, even the joint at the knee does not work true, the knee joint has a faulty motion, instead of breaking straight forward, it breaks out sideways as the rest of the leg starts to wing in. By building the foot mostly to the inside of the leg and having width and height of foot on the inside you are taking some of the power away that causes the winging in, and the breaking outward of the knee. ”

“ Of these, the knee-joint is most frequently affected, probably from the greater extent of cancellated and articulating surface. In young persons of unhealthy constitutions, the joints not unfrequently become affected one after another, and superficial abscesses form, terminating in open sores. I was obliged to amputate the upper extremity of a young lady a few days ago, in which a metacarpal bone and its articulation, the entire chain of carpal bones, the wrist and elbow joints, were all thoroughly involved in disease. ”

“ Many cases of wounds in the knee-joint, in which the capsular ligament has been wounded, and the articulation opened into without injury to the bones, do well, such as simple incised wounds made with a clean cutting instrument. The success attending all wounds of the knee-joint depends entirely upon absolute rest, upon the antiphlogistic mode of treatment being rigidly enforced, on the healthy state of the atmosphere, and on the locality being free from endemic disease. ”

“ There are a large number of bursae near the knee joint, one of which, common to the inner head of the gastrocnemius and the semimembranosus, often communicates with the joint. The hinge movement of the knee is accompanied by a small amount of external rotation at the end of extension, and a compensatory internal rotation during flexion. This slight twist is enough to tighten up almost all the ligaments so that they may take a share in resisting over-extension, because, in the erect position, a vertical line from the centre of gravity of the body passes in front of the knee. ”

“ In some cases it can be produced at will by the patient or the surgeon. We have observed one such case in a professional cyclist in whom this capacity of partially dislocating the knee entailed no disability. When the child begins to walk, an apparatus which will prevent hyper-extension and lateral motion should be fitted to the limb.
Congenital absence of the patella usually complicates other abnormalities of the knee-joint. The tubercle of the tibia is prominent and the extensor tendon unusually thick. In flexion the tendon rises on to the lateral condyle of the femur. ”

“ When the quadriceps is overcome by a contraction of the hamstrings, as in spastic paraplegia, the knee is fixed in the flexed position and the child is unable to walk. The flexion may be corrected by lengthening the hamstring tendons, bringing the divided biceps tendon through an opening in the vastus lateralis, and attaching it to the rectus and to the patella. If there is a combination of flexion and genu valgum, the knee-joint should be resected and ankylosed in the straight position. ”

“ 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. ”

“ A Loose Cartilage, or a Displaced Cartilage in the Knee Joint is apt to become caught in the hinge between the thigh bone and the leg bone, and by causing a sudden stretching of the ligaments of the joint to give rise to intense pain. ”

“ 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. ”

“ Most of the painful knee conditions of which patients complain are not directly due to true pathological conditions either of the knee joint itself or of its neighboring structures, but rather to affections of other portions of the leg that set a special strain upon the knee and, above all, to various kinds of foot disturbances. ”

“ 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. ”

“ Sprains of the knee are comparatively common as a result of sudden twisting or wrenching of the joint. In addition to the stretching or tearing of ligaments, there is usually a considerable effusion of fluid into the synovial cavity, and examination with the X-rays occasionally reveals that a portion of bone has been torn away with the ligament—sprain-fracture. The swelling fills up the hollows on either side of the patella, and extends for some distance in the synovial pouch underneath the quadriceps. ”

“ If a joint is left permanently stiff in an awkward and useless position, the limb may be greatly improved by excision of the joint. Thus, if the knee is left bent and the joint is excised a useful, straight limb may be obtained, somewhat shortened, and, of course, permanently stiff. If after disease of the hip-joint the thigh remains fixed in a faulty position, it may be brought down straight by dividing the bone near the upper end. A stiff shoulder or elbow may be converted into a useful, movable joint by excision of the articular ends of the bones. ”

“ 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. ”

“ In adolescent knock-knee the patient seeks advice because of the deformity or of pain after exertion, especially at the medial side of the epiphysial junctions, of being easily tired, and of incapacity for any occupation involving standing. The bones are coarse and badly formed, and there is frequently a spinous process projecting downwards from the medial side of the tibia about three finger-breadths below the joint. ”

“ No. 260. Some changes have been made in the ankle joint, but the notable modifications are a foot with thick sponge-rubber removable sole, K-K, in place of the rubber-covered core; for thigh amputations an adjustable steel knee cord and spring piston, combined in one piece, E, and knee-joint tightener, A.
The removable sole gives us an opportunity of strengthening the upper part of foot with a rawhide covering. Between the wooden part J and the rubber K at the toe part, layers of canvas and sole leather are placed to prevent breaking or turning up of the toe. ”

“ Painting the knee with tincture of iodine in spots as large as a silver dollar is also of service at this time. The knee should not be bent in walking until it can be moved by another person without producing discomfort.
Such treatment may be applied to the other joints in a general way. The elbow must be fixed by a splint as recommended for dislocation of the joint (p. 128) . The ankle is treated as advised for sprain of that joint (p. 68) . When a physician can be obtained no layman is justified in attempting to treat a case of water on the knee or similar affection of other joints. ”

“ 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. ”

“ They are most commonly met with in the knee-joint, producing inconvenience by impeding progression. Sometimes they are neither painful nor annoying, being small, and seldom becoming interposed between the articulating extremities of the bones during motion; such ought not to be interfered with. But when large, they may be so troublesome as to warrant incision and removal. The foreign body is made to project on one side, and, having been made as superficial as possible at a favourable point, is fixed by the fingers of an assistant. ”

“ The tibial collateral ligament, and through it the coronary ligament, are thus gradually stretched, so that the cartilage becomes less securely anchored, and is rendered liable to be displaced towards the centre of the joint during some sudden movement which combines flexion of the knee with medial rotation of the femur upon the tibia, as, for example, in rising quickly from a squatting position, or turning rapidly and pushing off with the foot, in the course of some game such as football or tennis. ”

“ The ambiens muscle, long and spindle-shaped, lying immediately beneath the skin, extending from the pectineal process or ilio-pubic spine to the knee, is the most median of the muscles of the thigh. When typically developed its long tendon passes the knee-joint, turning towards its outer side, and lastly, without being anywhere attached to the knee, it forms one of the heads of the flexor perforatus digit, ii. ”

“ In the treatment of stiffened knees, even where accidental bending of the joint gives very great pain, it is a grave mistake to put the knee in splints to prevent bending. What is wanted is to encourage bending as far as that can be done without much pain, so that the joint may not permanently stiffen. Even where, by the use of splints, permanent stiffness seems to have been brought on, the warm-water treatment recommended above will bring about a loosening and softening of the joint, which will permit first of a slight bending, and then, with gentle encouragement, a complete flexibility. ”

“ As regards treatment, a tightly fitting steel cage-like splint, which, gripping the thigh and leg, limits the movements of the knee to flexion and extension, may prove useful. But for a muscular, athletic individual the wearing of this apparatus may prove vexatious and disappointing. The only alternative is to open the joint and remove the loose cartilage. The cartilage may be found on operation to be split, torn or crumpled, and lying right across between the joint-surfaces of the bones, from which nothing but an operation could possibly have removed it. ”

“ Chronic effusion into the joint is most rapidly got rid of by rest and blistering. If the patient is unable to lie up, massage should be systematically employed, and a firm elastic bandage worn. A patient who has once had a severe sprain of the knee, or who has developed the condition of “footballer's knee,” must give up violent forms of exercise which expose him to further injuries, otherwise the condition is liable to be aggravated and to result in permanent impairment of the stability of the joint. ”

“ The use of a strong knee-cap may prevent falling, but as a rule an operation is required, and there is quite a number to choose from, the principle of them all being to prevent displacement of the bone without unduly restricting flexion of the joint. That devised by Goldthwait consists in exposing, by means of a vertical incision, the whole length of the patellar ligament, splitting it longitudinally, separating the lateral half from the tibia, passing it under the medial portion and suturing it to the periosteum; this gives the quadriceps a straight line of pull. ”

“ These joints can move backward and forward in one plane like a hinge, but they cannot move in a circle like the ball and socket joints. You cannot swing your forearm about on a pivot at the elbow as you can your whole arm, nor will the knee joint bend in every direction as does the joint at the hip. ”

“ In fracture of the leg between the knee and ankle we have pain, angular deformity or an apparent false joint in the leg, swelling and tenderness over the seat of fracture, together with inability to use the injured leg. Two bones form the framework of the leg; the inner, or shinbone, the sharp edge of which can be felt in front throughout most of its course, being much the larger and stronger bone. When both bones are broken, the displacement of the fragments, abnormal motion and consequent deformity, are commonly apparent, and a grating sound may be heard, but should not be sought for. ”