g the knee. On relaxing
the quadriceps, the fragments may be approximated more or less
completely.

_Prognosis._--In cases with little displacement, if the fragments have
been kept in perfect apposition, osseous union may take place, but in
the great majority of cases the union is fibrous. The shortening of
the quadriceps and the gradual stretching and thinning of the
connecting fibrous band may allow of further separation of the
fragments (Fig. 88), which to a variable extent interferes with the
stability and functions of the limb. The proximal fragment sometimes
becomes attached to the front of the femur, and moves with it, and the
fibrous band between the two fragments gradually becomes stretched.
After bony union has occurred, it is not uncommon for the patella to
be fractured again by a fall within a month or two of the original
accident.

[Illustration: FIG. 88.--Fracture of Patella, showing wide separation
of fragments, which are united by a fibrous band.

(Anatomical Museum of the University of Edinburgh.)]

_Treatment._--It is probably true that the best functional results are
most speedily obtained by operative measures. The laceration of the
aponeurosis of the quadriceps, the tilting of the fragments, and the
interposition of the torn periosteum between them, can in no other way
be rectified with certainty. The operation, however, should only be
undertaken by those who are familiar with wound technique, and who
have the means at their disposal for carrying it out. Operative
treatment is specially indicated in young subjects who lead an active
life, and in labouring men, particularly those who follow dangerous
employments necessitating stability of the knee.

As soon as the wound is healed,--in a week or ten days,--massage and
movement of the limb are commenced, and the patient is encouraged to
move his limb in bed. At the end of another week he may be allowed up
with sticks or crutches.

_Non-operative Treatment._--In the majority of cases occurring in
patients who do not follow a laborious occupation or otherwise lead an
active life, a satisfactory result can be obtained without having
recourse to operation. We have reason to be satisfied with the
following method: the patient is kept in bed for a few days, the
injured region being supported on a pillow and massaged daily, and the
patella moved from side to side as a whole to prevent adhesion to the
femur. About the fourth day he is allowed to get ab