f the bones being rawed and
adhesions divided. When the proximal fragment has become attached to
the femur, it should be separated and a layer of fascia interposed; it
is sometimes necessary to lengthen the quadriceps muscle by making a
number of V-shaped incisions through its substance; or a flap may be
turned down from the rectus and stitched to the patella and the
ligamentum patellae.

When operative treatment is contra-indicated, the patient should be
fitted with a firm apparatus which will limit flexion of the knee and
support the fragments.

#Dislocation of the patella# is rare. It results from exaggerated
muscular movements when the limb is in the fully extended position, or
from a blow on one or other edge of the bone. Laxity of the ligaments
and knock-knee are predisposing factors. It is sometimes associated
with fracture of the edge of the trochlear surface, which renders
retention in position difficult.

The _lateral_ is the most common variety--the _medial_ being rare.
Either may be complete or incomplete. Sometimes the bone is rotated so
that its edge rests on the front of the femur--_vertical_ dislocation;
and in a few cases it has been completely turned round, so that the
articular surface is directed forwards.

_Clinical Features._--The joint is fixed, usually in a position of
slight flexion, and the displaced patella can readily be palpated. The
deformity is a striking one, and at first sight suggests a much more
serious injury. Although easily reduced, the dislocation is liable to
recur.

To effect reduction, the quadriceps must be thoroughly relaxed by
extending the leg upon the thigh and flexing the thigh upon the
pelvis; the patella is then tilted by making firm pressure on that
edge which lies farthest from the middle of the joint, and at the same
time pushing towards the middle line. The limb is placed on a
posterior splint, and firm elastic pressure made on the joint to
prevent or diminish effusion. Massage and movement are carried out
from the first.

As the displacement is liable to recur, the patient should wear a firm
elastic bandage or a strong knee-cap.

_Permanent and recurrent dislocation of the patella_ will be described
later.

FRACTURE OF THE BONES OF THE LEG

The bones of the leg may be broken together or separately.

#Fracture of both Bones.#--The features of this injury depend to a
large extent upon the nature of the violence producing it. In fracture
by _direct_ vi