WOUNDS OF THE LOWER LIMBS
Lesions of the lower limbs are about two-thirds of the total wounded (Ferraton).
Wounds of the Soft Parts.
Before speaking of the wounds caused by weapons used in warfare, let us call attention to the oedema seen in men who are obliged to keep on their bandages (puttees) for too long a time; also to the ulcerated blisters on the sole, on the posterior part of the foot, regions that correspond to the tendo Achillis, to the malleoli, these excoriations being so frequent that formerly at the beginning of a campaign it was admitted that a fifth of the strength of an army was rendered unavailable through this cause. When badly treated, these excoriations give rise to reticular lymphangitis of the foot, which extends to the leg, and is too often followed by abscesses and diffuse putrid phlegmonous inflammation. Military surgeons cannot pay too much attention to the question of these complications, which cleanliness of the feet, inunction with some fatty body, employment of alum, formol, picric acid, or iodine, may prevent or mitigate.
We may also mention peritendinous cellulitis of the tendo Achillis and twisted foot-which is only a metatarsal fracture (Pauzat).
The foot is very frequently hit by projectiles, as often as the thigh.
The track is dorsi-plantar, planti-dorsal, or transverse.
Lesions of the Bones - Toes - Notwithstanding their small size, the toes are diaphysial bones. Their epiphysis may be hollowed out into a groove or perforated. When the diaphysis is hit, the groove and perforation are clean, or may be prolonged by fissures. These lesions are very small, even when present simultaneously on several toes.
The METATARSALS are diaphysial long bones with very compact tissue. Their lesions show on the body of the bone the classical characteristics of transverse and oblique contact fractures. They are very frequent. Grooves are found, also perforations of the usual type with lateral splinters. The free splinters are small; the adherent ones are only 2, 3, 4 centimetres long. In transverse fire, several metatarsals, specially those at the extremity of the arch of the foot, are fractured. Subdivision of the splinters is greater in the last bones hit. The metatarsal epiphysial extremities present typical epiphysial lesions, without splinters.
The BONES OF THE TARSUS, in spite of the variety in their shape, present grazes, furrows, tunnelling - regular canals without fissures or noticeable splinters.
By reason of its size, its structure of oblique fibres directed from below and from the back of the bone, we see in the os calcis tunnellings often accompanied by radiating open fissures, or rather fissures directed in an oblique way with regard to its fibres. The splinters limited by these fissures are generally adherent. We will deal later on with the lesions of the astragalus.
Diagnosis. - The diagnosis, based on the relations of the track to the bones it meets, is usually easy to the surgeon who is well acquainted with the anatomy of the foot. It is afterwards completed by radiography.
Complications -Wounds of the foot possess but little surgical interest excepting through their complications - haemorrhage, foreign bodies, infection, tetanus.
Haemorrhage comes from the dorsalis pedis artery or from the two plantar vessels, especially from the external, which is larger and longer than the internal. The dorsalis pedis has a well-known course. That of the plantar arteries not so familiar. We have already described it, and we will again call it to mind.
If, on the sole of the foot, we draw (i) a vertical line starting from a point on the centre of the heel, and going to the interdigital space that separates the fifth from the fourth toe, and (2) a line starting from the inner fourth of the heel, and going to the first interdigital space, the lines will give the direction of the two intermuscular septa, internal and external. Now, these septa divide the sole into three parts -the external, the middle, and the internal.
The external part contains no important vessels.
In the internal part runs the internal plantar artery, which becomes unimportant after reaching the metatarsus.
In the middle part, the external plantar describes a curve with an external convexity, which terminates at the base of the central metatarsal bones. The result of this arrangement is that the external part and the metatarsal can be traversed without danger to any important vessels and that, with regard to haemorrhage, lesions of middle part, and, in some measure, of the internal part, are the only ones to take into consideration.
A deep incision, of an appropriate length, which pushes aside the flexor brevis digitorum immediately inside the external intermuscular septum in the region of the tarsus allows us easily to find the external plantar artery and ligature it. (External plantar incision, Delorme.)
A tarsal incision inside the internal intermuscular septum allows us to find the internal plantar and ligature it (Internal plantar incision, Delorme.)
A skilled surgeon will utilize these direct incisions to put an end to plantar haemorrhage. Others will employ immediate compression after incision or mediate compression without incision, haemostatic proceedings that are rendered very useless by the wealth of anastomosis in the part.
The exploratory incisions we have described govern all the necessary surgery to deal with complications in wounds of the foot. They lay bare the vessels; they enable us to search for metallic foreign bodies; they also give an outlet to the discharge of plantar abscesses, almost exclusively localized in the middle part, before described, and which are pretty frequent owing to the dirt on the sole of the foot and on the pieces of the patients' socks and boots, these fragments having been carried into the wound, owing also to the sheaths of the tendons having been opened (deflected bullet, shrapnel bullet). Again, it is by the help of these incisions that we remove splinters that have been forced forward and are badly tolerated. They are the result of a bullet with a dorso-plantar track.
Tetanus is a rather frequent complication of these wounds.
Treatment. -Wounds of the foot very often end in recovery, and this is nearly always brought about by simple treatment-application of dry dressing, rendered antiseptic by iodine-and immobilization. Wet dressings must never be applied. On the foot they are absolutely pernicious.
The dressings, if they are thick enough, will themselves insure immobilization. It is only when the firmness of the foot is jeopardized by an extensive fracture that we should have recourse to an immobilizing apparatus.
A very bad practice, and one that is too much followed, consists in letting these patients walk whilst they are suffering from bone lesions of the foot. Their cure is thereby much retarded, and they are thus exposed to complications. All walking on the wounded foot should be forbidden for a long time, but this does not mean that the surgeon should abstain from utilizing passive movement.
Amputation is only admissible at first as a standard operation in very vast shattering transverse lesions the result of shell fragments. The technique of these operations can be simplified if the foot is considered as being formed of only one bone (Mayor).
Although primary conservatism must be the rule, we must not hesitate at a later date to rid the patient of deflected troublesome toes, and even of the foot, if it has become very much deformed, and inconveniences the man when he walks, and whose deviations we have been unable to correct by anastomosis of tendons, by tarsectomy, or by arthrodesis (Syme's operation).
Wounds of the Instep.
From the subastragalar articulation, the instep extends to 3 centimetres above the tibio-tarsal interspace.
Wounds of the Soft Parts - Indentations, perforations of the tendo Achillis and of the anterior and posterior tendons, opening of their sheaths, wounds of the anterior and posterior tibial arteries and of their accompanying nerves, represent the most interesting lesions of the soft parts of the instep.
Large shell fragments may become lodged between the tendo Achillis and the deep parts.
B. -The ASTRAGALUS may be eroded, hollowed out into grooves, or perforated. In anterior-posterior fire, perforation may be accompanied by separation of the bone into two parts. In transverse fire the neck may be divided. Fissures of the remainder of the bone are vertical or radiating.
Perforation is generally clean, and, thanks to the strength of the ligaments that are inserted into three of the surfaces of this bone, the fractured fragments remain in contact, even if the fissures are deep.
On the TIBIAL EXTREMITY the lesions are rarely of the epiphysial type, because the level of the cartilage of growth is only a centimetre high. So that in the perforations, which are the usual lesions, fissures are often seen, although they do not practically complicate the traumatism. These fissures form the limitations of wedges at the periphery of the bone, or else are radiated.
The EXTERNAL MALLEOLUS is hollowed out as with a gouge or perforated. At 1 centimetre above its base the lesion takes on the diaphysial type. It is always simple.
Diagnosis. - Generally, diagnosis is easy, in spite of rapid and sometimes considerable swelling. It is based on the relationship of the wound to the articulation.
Treatment. - Haemorrhage from the tibial arteries renders compression necessary, then ligature. Suppuration that has a synovial origin readily diffuses to the dorsal surface of the foot, to the anterior surface of the leg, to the plantar region, to the posterior surface of the leg. Incisions, as for ligature of the tibial arteries, or our external plantar incision, are indicated.
Primitive conservatism is the rule in osseous lesions of the instefi by bullets, and we may call its indications absolute.
Immediate immobilization is obtained by the wounded man's boot; this is replaced by a temporary apparatus, and finally, as soon as possible, by a gutter-like splint with a movable plantar portion similar to that in Raoult Deslongchamp's hollowed out leg-splint and in our own apparatus. We cannot imagine employment of any other apparatus. In any case, none other facilitates to the same extent subsequent inspection of the limb, application of dressings, and performance of any necessary intervention.
Vigilant watching of a region so easily infected as that of the instep should be incessant; the same may be said with regard to the foot. On the first threat of suppuration incisions must be made at the points we have indicated.
Suppurative arthritis will be treated by vertical anterior incisions following the borders of the internal and external malleoli. Infected splinters whose presence cannot be tolerated should be removed through these incisions, or through those of astragalectomy.
Primary removal of splinters is condemned.
In those cases where the lesions that can be seen give us cause to fear consecutive deviation, we should prolong the immobilization of the foot in a good position - that is to say, in flexion, not at a right angle, but at a slightly acute angle.
Cure of bullet wounds of the instep is very common, and is obtained without much difficulty.
Wounds of the Leg.
Wounds of the leg are pretty frequent. Fractures of the leg represent a quarter or a third of all fractures.
Wounds of the Soft Parts -The only wounds of this kind that deserve mention are extensive setons, the culs- de-sac, very often infected and giving rise to abscesses that must be opened at once, or we risk their diffusion; finally, the simple perforations of the interosseous space, with wounding of the tibial arteries and nerves.
Antero-posterior and postero-anterior bullet wounds do not seem much more frequent than the transverse.
Lesions of the Bones.-The FIBULA, after tangential fire, often exhibits transverse or oblique fractures.
Nearly always on this bone we see grooves and perforations. The former are simple - that is to say, they may consist of mere notches (indentations of the edges), or they may show at the same time the notch and a transverse or oblique fracture, or one with long splinters.
Perforations with adherent splinters 4 to 6 centimetres long, and short, free splinters are common.
TIBIA.- On the tibia we may see with remarkable clearness all the varieties of diaphysial lesions.
Contusions are very frequent. On the inner surface of the bone they are evident.
Longitudinal fissures may groove one surface or the three surfaces of the bone.
Transverse and oblique fractures by contact are seen on any part of the bone, but specially at the lower third.
Contact-fractures with large splinters, either of a simple or a comminutive type, may be observed at all parts of the bone.
Only a few examples are cited of perforation of only one side of the bone. The most usual osseous lesions are grooves with adherent splinters, and especially through-and- through perforation.
The type of perforation is always the same whichever surface of the bone is hit.
The adherent splinters of the perforation are often a third or a half as long as the bone. The free splinters are relatively large and big. They are 1, 2, 3 centimetres in length.
When the aperture of exit corresponds to the inner surface of the tibia, and when the bullet that produced the lesion has had a high velocity, the burst skin presents a big breach.
Simultaneous lesions of the tibia and fibula return to the usual types. The second bone hit presents a more comminuted fracture than the other bone.
All these fractures are with or without displacement. Generally the displacement is very slight.
Diagnosis.-The diagnosis is easy, and can be established by the help of the ordinary signs.
Treatment. - Haemorrhage and haematomata are frequent complications (one-tenth) of wounds of the leg. Pushing forwards of the splinters is not unconnected with their
frequency, as they are seen four times more often in cases of fracture than in wounds of the soft parts.
Either distant or mediate compression is the immediate treatment, direct ligature the surgical treatment.
When uncertain as to which of the posterior vessels has been damaged, we should make an axial incision which will allow us to reach both the posterior tibial and the peroneal arteries. We must not fear to freely relieve constriction by incisions, and here, as elsewhere, we must apply ourselves less to directly recognize the vessel, which is masked by the blood, and difficult to identify and to take up because its continuity has not been interrupted - than to discover the accompanying nerve. Once this last is found, the artery can easily be freed.
Abscesses should be opened through the incisions which would be employed to ligature the arteries.
The same incisions will serve also in the subsequent search after deep and badly tolerated foreign bodies.
Immobilization is obtained on the field of battle by fixation of the HEALTHY leg against the wounded leg.
A good temporary apparatus can be made of straw, covered with canvas, and used as bandages.
Ultimate apparatus may be of pasteboard, plaster, or zinc, framed on Raoult Deslongchamp's model, etc.; the best undoubtedly are the valvular metallic splints, hollowed out like a gutter. Our conviction on this point is stronger than ever. The use of these splints should be made general. No other keeps the parts in such good apposition, renders the dressing so easy, facilitates the bringing together of displaced splinters and the supervision of the limb. We have witnessed most deplorable displacements in fractures treated in hollowed out splints of iron wire, which quite wrongly are very much used, and we have many times verified and heard mentioned the difficulties that these
splints and plaster apparatus make the surgeon experience in the application of the dressings.
Apparatus for continuous extension can only very rarely be indicated, and those to aid walking are not often of use in our traumatisms.
When the fibula alone is wounded, the tibia serves as a splint.
We must do our best to obtain very satisfactory definite results, to avoid callus with angular points in front or at the back, especially lateral deviations, axial rotation, stiffness of the knee and of the instep. We must make a point of frequently ascertaining that a line starting from the first interdigital space cuts through the centre of the patella to get to the middle of Poupart's ligament. This line is that of the limb's normal direction.
We will not speak of the nervous lesions or of osteitis. Primitive amputation is contra-indicated in bullet wounds, unless the case be one of confirmed gangrene.
It is only admissible as an atypical operation to deal with a large wound that has been torn by shell fragments, and shows lesions of the vessels and of the nerves.
Wounds of the Knee.
The knee is comprised between an inferior transverse plane, passing through the anterior tuberosity of the tibia, and a superior one cutting through the thigh three fingers' breadths above the upper border of the patella.
Traumatisms of the knee caused by projectiles are very frequent (one-third of joint wounds, 3 per cent. of all wounds). Penetrating wounds are more often seen than non-penetrating.
Peri-articular Wounds. - These are nearly always posterior lesions, whose gravity consists entirely in wounds of the large popliteal vessels and nerves.
Wounds of the popliteal vessels give rise to very severe immediate haemorrhage or to arterial haematomata, that endanger the limb's vitality. and are very difficult to treat.
Compression at a distance does not securely arrest the haemorrhage, mediate compression is prejudicial to the collateral circulation. Direct ligature is the sole surgical treatment; but where is it to be applied, and how many surgeons could perform the operation ?
All these conditions make the prognosis of these wounds essentially gloomy.
These wounded men, threatened with gangrene, must remain on the spot, and we may look forward to have to perform amputation of the thigh after a very short delay, so soon as we see the first signs of gangrene, if direct ligature is impossible.
Popliteal haematomata are sometimes enormous; they invade the whole of the popliteal space, the leg, the thigh, being too often preliminary to gangrene and to diffuse suppuration. On other occasions the situation is quite different: the haematoma is circumscribed, and comes on late (arterial contusion). Direct intervention, to be of use, must treat the collateral circulation with caution, and no dissection should be carried out.
Wounds of the internal popliteal nerve that involve its whole thickness do not imperil the function of the most important muscles of the leg, whilst the foot, that does not undergo lateral deviation, can be very useful even after complete section of this nerve. Walking is quite possible and is steady.
Section of the external popliteal nerve, on the other hand, gives rise to very much greater inconvenience, yet the patient may still manage to walk with the help of an orthopaedic boot (Letiévant).
Wounds of the Joint without Osseous Lesions. - They are pretty frequent, and are produced by a ballet penetrating under the tendon of the quadriceps, going across the cul-de-sac beneath it, perforating the articulation, whilst the knee is flexed, and penetrating in the middle line under the apex of the patella. Such are the most common simple articular lesions.
Wounds of the Joint with Osseous Lesions.- The borders of the PATELLA are indented, its surfaces hollowed out as with a gouge; the bone is perforated from before backwards or transversely, cleanly, or with fissures. GENERALLY THERE ARE NO SOLUTIONS OF CONTINUITY.
FEMUR.-Lesions of the femur vary according to the part hit.
The line of the growth cartilage on this bony extremity corresponds to the base of the condyles. From this line the fibres ascend vertically, joining the body of the bone by the most direct and the shortest route. A bullet penetrating below the line of the cartilage gives rise to lesions of the epiphysial type; if it penetrates above the line, it produces. lesions of the diaphysial type.
On the condyles of the femur the lesion consists of contusions, furrows, peripheral perforations, with fissures of the external shell; of more central perforations, either clean or with rare separation of fragments. These fragments show different shapes; they are in juxtaposition or in dissociation. Even in such cases the lesion is usually simple.
If the bullet penetrates at the base of the condyles, it not only produces a perforated track, but it gives rise to fissures that imperfectly separate long external or internal wedges, either adherent or movable in antero-posterior fire, and anterior and posterior wedges, either adherent or movable in transverse fire.
TIBIA.- On the tibia the line of the cartilage is only a centimetre beneath the articular interspace. From this line the osseous fibres descend directly towards the surfaces of the bone. Lesions without fissures are therefore shallow, interarticular furrows, more rarely perforations. Most of these last are accompanied by fissures that limit external or
internal cuneiform fragments, whose points are downwards; they are more or less adherent. This does not complicate the lesion when recovery takes place without suppuration.
FIBULA.- On the upper extremity of the fibula lesions are simple (erosions, grooves, perforations). These last are more or less comminutive.
Diagnosis.- We must hardly expect to diagnose articular penetration by the outflowing of synovia. It is generally absent. We have only seen it once in about ten penetrations. On the other hand, opening of the periarticular serous membranes gives rise to it. Haemarthrosis, coming on rapidly, is a better sign to go by. It is common. But the relationship of the bullet's track to the different parts of the bone will often allow us to establish a localized diagnosis.
Later on pain along the fissures, or prominence of the extremities of the cuneiform fragments, and finally radiography, will all share in the diagnosis.
Prognosis.-We have pointed out that the thick adipose cushion which protects the synovial membrane often brings about in front of the femur occlusion of the osseous orifices that the soft parts obturate at the back. On the other hand, the present bullets, very much more than the old ones, separate rather than penetrate the vertical fibres of the capsule over the patella. The fibres of its ligamentous covering, being simply separated, stop up the wound in the bone. These are very favourable conditions for recovery. And there are still others: the narrowness of the wound; the rarity of the driving forward of foreign bodies derived from the clothes when the bullet is fired at point-blank range. With reference to this, there is a very different prognosis to establish between wounds thus made and those resulting from deflected bullets or from shell fragments that so often carry with them very infective pieces of clothing.
Formerly septic evolution carried off rapidly three-quarters of the soldiers wounded in the knee. Diffuse abscesses appearing very quickly, suppurating arthritis with crural and popliteal fistulae, were only preliminaries to septicaemia. Femoral or tibial osteomyelitis completed the series of the sources of infection. Nowadays a very large majority of these wounds recover without any trouble. From 11 per cent. during the Russo-Turkish War, the mortality fell to 4.5 in Cuba. Not only is recovery the rule, but it is obtained nearly always without loss, or, at any rate, without notable loss of the movements of the knee. This prognosis, favourable both relatively and naturally, must not make us forget that great attention, the closest supervision, are absolutely necessary in these cases, besides the skill which is requisite in their treatment.
As a principle, wounded men with penetrating lesions of the knee must not be transported any distance, and the articulation must ALWAYS BE IMMOBILIZED and covered over with a large dressing. This, we think, is not invariably done.
Treatment. - The first dressing should insure disinfection of the wound and of the surrounding parts (iodine application); it should be occlusive, but not tight.
Immobilization must be strict, brought about at first by the sound limb being fixed to the wounded one; afterwards it will be obtained by a metallic gutter-shaped splint, supported above by the thigh, below by the leg and the foot, and leaving the knee-joint free, so as to facilitate supervision and dressing (gutter splints with valves).
Very voluminous and very extensive haemarthroses may be drained through a puncture, or, if necessary, by an incision made and kept under strict aseptic conditions. It is carried out in the external part of the superior cul-de-sac of the synovial membrane.
In cases of suppurating arthritis (great oscillations in the temperature) the joint must be incised laterally, following the internal and external borders of the patella to an extent of from 8 to 10 centimetres. The articulation must be thoroughly washed out with hydrogen peroxide, and drained through a transverse drain; the dressing should not be renewed too often. A crural abscess should be opened by a deep or supra-patellar external incision carried down almost to the bone, a popliteal abscess by a median vertical incision, or by the lateral incision of Marchal de Calvi, under the internal condyle of the tibia, and femoral abscesses by deep external incisions.
Arthrectomy does not seem to us of much use, and we think that excision of the semilunar cartilages or scraping away large portions of bone with the idea of more easily opening the osseous focus should nowadays not be utilized.
We pass over search after foreign bodies, which must only be carried out at a late period and with every aseptic precaution after exact indications had been obtained, unless it is a question of shrapnel bullets, in which case extraction should be speedy if not immediate.
Amputation must at first be reserved for cases of gangrene, and afterwards for cases of very grave infective arthritis which has not been modified by arthrotomy. Excision .should only be employed at a late period; its indication is exceptional.
Wounds of the Thigh.The region of the thigh extends from a transverse plane three fingers' breadths from the superior border of the patella to a horizontal line which prolongs both in front and outwards to the fold of the gluteal region, the ischium.
Wounds of the thigh are very frequent.
Wounds of the Soft Parts.- Bullets produce on the thigh all the different kinds of lesions, even those that take up the whole length of the part. Sometimes shell fragments give rise to enormous wounds. The interesting points about these traurnatisms are especially in the vasculo-nervous complications.
The arteries in this situation are both numerous and large, hence haemorrhage from them is very grave. The femoral and its principal branch, the profunda; muscular and perforating branches; the ischiatic artery; besides the big veins, the femoral, the internal saphenous - all these constitute the blood-supply. In the large cellular spaces of the thigh voluminous haematomata develop rapidly.
Compression and ligature are the treatments of haemorrhage, whether immediate or late.
The sciatic nerve, by reason of its size, is not divided by bullets, but is indented or perforated when it is not merely contused.
Large foreign bodies often remain lodged in the thigh. In these cases we must remember those that come from the patient's pockets. Direct incisions allow us easily to extract foreign bodies when they have been recognized, and this is not so easy without radiography.
Diffuse abscesses, emphysematous gangrene, are not rare in the thigh. They are often caused by the infection of shrapnel bullets or of shell fragments. Therefore removal of these projectiles must be carried out as soon as possible.
Osseous Lesions.- On the femur we commonly see the most typical diaphysial lesions: Contusions, fissures, contact fractures, grooves, per/orations of one side of the bone, through-and through perforations, abrasions.
Contusions are frequent and nearly always unrecognized. The same may be said of fissures, which are generally very long.
Contact fractures, transverse and oblique, direct or indirect - that is to say, at some distance from the bony point that has been hit - are by no means rare. They are especially observed in the superior one-fourth or in the inferior one- fifth of the bone.
In contact fractures with large splinters these last are very large (8, 10, 12, 15, 20 centimetres). They give rise to crepitation which may be called appalling," but it does not become multiplied when they are separated from the fragments. The fractures heal without complications.
The comminutive type of contact fractures is also met with in the thigh.
Grooves are often accompanied by oblique fractures.
Perforations of only one side of the bone are rare.
Fracture by through-and- through perforation is a very common osseous lesion.
Adherent splinters are from 8 to 12 centimetres in length; free splinters are also often of a relatively large size (2, 3, 4 centimetres).
These splinters are stationary or forced forward.
On the femur, as on the tibia, at short range, we see explosive fractures with a very large aperture of exit.
Treatment.- Fractures of the femur through bullet wounds were considered for a long time as necessitating amputation of the limb; nowadays they ALL can be treated by conservatism, whatever their type, however extensive and complex the osseous comminution and the damage to the soft parts.
Primitive immediate immobilization is obtained at the first-aid stations, at the ambulance, by fixing the SOUND limb to the wounded one by bandages, or string, applied on a level with the insteps, and above and below the knees.
Fractures of the femur must be considered as a bar to the patient being transported any distance, at least at first. During the transport the displacements become more prominent and are made worse; the wounded man experiences pains that are followed by muscular reaction; the dressings are easily contaminated by the urine and the faeces. When blood has soaked through the dressings they are rapidly infected.
As final apparatus, hollowed out gutter splints of iron wire immobilize badly. Being convex, they give rise to bending of the callus and render the application of dressings difficult. They should be rejected.
Plaster apparatus immobilize well, but very often they make the application of the dressings difficult.
The metallic hollowed out gutter splints with valves are generally sufficient, and render admirable service. When extension is necessary, they effect it in the following manner: Counter-extension is made on the ischium. On this bone rest the zinc lamellae, which are bent on themselves and held in place by multiple notches made on the upper edge of the gutter. Abdominal bandages, supported at the same time by the bent and padded lamellae and by an external prolongation of the apparatus, secure the fixity of the counter-extension. Extension is obtained by the traction of the bandages on the foot. We have never treated fractures of the thigh by any other apparatus, and to its employment we owe our great and constant success.
We have recently used our valvular gutter splint in a continuous series of twenty-five very serious fractures of the thigh by projectiles; most of the cases had large wounds, also rotation with angular deformations and shortening, which in some reached 8 centimetres. Application of the splint was at once carried out, reduction was well kept up with disappearance of the shortening, besides, dressing was easy whatever the seat of the wounds.
Many surgeons use Tillaux's or Hennequin's extension apparatus. They establish a kind of rigid equation between the employment of these apparatus and our fractures; quite wrongly we think! for these last are often without notable axial displacement. The apparatus in question would seem to us more worthy of recommendation in fractures with axial displacement, But, in our opinion, they are inferior to the valvular gutter splint because they do not allow the large splinters to draw together their fragments in such a continuous and SURE manner, and this is an essential indication in the practice of war surgery; finally, because with them dressing is not so easy.
It is advantageous to combine immobilization with a complementary treatment. In fractures of the thigh we keep our patient constipated for eight or ten days (mucilaginous extract of opium, laudanum), then we open his bowels (oily enemata) only to constipate him again for about the same time. After another motion we may again constipate him for a third time.
During the constipation - that is to say, until the fracture is partly consolidated - we put him almost exclusively on meat diet.
The constipation is well borne by young healthy men; it gives rise to no elevation of temperature, and it has the great advantage of rendering unnecessary that constant supervision which is so tedious and difficult to procure, in order to suppress all movement on the part of the patient, to prevent soiling of the dressings and of the apparatus; finally, it renders regular consolidation far easier.
In fractures of the upper third it may be necessary to exercise traction in abduction, but we think this position ought not to be kept up.
Certain complicated apparatus employed in ordinary practice seem to us to be of very little use, and the diuretit sanguinary method is especially to be avoided. It complicate's the traumatism, and the points have some difficulty in penetrating and supporting the movable splinters.
We should strive to perfect the final results by using, at the right moment, passive movements of the foot and the knee; this is easily done with the valvular gutter splint we avoid in this way any deformed callus produced by rotation of the foot and bad coaptation of the fragments and of the splinters. Pseudarthroses will to a large extent be prevented if we refuse to perform any operation for the removal of splinters and if we do not carry extension too far, especially in very comminuted foci.
A cured fracture, with slight or average shortening of the limb, which, however, is in good axial position, is an honour to the surgeon who treated the patient.
When there is abundant suppuration of the focus, we must hasten to remove the free splinters which had been allowed to remain at first. Let us point out that these will be found in the neighbourhood of the aperture of exit.
Wounds of the Hip.The hip comprises the inguino-crural region in front, the gluteal region at the back, and deeply the coxo-femoral articulation.
Articular lesions of the hip are 3.8 per cent. of joint wounds.
Wounds of the Soft Parts.- In this fleshy region the setons are extensive, the culs-de-sac sometimes complicated by bulky foreign bodies. Large fragments of hollow projectiles give rise, on the buttocks and in the groin, to very large, ragged wounds. We have seen some that included the whole of one buttock.
Haemorrhage from the groin is especially serious. Both the femoral artery and vein are of easy access, their relations being so well marked. Their direct ligature is the surgical treatment of choice in haemorrhage due to their lateral or central perforation, whilst direct compression is the primary preparatory treatment. This last would be final in some surgeons' hands.
Wounds of the arteries in the gluteal region are formidable. We have seen some of these cases. The big classical incision for the gluteal artery would allow us to verify a difficult differential diagnosis, and to guarantee the application of the proper surgical treatment, Immediate compression after freeing the external wound would only be a makeshift. Tamponment and pressure must not be maintained for long, owing to their rendering the parts liable to diffuse putrid inflammation.
We have nothing special to say with reference to haematomata and to femoral or gluteal aneurysm, or about wounds of the sciatic nerve.
Osseous Lesions.- Openings in the capsule without osseous lesion are exceptional. They are impossible to diagnose.
FEMUR.-The line of the growth cartilage of the femoral head is lost in the anatomical neck.
Another line of cartilage, oblique below and externally, passes at the base of the great trochanter and separates this base from the remainder of the bone.
The lesser trochanter is, from the point of view of its constitution, a part superadded to the remainder of the femur.
The limits of the surgical neck are - Above, the anatomical neck; below, the intertrochanteric line. Its fibres that follow the fissural tract are divided into two fasciculi: one, the internal, large above, goes from the head of the femur to the lesser trochanter that it encircles; the other, the external, has a base corresponding to the head of the femur, and its fibres, some horizontal above, others oblique below, reach the base of the great trochanter and are prolonged under it.
1. The HEAD OF THE FEMUR may be eroded, hollowed out as with a gouge, perforated. These lesions are commonly simple, and the anatomical neck raises a bar to the extension of fissures. The cotyloid cavity, its pad, the round ligament, and the capsule, retain the free fragments.
2. Bullets that penetrate on the level of the ANATOMICAL NECK hollow it out as with a gouge, perforate it, and in the last case may separate the head either incompletely or completely by a subperiosteal fissure. There is no primitive separation.
3. On the SURGICAL NECK bullets may leave simple indentations, or give rise to perforations, which are either simple or radiated by fissural tracts. The most remarkable of these perforations with fissures is the one in which what may be called the femoral spur is separated. This spur is represented by a bony wedge that includes the head of the femur, the internal half or third of the surgical neck, and the lesser trochanter (Delorme).
4. Above the inteytrochanteric line the lesions are of the diaphysial type. The fissures are those of large diaphysial splinters.
FRACTURES, with solution of continuity of the surgical neck, are very much more uncommon than those with no solution of continuity.
5. THE GREAT TROCHANTER. may be eroded, furrowed, perforated; THE LESSER TROCHANTER may be hollowed out as with a gouge, abrased. These lesions are limited.
6. The COTYLOID BRIM may be eroded, furrowed. Again, the lesion is limited and simple.
7. When there is penetration from without inwards of both the GREAT TROCHANTER and the SURGICAL NECK, there is a tendency to separation of the femoral extremity into one or two incomplete lateral wedges, with a diaphysial inferior point; these wedges are always adherent.
Diagnosis.- Diagnosis of osseous lesions of the hip cannot be made by searching only for abnormal mobility, faulty position of the limb, shortening, outflow of synovia, or swelling of the region. These signs are often absent. Localized pain brought about by pressure is an excellent presumptive sign., It would be blamable to endeavour to find abnormal mobility or crepitation. The relationship of the wound to the region occupied by the articulation will specially serve as guide, and, with the indications we have given, will render the diagnosis easy.
1.(a) If we divide into three equal parts the Fallopian line (Poupart's ligament), which extends from the anterior superior iliac spine to the spine of the pubes, the middle segment gives from above the limits of the articulation.
2. Below the limits are fixed by the great and lesser trochanters. The superior border of the great trochanter is easily found. The lesser trochanter corresponds to the centre of the anterior surface of the thigh on a horizontal line that, prolonged outwards, would reach the ischium, which is easily felt, or, if preferred, on the line that, prolonged outwards, would reach the inner part of the gluteal fold.
3. Now let us unite by two curves, the superior one concave above, the inferior concave below, the two points limiting the middle segment of the Fallopian line (Poupart's ligament) to the great trochanter on one side, to the lesser trochanter on the other, and we shall then have marked out the area of the head, the anatomical neck, and the surgical neck of the femur IN FRONT.
(b) AT THE BACK we get the same result in the following way:
1. We trace a line that joins the ischium to the most prominent and the most external point of the iliac crest.
2 . We ascertain exactly the site of the lesser trochanter. It corresponds to the middle part of the posterior surface of the thigh on the horizontal line that starts at the ischium.
3. We then seek for the prominent border of the great trochanter.
4. If, at a finger's breadth above the superior border of the great trochanter, we draw a horizontal line, at the point of meeting of this line with the oblique ilio-ischiatic one already drawn, there we shall find the upper limit of the head of the bone. The lower limit of the head corresponds to the meeting of a horizontal line carried a finger's breadth below the level of the great trochanter's superior border to the oblique ilio-ischiatic line.
The points that limit the head of the femur thus indicated are afterwards united by curved lines to the great and lesser trochanter.
Thus we find out with sufficient accuracy the posterior area of the head, of the anatomical and of the surgical neck. The line between the trochanters separates that which is in relation to the epiphysis above and to the diaphysis below.
Later on, radiography will furnish very important information in the diagnosis, especially in cases of epiphysial diaphysial lesions.
Prognosis.- Formerly, prognosis of bullet wounds of the hip, with osseous lesions, was extremely severe. In the War of Secession the mortality was 84.7 per cent.; in the Franco-German War, 79.7 per cent. In the Cuban War it was 33 per cent., and in the Transvaal:28.6 per cent.
It was the suppurating arthritis of the joint that brought about the death of the wounded men; and in those unfortunately too rare cases that recovered an ankylosed articulation was left. Nowadays cure is frequent, and very often the mobility of the joint is preserved.
Yet infectious complications are still observed, such as large haematomata or foreign bodies, whose appearance is stimulated by the neighbourhood of the rectum and bladder.
The prognosis of wounds of the hip by firearms is influenced by that of the complications, and especially by grave hoemorrhage.
Certain conditions, in our opinion, seem to mitigate the prognosis; for example, wounding of the joint by a bullet fired point-blank from a great distance, which gives rise to very small lesions; or absence of a posterior wound, which is so easily infected. In posterior osseous lesions the neck of the femur is to a large extent untouched ; communicated infection is much easier when the track is widely open. In the anterior cul-de-sac wounds the thick capsule, the fibres of which have been separated, is in a certain measure an obstacle to infection.
Treatment.- Men with fractured hip should never be transported to any distance. Immediate immobilization is obtained by bringing together the two lower limbs. This method of temporary immobilization can still be of use as an ultimate measure when there is no osseous solution of continuity.
To immobilize the hip, various means have been proposed: decubitus on a well-padded plank, in Bonnet's gutter apparatus; the employment of Smith's splint, which takes its point of support from the whole of the anterior surface of the limb ; the external splints of Desault and Isnard ; large plaster apparatus; and, finally, various extension apparatus. We do not believe that the first-mentioned apparatus are necessary. There is no assimilation possible between lesions by firearms and ordinary fractures; and, on the other hand, extension creates the danger of separation of the fragments. As a general rule, we think that bringing together the lower limbs is sufficient.
In order to avoid any displacement of the fragments occurring, and also the pain which always accompanies the movements rendered necessary for alvine discharges, we constipate these patients as we do those with a fractured thigh.
The dressings must be large, going very much beyond the limits of the region; at the very least they should reach as far as the groove between the nates, and, above all, they should remain fixed in place. Now, what dressings realize these conditions at the present time? To obtain them it is necessary for a large compress - applied in the manner recommended by Mayor, taking its point of support from circular abdominal bandages or from a body bandage, and below from circular crural bandages, and then consolidated by a spica-entirely to cover a large mattress made of aseptic material. But we still ask for more, and we advise all surgeons to follow our practice, which consists in covering all the regions: inferior abdominal, crural, gluteal and perineal. The constipation of the patient allows us to do this; besides, it simplifies to a large extent the nursing.
Immediate extraction of free splinters is not necessary, but, in an infected focus, it may be obligatory, and still more, at the time of removal, we may find ourselves, in these cases, compelled to take away, with the splinters, osseous fragments of the head of the bone and even part of the surgical neck (spur). We must, however, be sparing with these operations, and only perform them in good earnest when driven by necessity. A fortiori we must not endeavour to do a typical resection.
The anterior incision of Hueter outside the femoral vessels brings us well and directly down on the joint, on the head, and on the neck of the femur. At the back, an incision following the direction of the fibres of the gluteus maximus allows us to bring into view the head, the neck, and the great trochanter, and, if necessary, the acetabulum. The difficulty does not lie so much in the exposure of the joint as in the removal of splinters that are partly adherent. We should proceed by successive freeing.
In no case should we resect under the line between the trochanters. The result is deplorable.
Abscesses are reached in front by the incision for ligature of the femoral at the back by the gluteal incision.
Primitive disarticulation of the hip-joint is contraindicated in bullet lesions with no complications. It may become necessary owing to gangrene or to nearly total abrasions produced by large shell fragments with laceration of the vessels and of the nerves, or subsequently owing to femoral osteomyelitis. The anterior racket operation with preliminary ligature of the artery is the procedure of choice.
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