Part 20 (2/2)
There is no doubt, moreover, that small bullets rarely lodge even in the neighbourhood of joints, unless at the distal end of a long track. To take the extreme example of large bullets, those employed as shrapnel, in comparison with the frequency with which wounds were produced by them, bullets lying at the bottom of short tracks in the neighbourhood of joints were not uncommon. Thus I saw one lying over the hip-joint, and another in close proximity to the shoulder capsule.
Wounds of the third cla.s.s, where the bones had been superficially grooved, were in some respects the most serious. This was especially so in the knee and ankle joints, and some cases will be quoted later under the heading of the special joints to ill.u.s.trate this point. Danger only arose in the event of suppuration; and here the presence of the long oblique superficial track in a neighbourhood liable to comparatively free movement was the important element. Such tracks usually opened the synovial sac more extensively than direct perforating wounds, and if suppuration occurred in any portion of the track, the pus was very liable to be sucked into the joint on any free movement. The presence of fine splinters of the bone displaced in the production of the groove was also a special character of wounds of this cla.s.s. Another point worthy of mention is that in these cases it was not always easy to be quite certain whether the joint cavity had been implicated or not, since cases often occurred in which, although the bones had been grooved, the joint cavity escaped. The indication, however, was to consider any wound in the immediate proximity of a joint as perforating until it was healed.
This course was the more easy to take, since a large proportion of such wounds were accompanied by some degree of synovial effusion, even when the neighbouring joint had escaped puncture.
Wounds of the fourth cla.s.s, although the most highly characteristic of the form of accident, were in many instances the most favourable in regard to their course. The tracks might course directly across the joint in any direction, or they might course obliquely, traversing either one or both the component bones. In the latter case the exit might be in the diaphysis, and be accompanied by the separation of an exit fragment such as is ill.u.s.trated in fig. 52, p. 169. The particularly favourable character of the direct transverse and antero-posterior wounds depended on the slight amount of splintering of the bones, the limited nature of the opening into the joint, and the shortness of the tracks in the soft parts, which ensured that, even if infection did occur, the resulting pus was near the surface, and generally spread in that direction and escaped.
Wounds of the fifth cla.s.s were the most dangerous, but the danger was entirely a secondary one, dependent on the occurrence of infection.
These injuries were liable to be accompanied by the presence of extensive irregular wounds of the soft parts, in which suppuration was frequent, and the suppuration of the joint frequently meant subsequent amputation, if not a worse result.
_Course and symptoms of wounds of the joints._--The immediate result of any perforation of a joint was the development of intra-articular effusion. This consisted of synovial fluid admixed with a varying proportion of blood. The degree of synovitis was apt to vary with the amount of force expended in the production of the injury; for this reason both high velocity and irregular impact were of importance in this relation.
The constant feature, however, depended on the effusion of blood; this was not rapid, or, as a rule, very abundant, but tended to increase during the first twenty-four hours. It resulted in a swelling of the joint, which possessed some peculiar features. At first elastic and resilient, it slowly decreased in volume with the a.s.sumption of a soft doughy character on palpation. In the case of the knee, where readily palpated, it very much resembled a tubercular synovial membrane, except for its extreme regularity of surface; still more closely the condition noted in a haemophilic knee of some duration. Absorption took place with some rapidity, and except for slight thickening, the joints might appear almost normal, in a period of from two to four weeks. With the development of the effusion there was local rise in temperature of the surface, and in a considerable number of the cases a general rise of temperature.
This latter was sometimes very marked, as in the case of all the other traumatic blood effusions, but not quite so regular in occurrence. It was important, as I have seen it give rise to the suspicion of suppuration, when tapping resulted in nothing more than the evacuation of turbid synovia mixed with blood. Pain was rarely a prominent symptom in consequence of the generally moderate degree of distension.
As a rule, these injuries were characterised by the small tendency to the development of adhesions; but this in great part depended on the care expended on their treatment. If kept too long quiet, either from necessity when the effusion was followed by much thickening, or when the external wound was large and so situated as to be harmfully influenced by movement, or in the ordinary course of treatment, troublesome stiffness, even amounting to firm anchylosis, sometimes followed. I saw several such cases, some of the most confirmed being wounds of the knee-joint complicated by injury to the popliteal vessels or nerves. The latter complication I saw altogether six times, but only once with a thoroughly bad knee, and in this case the injury had affected both the vessels and the internal popliteal nerve. The joint in that case was straightened out by continuous extension by Major Lougheed, when it came under his charge some six weeks after the primary injury, but I hear has again relapsed, and the popliteal paralysis is not much improved.
The small tendency to formation of adhesions in uncomplicated cases probably depended on the coagulation of a layer of blood over the whole internal lining of the joint. This kept the synovial surfaces apart at the lines of reflection of the membrane, and, given sufficiently active treatment, mobility was restored before any firm union could take place.
The primary escape of synovial fluid was rarely observed, as the wounds of the soft parts were too small and valvular to permit of it. Synovia in some abundance, mixed with pus, sometimes escaped in considerable quant.i.ty when infection had opened up the tracks.
Primary suppuration in any joint as a result of small and direct wounds was very rare. I observed it only on one occasion. On the other hand, a considerable number of cases in which secondary suppuration occurred came under my notice. In some of these the suppuration was secondary to comminuted fractures of the shaft of the tibia, in which the articular extremity was implicated. These offered no special peculiarity. In others infection of the joint was secondary to infection and suppuration in the deep part of long oblique wound tracks, and these were of sufficient interest to warrant the insertion of two ill.u.s.trative cases.
(43) In a man wounded at Paardeberg the bullet entered the leg to the inner side of the crest of the tibia, about 3 inches below the tubercle; thence it coursed upwards to emerge about 2 inches above the cleft of the knee-joint on the outer side.
Regulation dressings were applied, and a week later the man arrived at the Base, with little apparent mischief in the knee-joint. He was placed in bed and warned against movement; on the second day, however, he got up and walked to the latrine. When bending his knee to sit down he was seized with agonising pain in the joint, and had to call out for help; he was then carried back to bed in a more or less collapsed condition. The knee commenced to swell; there was rise of temperature and great pain, together with extreme restlessness.
I was asked to see him two days later, and after a consultation, Major Burton, R.A.M.C., freely incised the knee-joint bi-laterally. One opening was closed, the second plugged for drainage, as there was a large quant.i.ty of pus. No improvement followed, and a week later Major Burton amputated through the thigh. An attack of secondary haemorrhage a few days later, combined with the degree of septic infection, ended the man's life. On examination of the joint, a groove forming three-fourths of a tunnel was found in the external tuberosity of the tibia, leading into the knee-joint beneath the external semilunar cartilage. The bullet had then pa.s.sed upwards over the outer border of the cartilage, bruised the margin of the external condyle of the femur in such a manner as to depress the outer compact layer, and finally escaped from the joint near the upper reflection of the synovial membrane. The synovial membrane was granular in appearance and reddened, but there was no suppuration outside the confines of the joint, except in a cavity corresponding to 2 inches of the track before it actually perforated the tibia. A localised abscess had evidently formed here and been diffused into the joint by the movement of flexion already described.
(44) A man wounded during General Hamilton's advance on Heilbron was struck on the outer aspect of the heel. An oval opening of some size led down to a track in the os calcis; the bullet was retained. The foot was dressed, and put up later in a plaster-of-Paris splint. On the tenth day the splint was removed to see to the wound, which looked satisfactory and was re-dressed.
A few hours later the man was seized with very severe pain in the ankle, and a day later I was asked to see him by Mr.
Alexander. The man was anaesthetised, and I examined the wound with care, and also removed the retained bullet from the inner margin of the leg. The bullet was reversed, having no doubt suffered ricochet, hence the large aperture of entry, but it was in no way deformed. I could not certainly determine the presence of any fluid in the ankle-joint, and as the pain was apparently localised to the distribution of the musculo-cutaneous nerve, I decided not to freely open the joint. In this, however, I erred, and two days later, after consultation, the joint was freely incised by Mr. Alexander. It was then found that the bullet in its pa.s.sage had just touched the posterior aspect of the tibia and wounded the ankle-joint.
A localised collection of pus which had formed in the deep part of the wound had been diffused into the joint by the movements made when the splint was removed, in a similar manner to that described in the last case. This joint also did badly, and an amputation of the leg had to be performed by Mr. Alexander to save the man's life.
These two cases are particularly instructive as showing, first, how quietly a small amount of deep suppuration may sometimes take place; and, secondly, the importance of keeping the joints quiet on a splint when there is any reason to suspect their implication by wounds of this character.
_The general treatment_ of the wounded joints was simple. The old difficulties of deciding on partial as against full excision, or amputation, were never met with by us. We had merely to do our first dressings with care, fix the joint for a short period, and be careful to commence pa.s.sive movement as soon as the wounds were properly healed, to obtain in the great majority of cases perfect results. Careful light ma.s.sage, if available, was used to promote absorption of blood.
If suppuration occurred, the choice between incision and amputation had to be considered. In the early stages this choice depended entirely on the nature of the injury to the bones. If this were slight, incision was the best plan to adopt. I saw several cases so treated which did well, although convalescence was often prolonged, and only a small amount of movement was regained. Amputation was sometimes indicated in cases of severe bone-splintering, when the shafts were implicated, but was as a rule only performed after an ineffectual trial to cut short general infection of the septicaemic type by incision.
I have dwelt at such length on the subject of suppuration on account of its importance, but I should add that, on the whole, suppuration of the joints was uncommon, except in the case of injuries far exceeding the average in primary severity.
_Special joints._--Such deviations from the general type of injury as above described depended entirely on peculiarities of anatomical arrangement, and peculiarities in the situation of the joint clefts in the different parts of the body. A few words as to these are perhaps necessary.
_Shoulder-joint._--Wounds of this articulation were by no means common.
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