shrapnel wounds of the knee-joint - semantic scholar...struck by a shrapnel bullet in the back of...
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SHRAPNEL WOUNDS OF THE KNEE- JOINT.
By C. NEWTON-DAVIS, m.b., b.s. (Lond.),
Capt., i.M.S.
V The two following cases have many features
in common and are not without interest :
Case I.
Sepoy Abdullah was admitted to Hospital on
November 4th with a history that one week pre- viously while lying under cover he had been
struck by a shrapnel bullet in the back of the
right thigh. On admission patient was in some pain and
looked worn out after his experiences. His
temperature was normal. Ihe right leg was
flexed at the knee at an angle of 135. The joint was rather hot and there was a small amount of
fluid in it. Any attempt to move the joint caused
great pain. Behind in the middle line inches
above the mid point of the joint was a small
punctured wound. Through this a small amount of pus escaped.
The X-ray photograph showed a shrapnel bullet imbedded in the outer and posterior aspect of the inner condyle of the femur (i. e? in the inter condylar notch). Ihe patient was anaesthe- tised and the limb gently straightened. There
was a good deal of resistance felt in the joint. A back splint was applied. This was removed
daily, the limb massaged, and the wound dressed. In a fortnight the Wound in the popliteal space had completely healed. By this time the swell-
ing in the joint had disappeared. There was
now no evidence whatever of inflammation in the joint or around it.
Up till this time it had been thought inadvis- able to passively move the joint and so possibly infect it from the obviously septic channel made by the bullet. Now, however, daily passive movement of the
knee-joint were commenced. Under chloroform, some adhesions were broken down, but full flexion of the joint was not possible.
The removal of the bullet was decided on. Chloroform was administered. The patient was turned on to his left side in the semi-prone position. A vertical incision 5" long was made in the popliteal space }" to the inner side of the middle line. The track made by the bullet in entering was carefully avoided. The vessels and nerves were retracted to the outer side. All bleeding was stopped and the edges of the wound well retracted. On opening the joint a small amount of clear synovial fluid escaped. The limb was slightly flexed and the posterior part of the capsule opened for lV'. Exploration of the joint with the finger at first revealed no foreign body. A head light was not available and working, as we were, in an improvised theatre, it was not
possible to get a good view of the structures inside the joint. Systematic search revealed a chij) of bone hidden by a fold of synovial mem- brane. This fragment had been scooped out of the upper part of the internal condyle by the bullet in its course. Renewed search failed to reveal the bullet, and further operation was post- poned and a telephone bullet probe sent for. This instrument in a very short time gave un- mistakable evidence of the presence of a metallic foreign body. Following the probe with the finger the rounded surface of a bullet was felt slightly raised above the level of the bone. The posterior three-quarter of the bullet was
firmly imbedded in the bone. It was removed with some difficulty being finally levered out with a gouge. The adjacent bone and ioint surfaces were cleared of debris and the capsule closed with catgut. The wound was closed, no drain being- left. The limb was placed on a back splint. The patient and joint were watched very carefully but no complications arose. The stitches were removed on the eighth day
when the wound was healed.
Massage and passive movements were com- menced at once. Movements rapidly returned and a month after the operation active extreme flexion was painless and the man able to walk without difficulty.
Case II.
Sepoy Narjit Alie was admitted to hospital on December 2nd with the history that 8 days previously he had been struck in the back of the left knee by a bullet from a bursting shell.
246 THE INDIAN MEDICAL GAZETTE. [July, 1915.
On admission patient looked ill. His left
knee was flexed. The joint was distended with fluid, very hot and extremely painful. Behind, in the popliteal space just above the mid point of joint was a small circular hole, the skin edges of which were inverted. From the wound pus was coming in considerable quantities.
The temperature was 100, pulse 85. The limb was cleaned up and placed on sand
bags. The next day an X-ray photograph showed a
shrapnel bullet lying in front of the condyles. Temperature 100*2, pulse 84. It was thought that the joint probably contained blood and had
not been infected by pathogenic organisms. Two days later the man's temperature rose to
103, pulse 110. It was decided to explore the joint and remove
the bullet.
The localization was done by means of the
florescent screen, cross lines being taken, and the four points marked on the skin.
Under chloroform a curved incision was made
With convexity downwards from the inner margin of the patellar ligament to the anterior border
of the lateral ligament. The skin flap was
reflected upwards. The joint was opened by incising the capsule f" above the flap incision.
The interior of the joint was bright red, the
synovial membrane was swollen, (edematous, and
jelly like. The joint contained much old
blood clot. Two small fragments of bone
were found lying loose, and removed. Several small fissures in the articular surfaces of
the condyles were felt. The bullet was found
lying loose on the outer aspect of the internal
condyle immediately beneath the patella. The
joint cavity was irrigated with saline and all
blood clot removed. The wound was sutured
in two layers. A medium sized drainage tube was inserted and removed in 3G hours.
A back split was applied. For several days after the operation the condi-
tion of the joint gave rise to some anxiety. The
temperature ranged between 99? and 100'2?, and pulse. 80?100. The condition of the patient gradually im-
proved. The stitches were removed on the tenth
day. The wound was healed except for slight discharge from the hole left by the tube.
Passive movement and massage were com- ?
menced.
The wound in the popliteal space rapidly healed.
A month after the operation the patient was sent back to India. He could then walk with the aid of a stick. He had 90? of movement in his knee-joint and was on the way to perfect recovery.
Notes.
The similarity of the injury in these two cases is remarkable. The history of case I is that he
was lying down when struck. Case II does not
remember, but it is difficult to see how he came
by the injury if in any other position. Moreover
in the latter case the joint must have been totally relaxed in order that a foreign body of such size'
should be able to pass between the articular
surfaces of the tibia and femur without being itself greatly deformed or causing extensive bony injury. The bullets were of very soft lead easily grooved by the finger nail. Neither bullet al-
though of such large calibre damaged the struc- tures in the popliteal space. In both cases there
was bony injury inside the joint. The consequent intra-articular haemorrhage gave rise to the swell-
ing and heat. In addition there would be an
increased amount of synovial fluid secreted. A septic body of considerable size passed through
dirty clothing, uncleaned skin, and into the knee- joint, yet no septic arthritis occurred. Perhaps the bullet in passing through the soft tissues ex- hausted its powers as a "carrier" on its track.
In case I the difficulty in finding the bullet was considerable. After the most careful localization with the X-rays bullets are sometimes extraordi- narily elusive. When large numbers of cases
have to be dealt with very elaborate and lengthy methods of localization are not suitable. The
interpretation of X-ray plates is often misleading even to the expert who took them. For instance
in Fig. No. I the bullet does not appear to be
three-quarters imbedded in bone. The florescent screen used with the ring
localization seems to be the simplest and most
efficient way to form a correct estimate of the
position and depth of the foreign body. In this
method the skin is marked above and below the shadow as seen by the screen, the limb is then
placed in a different position, and two more
marks made. The bullet will be at the point of intersection of the lines joining these points. It is an advantage to have these lines as nearly
? 11 at right angles as the condition of the limb will
allow. If the marks are made with a grease pencil
tliey will not be obliterated by subsequently painting the part with iodine.
The telephone bullet probe is an invaluable
instrument. It saves a lot of time and the
damage done by prolonged hunting to the tissues. It consists of a small telephone receiver fixed to
the ear by means of a head band. From it go two wires. To one is attached a large flat metal
terminal. This is moistened with salt solution
and placed in contact with the patients' skin
away from the seat of operation. The other wire
has a screw clip to which can be fixed an ordinary silver probe. When another metal in contact
SHRAPNEL WOUNDS OF THE KNEE-JOINT.
By Cai>t. C. NEWTON-DAVIS, m.b., b.s. (Loud.), i.m.s.
..
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July, 1915 ] CASES OF CEREBROSPINAL FEVER. 247
with the patient is touched by the probe a ring- ing noise is heard. After a little practice this noise is characteristic and can be distinguished from such sounds as those produced by the con- tact of the probe with bare bone, etc. One fallacy must be avoided. Some portion of the probe may by chance touch an instrument such as a
retractor or a pair of pressure forceps in the
wound when the sound heard may lead to great error.
For both excellent skiagrams and valuable
help in the operations I am indebted to
Lieut. H. Mowat, r.a.m.c. (temp.).