Until recent times gunshot injuries of the joints formed a class entailing the gravest anxiety to the surgeon, both in regard to the selection of primary measures of treatment and in the conduct of the after progress of the cases. The external wounds were severe, comminution of the bones was great, and retention of the bullet within the articulation was not uncommon. Operative surgery therefore found a large field in the extraction of bullets, removal of bone fragments, excision of the joints, or even amputation of the limbs.
The introduction of bullets of small calibre has robbed these injuries of much of the importance they possessed in earlier days and during the present campaign direct clean wounds of the joints were little more to be dreaded than uncomplicated wounds of the soft parts alone. No more striking evidence of the aseptic nature of the wounds, and the harmless character of the projectile as a possible infecting agent, than that offered by the general course of these injuries in this campaign, is to be found in the whole range of military surgery.
The aseptic nature of the wounds, and the slight and localised character of the bone lesions, have in fact justified the opinion previously expressed by Von Coler, that these injuries in the future would be less feared than fractures of the diaphyses of the bones.
Not less important than the localised character of the bone lesion itself is the fact that the accompanying wounds of the soft parts retain the small or type forms. Thus I occasionally observed more troublesome results from minor shell wounds in the neighbourhood of joints, but not implicating the synovial cavity, than in actual perforating injuries produced by bullets of small calibre.
Vibration synovitis.--Before proceeding to the consideration of wounds of the joints, a short account is necessary of a condition of some importance which is, I believe, more or less special to injuries from bullets of small calibre travelling at high rates of velocity. This condition, if not novel, at any rate excited little comment in the descriptions of the older forms of injury, although this may have depended on the more serious nature of the primary local lesions accompanying wounds from the larger bullets, among which it formed a comparatively unimportant element.
The condition referred to was the occurrence of considerable synovial effusion into the joints of limbs in which the articulation itself was primarily untouched. These effusions sometimes occurred even when the soft parts alone were perforated, especially when the wounds were situated above or below the knee-joint. They were apparently the direct result of vibratory concussion of the entire limb dependent on the blow received from the bullet.
The effusions were most strongly marked in cases of fractures of the diaphyses, although this was more noticeable in some situations than others. Thus with fractures of the shaft of the femur anywhere below the junction of the upper and middle thirds of the bone, and in some cases even higher, effusion into the knee-joint was very common, and sometimes extreme. On the other hand, similar effusions into the hip-joint were less marked, since I failed to determine their existence in the majority of cases. I am inclined to ascribe this to the different anatomical arrangement of the two joints, particularly to the fact that the head of the femur is included in a bony cup, into the hollow of which it is accurately fixed by the resilient cotyloid fibro-cartilage. The latter by its firm grasp of the head allows of little play in the joint; hence vibrations are conveyed directly to the acetabulum in continuous waves, and rocking of the articular surfaces is prevented. Beyond this no doubt the difficulty of detecting small effusions in this joint is an element which must be taken into consideration.
I do not think that wrenches of the knee-joint in the act of falling can be suggested as an explanation of the frequency of effusions into that articulation, since the fractures of the femur were not always received while the erect position was maintained, and effusion was most marked when the diaphysis was the part affected, the latter point illustrating the greater resistance offered by compact bone. Again, when fracture had taken place, the solution of continuity rendered the directly injured point the most mobile, and tended to prevent lateral strain from falling on the joints.
Effusion into the knee or ankle, or sometimes both joints, was common in fractures of the shaft of the tibia.
In the articulations of the upper extremity the condition was also common, but somewhat less marked than in the lower limb. Effusions into the shoulder or elbow occurred. In the former these were less striking; again, perhaps, as a result of the difficulty of detecting small effusions in this situation. The elbow was to a certain extent protected by the possession of a degree of fixity somewhat resembling that already mentioned in the case of the hip-joint, although here depending on the conformation of the bones alone. I think this explained the absence of free effusion in many cases of fracture of the humeral shaft, but when the latter affected the lower third effusion into the elbow was usually abundant.
The lighter weight and greater mobility of the upper extremity as a whole, as decreasing the resistance to the bullet, were also probably an element in the fact that these effusions were less severe than those in the joints of the lower limb.
The nature of the effusions was apparently simple, since they were rapidly reabsorbed, and little thickening of the synovial membrane remained to suggest either a marked degree of inflammation, or the deposition of blood-clot on the inner aspect of the same.
The only treatment indicated was a short period of rest, accompanied in the early stages by pressure and slight fixation, followed later by massage and movement if necessary.
Before dismissing this subject, I should like to particularly emphasise the fact, that in the cases described there was no reason to suspect the extension of fissures from the point of fracture in the shafts into the articular ends of the bones. This was as far as possible excluded by clinical examination, and in the cases where wounds of the soft parts only were present, the rapid return of the patients to active duty, with absence of remaining joint trouble, negatived the possibility of such fractures.
I only saw one case in which a longitudinal fracture actually extended for any considerable distance into a neighbouring joint. In this a comminuted fracture occurred just above the centre of the shaft of the humerus. At the time of examination and putting up of the fracture there was considerable swelling of the whole arm, and nothing special was noticed about the shoulder-joint. Three weeks later, however, when the fracture was consolidating, difficulty in abduction of the shoulder was noted, and the arm could not be placed closely in contact with the trunk. There was no evident displacement of the head of the humerus forwards. A skiagram, which I much regret I have not been able to insert, showed that a longitudinal fissure extended from the seat of fracture upwards in such a manner as to divide the upper fragment into two parts, of which the outer bore the greater tuberosity, the inner the articular surface of the head. The latter fragment had become somewhat displaced downwards, and had united in such a manner that the head rested on the lower part of the glenoid cavity. Abduction of the limb therefore brought the greater tuberosity into contact with the acromion process, and movement was checked. This case passed out of my observation shortly afterwards, and I have no knowledge of the final result as to movement.
Fractures of the bony processes surrounding the elbow-joint, and of the malleoli of the tibia and fibula, were not infrequent, but offered no special features.
One other form of injury indirectly affecting the joints is perhaps worthy of mention, but I observed it only once, and that in the case of the shoulder, the only joint where it is likely to be marked. I refer to the displacement of the head of the humerus by the force of gravity, when the circumflex nerve is injured. In the instance I refer to, a fracture of the surgical neck of the humerus was accompanied by complete motor paralysis of the deltoid and very rapid wasting of the muscle. Circumflex sensation was impaired, but not absent at the time the condition of the muscle was noted--a favourable prognostic sign of much importance. At the end of five weeks, when the fracture of the bone was consolidated, the head of the humerus had dropped vertically at least an inch, but could be replaced with ease. Shortly afterwards an improvement in the condition of the muscle commenced, and with this the head of the humerus was gradually raised. This patient later recovered his power in great part, but not completely.
In a few cases bullets lodged in the neighbourhood of joints in such positions as to limit movement by mechanical impact with the bones. Thus I saw one case in which a bullet lay between the radius and ulna just below the lesser sigmoid cavity; in another the bullet lay in front of the ankle-joint, and limited the possibility of flexion; and in a case related to me by Mr. Bowlby, a bullet was removed by him from the wall of the acetabulum where it was tightly fixed in the substance of the bone. In two other cases I saw bullets lying deeply on the anterior surface of the hip capsule and so limiting flexion. In all such cases the indication for removal of the bullet was sufficiently strongly marked.
WOUNDS OF THE JOINTS
These may be divided into several classes, varying much in comparative severity, and in prognostic importance.
1. The comparatively rare instances in which a wound implicated a joint cavity, without accompanying lesion of any bone.
2. Perforating wounds in which the bullet was retained within the articular cavity. These were also rare.
3. Wounds of the joints accompanied by grooving of the articular extremities of the bones.
4. Complete perforating tracks through the articular ends of the bones, crossing the joint cavity in various directions.
5. Comminuted fractures of the terminal parts of the diaphyses extending into joints.
Of these several classes, the first was of the least prognostic importance. In the absence of bone injury the wounds usually healed without any obvious ill effect beyond the transient effusion into the joints of a mixture of blood and synovial fluid. When suppuration of the wound in the soft parts occurred, however, the remarks made as to the injuries classed under the third heading also apply here in a lesser degree.
With regard to the retention of the bullet, in the case of bullets of small calibre this was a distinctly rare occurrence. I never happened to see an instance of retention of either a Mauser or Lee-Metford bullet in an articulation. It is only possible with bullets practically spent, or travelling at a very low rate of velocity and making irregular impact.
The influence of both volume and velocity of flight was well illustrated by my own small experience of retained bullets. In one case a Martini-Henry was found impacted between the femoral condyles, having slipped in beneath the margin of the patella. It caused a semiflexed position to be assumed by the joint, and was removed by Mr. Brown in No. 1 General Hospital at Wynberg. The second instance I saw in the Portland Hospital at Bloemfontein in a patient of Mr. Bowlby's. The bullet was a Guedes, a form which has been already described as possessing low velocity and deficient power of penetration; beyond this, in the particular instance irregular impact was evidenced by the presence of a large irregular contused wound of entry over the tuberosity of the tibia.
The presence of the bullet in the knee-joint was later determined by the X-rays, and Mr. Bowlby removed it successfully. Seven months later the range of movement was nearly normal.
I may add that I saw several instances of large leaden bullets lodging in the popliteal space, and a comparatively insignificant number of bullets of small calibre in the same situation. This was very striking, in view of the immense relative frequency of use of the latter forms. 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 class, 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 illustrate 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 class. 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 class, 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 illustrated 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 class 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 assumption 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 hæmophilic 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 quantity 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 illustrative 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 quantity of pus. No improvement followed, and a week later Major Burton amputated through the thigh. An attack of secondary hæmorrhage 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 passed 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 anæsthetised, 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 passage 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 passive movement as soon as the wounds were properly healed, to obtain in the great majority of cases perfect results. Careful light massage, 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 septicæmic 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. This depended, I think, on two points in the architecture of the joint: first, a bullet to enter the front of the cavity and traverse the joint needed to come with great exactitude from the immediate front; secondly, wounds received from a purely lateral direction calculated to pierce the head of the humerus and the glenoid cavity were naturally of very rare occurrence. Wounds of the prominent tip of the shoulder received while the men were in the prone position were not uncommon, but it was remarkable how rarely the shoulder-joint was implicated in these. The question of the narrow nature of the cleft exposed also comes up in this position. As far as my experience went, injuries to the lower portion of the capsule accompanying wounds of the axilla were those most often met with. The ease and neatness with which pure perforations of the head of the humerus can be produced was also an important element in the frequent escape of this joint. No case of fracture of the glenoid cavity happened to come under my notice.
I saw few instances in which the joint needed incision, and cannot recall or find in my notes any case in which serious trouble arose.
Elbow-joint.--Injuries to this joint came second in frequency in my experience to those of the knee. They were, in fact, comparatively common, especially in conjunction with fractures of the various bony prominences surrounding the articulation. Fractures of the lower end of the humerus were of worse prognostic significance than those of the ulna, on account of the greater tendency to splintering of the bone. I saw several cases of pure perforation of the olecranon without any signs of implication of the elbow-joint. In a case which has been utilised for the illustration of some of the types of aperture (fig. 20, p. 59), at the end of a week there was no sign of any joint lesion, although the bullet had obviously perforated the articulation.
Several cases of suppuration which came under my notice did well. I saw one of them a few days ago, six months after the injury, with perfect movement. In another of which I took notes, the bullet entered over the outer aspect of the head of the radius, to emerge just above the internal condyle anteriorly. A considerable amount of comminution of the olecranon resulted, and when the man came into hospital some ten days later the joint was suppurating. The joint was opened up from behind, and some fragments of bone removed by Mr. Hanwell. On the 26th day this joint was doing well, and considerable flexion and extension were possible without pain. There was a somewhat abundant discharge of bloody synovia during the first few days after the operation.
[Illustration: FIG. 59.--Illustrates the very neat and limited injury to the Phalanges over the dorsal aspect of the first inter-phalangeal joint of the Middle Finger, accompanying a gutter wound received by the patient while holding a rifle.]
I never saw any troublesome results from perforations of the carpus. The joints of the fingers also offered little special interest, except in so far as they afforded astonishing examples of the extreme neatness of the injuries which a small-calibre bullet can produce. Fig. 59 is a good example of such an injury.
Hip-joint.--I can only repeat with regard to this joint what I have already said as to the injuries to the head of the femur. I had practically no experience of small-calibre bullet injuries to the femoral constituent, and beyond the single case of injury to the acetabular margin mentioned on p. 193 I saw no obvious wounds of the joint at all.
The knee, as usual, proved itself par excellence the joint most commonly injured, no doubt as a result of its size, the extent of its capsule anteriorly, and its exposed position. In spite, however, of the frequency with which it suffered injury, and the opportunities it afforded for observation of the progress of the effusions towards absorption, the injuries to the joint gave less anxiety and attained a more favourable prognostic character than is the case in civil practice. This depended on the very favourable course observed in the frequent pure perforations following a direct line. These occurred in every direction, the accompanying hæmarthrosis usually disappearing completely in an average period of little over a month. The extremes can be fairly placed at a fortnight and six weeks. Limitation of movement was slight or non-existent in many cases; in others it was of a very moderate character, and I only remember to have seen one case in which a really serious anchylosis developed. In this the man was struck from a distance of 300 yards, and a considerable amount of bone dust from the femur was found in the lips of the exit aperture. The wounds healed per primam, but when I saw the man two months later anchylosis in the straight position was apparently complete.
The comparatively frequent association of popliteal aneurisms with wounds of the knee-joint has already been spoken of in relation to anchylosis. Wounds of the popliteal space from larger bullets sometimes caused more troublesome after-stiffness than wounds of the articulation itself. Again I remember a small pom-pom wound at the inner margin of the ligamentum patellæ without obvious wound of the joint, which was accompanied by synovitis from contusion, and was followed by very considerable limitation of movement. This had only been partially improved when the patient returned home, in spite of prolonged massage and passive movement.
The general remarks on the joints cover all that need be said as to suppuration of the knee-joint.
The ankle-joint maintained the undesirable character which it has always held as a subject for gunshot injuries. This is entirely a question of sepsis, and in great measure depends on the fact that the foot, as enclosed in a boot, is invested with skin particularly difficult to thoroughly cleanse; while the socks are an additional source of infection to the wounds before the patients come under proper treatment.
Of seven cases of suppurating ankle-joint, of which I have notes, only two retained the foot, and one of these after a very dangerous illness. This case was one of special interest as exemplifying the results dependent on variations in velocity on the part of the bullet. The patient was struck at a distance of twenty yards. The bullet entered the front of the right ankle-joint and emerged through the internal malleolus, just behind its centre, causing no comminution of the latter. It then entered the left foot by a type wound one inch behind and below the tip of the internal malleolus, traversed and comminuted the astragalus, and emerged one inch below the tip of the external malleolus. The first joint healed per primam. The second produced by the bullet when passing at a lower rate of velocity was accompanied by considerable comminution of the bone. It suppurated, and gave rise to great anxiety both for the fate of the foot and the life of the patient. It is probable that the more abundant hæmorrhage which took place from the second wound was in part responsible for the occurrence of infection.
The second of the two cases is of some interest in relation to the doctrine of chances as to the position in which a wound may be received. The man was wounded in one of the earlier engagements, a bullet passing transversely through his leg immediately behind the bones and about half an inch above the level of the ankle-joint. He recovered, and rejoined his regiment, only to receive at Paardeberg a second wound, about an inch lower, which traversed the ankle-joint. On his return to Wynberg he happened to be sent to the same pavilion, and occupied the same bed he had left on returning to the front.
The subject of the result of wounds of the joints of the foot has received sufficient consideration under the heading of wounds of the tarsus.
The repetition of the fact that, among the whole series of cases on which this chapter is founded, not a single instance of primary or secondary excision of a joint, either partial or complete, is recorded, forms an apt conclusion to my remarks on this subject.