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.

..

?i 1

-

I % B ill

IHHHH!

, J . -

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.).