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great vessels inward, until the tendon of the ilio-psoas could be identified at its insertion into the lesser trochanter. By means of long narrow retractors, the joint capsule was exposed at this point, incised, and the fragment found after some little search.
The next two cases show methods applicable to foreign bodies in the ankle-joint. In the first, the projectile lay in the calcaneo-astragaloid joint, just anterior to the strong interosseous ligament (see Fig. 73). On first view, it would seem advisable to employ an incision just below the internal malleolus; yet this would have involved considerable traumatism to the tendons which have their course in this situation. I therefore used a posterior incision, dividing the Achilles tendon at
Fig. 75.—Photograph (two exposures on one plate) illustrating the range of flexion and extension of the foot subsequent to removal of the projectile shown in Fig. 74.
the level of the calcaneo-astragaloid joint. The two bones were held apart by appropriately shaped blunt retractors, and the bullet easily extracted from the joint. The capsule and the divided Achilles tendon were united by interrupted chromic gut sutures and the leg immobilized for three weeks. Normal function both of the tendon and of the joint resulted. In the second case, the bullet was lodged in the astragalus, with its tip projecting through the joint into the inner malleolus (see Fig. 74). A horse-shoe shaped incision over the internal malleolus permitted its division just where it joins the lower extremity of the tibia. It was then turned upward like a trapdoor, the bullet removed, and the malleolus sutured in place. The resulting motion, as shown in Fig. 75, was practically normal.
Atypical Joint Operations.—Complicated injuries to joints frequently call for atypical operations, as in the instance illustrated in Fig. 76, an extensive injury to the shoulder in which
Fig. 76.—Extensive injury to the shoulder with fracture and downward displacement of the tip of the acromion and of the clavicle. The fragments were wired in place and the arm fixed in abduction. A useful shoulder resulted which enabled the patient to continue his military service.
the tip of the acromion and part of the clavicle were displaced downward. The fractured parts were wired in position and the arm placed in abduction. At a later operation a bony spur of the humerus was removed with a resultant useful shoulder which enabled the patient to continue his military service.
Were the conditions for treatment of gunshot injuries ideal, and were all surgeons experienced in this type of work, contractures would seldom occur. The conditions, however, are seldom ideal, and all too frequently the medical attendant does not realize the importance of proper postural treatment and of early mobilization. Therefore, contractures are frequent in the patients referred to the base hospital.
The most common are the following:
1. Contracture of the pectoralis major, binding the arm to the side of the body. This occurs in almost all wounds of the axilla where the abduction treatment has not been followed. When seen at an early stage before too much scar tissue has developed, the arm can be abducted under anæsthesia, and must of course be kept in that position until all tendency to contracture has disappeared. In the later cases, this bloodless method is, however, impossible, and a tenotomy must be done; if possible, subcutaneously, or if division of the lower portion of the tendon, accessible by the subcutaneous method, does not sufficiently free the arm, a longitudinal incision must be made over the insertion of the tendon, as in the treatment of birth palsy contracture, advocated by Sever, and the entire tendon divided at this point.
2. Flexion Contracture of the Elbow-joint.—This is usually due to injuries of the biceps and brachialis anticus. As in the first case, the contracture can be cured, when not of too long standing, by stretching under anæsthesia. If this does not succeed, the tendons should be divided and the arm placed for a time in the extended position.
3. Flexion Contracture of the Fingers and Wrist. This corresponds to the type frequently seen after an ischæmic gangrene. The method of Sir Robert Jones gives brilliant
results in many cases.
The wrist is flexed a few degrees beyond the customary position, thus allowing some extension of the fingers, which are then fixed in this position. Gradually, from day to day, with the fingers thus extended, the wrist is extended by a suitable splint until a normal position is secured. In other cases, the Schede splint (see Fig. 77) or corrective plaster dressings are effective. In other instances, however, these methods are not applicable, owing to the density of the scar tissue. This is particularly true of the adduction contractures of the thumb. Operation is necessary. A transverse incision is made through the scar tissue, thus liberating
b Fig. 77.-Flexion contracture of the fourth and fifth fingers due to gunshot injury of the flexor muscles. a, When brought to the base hospital. b, Three weeks later subsequent to treatment by means of the Schede finger splint.
the thumb. After abducting it, the resultant skin defect is covered by pedunculated flaps from the dorsum of the hand. Similar operations can be devised for contractures of the other fingers.
4. Adduction and Flexion Contracture of the Hip.—It is seldom possible to overcome this except by division of the shortened muscles. The adductors are divided by a 2-inch incision over their insertion, the flexors by a longitudinal incision near the anterior-superior spine. The Soutter method of subperiosteal downward displacement of the flexors gives good results.
5. Flexion Contracture of the Knee. Here, too, operative methods are usually necessary, although in some instances, even of long standing, the Schede splint or the genuclast will
Fig. 78.—Plaster splint for injuries in the neighborhood of the wrist holding the hand in hyperextended position. In this instance complicating injuries to the hand produced an adduction spasm of the fingers, which were held apart by means of straps passing through slits in the plaster splint.
Fig. 79.—Dorsal view of the splint shown in Fig. 78, illustrating the manner of holding the fingers apart when there is a tendency to adduction contracture.