Clinical Paper: Compound comminuted fracture of the right thigh and serious injury to the left leg

The Lancet, 15 August 1863, volume 82, number 2085, pages 185-186 

ON A CASE OF COMPOUND COMMINUTED FRACTURE OF THE RIGHT THIGH AND SERIOUS INJURY TO THE LEFT LEG, THE RESULT OF A TIMBER WAGGON PASSING OVER BOTH LIMBS ; RECOVERY.

BY JOHN TUDOR, ESQ., M.R.C.S., SURGEON TO THE DORSET COUNTY HOSPITAL.

G. L–, aged sixteen, was admitted into the Dorset County Hospital March 18th, 1862, with a compound comminuted fracture of the lower third of the right femur, and a contused wound of the inner side of the left leg and thigh. From the history it appears that, whilst riding upon the front of a timber waggon laden with about five tons’ weight of timber, he fell down behind the horse and between the fore-wheels, and in attempting to escape by the side from under the waggon one of the hinder wheels passed over both his legs. He was taken home some distance, and attended to by a medical man who found the patient suffering from a profuse haemorrhage, proceeding from a ragged wound in the lower and back part of the right thigh, at the upper boundary of the popliteal space, caused by the protrusion of the fractured ends of the bones. There was some trouble in checking the bleeding, and hare-lip needles were made use of, several being passed in different directions through the wound, which was brought together by twisted sutures. The accident occurred late in the evening, and the patient was not brought to the hospital, a distance of about twelve miles, until the next day.

On admission he was in a state of great prostration from pain and loss of blood. A long splint was very carefully applied with a many-tailed bandage, and the limb placed upon pillows; stimulants, beef-tea, and opium being ordered. The following morning, in consequence of the increasing tension, the needles were removed, when a considerable quantity of decomposed blood and serum escaped, with fetid gas; whilst the lacerated hamstring muscles protruded through the wound. It was now apparent that a splint could not be used in consequence of the damaged state of the limb, and the impaired vitality, which seemed to threaten gangrene. The splint was therefore removed, and the limb merely laid upon pillows, which were covered with waterproof material, and so arranged as to allow an interval corresponding to the position of the wound, which was surrounded with water dressings, the whole being steadied by means of long sand cushions.

In a few days there was sloughing of the wound and cellular tissue in the course of the muscles, with foul discharge; also diffuse suppuration beneath the integuments, extending up to the trochanter. This was freely opened. Upon the inner side of the left leg there was a contused wound, about seven or eight inches in length by about three in breadth, extending above and below the knee, which in the course of a few days assumed a very unhealthy character. Early incisions were made; but the entire surface sloughed, completely denuding the muscles and tendons of the part. The knee in the meanwhile had been flexed to an acute angle to relieve pain. This was remedied as soon as possible, and the joint retained in a straight position. The wound was dressed with broad strips of lint, spread with resin cerate, which were carried round the circumference of the limb, and clothed with cotton wadding.

For a week or ten days the patient took little or no nourishment, and was sustained chiefly upon brandy and opium, his condition being most critical. In consequence of the large amount of discharge from both limbs, and of its offensive character, considerable difficulty and trouble was experienced in the dressing. This, however, was much diminished by the use of a double-framed bed, the sacking of which was made up of bands four inches in breadth, fixed at the sides, and movable at will. Two or three of these bands were removed as required; and when the upper part of the bed-frame was raised in the ordinary way, the fractured limb could be washed and dressed from below. It, however, required great care to prevent the fractured extremities doubling upon each other, and thus protruding through the wound. This was obviated partly by the arrangement of the pillows and by the use of a double perineal band fixed to the head of the bed, whilst the foot, carefully covered in thick folds of cotton, was secured by a broad bandage to the bottom of the bed. Little else could be attempted for some time than to dress the wounds and induce them to heal, and to support the patient’s strength. No effort was made to apply a splint until a sound healthy nutrition was re-established.

At the end of two months some callus was developed, and the wound contracted. Support was now given by means of gutta-percha applied to the anterior surface. Everything henceforward progressed favourably, and about the beginning of the fourth month the patient could raise the limb slightly. Loose bone was now discovered through a sinus opposite the seat of fracture. The cicatrix was opened, and a portion of the shaft of the bone, about an inch and a half in length, with several smaller pieces, were removed.

The patient was discharged on the l8th of October, with a very useful limb ; a high-heeled boot compensating for the loss of length.

A few points as to the immediate treatment of such a case seem to suggest themselves for consideration. As to the best mode of checking the haemorrhage, of course any vessels within reach should be ligatured or twisted; but as there would in such an extensive injury be rupture of many small vessels, arteries as well as veins, impossible to control by such means, and from which extensive haemorrhage may take place, we must resort to pressure; and the method most suitable seems to be the introduction of narrow strips of oiled lint within the wound by means of the finger, so as to completely fill it from the bottom; a compress should then be applied, and secured by strapping or a few turns of a bandage, due regard being observed as to the amount of pressure used. There seems to be an advantage in using oil: the lint can be more readily introduced, and it adapts itself more easily to the interstices; moreover, I believe it has a soothing effect, and, what is important, the lint can be more readily removed without causing a recurrence of the bleeding. The use of sutures in lacerated wounds rarely or never answers, more especially where the surrounding parts have been much damaged and the wound is deep. Haemorrhage goes on within the wound, and the effused blood finds its way into the cellular membrane and between the muscles, in many instances decomposing and causing the death of already damaged tissues, besides exerting an outward pressure which must greatly aggravate the mischief already existing in the integument itself.

The importance of early attention to the position of the left limb, and in straightening the knee, must be obvious. Nevertheless it is remarkable how often this rule of treatment is overlooked. The records of orthopaedic surgery doubtless could exhibit many instances of such cases; whilst I myself have operated upon several deformities arising from a similar cause.

Dorset, August, 1863.

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