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Tous las autras axamplairas originaux sont filmte an commandant par la premiere page qui comporte une ampreinte d'impression ou d'iilustration at an terminant par la darnlAre page qui comporte une telle empreinte. Un dee symbolas suivants apparaitra sur la damlAre image de cheque microfiche, selon Ie caa: Ie symbols — ^ signifie "A SUIVRE". Ie symbols V signifie "FIN". Lee cartes, planchaa, tableaux, etc., pauvent dtre flimAe d dee taux de rMuction diff«rents. Lorsque Ie document est trop grand pour dtrs reproduit en un seui cliche, il est fiimA i partir de I'angie supArieur gauche, de gauche d droite, et de haut en baa. en prenant la nombre d'imagas nicessaire. Las diagrammes suivants illustrent la m^thoda. 1 2 3 1 2 3 4 5 6 Ut TREATMENT OF WOUNDS OF THE ANTERIOR TIB- IAL ARTERY. COMPLICATING COMPOUND FRACTURE OF THE LEG; WITH REPORT OF A CASE.' By FRANCIS J. SHEPHERD, M. D, C. M., OF MONTREAL, SURGEON TO THE MONTREAL GENERAL HOSPITAL. JF., aged 50, native of France, quarryinan, on the 19th of Janu- , ary, 1884, whilst at his work in the quarry, was struck on the right leg by a large stone, which fell from some distance above him. He was immediately brought to Hospital, where on examination it was found that he had sustained a compound fracture of both bones r>f the right leg, about the junction of the middle wth the upper third. The wound in the soft parts was situated on the front of the leg, and extended from one inch below the tubercle of the tibia in a direction downwards and outwards. The fracture of the tibia was oblique, the upper fragment overlapping the lower ; the fibula was fractured higher up through the neck. When the man was admitted, his leg was enveloped in a tight bandage, on the removal of which very free bleeding took place; this was easily controlled by sponge pressure. The wound was washed out with a solution of carbolic acid 1-40, and the limb was encased in plaster bandages, an opening being left oppo- site the wound. The wound was dressed with iodoform and anti- septic gauze, and a carbolized sponge placed over the layer of gauze, and firmly kept in position by an evenly applied antiseptic bandage. By this means the hemorrhage was almost completely arrested, The next day, owing to the free oozing of blood, the dressings had to be renewed. After this there was no more oozing, and the case went on well till the fourth day, the temperature never having risen above 99° F. On January 23, the man complaining of uneasiness and a throbbing sensation, the dressings were removed, and at the site of the wound, which had become closed by blood clot, a pulsating swelling, about the size of an egg, was seen. From the situation of the swell- •Read before the Canada Medical Association, August, 1884. (7) 8 FRANCIS y. SHEPHERD. laceration of the aneerior tibkl artery '"' '° ''"' "'"' ^ .*ia, arfery atT "slStL' t^'^'i Vo'i fe™ On' "' "' ^"'t' plaster bandage th- lea w^« fn„n^ / k P^^^'*^'^' ^^ removing the ing been applied, I enlarged the wound o^ the ta^ ''"'^If ^ ^^"■ between three and four'inches long, tl d orth! ' ? f ^' "" began my search for the injured vesse ThnH • n ^""^ ''°''' ^"^ forming the orthodox operaLn o cutlg beteT^^^^^^ ''- and extensor longus digitornm mnc u ^ ^''^'^^'^ ^"''^"^ infiltrated condition of n^^^^^^^ ^'^^^™ ^"^ I then endeavored to reacTfhr' ^ / '"^ ^' "° ^"^^ *^«'^' «« which already si ghtirexSed h \ ^y mcreasing the separation the bone. l^Sr.r^::riX;^'f- -^- -c'e and interos-eous membrane and a h tt InT . " ^^""^ "P°" *^ nerve, with the artery to^"mnj^^^^^^ ^"^^"^ ^^^ial searched for- bv carefullv tT u ^^^ '"J"'-^^ Portion was then sionally relax nc the S ^" ""'"^ '""^ ^''°" "P ^"^ «^^- mediatVinZnt of thence Xre'^r ^^^ ;°""'' ^^ '^ ^^'"^^^ ^"^■ seous membrane. Fortunatelv the .r. ^'"'^'^ ''" ^"^^^°^- through, for -no doubt W J "^ ^^^ "°' completely torn ™ r™o.a, a„a . ™ „o„ /ee„ .rrLi^irrcoXts; .rude aXa X ,:,;T;„ter:r;:''* ''^'' ^ "-"^-^^ ^ ""■ t™ fragments of L mtz"S,-iT^::r:i':^^f "■" *^ Sliver wire siifiirf» A r.,Ki. j • -^--ur^irf^ apposition by a strong and broughet a. Ae™ o^H 7' ""' "" ""'"* '"'° ""^ ""^ ugn. out at the most dependent point at the outside of the leg, WOUNDS OF ANTERIOR TIBIAL ARTERY. 9 and in front of the fibula, to ensure thorough drainage. The wound hav- ing been washed out with carbolic acid 1-40, and dusted over with powdered iodoform, was closed with catgut sutures, and dressed as before with iodoform gauze and borated cotton ; the leg was then put in a Mclntyre splint, and kept in place by a bandage. For two days after the operation the patient had some elevation of temperature — ioi°-io2° F. On January 26, some staining of the dressings appearing, they were removed. The wound looked well, the lower part suppurating a litde. Two days later the discharge was very profuse, and pus had burrowed almost as far as the ankle between the skin and fascia. This was apparently caused by the breaking down of the blood clot produced by the bruising at the time of the accident. Free incisions were made, and drainage tubes inserted, and the burrow- ing of pus was thus arrested. By the 3d of February the wound was suppurating freely, the stitches had given away, and bare bone could be seen and felt through the wound. The wound had always been sweet, and the temperature, after the first three days, had never reached 100° F. Owmg to the profuse suppuration the dressings were changed every other day, and the wound washed out with 1-40 carbolic acid solution. The following note was made on February 15:" Patient going on well; discharge much lessened, some large shreds of sloughy fascia having come away from the deeper parts. The bare bone is becoming covered with granulations. The silver wire which united the broken ends of bone gave way some days ago, but is still holding a httle, and h^lps to keep the fragments in position. Temperature for the last week has been 100° F. at night, and 98^-° F. in the morning. Appe- tite fair, and general condition good. Takes a pint of claret daily." From this time the case progressed most favorably, and the tempera- ture soon became perfecdy normal. For some time there was free suppuration, and many sloughs of cellular tissue came away, as did also several pieces of dead bone. On March 15 the silver wire was removed, and the drainage tubes were dispensed with, only a small sinus being left at the site of the old wound, through which some bare bone could still be felt. Several small pieces of dead bone came away on the 30th of March, and also one of the silk ligatures which had been placed on the anterior tibial artery. There was now firm union of the bones. The man was about on crutches early in April, and seemed to be going on well, when, crossing the ward one day, he slipped, fell and re-fractured his tibia. He was immediately put to bed, the splint re-applied, and the wound, from which there was a good deal of bleed- ing, dressed as before. The leg new became much congested, swollen and painful, but in a day or two these symptoms subsided. lO FJfAXC/S y. SHEPHERD. m J',:-! P By the end of May the bones had again united, and although there was still a small sinus, no bare bone could be felt. He was discharged from Hospital June 28, 1884. When seen in July, he was walking about with a stick. I'he wound in the leg had completely healed, and he said that he could walk a mile without much difficulty, and that his condition was improving daily.' Ligature of the anterior tibial artery is an operation which IS rarely called for. The low operation is comparatively an easy one, but the high operation, owing to the depth at which the vessel is placed, presents many difficulties, and is rarely performed except on the dead subject. In the case narrated above, the great depth of the vessel, and the narrowness of the space in which it lay, as well as the infiltrated condition of the neighboring tissues, made the operation a most tedious and difficult one, but, on the whole, fewer difficulties were encountered than I expected. As I remarked in narrating the case, I was unable to satisfactorily follow the line of division between the anterior tibial and long extensor muscles, so reach- ed the vessel by separating the anterior tibial muscle from the bone ; in this way the artery was easily seen, and the advantage of having one side of the wound bounded by bone and thus, so to speak, fixed, was evident, for, only one retractor being neces- sary, more room was obtained. Laceration of the main arteries in the leg, due to fracture, is not a common injury. Dupuytren, in twenty-three -^ars; skw seven cases of diffiise aneurism due to fracture of the leg, and advocated ligature of the femoral, in preference to amputation, m such cases. This procedure Dupuytren advocated in fract- ures, both simple and compound, where the artery was wounded and a diffiise aneurism had formed,'^ Erichsen (Vol. L, p. 252, 2d ed.) says: In most cases it is net practicable to carry out the instructions of some surgeons to enlarge the wound and attempt to tie the artery wher^ it has been injured, as the surgeon would have to grope in the midst of bleeding and infiltrated tissues, and would experience the greatest possible difficulty in finding the wounded vessel, iThe patient was exhibited to the members of the Association at the August meeting. * ^Mr. Guthrie {Wounds a„d Ininrics of Arteries, 1 830) strongly condemns the proceedmg of Baron Dupuytren, and insists on ligature of the vessel at the injured point. John Bell {Principles of Surgery, Vol. IV., 1826) advocates the same practice. tj WOUJVDS OF ANTERIOR TIBIAL ARTERY. II after a search which vould materially tend to increase the dis- organization of the limb. If pressure fails, and the artery wounded be deep, he advises immediate amputation. Frank Hamilton says very little about wounds of arteries in fractures; he merely remarks (p. 69, 6th ed., 1880): "Rup- tured arteries, if within reach, ought always to be tied ; and if arteries situated remote from the surface bleed freely and for a long time, we may make some effort to find the open mouths in the wound ; but in this we rarely succeed, nor is it safe gen- erally to trust to the ligature of a main branch which supplies the part. Fortunately, this bleeding, although at first profuse, generally ceases in a few hours under the steady employment of cold lotions, moderate compression and rest. If it does not, the chances are the case will call for amputation." Agnew ( System of Surgery, Vol. I., p. 997 ), in speaking of hemorrhage in fracture of the leg, says : " If it is at the upper part of the leg, and the bleeding is persistent, we have but one recourse — amputation." In rupture of the tibial arteries in simple fractures of the leg, Mr. T. Holmes {System of Surgery, Vol. III., 1883, p. 86) does not advise surgical interference, and says that, as a rule, these cases do well if treated by position, rest, and light and even compression. In compound fractures he lays down the general rule that the wound must be enlarged, and the wound of the vessel treated, irrespective of the fracture. Petit, in a case of simple fracture with wound of the anterior tibial and the formation of a traumatic aneurism, cut down and successfully tied the bleeding vessel. Verneuil, in 1859, made use of a different method of treat- ment; he compressed the femoral on the pubis by the finger and with bags of shot. The successful case reported by him was rupture of the anterior tibial with simple fracture of the bones. Vallette obtained a good result by the same means in a case of compound fracture of the leg with wound of the artery. ♦ In cases of simple fracture with wound of the artery, rest, position, even pressure, and, if this fails, compression of the femoral are, no doubt, the best means to first employ, a com- pound fracture being thus avoided. Many successful cases have been reported where there was no surgical interference. t I 12 FHANCIS y. SHEPHERD. I! iH i When, however there is already an external wound communi- cating with the fractured bone, it seems to me that the sim- plest, surest and best practice, especially in these days of Esmarch s bandage and antiseptic surgery, is to enlarge the wound and search for the bleeding-point, as I did in my case. If we delay, the chances are that the limb will have to be am- putated. Compression of the main artery, in a limb whose vitality IS already impaired by severe injury, offers no special advantages delays union, and may lead to serious conse- quences. Dr. Lidell, in his valuable article in the Interna- tional Encyclopaedia of Surgery on " Injuries of Blood-vessels " tabulates sixteen cases of wounds of arteries of the leg treat- ed by various methods. In three cases ligature was applied to the wounded vessels, and two died. In three cases where compression of the femoral was employed all recovered. The cases of ligation, however, were before the days of antiseotic surgery, so Dr^ Lidell's condemnation of ligaturet the e cases does not hold. me^hl ' 'k ''''!.^ ''"""'' '"'"' ^ ^^^"^^ ^"^Pl°y the same ast; oLr""' ^'^ '"^^ ""'''' ^"' ^-^^^"' -^ ^^^^ - -^^ n me care of Prof. T. G. Roddick, to whom my thanks are extended for the courteous manner in which he has allowed me to make use of this dse Jtu're'of LTh T "' Tl 7""^' "'"^ ^"'P""^ ^•^"- T''-^ -- - --pie pdnTu and col? '^f ' '" ""' "^^ ^"°™°"-^'y -°»-. discolored, knee The no i Tk i "^'^ '"'""^ '"'^^"^'^'^ '^^^'y- -P--"y ^^^lo- th^ lus but th? f f, "■''•■' "'' '^" P"'^^*'"S ^^^'"^ *e '»te-al malleo- Ind the ^f --.';°">'i not be made out. The swelling increasing rapidly, and the general condition of the man being unfavorable. Dr. Roddick, though susl peeing rupture of the anterior tibial artery, wisely decided on amputa ionTbec u e of the obscunty of the case, and the unfavorable condition of the limb, wl^chw" b rrpL'" T- '''' "f ^'' ^^'""-^' ^-' ^'^ -" recovTitl without bad symptom. On examining the amputated limb it was found that there was com- plete rupture of the anterior tibial vessels where they passed through the i„te- osseous membrane; the upper end of the artery had retracted through the tn cle the lower end was some two inches distant from the upper. There was .„ oblique fracture of the tibia at the junction of the middle and upper thiiT an racture of the fibula through its neck. The vessels had evidentlyTeent ';, by the tearing ot the interosseous membrane, and were clearly not injured by Z fractured bones. Had ligature been attempted in this case' failure to find he upper end of the wounded vessel would have resulted, and amputation would he been necessitated under much less favorable circumstances. muni- sim- ys of e the case. t am- .'hose •ecial onse- erna- sels," reat- plied 'here The :ptic hese lame safe )f the pital, r the mple into Dred, 1 the lleo- idly, sus- ause was )ut a oni- iter- torn lUS- 3 an anil tred the the ave