Avulsion of the Lower Extremity

Anomalies and Curiosities of Medicine
by George M. Gould, M.D., Walter L. Pyle, M.D.

(Page 15 of 25)

The symptoms following avulsion of the upper extremity are seen as well in similar accidents to the leg and thigh, although the latter are possibly the more fatal. Horlbeck quotes Benomont's description of a small boy who had his leg torn off at the knee by a carriage in motion; the child experienced no pain, and was more concerned about the punishment he expected to receive at home for disobedience than about the loss of his leg. Carter speaks of a boy of twelve who incautiously put the great toe of his left foot against a pinion wheel of a mill in motion. The toe was fastened and drawn into the mill, the leg following almost to the thigh. The whole left leg and thigh, together with the left side of the scrotum, were torn off; the boy died as a result of his injuries.

Ashurst reported to the Pathological Society of Philadelphia the case of a child of nine who had its right leg caught in the spokes of a carriage wheel. The child was picked up unconscious, with its thigh entirely severed, and the bone broken off about the middle third; about three inches higher the muscles were torn from the sheaths and appeared as if cut with a knife. The great sciatic nerve was found hanging 15 inches from the stump, having given way from its division in the popliteal space. The child died in twelve hours. One of the most interesting features of the case was the rapid cooling of the body after the accident and prolongation of the coolness with slight variations until death ensued. Ashurst remarks that while the cutaneous surface of the stump was acutely sensitive to the touch, there was no manifestation of pain evinced upon handling the exposed nerve.

With reference to injuries to the sciatic nerve, Kuster mentions the case of a strong man of thirty, who in walking slipped and fell on his back. Immediately after rising to his feet he felt severe pain in the right leg and numbness in the foot. He was unable to stand, and was carried to his house, where Kuster found him suffering great pain. The diagnosis had been fracture of the neck of the femur, but as there was no crepitation and passive movements caused but little pain, Kuster suspected rupture of the sciatic nerve. The subsequent history of the case confirmed this diagnosis. The patient was confined to bed six weeks, and it was five months afterward before he was able to go about, and then only with a crutch and a stick.

Park mentions an instance of rupture of the sciatic nerve caused by a patient giving a violent lurch during an operation at the hip-joint.

The instances occasionally observed of recovery of an injured leg after extensive severance and loss of substance are most marvelous. Morton mentions a boy of sixteen, who was struck by one of the blades of a reaping machine, and had his left leg cut through about 1 1/4 inches above the ankle-joint. The foot was hanging by the portion of skin corresponding to the posterior quarter of the circumference of the leg, together with the posterior tibial vessels and nerves. These were the only structures escaping division, although the ankle-joint itself was intact. There was comparatively little hemorrhage and no shock; a ligature was applied to the vessels, the edges of the wound were drawn together by wire sutures, and the cut surfaces of the tibia were placed in as good apposition as possible, although the lower fragment projected slightly in front of the upper. The wound was dressed and healing progressed favorably; in three months the wound had filled up to such an extent that the man was allowed to go on crutches. The patient was discharged in five months, able to walk very well, but owing to the loss of the function of the extensor tendons the toes dragged.

Washington reports in full the case of a boy of eleven, who, in handing a fowling piece across a ditch, was accidentally shot. The contents of the gun were discharged through the leg above the ankle, carrying away five-sixths of the structure - at the time of the explosion the muzzle of the gun was only two feet away from his leg. The portions removed were more than one inch of the tibia and fibula (irregular fractures of the ends above and below), a corresponding portion of the posterior tibial muscle, and the long flexors of the great and small toes, as well as the tissue interposed between them and the Achilles tendon. The anterior tibial artery was fortunately uninjured. The remaining portions consisted of a strip of skin two inches in breadth in front of the wound, the muscles which it covered back of the wound, the Achilles tendon, and another piece of skin, barely enough to cover the tendon. The wound was treated by a bran-dressing, and the limb was saved with a shortening of but 1 1/2 inches.

There are several anomalous injuries which deserve mention. Markoe observed a patient of seventy-two, who ruptured both the quadriceps tendons of each patella by slipping on a piece of ice, one tendon first giving way, and followed almost immediately by the other. There was the usual depression immediately above the upper margin of the patella, and the other distinctive signs of the accident. In three months both tendons had united to such an extent that the patient was able to walk slowly. Gibney records a case in which the issue was not so successful, his patient being a man who, in a fall ten years previously, had ruptured the right quadriceps tendon, and four years later had suffered the same accident on the opposite side. As a result of his injuries, at the time Gibney saw him, he had completely lost all power of extending the knee-joint. Partridge mentions an instance, in a strong and healthy man, of rupture of the tendon of the left triceps cubiti, caused by a fall on the pavement. There are numerous cases in which the tendo Achillis has recovered after rupture, - in fact, it is unhesitatingly severed when necessity demands it, sufficient union always being anticipated. None of these cases of rupture of the tendon are unique, parallel instances existing in medical literature in abundance.

Marshall had under his observation a case in which the femoral artery was ruptured by a cart wheel passing over the thigh, and death ensued although there were scarcely any external signs of contusion and positively no fracture. Boerhaave cites a curious instance in which a surgeon attempted to stop hemorrhage from a wounded radial artery by the application of a caustic, but the material applied made such inroads as to destroy the median artery and thus brought about a fatal hemorrhage.

Spontaneous fractures are occasionally seen, but generally in advanced age, although muscular action may be the cause. There are several cases on record in which the muscular exertion in throwing a stone or ball, or in violently kicking the leg, has fractured one or both of the bones of an extremity. In old persons intracapsular fracture may be caused by such a trivial thing as turning in bed, and even a sudden twist of the ankle has been sufficient to produce this injury. In a boy of thirteen Storrs has reported fracture of the femur within the acetabulum. In addition to the causes enumerated, inflammation of osseous tissue, or osteoid carcinoma, has been found at the seat of a spontaneous fracture.

One of the most interesting subjects in the history of surgery is the gradual evolution of the rational treatment of dislocations. Possibly no portion of the whole science was so backward as this. Thirty-five centuries ago Darius, son of Hydaspis, suffered a simple luxation of the foot; it was not diagnosed in this land of Apis and of the deified discoverer of medicine. Among the wise men of Egypt, then in her acme of civilization, there was not one to reduce the simple luxation which any student of the present day would easily diagnose and successfully treat. Throughout the dark ages and down to the present century, the hideous and unnecessary apparatus employed, each decade bringing forth new types, is abundantly pictured in the older books on surgery; in some almost recent works there are pictures of windlasses and of individuals making superhuman efforts to pull the luxated member back - all of which were given to the student as advisable means of treatment.

Relative to anomalous dislocations the field is too large to be discussed here, but there are two recent ones worthy of mention. Bradley relates an instance of death following a subluxation of the right humerus backward on the scapula It could not be reduced because the tendon of the biceps lay between the head of the humerus and a piece of the bone which was chipped off.

Baxter-Tyrie reports a dislocation of the shoulder-joint, of unusual origin, in a man who was riding a horse that ran away up a steep hill. After going a few hundred yards the animal abated its speed, when the rider raised his hand to strike. Catching sight of the whip, the horse sprang forward, while the man felt an acute pain and a sense of something having given way at his shoulder. He did not fall off, but rode a little further and was helped to dismount. On examination a subcoracoid dislocation of the head of the humerus was found. The explanation is that as the weight of the whip was inconsiderable (four ounces) the inertia of the arm converted it into a lever of the first order. Instead of fulfilling its normal function of preventing displacement, the coraco-acromial arch acted as a fulcrum. The limb from the fingers to that point acted as the "long arm," and the head and part of the neck of the humerus served as the "short arm." The inertia of the arm, left behind as it were, supplied the power, while the ruptured capsular ligament and displacement of the head of the bone would represent the work done.