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162 Royal Army Medical Oorps, Rouen Medical Society
at the field ambulance or clearing hospital as a precautionary measure.
In the case of the knee, as soon as a diagnosis of suppuration is made,
provided adequate treatment can be carried out.
The surgical theatre of war may be divided into three zones: The
zone of first aid-from the front to the field ambulance; the zone of
transport from the field ambulance to the base. hospital; the zone of
rest at the base. There is only one place of choice at which an operation
can be performed and that is the base hospital; circumstances may render
it imperative that an operation be performed elsewhere, but the base
remains the place of choice. It is exceedingly difficult to indicate when
a septic knee should be operated upon, and I fear that an operation
earlier than at the base will be impossible.
The knee-joint may be regarded as a double joint divided into two
compartments by the femur. It is impossible to deal with the posterior
compartment by an anterior incision. Both anterior and posterior incisions are necessary. If a joint is to be drained a very radical operation
must be performed.
Should comminuted fracture of the lower end of the femur be complicated by septic infection of the knee-joint so that the lower end of the
femur is represented by numerous fragments lying in a bag of pus,
amputation is the most humane treatment. The immediate and remote
prospects of such a case are appalling. The mortality of cases of septic
knee plus fracture of the femur is exceedingly high, and it is necessary to
remember that a man has two legs but only one life.
CASES OF PENETRATING WOUNDS OF THE KNEE-JOINT IN
NO. 12 GENERAL HOSPITAL, ROUEN, DURING OCTOBER,
NOVEMBER, AND DECEMBER, 1914.
By CAPTAIN A. C. SEDGWICK.
Royal Army Medical Oorp8.
THERE were five cases in all. They were all apparently caused by
small-bore bullet wounds; there was no case of infection of the general
joint cavity. In both Case 1 and Case 2 the popliteal artery was injured
and a circumscribed traumatic aneurysm was present.
CASE 1.
Penetrating wound of the knee-Joint with injury to the popliteal artery.-Serjeant H., 2nd Gordons, admitted November 1. Entry
wound two inches behind upper border of patella on inner side, exit at
centre of popliteal space. Course of bullet probably through posterior
ligament close to internal condyle of femur. Joint distended with blood.
Slight pyrexia. Tumour with expansile pUlsation in popliteal space.
Well-marked bruit audible over swelling.
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Royal Army Medical Oorps, Rouen Medical Society 163
Progres8.-Wounds ran an aseptio oourse and the patient was transferred to England in less than three weeks, by whioh time the popliteal
swelling had considerably decreased in size.
CASE 2. Penetrating wound of the knee-joint with injury to the popliteal artery.-Private P., 2nd Queen's, admitted November 1. Entry
wound over internal condyle of femur. Exit on outer side of popliteal
spaoe, just behind ilio-tibial band. Wounds small and clean. Probable
course of bullet: through internal condyle and posterior ligament. Joint
distended with blood. A swelling with an expansile pulsation was present
in popliteal spaoe. A loud bruit was audible over the swelling; the
pulse in the dorsalis pedis was not to be felt, and that in the posterior'
tibial only with difficulty.
Progres8.- Wounds remained aseptic and the patient was transferred
to England eighteen days later.
CASE 3. Penetrating wound of the knee-joint.-Private C., 2nd
Warwick Regiment, admitted November 5, 1914. Entry wound over
inner edge of ligamentum patellre. Exit to inner side of middle line of
popliteal space. Wounds small and clean. Probable course of missile:
between condyles of femur. There was remarkably little pain considering
that the joint had been traversed.
Progress.-The patient did extremely well. The wounds remained
aseptic and he was transferred to England in three weeks' time with
every hope of obtaining a freely movable joint.
CASE 4.
Bullet wound of the knee-joint with injury to patellar
ligament.-Private M., 1st Gordons, admitted November, 29. Entry
wound on outer side of ligamentum patellre. Exit: about two inches from
entry wound on inner side of knee. Both wounds small and clean.
Probable oourse of missile: under ligainentum patellre, grooving anterior
surfaoe of tibia. The joint was distended and painful. ' Slight pyrexia.
Progress.-As the patient recovered it was found that on any attempt
being made to extend the, knee the patella was drawn several inches up
on the thigh; it was evident that the patellar ligament had either' been
completely or partially severed. Patient transferred to England.
CASE 5. Penetrating wound of the knee-joint.
Wounds septic, but no
infective arthritis of joint.-Oorporal P., 2nd Royal Scots, admitted
November 17. Entry wound, one inch below upper margin of tibia
anterior to insertions of gracilis, sartorius and semi-tendinosus. Exit:
about size of half a crown, just internal to patella, near upper margin of
the bone. Both wounds were septic. Temperature 100·6° F. Probable
oourse of missile: through head of tibia. There was no pain while the
knee remained at rest. ,The temperature fell to normal in a few days.
Though both wounds were septic, and the knee-joint plainly traversed,
the infection did not extend to the joint cavity itself. The patient was
transferred to England in three weeks' time.
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Cases of Penetrating
Wounds of the Knee-Joint in
No. 12 General Hospital,
Rouen, During October,
November, and December,
1914.
A. C. Sedgwick
J R Army Med Corps 1915 24: 162-163
doi: 10.1136/jramc-24-02-10
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