War Surgery and Medicine
Appendix — CASE ILLUSTRATING THE RESULTS OF FASCIOTOMY
CASE ILLUSTRATING THE RESULTS OF FASCIOTOMY
A case is recorded in full illustrating the progress following immediate ligation of the lower end of the femoral artery with associated division of the aponeurosis covering the calf muscles and the anterior compartment of the leg.
Wounded 25 September 1944 by shell with some destruction of muscle and division of the femoral artery in the lower third of Hunter's Canal. the vein being intact. This produced severe bleeding and shock for which he was given two pints of blood at the ADS, the second pint being continued in the ambulance. At the MDS he was given a third pint of blood, and operation was performed.
The report of Major Owen-Johnston, the surgeon, is as follows:
‘The femoral artery was divided near the lower limit of Hunter's Canal leaving the vein intact. There was extensive division and laceration of the page 338 soft tissues at the level of the junction of the mid and lower third of the thigh. The wound of entry, some two inches in diameter, was over the outer aspect, and that of exit, four by three inches, was over the antero-internal aspect. Almost the whole of the muscle anterior to the femur was divided, as well as a fair mass of the adductors on the inner aspect. So as at least one-third of the muscle mass of the thigh was sectioned, it was thereby less probable that a satisfactory collateral circulation would develop. Also, to minimise the possibility of the onset of Gas Gangrene, a wide area of devitalised muscle was removed-a further embarrassment of any possible collateral circulation. Where the lower femoral or popliteal artery is tied in such wounds, in almost every case the ultimate onset of mass ischaemic necrosis leads to amputation of the limb. It has recently been suggested that splitting of the aponeurosis covering the calf muscles would possibly counteract the onset of ischaemia. In my own personal experience I have found that the splitting of the aponeurosis over the anterior group of leg muscles is most helpful in relieving embarrassment of the leg circulation resulting from severe injury at a higher level. So, in this case, after dealing with the wounds, we split, throughout the entire length of the leg, the aponeurosis both over the calf and anterior group of muscles. TJie wound was treated with penicillin irrigation, and he also received penicillin intramuscularly. We examined this man again at 1 NZ Gen. Hosp. three days after the operation. His general condition was excellent; he had no complaints; his foot was warm and he could move his toes freely. If ischaemic gangrene does not develop in this case, then I think it can be accepted as a very good test of the efficacy of fasciotomy of the leg aponeurosis in preventing the onset of ischaemia, where the popliteal or lower femoral artery has been tied in battle casualties.
‘On 1 Oct. 44 I examined [the patient] at 1 NZ Gen. Hosp. The state of the circulation in the foot had continued to improve. On the 30 Sept. the wounds were all inspected and sutured. The toes were warm, there was no numbness, and he could use them freely.’
Five days later at 1 NZ General Hospital his wounds were sutured without tension. Partial palsy was noted in his leg. The sutures were removed on the 12th day and except for slight superficial stitch sepsis the wounds had all healed well. The circulation of the foot was noted to be good. There was some anaesthesia present on the outer aspect of the foot and pain in the pero-neal and anterior tibial group of muscles. A plaster splint was applied to keep the foot at a right angle. He was then evacuated to 3 NZ General Hospital and boarded for New Zealand. The circulation was noted to be still subnormal and the skin of the foot mottled and the anterior and posterior tibial pulses were not felt. Sensation was impaired below the knee to the ankle, but the sensation in the sole was normal. There was paresis of flexions and extensions of the toes. Physiotherapeutic treatment was instituted. Slow improvement took place in muscle function, but marked muscle wasting was present. He was evacuated to New Zealand, being unable to walk any distance.
When he was examined in October 1945, a year after his wound, he could then walk half a mile and had improved considerably. He had gross tissue loss in adductors and vastus internus. The circulation of the foot was good, and faint pulsation was noted in dorsalis pedis and posterior tibial vessels. He had full movement in the hip, knee and ankle, and slight limitation in the foot. All the muscles of the leg were acting, but both the anterior tibial and the peroneal groups were weak. Sensory loss was confined to the saphenous distribution.page 339
A year later, in 1946, it was noted that he tended to go over on his ankle and that he had some pain on the ball of the foot after walking. He also experienced cramp in the calf in cold weather and some tightness in the calf after walking. He had no limp. He had then strong pulsation in the dorsalis pedis and posterior tibial vessels. A metatarsal bar was provided.
On further examination in November 1947, three years after the injury, he had improved further. There was still some pain in the calf after long walks. The ankle was stronger. There was weakness of flexion of the toes but no calluses on the sole.
In November 1948 he was still experiencing cramp but had no pain in his foot, the sensation of which was normal. There was still weak action of his toe flexors. He had been granted a permanent pension of 15s. a week, equal to 25 per cent disability. He was employed driving a baker's delivery van.
There has been an excellent recovery following the immediate ligation of the lower part of the femoral artery. The radical division of the deep fascia of the calf and the anterior part of the leg in all probability contributed a great deal to the success obtained, and as the wounds of the leg were sutured five days later and healed well with no permanent disability the fascial division certainly did no harm. The association of motor and sensory nerve disability makes the outcome still more satisfactory.
Vascular Injuries Invalided from2 NZEF, 1940–45
|Brachial artery and vein and ax. vein||1|
|Axillary artery and vein||4|
|Superficial femoral artery||2|
|Superficial femoral artery and vein||2|
|Popliteal artery and vein||1|
|Posterior tibial artery||4|
|Posterior and ant. tibial artery||1|
|Internal iliac artery||3|
|Arterio-venous aneurysm neck||1|
|Aneurysm common carotid artery||2|
|Arterio-venous aneurysm mastoid region||1|
|Arterio-venous aneurysm subclavian||1|
|Aneurysm brachial artery||1|
|Aneurysm ulnar artery||1|
|Aneurysm femoral artery||3|
|Aneurysm post, tibial artery||1|
|Arterio-venous aneurysm popliteal||4|
|Arterio-venous aneurysm thigh||1|
|Haematoma brachial artery||1|