Traumatic Avulsion at the Shoulder and

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An example of forequarter separation at the shoulder (Fig. 3.4) was described by Cheselden in 1741 as follows:

"Samuel Wood a miller, whose arm, with the scapula was torn off from his body, by a rope winding round it, the other end being fasten'd to the coggs of a mill. This hap-pen'd in the year 1737. The vessels being thus stretch'd bled very little, the arteries and nerves were drawn out of the arm; the surgeon who was first called plac'd them within the wound, and dressed it superficially. The next day he was put under Mr Feme's care, at St Thomas's hospital, but he did not remove the dressings for some days: The patient had no severe symptoms, and the wound was cur'd by superficial dressings only, the natural skin being left almost sufficient to cover it;"37

This type of injury has since been associated with fast-moving belts of powered machinery, the belt drawing in the arm until blocked by the trunk and, it is assumed, reflex resistance by the victim to produce separation of the shoulder girdle from the trunk with tearing of attached soft tissues, predominately muscles, vessels and nerves. As Cheselden noted the arteries are stretched and bleed very little, presumably because they shut down immediately after tearing due to retraction of the elastic inner and middle coats of the vessels within a sheath of the tougher outer fibrous layer. The writer has seen a very similar shoulder avulsion involving a coal miner whose arm was caught in a moving belt; despite this massive injury he was able to walk some distance to the cage bottom before evacuation and, on reception in the acci-

Fig. 3.4. Engraving of Samuel Wood, a miller, whose arm was caught by a rope attached to the moving cogs of a mill, suffering an avulsion of the arm and attached scapula, in 1737. He survived, having bled very little, as it was observed the stretched arteries clamped down immediately; the wound was simply dressed and healed over gradually. (From Cheselden W. The Anatomy of the Human Body. London: Bowyer, 1741:320.37)

Fig. 3.4. Engraving of Samuel Wood, a miller, whose arm was caught by a rope attached to the moving cogs of a mill, suffering an avulsion of the arm and attached scapula, in 1737. He survived, having bled very little, as it was observed the stretched arteries clamped down immediately; the wound was simply dressed and healed over gradually. (From Cheselden W. The Anatomy of the Human Body. London: Bowyer, 1741:320.37)

dent department, was barely shocked. Exploration demonstrated the torn vessels had sealed themselves, presumably at the moment of rupture, due to severe stretching of the elastic vessel walls with little blood loss. He made a good recovery as an amputee. This mechanism has been reported to cause bilateral avulsion at the shoulder with survival, an extremely major disability.38

By contrast, hindquarter avulsion is even more traumatic, based on the history of two victims described by McLean in 1962.39 One was a 23-year-old mine labourer whose right ankle was entwined in the coil of a steel rope which was attached to a powerful winch. When the winch operated, he was thrown into the air and his right leg was completely avulsed. Admitted to hospital severely shocked, the whole of the right side of his pelvis and much musculature including the psoas and gluteal muscles were missing; the urethra was torn across (Fig. 3.5). After resuscitation and surgery he developed various complications but ultimately walked with sticks. The second patient sustained a similar injury but avulsion took place at the hip joint, removing only part of the acetab-ulum and the ischium; although the gluteal muscles were avulsed, there was no urethral injury. Wound contamination required a temporary colostomy; he left hospital with a lower limb prosthesis after 3 months.

In the 18th century several lesser "pull-offs" were described in the Memoires de l'Academie de

Fig. 3.5. X-ray of pelvis and upper femora of mine worker, aged 23 years, whose right foot was caught in a wire coil attached to a powerful winch which suddenly avulsed his leg and most of the hemipelvis, and part of the left pubis, with a urethral tear. He survived and later formed a bladder calculus but was able to mobilise with crutches. (From McLean EM. Avulsion of the hindquarter. J Bone Joint Surg 1962:44B:384-385, with permission from Journal of Bone and Joint Surgery. © British Editorial Society of Bone & Joint Surgery.)

Fig. 3.5. X-ray of pelvis and upper femora of mine worker, aged 23 years, whose right foot was caught in a wire coil attached to a powerful winch which suddenly avulsed his leg and most of the hemipelvis, and part of the left pubis, with a urethral tear. He survived and later formed a bladder calculus but was able to mobilise with crutches. (From McLean EM. Avulsion of the hindquarter. J Bone Joint Surg 1962:44B:384-385, with permission from Journal of Bone and Joint Surgery. © British Editorial Society of Bone & Joint Surgery.)

Chirurgie of Paris, mainly fingers and toes, but included was an observation by Benemont concerning a boy of 9 or 10 years who, jumping on the back of a passing coach pulled by six horses, put a leg between the spokes of a wheel which pulled off the limb at the knee joint, exposing the lower femur. Holding on to the coach until it stopped, he was found to have lost little blood and, having seen his detached leg, he demanded the surgeon to reattach it before telling his mother about the accident! Lacking the technology to perform this modern miracle, the surgeon noted the vessels were stretched and sealed off, and after shortening the femur the wound healed uneventfully.40 It is intriguing to reflect the concept of reattachment was raised by a small boy two centuries before its eventual execution.

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