The question of operative fixation rarely needs consideration; it occasionally happens, however, that oblique fractures, such as one mentioned on p. 166, are met with, in which s.c.r.e.w.i.n.g or wiring of the bone ends is advisable. What has been said above as to fractures, accompanied by loss of continuity, applies equally to cases of severe wedge-fracture, where many loose fragments exist.

As to the disinfection of the limb, primary cleansing, mainly by soap and water, of course precedes the exploration, and when the latter has been carried out a second cleansing and disinfection, preferably with spirit and carbolic acid lotion, are imperative.

Immobilisation is a more difficult problem. In practised hands plaster-of-Paris splints answer most requirements except in the case of the thigh; but the splints take time to apply and also to set firmly, and, as sometimes needing frequent removal, are not altogether suitable for Field hospital work. Of all the splints I saw in use, I think the best were wire splints, and the Dutch cane folding splints for the thigh and leg (figs. 56, 58); wire-gauze splints with steel at the margins (fig. 54), or strips of ordinary cardboard applied with some variety of adhesive bandage for the arm and forearm; and plain wooden of various lengths for any situation.

A question of constant difficulty was that of frequency of dressing; in a Stationary or Base hospital this is not difficult, as the same surgeon has the patient continuously under his charge, and can readily decide as to the proper moment for the renewal of the dressing. When the patient is, however, being moved from the Field to the Stationary hospital, and thence to the Base, a constant succession of surgeons has the case in hand for short periods, the movements during transport disturb the fixity of the dressing, and, in consequence, dressings are apt to be far more frequent than is advisable. This question raises the larger one of the advisability of _any_ transport beyond what may be an actual necessity. There is only one answer to this. No fractures of the thigh or leg, and few of the arm, can be transported for any distance without material disadvantage. The risks attendant on disturbance of the fracture and tissue injury, septic infection as a result of slipping of the dressing and the impracticability of efficiently renewing it, far more than counterbalance any advantage to be gained from the superior comforts available at a Base hospital. For these reasons, if possible, all fractures of the arm, thigh, or leg should be kept at a Stationary hospital for a period of three or more weeks, and, as far as splints and appliances are concerned, these should be as numerous and complete as at a Base hospital. I have had a useful set made of aluminium. A word will be added later as to the splints suitable for different regions of the body.

The necessity for _primary amputation_ chiefly depends on the nature of the injury to the soft parts, less commonly on the extent of the injury to the bones, and should be decided on exactly the same lines as in civil practice. So-called intermediate amputations are always to be avoided if possible; the results were consistently bad, and the operation should only be undertaken in cases of severe sepsis where little can be hoped from it, or for secondary haemorrhage. When the operation could be tided over until the septic process had settled down and localised itself, secondary amputation gave very fair results. In either intermediate or secondary amputation for suppurating fractures, it was necessary to bear in mind the special likelihood of the existence of extensive osteo-myelitis. If this condition affected the upper fragment, an amputation was of little use unless the whole bone was removed, as septic infection continued and brought about a fatal issue, or a fresh amputation was required in order to obtain a stump that would heal.

SPECIAL FRACTURES

_Upper Extremity._--Fractures of the _scapula_ were not uncommon, but were mostly of the perforative variety; thus perforations both of the spine in longitudinal wounds of the back, and of the ala in perforating wounds of the thorax, were tolerably frequent. They possessed little practical interest; as a rule, the openings were not large, and the most unexpected feature was the small interference with the movements of the bone on the chest wall that resulted. It might be a.s.sumed that comminuted fragments would project into the muscles and cause both pain and interference with movement; but neither was the case. I saw grooving of the crest of the spine, but never happened to meet with a fracture of the acromion process. Many axillary tracks pa.s.sed in the closest proximity to the coracoid, but this again I never saw separated. One practical point of importance with regard to the scapula was the frequency with which bullets lodged in the venter, or the firmly bound-down muscles of the supra- and infra-spinous fossae. These retained bullets often gave rise to remarkably little trouble in this situation; thus I have a skiagram of a shrapnel bullet lying in the deepest part of the subscapular fossa, which did not inconvenience its possessor.

[Ill.u.s.tration: FIG. 53. Head of Humerus, showing broken perforation. The roof forms a hinged covering to a groove.]

Every variety of _fracture of the clavicle_ was met with, even perforation of the most compact portion of the shaft; comminuted, wedge, or notched fractures were, however, the more common, and were accompanied by the development of very large ma.s.ses of provisional callus during the process of healing. An interesting skiagram is reproduced in plate III., which shows a compound form of injury to the clavicle. The bullet has pa.s.sed obliquely beneath the acromial end, rising to perforate the posterior compact margin, and producing one of the diamond-shaped openings sometimes occurring in compact bone with the pa.s.sage of bullets at a low rate of velocity. No case of perforation of the subclavian vein by comminuted fragments of the clavicle came under my notice.

_Fractures of the humerus_ of every variety were common, and I think when the statistics of the campaign are published, it will be shown that the humerus was the most frequently injured individual bone in the whole body. I remember to have seen thirteen fractures of the shaft of the humerus in one pavilion alone at Wynberg after the battle of Paardeberg.

Perforations of the upper articular extremity were common, and as a rule gave rise to wonderfully little trouble in the shoulder-joint. The outer aspect of the head of the humerus is a common situation for the production of a special form of broken ca.n.a.l or groove (fig. 53). The slope from the greater tuberosity to the shaft naturally favours the production of the injury in this position.

I saw only one case in which a vertical fissure extended from a fracture of the shaft into the shoulder-joint; in this case the transverse solution of continuity was at the upper part of the middle third of the bone. Skiagram, plate IV., ill.u.s.trates a well-marked stellate comminution of the shaft with large fragments. Plate V. shows extreme comminution with fragments blown out of the wound. Two plates, Nos. VI.

and VIII., ill.u.s.trate well the difference resulting from the oblique pa.s.sage of a bullet at high and low rates of velocity respectively. In both cases good results were obtained; in the more severe the resultant ma.s.s of ensheathing callus was very large, temporarily interfered with flexion of the elbow-joint, and consolidation was very slow (see plate VII.). The patient was wounded at Belmont in November 1899, but he was able to row at the end of the summer of 1900, although very prolonged suppuration occurred, and the elbow movements became practically normal.

Plate IX. ill.u.s.trates a transverse track, the bullet having undergone considerable injury during its pa.s.sage through the bone, as evidenced by the presence of fragments both of mantle and lead in the limb. This might be called an example of transverse fracture, and ill.u.s.trates the nearest approach to one seen when the bone is struck fairly plumb.

[Ill.u.s.tration: PLATE IV.

Skiagram by H. CATLING

Engraved and Printed by Bale and Danielsson, Ltd.

(24) COMMINUTED FRACTURE OF THE HUMERUS

Range about '300 yards.'

The wound track took a directly antero-posterior course. Impact rectangular. The musculo-spiral nerve was completely divided.

The plate affords a good example of the so-called 'b.u.t.terfly' fracture.

Two long doubly wedge-shaped lateral fragments, and pointed extremities to both main fragments, are shown.

The fracture healed well, with the deposition of a large ma.s.s of provisional callus. The musculo-spiral nerve was united by suture some three months later.]

Plate VIII. exhibits an oblique fracture of the lower part of the shaft produced by a bullet pa.s.sing at a low rate of velocity. It does not widely differ from a perforation, and the ill.u.s.tration possesses some further interest as showing the deviation of a bullet likely to occur when a bone lies in its course. Although the velocity with which this bullet was travelling must have been very low, when the bone had been traversed the deviation in its course was slight. A few bony fragments from the compact tissue of the posterior surface of the humerus have been carried into the distal portion of the track.

Fractures of the various prominences of the lower articular extremity were not uncommon, but deviated little from the types with which we are familiar in civil practice; the after results were good, both as to union and movement of the elbow.

Explosive wounds of the soft parts were not infrequent in the arm, and fig. 48, p. 158, exhibits an extreme example. The humerus in respect of depth of covering, however, comes between the femur and the bones of the leg and forearm; hence such injuries were not so easily produced as in the latter segments of the limbs.

In connection with the subject of fractures of this bone, one word must be added as to the occurrence of the most characteristic of its complications, musculo-spiral paralysis. This was frequent in every position of the fracture, and came on either immediately, or, at a subsequent period, as a result of callus irritation or pressure. Its frequency is only what would be expected when the nature of the fracture is considered, but the chief interest of the condition lay in the difficulty of certainly detecting it in the initial stages of the cases; this depended on the fact that in many of them the local shock to the limb was so severe that the function of the whole of the muscles was lowered, or in some cases, although the musculo-spiral was the nerve chiefly affected, the other large trunks had also suffered concussion or contusion. In consequence of this difficulty the actual localised paralysis often only became evident at the end of a week, or even more, when there was difficulty in deciding as to whether the paralysis was primary or due to secondary trouble. In the fracture ill.u.s.trated by skiagram, plate IV., the nerve suffered complete division, and was united some three months later, improvement in the symptoms being very slow. The latter was a common experience, and although not unusual in civil practice, I think it is more marked in these injuries as a result of the more widespread character of the nerve lesion.

[Ill.u.s.tration: PLATE V.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(25) COMMINUTED FRACTURE OF THE HUMERUS

Range '50 yards.' Velocity extreme.

Impact somewhat oblique. The bullet entered anteriorly about 3 inches above the elbow crease. The wound of exit was on the inner aspect of the arm and explosive in character; it still measured 4 inches by 2 inches three weeks after the injury was received.

The wounds suppurated locally, but at the end of six weeks fair union of the bone had taken place and the wound of exit had contracted to a sinus. The musculo-spiral nerve was concussed, but not divided.

The skiagram was taken three weeks after the reception of the injury.

Comparison with plate IV. demonstrates the effect of high velocity in free comminution of the bone, the sharper radiation of the stellate lines of fracture, and the propulsion of bone fragments.]

The _bones of the forearm_ were also often fractured. The princ.i.p.al peculiarity of these fractures was the common localisation of the injury to one bone, which is readily seen to be probable.

Each bone offered some special features dependent on its structural character and anatomical position. In the case of the _ulna_, pure perforation of the olecranon process, without obvious evidence of implication of the elbow, was seen on several occasions. The other important feature with regard to this bone depends on its subcutaneous position, which accounted for the frequency with which highly developed explosive exit wounds were met with. One is figured in the general section (fig. 47, p. 156). This, however, is a very slight instance compared with what was often seen in the upper and middle thirds of the bone, where the lateral soft parts often protruded as a much larger tumour, the particular ill.u.s.tration being mainly designed to show the nature of the injury to the skin. The _radius_, as more deeply placed in the upper part of its course, was less often the seat of such well-marked explosive injuries; but when the lower end was struck this character was sometimes very striking: thus in a track pa.s.sing antero-posteriorly through this bone, the whole lower end appeared shattered, all the tendons at the back of the wrist being implicated in the protruding ma.s.s, while the bone itself seemed shortened, so that the hand took up the position common in Colles's fracture. It was found impossible to place the bone in good position; nevertheless the patient retained his hand, which is still of use in writing.

Plate X. is a good example of a high-velocity injury in which lateral contact with the radius has produced local comminution, some slight injury to the casing of the bullet, and the separation of a large wedge.

The case from which this was taken also ill.u.s.trated well one of the chief troubles of such fractures of the forearm; the degree of splintering resulted in the formation of a large ma.s.s of callus, which for a time rendered any degree of p.r.o.nation and supination impossible.

[Ill.u.s.tration: PLATE VI.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(26) COMMINUTED FRACTURE OF THE HUMERUS

Range '250 yards.'

Impact oblique. Wound of entry 1 inch below the insertion of the deltoid; exit, on inner aspect of arm at a slightly lower level. The bullet probably struck the bone laterally, and drove out the central fragment.

Prolonged suppuration resulted, but the humerus healed well, and good movement of the elbow was preserved.

The effect of oblique impact together with high velocity is well ill.u.s.trated. Had the resistance been greater, as in the case of the femur, a nearer resemblance to the effect seen in plate XV. would have been the result.]

Of _fractures of the hand_ I have little to say. In the case of the _carpus_, the slight degree of resistance offered by the bones rendered injuries of an explosive character rare. I never saw one. Fractures of the _metacarpus_, on the other hand, presented exactly the opposite features. The density of these small bones was well ill.u.s.trated by the frequency with which the bullet suffered injury, even amounting to fragmentation, and the great comminution they themselves suffered. The breaking up of the bullet in these fractures was a curious feature, which may perhaps be explained by the tendency of the distal part of the limb to be driven in the course of the bullet, with the result of somewhat lengthening the period of contact of the projectile, or more probably by somewhat frequently occurring irregular impact. Plate XI. is a good example of an injury of this nature of moderate severity. The soft parts suffered much in these injuries, the tendons were torn and lacerated at the moment, and were very apt to acquire more or less permanent adhesion. This latter condition was sometimes to be improved by the removal of bone fragments, and I have freed tendons from actual clefts in the bones where they had been carried in by the bullet. In some cases very great deformity of the digits, due to shortening, developed, even when no fragments were removed beyond those blown away by the bullet.

One form of injury of some interest was multiple fracture of the phalanges produced by a bullet travelling in a course parallel to the length of the rifle when pointed by the patient. Occasionally several digits were lost.

_Treatment of fractures of the upper extremity._--The general lines of this have already been foreshadowed in the general section, the remarks as to transport being applicable to all serious fractures of the shaft of the humerus, and this is the only one of the bones of the upper extremity on which anything special need be said, as the treatment of all the other fractures exactly coincides with that of ordinary civil practice.

[Ill.u.s.tration: PLATE VII.