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(26_a_) CONDITION OF THE SAME FRACTURE SHOWN IN PLATE VI., A YEAR AFTER ITS PRODUCTION

The ensheathing callus is still very abundant, but less so than at an earlier date. No trouble with the musculo-spiral nerve was noted, but residual abscesses occurred from time to time in connection with the fracture.]

[Ill.u.s.tration: FIG. 54.--German Wire Gauze Splint on steel wire foundation.

(German Ambulance, Heilbron)]

The treatment of wounds should be on the lines already laid down: thorough cleansing, and then an attempt to seal. In severely comminuted fractures, however, the exit wound may be of very large size, and then frequent dressings are necessary. Loose fragments, by which those freed from their periosteal connections are meant, need removal. The question which most interested me was the best method of fixation. This needs to be sufficient to effect immobility, but on the other hand in many cases the weight of the arm as a means of extension is very valuable. Some of the most successfully treated cases that I saw were fixed by means of simple strips of pasteboard, applied moist, and fixed with an adhesive bandage. Ordinary book-muslin bandages are as good as anything for this purpose, as they can be reinforced by a stronger form outside them.

Where necessary, an angular piece of cardboard can be applied on the inner aspect, or a wooden angular splint may be subst.i.tuted, if it is at hand; but in this case most of the advantage of the weight of the arm as a means of extension is lost. The cardboard cases possess the great advantage of being readily cut off and reapplied much as is done with plaster of Paris. During the period in which dressing may be necessary I believe this form of splint is as good as can be got for use in Field hospitals, the only point needing care being to ensure that the bandaging is not too tight. It is much more reliable than are ordinary splints if transport is unavoidable, and is much lighter and less irksome to the patient. With such strips of cardboard, a few of the gauze splints (fig. 54), and a few angular and wooden splints, I believe a Field hospital is fully equipped for the treatment of any fractures of the upper extremity.

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

Skiagram by H. CATLING.

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(27) OBLIQUE FRACTURE OF THE HUMERUS OF THE NATURE OF A PERFORATION

Range more than '1,000 yards.'

The distance was probably much greater, as the bullet was retained and undeformed, and the comminution of the bone was very slight. The wound of entry was just below the elbow.

The bullet has cut its way through the inner half of the humerus, producing little comminution and mere solution of continuity of the bone without displacement]

_Fractures of the pelvis._--These, as a rule, were of so slight a nature as to form a very insignificant part of the entire injury with which they were a.s.sociated, or when uncomplicated they were of little more importance than simple wounds of the soft parts. The very great majority were of the simple perforating type. I had the opportunity of examining three at the brim of the pelvis, these all pa.s.sing in a downward direction. The openings were of about the same calibre as the bullet, and at their entrance was a small amount of bone dust such as would be found at the entry hole of a gimlet. It was these that made me consider the possibility of the rifle grooves having some part in the ease with which certain perforations are made. Of a large number of cases in which bullets traversed the ilium, the openings in the bone, as a rule, were with difficulty palpated. I must say that I was astonished that I never met with an instance of an extensive stellate fracture in the case of the ilium. Such may have occurred in some of the cases fatal on the field or shortly afterwards, but I never came across one in the hospital. It says much for the combined density and toughness of the human pelvis.

Comminuted fractures were, however, occasionally met with when the bullet pa.s.sed in a track parallel to the plane of the bone. One such of an unusual character has already been mentioned on p. 171. A still more interesting form, and one highly characteristic of flat bone injuries, is shown in fig. 55. The patient, a man wounded at Modder River, was struck at a range of 300 to 400 yards. The bullet entered over about the centre of the ilium and emerged in the anterior abdominal wall about 2 inches above the anterior-superior spine. As there was some doubt as to penetration of the abdomen, and as the exit wound was of considerable size, the wound was explored, an anaesthetic having been given. A clean-cut track in the bone was discovered which allowed the middle finger to be placed in it. There was little splintering of either inner or outer table of the bone beyond the width of the track, but plates of each table adhered on the one side to the origin of the gluteus medius, and on the other to the iliacus, the latter muscle being somewhat widely separated from the venter ilii by effused blood. There was no perforation of the abdominal cavity.

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

Skiagram by H. CATLING.

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(28) LOCALISED COMMINUTED FRACTURE OF THE HUMERUS

Range '100 yards.'

The entry and exit wounds were on the front and back aspects of the arm, about 3 inches above the elbow.

Fragmentation of the mantle of the bullet has occurred. It will be noted that the fragments are lodged in both the proximal and distal segments of the track. This may indicate that the bullet was damaged prior to entry, or the recoil of fragments. I incline to the latter view. The skiagram was taken a fortnight after the injury.

The large median fragment carried forwards, and the small degree of comminution, suggest the decrease of resistance and prolongation of impact by carriage back of the arm when struck.

The fracture is one of the nearest approaches to a transverse cleft that I met with.

The plate may well be compared with No. XII., where the effect of increased resistance in augmenting the degree of comminution is seen.]

Lesser degrees of the same kind of injury amounting to grooving of the surface or notching of the crest of the ilium were not uncommon, and the occasional large character of exit openings in b.u.t.tock wounds pointed to contact of travelling bullets with other parts of the external pelvic wall.

[Ill.u.s.tration: FIG. 55.--Clean Gutter Fracture of the Ilium (range placed by patient at 300 yards. Highland Brigade, Magersfontein). The gutter was clean cut, and admitted the forefinger. The inner and outer tables of the bone were in part blown out of a large irregularly circular exit opening about 1-1/2 in. above the crest of the ilium. The cancellous tissue was probably entirely blown out. Plates of the outer and inner tables still remained connected by their periosteum to the deep aspects of the iliacus and gluteus medius muscles. The peritoneal cavity was not opened. The patient did well. Compare with the gutter fractures of the skull shown in figs. 64, 66.]

Certain portions of the pelvis were subject to more severe comminution; thus in one case in which the bladder was wounded, a very much comminuted fracture of the horizontal ramus of the p.u.b.es was produced by a bullet which subsequently lodged in the thigh behind the femoral vessels. In this case the track was so oblique as to have necessitated almost pure lateral impact on the part of the bullet; hence the form of injury was nearly allied to the comminutions of the ilium already described.

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

Skiagram by H. CATLING

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(29) Wedge-shaped Fracture of the Radius

Range 'a few yards.'

The officer shot the man, his a.s.sailant, with a revolver. The entry wound was on the posterior aspect of the forearm at the junction of the middle and lower thirds. The exit wound was on the anterior aspect of the forearm, 1 inch below the elbow crease, and of moderate size.

Some fine fragmentation of the mantle of the bullet is indicated, and very fine comminution of the bone. The fracture healed well, but the resulting ma.s.s of callus at the end of three months prevented any movements of p.r.o.nation or supination.]

I never observed a fracture of the floor of the acetabulum by a bullet which had entered from the back of the pelvis, although tracks entering by the great sciatic notch were not infrequent. I saw one case in which a bullet which traversed the upper part of the shoulder and emerged at the axilla entered a second time an inch behind and above the anterior superior spine, and split off a layer of the outer table of the ilium of the extent of two square inches, which involved the upper portion of the rim of the acetabulum. No displacement upwards of the femur resulted; but external rotation was accompanied by crepitus. The wound suppurated, and some general infection resulted, but six weeks later there was no evidence of fluid in the hip-joint, the limb was adducted and slightly rotated outwards, and some movement in each direction could be made without causing any great amount of pain. I can say nothing of the further course of this case, as I neglected to take the patient's name.

I saw one or two instances of perforation of the sacrum. One is mentioned in the chapter on injuries to the abdomen, in which a central puncture at the level of the fourth vertebra was accompanied by temporary incontinence of faeces.

Fractures of the _femur_ were fairly numerous and formed one of the most serious cla.s.ses of case we had to treat, as well as one of the most fertile sources of mortality in the Base hospitals. In spite of the last observation, however, it is probable that the results in this campaign will be far better than in any previous war, both as to the smaller proportion in which amputation was needed and as to recovery.

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

Skiagram by H. CATLING.

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(30) COMMINUTED FRACTURE OF THE SECOND METACARPAL BONE

Large fragments of the mantle of the bullet.

Fragmentation of the bullet was comparatively common when the metacarpal bones were struck, also free comminution of a somewhat coa.r.s.er variety than that seen when bones offering greater resistance were struck.

This may be a result of the more frequent lateral impact of the bullet on these small bones.]

In spite of a considerable experience, I never saw a case of perforation of either the head or neck of the thigh bone. I saw numerous tracks emerging at the side of the femoral vessels and entering at the b.u.t.tock or vice versa, but never one accompanied either by effusion into the hip-joint or impairment of movement. Considering the regularity with which haemarthrosis occurred when the other joints were crossed, and also the nature of the compact tissue of the neck of the femur, which must have ensured some splintering, I do not think I can have overlooked an injury of this nature. No doubt also the escape of the neck of the bone was explained in some of the cases by the fact that the injuries were received while the hip-joint was in a position of flexion, the bullet pa.s.sing over the neck of the femur. In two cases of extensive comminution of the upper third of the femur that I saw, the fissures stopped short at the inter-trochanteric line anteriorly, but in one of them a large angular fragment was torn out of the posterior surface of the neck.

Excepting transverse fracture every form was met with in the shaft, although I saw only two instances of perforation. One has been already alluded to and was situated in the broadening portion of the lower third, the bullet taking an antero-posterior course. The second is seen in plate XVII.

Plate XII. shows an instance of extreme comminution of the upper third accompanied by the presence of two typical elongated fragments. The course taken by the bullet was almost directly antero-posterior, and the wounds were of moderate size even in the case of the exit one. This seems to preclude the possibility of the injury having been produced by a ricochet bullet, while the fact of perforation and escape of the bullet in spite of the serious damage suffered by the mantle points to the injury having been produced at a short range of fire. The patient himself owns to being quite unable to give any estimate of the distance.

Although no suppuration occurred, this fracture was very slow in consolidating, and the free comminution with consequent inaccurate apposition led to the development of four inches shortening of the limb.

The skiagram was taken about six weeks after the occurrence of the injury, a few days after I first saw the patient; I have, however, had the opportunity of seeing a second skiagram taken some four months later. This is of considerable interest, as throwing light on the mode of union of such fractures. The two elongated fragments in the later skiagram are widened to three times their original breadth, and form b.u.t.tresses on either side of the point of union, while the irregular ends of the shaft are rounded off, and the ma.s.s of fine fragments behind is consolidated. Beyond this the second skiagram shows that the upper fragment, apparently intact in the first, was really split longitudinally, and therefore was far less useful as a point of support than might have been a.s.sumed from the earlier skiagram, plate XIII. The case ill.u.s.trates well the chief difficulty in the treatment of such fractures: that of maintaining the fragments in line, since absolutely no help is received from the apposition of the two ends, and artificial traction alone must be relied upon.