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

Skiagram by H. CATLING.

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(31) HIGHLY COMMINUTED FRACTURE OF THE UPPER THIRD OF THE SHAFT OF THE FEMUR

Range 'short.'

Impact fairly direct. The wounds were of moderate size and at nearly the same level. The exit wound near the b.u.t.tock fold was of moderate size, and presented no special features.

Considerable fragmentation of the bullet occurred. The comminution of the bone is very fine, suggesting high velocity, and great resistance by the bone. The skiagram was taken five weeks after the injury was received, and at that time no union had occurred.

Reference to plate XIII. will explain more fully the difficulty experienced in maintaining this fracture in position. The upper fragment is seen to be split into fragments, beyond the separation of the long splinter on the inner side; hence no aid was to be obtained from the apposition of the ends. About 2 inches of the shaft were actually pulverised; the fine fragments seen in a ma.s.s to the inner side of the bone in the exit portion of the back, eventually formed a large ma.s.s of callus, and the fracture united, with considerable shortening.]

Plate XIV. offers a good contrast; the fracture here presents a typical stellate form, and a good result without shortening was readily obtained. I a.s.sume that the difference in character of these two fractures depended mainly on the rate of velocity with which the bullet was travelling, since it pa.s.sed fairly directly across the limb in each.

I think it is clear, however, that the bullet struck the femur rather nearer the centre of the width of the shaft and therefore more directly, in the more severe injury.

This brings me to the question of explosive exit wounds in the thigh. In spite of the great tendency to comminution of the shaft, these were rare in a severe form. This depended simply on the depth and thickness of the coverings of the bone, and, as already mentioned, although the skin openings were often comparatively small, a large cavity or area of destroyed soft tissues may be contained within the limb. I do not think I ever saw an exit wound in the thigh exceeding 1-1/2 inch in diameter.

The oblique fracture ill.u.s.trated by plate XVI. has been already referred to, and the influence of the weight and movement of the trunk on its production has been considered.

Plate XV. ill.u.s.trates an obliquely comminuted fracture of another character. The bullet has here been stripped of its mantle, which has undergone fragmentation, but the leaden core is little altered in shape.

This is of much interest, since it shows that the bullet struck the bone by its side. The effect of such lateral impact on the part of the projectile is well shown: there is great bone comminution of a less regular character than usual, and the bullet is retained. Retention in this case was probably not a result of low velocity of flight, but of the increased resistance offered by the broad area of bone struck, and the check exerted on the axial rotation of the bullet by the lateral contact.

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

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(31_a_) THE FRACTURE SHOWN IN PLATE XII., SIX MONTHS AFTER RECEPTION OF THE INJURY

The amount of callus furnished around the loose fragments is very striking.

The upper end of the bone is shown to have been divided into at least two fragments, hence one of the difficulties of maintaining the ends in apposition. The stoppage of the fissuring short of the epiphysis is characteristic.]

Slighter injuries to the femur in which the shaft was chipped or grooved without loss of continuity were not uncommon, and showed well the capacity of the bone to withstand the lateral shock transmitted by small bullets. Two figures inserted in the chapter on wounds in general (figs.

22, 23, pp. 61, 62) are of cases in which, from the appearance of the wound of exit, the bullet probably underwent deformation, or was so deflected as to escape on a considerably altered axis. Beyond the nature of the exit wound in the case depicted in fig. 22, some thickening beneath the femoral vessels denoted bone injury, but unfortunately no skiagram was taken.

I saw no case in which a transverse fracture of the shaft accompanied such injuries, but am under the impression that, if they had been produced by bullets of greater volume and weight, transverse solution of continuity would have been more common. In point of fact, no case of pure transverse fracture of the femur ever came under my notice.

The diagram depicted in fig. 51, p. 164, is from a sketch made of the lower end of a femur in which a severely comminuted fracture followed by suppuration necessitated an amputation of the thigh, performed by Major Lougheed, R.A.M.C. It is inserted as an ill.u.s.tration of the tendency of the fissures to stop short above the actual articular extremities of the bones. In this case the comminution was extreme and accompanied by the usual long lateral fragments, one of which measured five inches in length and might well have extended into the knee-joint had that been an ordinary occurrence.

Perforations of the lower extremity of the bone were very common. These were sometimes transverse and limited to the articular extremity itself, or the same limitation occurred to the antero-posterior tracks. These were the slightest forms of injury, putting on one side incomplete tunnels and grooves on the surface of the bone. With regard to the latter, however, when they invaded the joint cavity the injury was liable to be more severe than a complete perforation, in consequence of the projection of comminuted fragments into the joint cavity near the line of reflection of the synovial capsule and ulterior interference with freedom of movement.

[Ill.u.s.tration: FIG. 55_a_.--Diagram of 'b.u.t.terfly' type.]

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

Skiagram by H. CATLING.

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(32) TYPICAL STELLATE (b.u.t.tERFLY) COMMINUTED FRACTURE OF THE FEMUR

Range 'short.'

Wounds small, impact direct, very little fine comminution. The bone united without shortening of the limb.]

Other tracks took a direction of longitudinal obliquity, and then implicated both epiphysis and diaphysis. Fig. 52, p. 169, shows an example, and also the peculiarity likely to be a.s.sumed by the exit aperture in the bone, especially if the bullet was travelling at a low rate of velocity, a considerable plate of the compact bone being driven out. In some cases these oblique tracks involved both femur and tibia.

They will be referred to again under the heading of injuries to the joints, and some remarks will also be found there regarding the synovial effusion so often occurring into the knee-joint in cases of fracture of the shaft of the bone.

It may be of interest to insert here a few remarks as to the clinical characteristics of fractures of the femur. First with regard to the primary signs and symptoms. A very considerable degree of general or const.i.tutional shock usually accompanied them, and this was perhaps more constant than in the case of any other injury in the body. This was, moreover, no doubt increased by the unfavourable conditions in which patients on the field of battle are situated in regard to transport.

When the patients were brought into hospital some delay in the primary treatment was often necessary until reaction took place. Local shock to the part was also a prominent feature. Abnormal mobility was very free in the badly comminuted cases. Crepitus was often loose, and of 'the bag of bone' variety. The result of local shock and consequent flaccidity of the muscles was to reduce the development of primary shortening; in some cases of severe comminution this was practically nil during the first day or two, when, with return of tone in the muscles, it sometimes became very considerable. Swelling of the limb was often very great, and vascular injury definitely far more common than in the fractures of civil practice, in consequence, no doubt, not only of the number and sharpness of the fragments, but also of the force with which they were driven into the surrounding tissues. The exit segment of the track was out of all proportion in size to the entry, as a result of the propulsion of bone fragments through it. This often made the closure of the exit wound a very protracted event, the track continuing to discharge a small quant.i.ty of b.l.o.o.d.y serum and fragments of necrosed tissue for many weeks.

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

Skiagram by H. CATLING.

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(33) COMMINUTED FRACTURE OF THE FEMUR

Range 'short.'

Normal entry wound of slightly oval form.

Oblique lateral impact on the part of the bullet, the mantle of which burst into numerous fragments. The bullet is seen to the inner side of the shaft, almost devoid of its mantle, and little deformed at the tip.

The comminution of the upper portion of the fracture is very fine; the bullet has merely cut its way down the lower portion, and one or two long fragments are separated. The skiagram shows well the result of lateral impact by the side of the bullet.

Compare this plate with No. VI. as ill.u.s.trating lesser resistance, and No. VIII. as ill.u.s.trating the effect of lower velocity.]

In a large proportion of the cases which were transported for any distance suppuration occurred; this must have been the case in at least 60 per cent. of the fractures. Suppuration was of the character already described in the general section, affecting particularly the bone itself, and accompanied by very marked signs of general infection.

_Prognosis in fractures of the femur._--As regards mortality fractures in the upper third of the bone proved one of the most formidable injuries which came under treatment. Suppuration was common, at least 60 per cent. of the wounds becoming infected. This depended on several reasons, often inseparable from the injuries, or from their treatment in Field hospitals: such as (1) the exit wound being situated in the dangerous region of the thigh; (2) ineffective dressing and fixation; (3) the impossibility of ensuring primary cleansing and removal of detached fragments of bone; (4) the necessity of the early transport of patients to the Stationary or Base hospitals, often for great distances; (5) the comparatively long period that often had to elapse before the opportunity of doing the first efficient dressing arrived.

Fractures in the middle and lower thirds of the bone were more easy to treat successfully, but these also added to the list both of amputations and fatalities.

Punctured fractures of the lower articular extremity were usually of little importance, as they progressed without exception, as far as my experience went, favourably.

I can give no idea of the general results obtained during the whole campaign, but I am able to state the results of the fractures of the shaft treated at No. 1 General Hospital during my stay in South Africa.

Thirty-two cases of fracture of the shaft of the bone came under treatment, and of these 6 or 18.7 per cent. needed amputation, and of the whole number 5 or 15.6 per cent. died. To emphasise the satisfactory nature of these figures I need only quote the results attained in the American War of the Rebellion; mortality in upper third, 46 per cent.; middle third, 40.6 per cent.; lower third, 38.2 per cent.

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

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(34) OBLIQUE FRACTURE OF THE SHAFT OF THE FEMUR

Range '300 to 400 yards.'