Part 3
The course of the bullet in long range was diagonally anteroposterior through the ulnar side of the lower end of the bone, with the wound of entrance on the anterior and the wound of exit on the posterior aspect of the wrist. The wound of exit was slightly lacerated by several small fragments driven off from the ulnar side of the radius. These fragments were removed through an incision before the radiograph was made.
The emergency treatment of such cases is only antiseptic dressing and splint immobilization.
When wound is aseptic or after it has closed, a secondary operation for coaptation, with proper facilities available, might be indicated.
The results as to full restoration of joint function are not favorable.
RIFLE--PLATE 30.
UPPER EXTREMITY.
Gunshot Fracture of the Lower End of the Radius.
The course of the missile was diagonally transverse, striking the radius in its lower third.
The projectile in this case is unknown, as it might have been either a shrapnel ball or a deformed rifle bullet with a torn jacket, exposing the lead core and marking its course with small particles of lead.
The fissures in the lower fragment and the finer fragmentation at the seat of impact, indicate a great striking energy, that more often resides in the high velocity of a rifle bullet than the low velocity of a shrapnel ball. The wound is therefore classified with rifle wounds.
The treatment is conservative. The course in such cases, without infection, is very favorable, and not unfavorable even with infection.
Results should be good.
RIFLE--PLATE 31.
UPPER EXTREMITY.
Gunshot Fracture of the Lower End of the Radius.
Wound of entrance, anterior aspect of wrist, over internal border of radius.
Wound of exit, posterior aspect of wrist between radius and ulna, with laceration.
The range was described as “close”--within a hundred yards--with the bullet in high velocity. The energy of the projectile, imparted to small fragments of cancellous tissue, drove them through the wound of exit, and caused the laceration of the superficial tissues. The wound was infected (swelling of soft parts clearly shown): resolution followed extended treatment, with ankylosis of the wrist and radial displacement of the carpus.
Emergency treatment in all such cases is antiseptic dressing without exploration or manipulation of fragments, and with splint immobilization.
Results are unfavorable as to function, depending upon extent of destruction of tendons.
RIFLE--PLATE 32.
UPPER EXTREMITY.
Gunshot Fracture of the Ulna.
The course of the bullet was transverse through the arm at the junction of the middle and upper thirds from behind the radial border externally to the ulnar border internally, striking the wall of the medullary canal with a punching effect that partly split off short longitudinal fragments and caused transverse and longitudinal cracks, without separation or displacement of fragments.
The same ballistic conditions applied to cancellous tissue at the end of the bone would probably have bored through it without fracture.
This effect is generally seen in wounds of small-caliber bullets traveling at reduced velocity of long range.
The treatment is that of a simple fracture.
Results, in such cases without infection, could not be bad.
RIFLE--PLATE 33.
UPPER EXTREMITY.
Gunshot Fracture of the Left Ulna.
The course of the missile was from within outward, ranging downward to the wrist, by deflection, after striking the ulna in its upper half. The considerable striking energy retained in a small portion of the mass--consisting of only the nose and a little more of the jacket of the bullet, but sufficient to fragment a large section of the bone, and then to traverse more than half the length of the forearm--leaves no doubt that the shot was fired at very close range, and that the bullet was broken on a nearly resisting surface, leaving in the nose of the bullet a striking force equal to that of the entire projectile at long range.
The posterior surface of the forearm is next to the plate, as the distinct outline of the styloid process of the ulna and the posterior border of the articular surface of the radius shows. The radius and ulna are parallel in the most natural position of supination. The normal diameter and sharp outline of the nose of the bullet show it to be next to the plate and on the posterior surface between radius and ulna.
Fragments of the exposed lead core of the bullet have scraped off on the line of fracture in a manner peculiar to shrapnel wounds, but never seen in bullet wounds in which the jacket covers all of the lead core.
The treatment is regularly conservative and without interference, as in this particular wound, which was aseptic.
Secondary treatment may indicate correction of bone deformity.
RIFLE--PLATE 34.
UPPER EXTREMITY.
Gunshot Fracture of the Ulna.
The ballistic conditions of the projectile causing the wound shown in this plate are substantially those of the wound shown in plate 32.
The wound of entrance and exit would be practically the same in chipping off a few small fragments and causing a clean transverse fracture without any displacement.
The bullet at long range has struck the wall of the medullary canal, appearance.
Treatment that of a simple fracture.
Results must be good.
RIFLE--PLATE 35.
UPPER EXTREMITY.
Gunshot Fracture of the Ulna.
The course of the bullet at long range has been anteroposterior through the middle of the forearm, passing through the side of the shaft, chipping off a few small fragments and causing a long oblique fracture.
The conditions were much the same as those shown in plates 28 and 29, except that the striking energy of the projectile was somewhat greater with the velocity of mid range.
The treatment, without infection, is that of a simple fracture.
Results will be uniformly good.
RIFLE--PLATE 36.
UPPER EXTREMITY.
Gunshot Fracture of the Ulna.
The course of the bullet was anteroposterior through the ulna a little above the middle of the forearm, and fairly through the long axis.
This is a bone effect much similar to those shown in plates 28, 29, and 31, except that this condition is due to the impact of a missile, with a still higher velocity of shorter range, imparting its energy to small fragments of bone, which added their momentum to the destructive force of the projectile.
No large fragments were carried along with the missile to cause any more destruction of tissue in exit than in entrance, so that the skin wounds, under these conditions, are about the same in appearance.
The treatment is conservative and expectant with immobilization.
Results in such cases are uniformly good.
RIFLE--PLATE 37.
UPPER EXTREMITY.
Gunshot Fracture of the Ulna.
The course of the bullet was in an anteroposterior direction at a high velocity of short range, which, imparting its energy to the fragments, drove some of them through the tissues as “secondary missiles” and caused a laceration of the wound to exist.
The longitudinal fragmentation and splitting indicates a considerable energy of the projectile, which may have been deflected, as its long axis was turned somewhat from the trajectory at the time of impact.
The emergency treatment is antiseptic dressing and splint immobilization.
The subsequent treatment is conservative with the removal of detached fragments and with control of infection as the course indicates.
RIFLE--PLATE 38.
UPPER EXTREMITY.
Gunshot Fracture of the Left Ulna.
The course of the bullet was transverse through the middle of the forearm, striking the posterior border of the ulna.
Small fragments were broken from the posterior wall of the medullary canal, without destroying the longitudinal continuity of the anterior wall.
The velocity of the bullet was probably that of mid-range, as the striking energy of the impact was fairly great.
The posterior surface of the forearm lay next to the plate.
The emergency treatment is antiseptic dressing and splint immobilization.
The subsequent treatment is that of a simple fracture, as infection is not usual.
RIFLE--PLATE 39.
UPPER EXTREMITY.
Gunshot Fracture of the Left Ulna.
The course of the bullet, with the velocity of long range, was anteroposterior through the lower third of the forearm, striking the outer side of the bone. The initial velocity of the projectile was much reduced, as is shown by the tendency to puncture the bone without much fragmentation.
There was no displacement of fragments as a direct result of the impact, although muscular contraction has caused some slight subsequent overriding.
The wounds of entrance and exit were about the same, if not quite similar in appearance.
The emergency treatment is the conventional antiseptic dressing with splint immobilization.
The subsequent treatment is usually that of a simple fracture, as infection in such cases is rare.
RIFLE--PLATE 40.
UPPER EXTREMITY.
Gunshot Fracture of the Ulna.
The course of the bullet was obliquely anteroposterior through the lower third of the forearm, striking the radial edge of the bone with a velocity of long range.
The wounds shown in plates 35 and 39 represent conditions similar to those causing this wound, except that the ranges were progressively greater.
In this case the projectile exhibited a punching effect at the point of impact, and although the lines of force are shown in characteristically divergent fissures, the energy imparted to the fragments--less than in the preceding cases--has not been sufficient to separate or to displace the fragments.
The emergency and subsequent treatment is conventionally conservative, as in the preceding cases.
RIFLE--PLATE 41.
UPPER EXTREMITY.
Gunshot Fracture of the Wrist.
Wound of entrance, posterior aspect of forearm over the lower end of the radius, with the bullet ranging forward and slightly downward to the wound of exit and covering with great laceration the anterior aspect of the wrist joint.
The range was close, and the energy of the high velocity of the missile was imparted to fragments, which, becoming “secondary missiles,” emerged with the projectile to cause extensive laceration and destruction of tissue.
The case was received for amputation in the second week, when a grave degree of infection extended in a cellulitis to the elbow. The ulnar nerve and vessels were intact, but the flexor tendons were almost entirely destroyed.
The plate, made after several weeks, when infection was under control and after the end of the radius and fragments of the carpus had been informally removed, shows a rarefaction of the carpus and proximal ends of the metacarpus, due to infection and disuse.
Frequent incisions and extension of drainage, with removal of detached fragments, was continued for several months. The wound was closed in the sixth month, with ankylosis and deformity of the wrist, as shown in plate 42.
RIFLE--PLATE 42.
UPPER EXTREMITY.
Gunshot Fracture of the Wrist.
This plate, presenting a lateral view of the wound shown in plate 41, shows considerable deformity of the joint, after four months’ treatment, which was even more marked two months later, when the case was discharged with an ankylosis of the wrist joint, contracture of the flexor tendons of the fingers, and slight flexor function of the thumb, permitting apposition with the first finger.
The result, while leaving much to be desired, preserved a function of the hand vastly superior to that of a forearm stump.
The treatment in such cases is always courageously conservative, with amputation only as the extreme measure to save life, with risks of judgment in favor of conservatism.
Corrective measures may be employed after management if the treatment of the infection is successful and when the case passes out of the military category. It is not possible, during a long infection, to maintain better position in such cases.
RIFLE--PLATE 43.
UPPER EXTREMITY.
Gunshot Fracture of the Metacarpus.
Wound of entrance, inner aspect of the hand over proximal end of the fifth metacarpal.
Wound of exit, on the outer border of the hand over the distal end of the second metacarpal.
The velocity of the bullet was in mid or long range, as it displaced no fragments, and as it made a point of entrance and exit about the same in appearance.
The wound was infected, which is more frequently the case in the hand than in the forearm.
The treatment is conservative with free incision and drainage in the management of infection.
RIFLE--PLATE 44.
UPPER EXTREMITY.
Gunshot Fracture of the Third Phalanx.
The course of the bullet was anteroposterior through the base of the proximal phalanx of the middle finger, with a velocity of long range. It practically punctured the bones and split off a few fragments without displacement.
The wound of entrance would be much the same as the wound of exit, with the latter, but a little larger.
Treatment is conservative.
RIFLE--PLATE 45.
CHEST.
Penetrating Gunshot Wound of the Chest, with Lodgment of the Projectile Near Posterior Chest Wall.
Point of entrance, pectoral border and fourth rib.
Point of exit, none.
The distinct shadow of the angle of the ribs shows that the posterior chest wall was next to the photographic plate, and that the larger and less distinct outline of the anterior portions of the upper ribs was farther from the plate.
The nearly normal size of the shadow of the projectile shows it to be much nearer the posterior than the anterior chest wall. The blurred outline shows it to have moved with respiration. Such conditions locate its position within the thoracic cavity.
The emergency treatment is antiseptic dressing and rest.
The subsequent treatment depends upon pleural involvement or the extremely rare infection of the lung.
These cases are nearly all aseptic, and if the great vessels and nerves of the chest escape injury results are generally favorable.
RIFLE--PLATE 46.
PELVIS.
Gunshot Wound of the Pelvis, with Lodgment of the Missile in the Abdomen.
The course of the bullet was from behind forward, striking the crest of the ilium, on which it was deflected, and spattering off some lead fragments. The slight penetration indicates a velocity of extremely long range and a striking energy lessened by ricochet.
The irregular outline of the shadow of the projectile shows its deformity, and the blurred outline indicates intra-abdominal movement with respiration.
While the missile, as revealed by its shadow, is not a shrapnel ball, the distribution of lead particles is more suggestive of a shrapnel than of a rifle projectile, and the ballistic conditions are more characteristic of the former than of the latter.
There was no abdominal reaction; the invasion of the abdomen was revealed by the radiograph.
The treatment in such cases is noninterference unless subsequent developments furnish definite indications.
RIFLE--PLATE 47.
LOWER EXTREMITY.
Gunshot Wound of the Gluteal Region, with Lodgment of the Bullet Near the Ischium.
Wound of entrance, over gluteal prominence on a transverse line through the great trochanter.
Wound of exit, none.
There was no bone injury in this case. The bullet, to have lodged in the soft parts after relatively slight penetration, must have struck the body at extreme range when its energy was almost spent in flight, for its normal outline indicates that it was not retarded by ricochet. The long axis is almost perpendicular to the plate. As the posterior pelvis was next to the plate, the fairly dense shadow shows the projectile was not far from the plate and behind the ischium.
The treatment is conservative; infection in such cases is extremely rare; and only pain or impaired function after many months of convalescence justifies operation for removal of the missile.
RIFLE--PLATE 48.
LOWER EXTREMITY.
Gunshot Wound of the Thigh, with Lodgment of the Bullet.
Wound of entrance, outer aspect of the thigh at the junction of the upper and middle thirds.
The slight penetration without bone injury and with slight deformity of the nose of the bullet indicates that the wound was caused by a ricochet shot at extreme range, after its energy was almost spent.
With the posterior aspect of the thigh next to the plate, the dense shadow and the nearly normal size of its outline indicate that the bullet was in the same relative position and that it lay posterior to the neck of the femur.
As such wounds are rarely infected, the treatment is conservative, and a search for the missile is only justified by serious infection, pain, or impaired function.
RIFLE--PLATE 49.
LOWER EXTREMITY.
Gunshot Wound of the Right Thigh, with Lodgment of the Bullet Behind the Femur.
There is no injury of the bone in this case, as the bullet lodged in the muscles posterior to the lower third of the femur without striking the bone. The lighter circular area of the larger end of the shadow of the projectile shows that its base is farther from the plate than its nose, which was probably flattened and bent by the ricochet which reduced its velocity so as to give it but slight power of penetration.
It is not easy to determine from inspection of the plate which side of the leg lay next to the plate.
With a history of the wound of the right thigh and with the outside of the leg next to the plate, the projectile must have lain near the plate on the outside behind the lower end of the femur, midway between the skin and bone.
The markings seen on the bone are not concerned with the wound, as the same effect in the plate is seen in the areas beside the bone.
The treatment is conservative; infection is rare.
RIFLE--PLATE 50.
LOWER EXTREMITY.
Gunshot Wound of the Right Thigh, with Lodgment of the Bullet Behind the Femur.
There is no injury to the bone. The large diameter, shortened length, and slight density of the shadow show the bullet to be some distance from and inclining toward the plate and lodged in the muscles behind the femur, nearer the side away from the photographic plate. It is difficult to identify the right or left thigh from the radiograph, but with the history of the wound in the right thigh and the outside of the leg next to the plate the ball would lie nearer the inside than the outside of the thigh, nearer the surface behind the femur. As the shadow shows irregular outline and the location of the bullet low velocity, the wound was caused by a ricochet shot at very long range.
The treatment is expectant and the course naturally favorable.
RIFLE--PLATE 51.
LOWER EXTREMITY.
Gunshot Wound of the Thigh, with Lodgment of the Missile.
As there is no injury to the bone, the bullet is not deformed. Its penetrating power was not great enough to carry it through the tissue so it must have struck the leg at extreme range when its energy was almost spent.
The actual length of the bullet is 1.25 inches; the length of the shadow is about 1.50 inches.
The increased length and the relatively slight density of the shadow indicate the bullet to be some distance from the plate. The case history places the wound in the right thigh, and the posterior surface of the leg lay next to the photographic plate. As the density of the shadow is not greater than the thickest portion of the bone, the bullet probably lies in front of the border of the outer tuberosity of the femur.
Although the surgeon’s diagnosis had to be made from the only available plate, there is something of a speculative element in these deductions, because if the reaction in the knee joint prevented the patient from extending the leg the increased length of the bullet shadow could be accounted for by this position, which would permit the bullet to lie behind the bone and yet far enough from the plate to account for the shadow enlargement. The nose of the bullet is at the epiphyseal line, which is shown in the femur.
RIFLE--PLATE 52.
LOWER EXTREMITY.
Gunshot Fracture of the Upper Shaft of the Femur.
The course of the bullet was anteroposterior and pierced the axis of the shaft of the femur with three radiating lines of fracture, resulting from the perforating action of the bullet striking the bone at long range and with greatly reduced energy.
This plate shows the lateral separation of large fragments, which is typical of gunshot wounds of long range.
Such wounds are usually not infected.
Emergency treatment is antiseptic dressing and coaptation with extension and temporary splint, so that it may support the bone for transportation and may be easily removable at place of continued treatment.
In these cases with lateral separation of fragments, it is imperative to supplement extension with pressure in a line perpendicular to the long axis of the femur.
RIFLE--PLATE 53.
UPPER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur with Lodgment of the Bullet.
The course of the bullet was antero-posterior and diagonally inward from the antero-external border of upper third of the thigh. A thin longitudinal fragment was split off without transverse fracture.
The missile struck the thigh after its energy had been greatly reduced by ricocheting as a result of striking a resisting object which flattened its nose and “set up” its body, as shown by the wavy outlines of the shadows.
The dense and normal-size shadow shows the bullet to be near the plate and probably in the muscles superficially behind and below the lesser trochanter.
As the prominent outline of the lesser trochanter shows that the leg was in external rotation when the negative was made, it is evident that, with the rotation back to the anatomical position, the projection of the shadow of the bullet would fall close to or in line with the shaft of the femur; the position of the bullet is behind the femur.
The treatment is conservative, with no trouble to be expected from infection.
RIFLE--PLATE 54.
LOWER EXTREMITY.
Gunshot Fracture of the Lower End of the Shaft of the Femur.
The course of the bullet was anteroposterior through the axis of the femur. Several large fragments which were not displaced were separated by the force of impact. The separation of the fragments and the overriding of the ends of the proximal and distal large fragments were due to bearing bodily weight or to muscular contraction.
The projectile causing the wound was moving with the velocity of mid range. The wound of exit was not lacerated.
The emergency treatment is antiseptic dressing and temporary splint immobilization. Permanent dressing, with extension and lateral compression, is the rule.
Infection in such cases is frequent owing to lack of facilities for proper dressing on the field.
Results in saving life and limb are generally good.
RIFLE--PLATE 55.
LOWER EXTREMITY.
Gunshot Fracture of the Lower Third of the Shaft of the Femur.
The course of the bullet was diagonally anteroposterior, with a velocity near mid range, without causing much displacement of fragments.
The wound of entrance and exit would be almost the same in appearance.
Treatment and results would be similar to case shown on plate 54. Many of these wounds are infected, due, no doubt, to the difficulties of arranging a clean first-aid dressing and effecting satisfactory immobilization during the first stage of transportation.