Part 4

Infection from clothing carried into the wound is rare, as the fairly high velocity of the bullet causes a spreading of the fibers without division or punched-out section before the bullet.

As a rule the infected cases of this class recovered without loss of limb. Amputation was very rare.

RIFLE--PLATE 56.

LOWER EXTREMITY.

Gunshot Fracture Below the Middle of the Femur, with Lodgment of the Bullet Near the Fracture.

The course of the projectile was transverse. The long splitting fracture, with few large fragments and the lodged undeformed missile, indicate that the injury to the bone was caused by the missile striking the bone with large cross section or at an inclined angle so that all of the remaining energy of the projectile at long range was absorbed by the bone.

Had the point of the ball struck the bone with the same energy, it would have produced smaller fragments and might then have passed beyond the bone. The normal size of the diameter, slightly shortened length, greater density of the point of the shadow, shows the bullet to lie behind the bone with its nose pointing slightly backward. The actual length of the bullet is 1.25 inches: the length of the shadow is 1 inch.

Treatment and results would be about the same as in plates 49 and 50.

RIFLE--PLATE 57.

LOWER EXTREMITY.

Gunshot Fracture About the Middle of the Femur, with Lodgment of the Fragments of a Deformed Bullet.

The course of the missile was transverse. All of the remaining energy of the retarded velocity of the short range of a ricochet shot was stopped by the bone with the result of a long splitting fracture, and the lodgment of one large and a few small fragments of the missile.

The small notched metal fragment lying to the right of the upper bone fragment is a small bent piece of the jacket, detached from the greatly deformed lead core, which can be faintly seen lying behind the lower end of the left side of the upper bone fragment.

The treatment is extension with lateral compression, although this case, showing by callus formation advancing convalescence, reveals very bad position.

Results as to life and limb are favorable in such cases, but some deformity is to be expected.

It should be noted that this is a case from Gulhané Hospital, the best military hospital in Constantinople, where the surgical service, under Prof. Wieting Pasha, was skillfully conducted.

RIFLE--PLATE 58.

LOWER EXTREMITY.

Gunshot Fracture of the Lower End of the Femur.

The course of the bullet was anteroposterior.

The long, oblique, splitting fracture without separate fragments indicates the long range of the missile in low velocity.

The wound was infected as is indicated by the drainage tubes in place. The well-advanced callus formation indicates established convalescence.

Results are favorable for recovery with only fair position and some shortening.

It may be observed that this is also a case from Gulhané Hospital.

RIFLE--PLATE 59.

LOWER EXTREMITY.

Gunshot Wound of the Left Knee-Joint, with Lodgment of the Missile in the Joint.

The course of the bullet was transverse, entering the capsule posterior to the patella without injury to the bone.

As its shadow projection is almost circular, the bullet must be standing almost on its end pointing toward the plate with its long axis almost parallel to the line of projection.

As the fibular side of the leg lay next to the plate and as the only slightly enlarged shadow of the bullet indicates it to be near the plate, its position is in the joint near the fibular side.

As the bullet is undeformed and its penetrating power very slight, its velocity was that of extreme range.

The emergency treatment, is, of course, a simple antiseptic dressing with the leg held in the most comfortable position by muscular action.

The subsequent treatment is removal of the bullet when proper surgical conditions obtain.

RIFLE--PLATE 60.

LOWER EXTREMITY.

Gunshot Fracture of the Tibia and Fibula, with Lodgment of the Missile.

The course of the bullet was diagonal from within outward and backward about the middle of the leg, with the impact tangential on the tibia and direct on the fibula. The bullet lies just behind the tibia.

It is apparent that the bullet has been greatly deformed and that its jacket has been badly torn from the core. The force of impact on the object from which it ricocheted must have been contributed by the velocity of short range, which reduced the striking energy so greatly that the bullet was lodged by the resistance of the tibia and fibula.

The wound was not infected, and callus formation shows that repair has begun.

The treatment in such cases, without infection, is noninterference. The lodgment of the missile need not prejudicate the prognosis, and certainly the additional damage in the search for the bullet is not warranted, except under special indications.

RIFLE--PLATE 61.

LOWER EXTREMITY.

Gunshot Fracture of the Lower Ends of the Tibia and Fibula.

The course of the bullet was transverse, with the velocity of mid-range.

The fragmentation of the fibula, lying close to the skin, would produce considerable laceration in the wound of exit.

The treatment is conservative. Infection would depend almost entirely upon the integrity of the first dressings and immobilization.

Results should be favorable, with care in subsequent treatment.

RIFLE--PLATE 63.

LOWER EXTREMITY.

Gunshot Wound of the Middle of the Tibia, with Few Large Fragments.

The course of the bullet was transverse from without inward.

The direct impact of the bullet, in high velocity of short range, has produced the typical “X” fracture due to the radiating lines of force.

The wound was infected, as is shown by the drainage tubes in the wound.

The emergency treatment in such cases is simple antiseptic dressing and temporary splint immobilization.

The subsequent treatment is the management of the infection.

The results in such cases are favorable.

RIFLE--PLATE 64.

LOWER EXTREMITY.

Gunshot Fracture of the Tibia.

The course of the bullet was diagonal, from without inward and from before backward through the middle of the tibia. Small particles of metal have lodged at the site of the fracture--a condition which never occurs in a rifle wound with the jacket of the bullet intact, while it is the invariable accompaniment of a shrapnel wound of a bone.

It is inferred that the jacket of the bullet in this case was damaged by ricochet, or that some metal particles from the object against which the bullet ricocheted were carried into the wound, as some other small pieces of metal are seen in areas distant from the seat of fracture.

As the fragments are small and not displaced, the velocity of the missile, at least that of mid-range, was almost sufficient to perforate the bone without fracture.

RIFLE--PLATE 65.

LOWER EXTREMITY.

Gunshot Fracture of the Tibia.

The course of the bullet was transverse, from within outward, striking the bone near the outer border with the velocity of mid or long range, producing long fissures without separation of fragments.

The safety pin, of course, lies in the dressings and on the side away from the plate, as shown by its somewhat indefinite outline and increased length.

The wounds of entrance and exit are practically the same.

The treatment in such cases is that of a simple fracture, except for the management of an occasional infection, and the results are favorable.

RIFLE--PLATE 66.

LOWER EXTREMITY.

Gunshot Fracture of the Middle of the Tibia, with Lodgment of the Missile.

The course of the bullet was transverse, from without inward, striking on the side of the shaft of the tibia.

The bullet was so badly damaged by ricochet that only a portion of it was the cause of this wound.

The range was short, if not close, as the missile after striking a resisting object with force enough to break itself retained enough energy in a fragment of less than half its mass to cause a long fissure fracture, with the separation of smaller fragments.

The treatment is noninterference, except for infection, which, contrary to what might be expected from presumable contamination from the object from which it ricocheted, does not occur more frequently in ricochet than direct wounds with lodgment of the projectile.

RIFLE--PLATE 67.

LOWER EXTREMITY.

Gunshot Fracture of the Lower Third of the Tibia.

The course of the bullet, with reduced energy of long range, was anteroposterior, striking the inner border of the bone and punching out a circular area of small fragments with a single transverse line of fracture.

The wound of exit was slightly larger than the wound of entrance.

The treatment is conservative. Infection is not probable if emergency dressing is clean.

RIFLE--PLATE 68.

LOWER EXTREMITY.

Gunshot Fracture of the Lower Third of the Tibia.

The course of the bullet was diagonally anteroposterior, from without inward, striking the internal border of the anterior surface of the bone, and partially splitting off fragments from the side with a perforating effect.

The range of the shot was long.

The dense and irregular shadows to the right of the fracture are caused by the material used in dressing and indicate a slight infection. The small shadows on the tibial side are not a part of the wound, but are due to opaque material caught in the dressing.

RIFLE--PLATE 69.

LOWER EXTREMITY.

Gunshot Fracture of the Lower End of the Tibia.

The course of the bullet was transverse, from without inward, through the lower end of the bone, with a piercing effect and a fissuring of the upper fragment.

The velocity was that of short range.

The wound of exit would be slightly larger than that of entrance, as some small fragments can be seen extending along the tract of the missile from the line of transverse fracture toward the internal border of the leg. There was no laceration of the wound of exit. The wound was clean.

The treatment is conservative.

Results should be favorable. Infection would depend most probably upon the asepsis of the first dressing.

RIFLE--PLATE 70.

LOWER EXTREMITY.

Gunshot Fracture of the Tibia, with Lodgment of the Missile.

The course of the bullet was from within outward, striking the posterior surface of the tibia about 2 inches above the ankle, and causing a slight crack in the bone at the point where its course was deflected.

The velocity was that of extreme range, as the wholly normal outline of the projectile and the slight penetration indicates that its energy was almost entirely lost in flight and not by ricochet.

The sharp outlines of the lower border of the fibula and the external border of the articular surface of the lower end of the tibia indicate the position of the fibula as next to the photographic plate.

The bullet lies at a very slight angle with the plate, as is shown by the curved outline of its base, which condition alone would give a projection shadow somewhat shorter than the bullet. But as the shadow is actually somewhat longer than the bullet (about one-eighth inch, or one-tenth its length), the position of the bullet is some distance from the plate and most probably lies behind the tibia, at the inside of the fibula.

RIFLE--PLATE 71.

LOWER EXTREMITY.

Gunshot Fracture of the Fibula.

The course of the bullet was anteroposterior through the lower third of the leg, striking the fibula squarely, passing through the bone with a perforating effect, accompanied by slight fragmentation and with a reduced velocity of long range.

The wounds of entrance and exit would be almost the same in appearance. Asepsis in such cases is the almost invariable rule, and the treatment after the simple dressing is that of a simple fracture.

RIFLE--PLATE 72.

LOWER EXTREMITY.

Gunshot Fracture of the Ankle.

The course of the bullet was anteroposterior, striking the fibula from behind with a velocity of long range, and causing some slight fragmentation without displacement of the fragments.

The joint architecture is slightly disturbed. The joint mortice is a bit widened by the external deflection of the external malleolus, which permits a slight outward rotation of the astragalus.

As the dangers of infection are usually escaped, the treatment is that for Pott’s fracture.

RIFLE--PLATE 73.

LOWER EXTREMITY.

Gunshot Wound of the Heel, with Lodgment of the Missile.

The course of the bullet was from behind forward through the insertion of the tendo Achillis and its lodgment along the outer border of the os calcis.

There was no injury to the bone. The path of the bullet is shown by the slight mottling above the posterior extremity of the os calcis.

The nose of the bullet is slightly deformed by ricochet at long range.

The very slight penetration and the slight deformity of the nose of the bullet indicates a velocity of extreme range of both impact of the ricochet and of the wound.

The sharp outline of fibula and the base of fifth metatarsal shows the fibula to be next to the plate. The only slight enlargement and square base of the shadow of the bullet show it to be parallel to the plate, or at right angles to the line of projection, and thus indicate its position to be on the fibula side of the os calcis, below the tip of the external malleolus.

RIFLE--PLATE 74.

LOWER EXTREMITY.

Gunshot Wound of the Heel.

This is the same case as shown in plate 69, but with the shadow projected from above downward instead of from side to side, as in the preceding plate. The interpretation of the shadows in the preceding plate is thus confirmed.

As the heel lay on the plate, the projectile at a sharp angle with the plane of the plate, several inches farther from the plate than in the preceding radiograph, and with the line of projection at about right angles to the long axis of the projectile, the shadow projection is considerably enlarged.

SHRAPNEL--PLATE 75.

HEAD.

Gunshot Fracture of the Vertex, with Intracranial Lodgment of the Missile.

Wound of entrance, left anterior parietal region.

Wound of exit, none.

The missile left a few small fragments spattered on the bone at point of entrance, with a slight deformation of the ball due to this cause, as shown in the plate.

The distinct outline and normal size of the ball shows it to be very near the plate and on the left side of the head, while the enlarged and blurred image of the safety pin shows its position to be on the side of the head farther away from the plate.

Emergency treatment is antiseptic dressing only. Subsequent treatment is directed to fragments and depression, without search for ball. Septic condition might indicate some later interference.

Results in such cases are favorable if wound is not infected.

SHRAPNEL--PLATE 76.

HEAD.

Gunshot Fracture of the Vertex.

Wound of entrance, upper right and mid-parietal region.

Wound of exit, none.

The missile probably was deformed before striking the skull, upon which it was fragmented by impact, with several fragments following the internal contour of the vertex and others remaining spattered about the wound of entrance.

It is probable that a larger mass of the shrapnel ball, causing the greater damage to the bone, ricocheted out of the wound.

The distinct outline of the central safety pin and the less definite image of the shrapnel fragments show the wound to have been farther from the plate than the safety pin on the left side.

The treatment is expectant, without search for the missile.

Results in such cases are favorable, except for danger of infection.

SHRAPNEL--PLATE 77.

HEAD.

Gunshot Fracture of Zygoma, with Lodgment of the Missile in the Zygomatic Fossa.

Wound of entrance, external border of right supra-orbital ridge.

Wound of exit, none.

A few metallic fragments are seen where the missile lodged near the point of impact with the bone.

The treatment is expectant. Removal of the ball from its superficial location is indicated if the wound is infected.

Result in such cases is favorable.

SHRAPNEL--PLATE 78.

HEAD.

Gunshot Fracture of the Mastoid Process.

Wound of entrance, upper posterior cheek, in front of the ear.

Wound of exit, posterior to mastoid process, lacerated.

The course of the missile was tangential, with the damage limited to the outer table of the mastoid. The metal particles scraped off of the ball by its contact with the bone mark the site of the wound.

Treatment is expectant.

Results are favorable.

SHRAPNEL--PLATE 79.

HEAD.

Gunshot Fracture of the Left Maxilla, with Lodgment of the Missile in the Neck Behind the Angle of the Jaw.

Wound of entrance, below infraorbital ridge, with course through the mouth.

Wound of exit, none.

Missile left a few small metallic fragments spattered on the bone at the point of entrance. There is slight mark of deformity of the missile caused by its contact with the bone, shown in its shadow in the plate.

The distinct outline and normal size of the ball shows it to have been on the side next to and near the plate.

Treatment indicated is expectant.

Results in such cases are favorable, as seat of probable infection is readily accessible.

In this particular case, recovery followed with the ball left _in situ_, without causing the patient trouble enough to induce him to permit interference.

SHRAPNEL--PLATE 80.

HEAD.

Gunshot Fracture of the Anterior Table of the Frontal Sinus, with Lodgment of the Missile in the Posterior Nares.

Wound of entrance, over the left internal super supra-orbital ridge, with course downward, slightly backward, and slightly to the left posterior nares.

Wound of exit, none.

The distinct outline and practically normal size of ball shows that the patient’s face was superimposed on the photographic plate, as the anterior location of the missile was suspected. The slight deformity of the ball is due to the impact with the bone. This personal case was received from the service of Prof. De Page, of the Belgian Red Cross Mission, at Josh Keshla Hospital, Constantinople, after an operation for infections of the frontal sinus, in which the anterior table was entirely removed, with free drainage into the posterior nares, before the radiograph was made or the exact location of the ball suspected. The missile is seen in the nares--very near the face--probably in the middle meatus, in the inferior turbinates, against the septum, deviated by its lodgment.

Convalescence was finally established and the frontal-sinus wound practically closed when, without any subjective symptoms, an obstruction was objectively determined in the left posterior nares, suggesting the radiograph.

The patient was so entirely free from any symptoms of the lodged missile that he wisely refused any meddlesome interference. He was discharged with sinus wound closed very remarkably without indication for plastic operation and with no symptoms.

SHRAPNEL--PLATE 81.

HEAD.

Gunshot Fracture of Anterior Table of the Parietal Bone and the Vomer, with the Lodgment of the Missile in the Posterior Nares.

This plate is a side view of the case in plate No. 80, showing the antero-posterior location of the ball.

The indefinite outline and enlarged size of the ball shows the ball to have been farther away from the plate than in plate 80.

SHRAPNEL--PLATE 82.

UPPER EXTREMITY.

Gunshot Wound of the Shoulder, with Lodgment of the Missile.

The course of the missile was transverse from the posterior surface of the greater tuberosity of the humerus to the internal border of the scapula, distributing small metallic fragments along its path.

There is no injury to the bone. The remnant of the ball has passed behind the scapula and lies near its superior angle.

The treatment in such cases is, of course, conservative, with no serious consequences expected from infection.

SHRAPNEL--PLATE 83.

UPPER EXTREMITY.

Gunshot Wound of the Shoulder, with Lodgment of the Missile.

The course of the ball was transverse through the posterior border of the deltoid muscle without contact with the bone, which would have been revealed by small particles of lead scraped off from the ball.

The actual size, normal outline, and great density of the shadow of the ball show that it lay next to the plate and that it is, therefore, lodged posterior and mesial to the glenoid portion of the scapula.

The treatment is noninterference unless removal be indicated by pain, impairment of function, or infection.

The results should always be good.

SHRAPNEL--PLATE 84.

UPPER EXTREMITY.

Gunshot Wound of the Shoulder, with Lodgment of the Missile.

The course of the bullet was from before backward and upward through the deltoid to the anterior surface of the head of the humerus.

The missile is not the conventional shrapnel ball, which is spherical and about one-half inch in diameter, for the shadow shows a larger axis in one direction with parallel sides, too symmetrical to be attributed to deformation. The ballistic conditions are those of shrapnel.

The missile struck the bone an inch or two below the point of lodgment. Its path is shown by particles of metal.

Pain or interference with function would be cause for interference in subsequent treatment, which otherwise would be expectant.

SHRAPNEL--PLATE 85.

UPPER EXTREMITY.

Gunshot Wound of the Shoulder, with Lodgment of the Missile.

The missile lies behind the head of the humerus, under conditions similar to the cases shown in plates 83 and 84.

The position of the hall is indicated by the outline and depth of shadow of the normal size of a shrapnel ball. The ball must therefore be very near the plate and behind the head of the humerus.

There is no injury to the bone. The slight deformity of the ball was caused by ricochet before it caused the wound, as no particles of lead are seen on the bone to account for the impact of the missile.

SHRAPNEL--PLATE 86.

UPPER EXTREMITY.

Gunshot Fracture of the Clavicle.

The ball ranged from before backward and upward, comminuting the outer half of the clavicle.

The fragments have been removed. The particles of metal which mark the path of the ball lie in front of the acromion process of the scapula, because lack of density and indistinct outline of the shadows show them to be farther from the photographic plate than the spine of the scapula which rested on the plate, escaping the imminent danger of wounding the subclavian vessels.

The treatment is conservative and results are favorable.

SHRAPNEL--PLATE 87.

UPPER EXTREMITY.