Part 6
The treatment is expectant. Such wounds are rarely infected. Pain or impairment of function only would indicate removal of the missile from a clean wound.
SHRAPNEL--PLATE 115.
PELVIS.
Gunshot Fracture of the Crest of the Right Ilium, with Lodgment of the Missile.
As the wound was received while the soldier was lying prone, the course of the missile in the body was from above downward, striking the crest of the ilium, on which it was fragmented, and trailing its fragments as far down as the great trochanter. The injury to the ilium was a crushing fracture, with the displacement of small fragments from the antero-superior spine.
As the sacrum was next to the photographic plate, the missile, judging from its indistinct shadow, lies farther from the plate and in front of the bone. The relative distinctness of the large fragment seen on the wing of the ilium indicates its probable position to be on the outside of the ilium.
The trail of the smaller metal fragments lies between the antero-superior spine and the great trochanter, anterior to the plane of the femur.
The treatment in such cases is always conservative.
SHRAPNEL--PLATE 116.
LOWER EXTREMITY.
Gunshot Wound of the Thigh, with Lodgment of the Missile.
With the posterior aspect of the thigh lying next to the plate, the very greatly enlarged shadow of the deformed shrapnel ball indicates that it lies a relatively great distance from the plate, so that its location can be determined to be near the internal border of the adductor muscles, anteriorly, and below the transverse plane of the lesser trochanter.
SHRAPNEL--PLATE 117.
LOWER EXTREMITY.
Gunshot Wound of the Thigh, with Lodgment of the Missile.
With the sacrum lying next to the plate, the normal size, clear outline, and dense shadow of the shrapnel ball indicates its position to be near the plate. The location can be roughly estimated as the superficial gluteal region, external to the ramus of the ischium and near the aerior plane of the upper border of the acetabular cavity.
SHRAPNEL--PLATE 118.
LOWER EXTREMITY.
Gunshot Wound of the Thigh, with Lodgment of the Missile.
The normal size, distinct outline, and considerable density of the shadow of the shrapnel ball show that it lies very near the plate, posterior to the bone and in the buttocks, quite superficially.
The treatment in such cases is always conservative. Pain or impairment of function indicate removal after convalescence.
SHRAPNEL--PLATE 119.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of the Missile.
The direct subtrochanteric impact disintegrated the missile and delivered all of its energy to the bone, with a resulting transverse fracture of the upper end of the shaft of the femur and longitudinal fragmentation of the shaft. The course of the shrapnel ball was from behind forward and from above downward, as is shown by the track of the metal fragments and the lodgment of a larger lead fragment on the shaft below the seat of fracture. The uppermost large lead fragment, as shown by the depth of its shadow, lies farther behind the bone and nearer to the photographic plate than do the other pieces of the ball, as indicated by their lighter shadows. All of the fragments seem to lie behind the bone.
The conservative treatment of this wound is justified by the attempt at repair, as indicated by the callus formation; but it is manifest, from the extremely faulty position, that the indication for immobilization and extension in strong abduction were not appreciated.
Proper management of conservative treatment in such cases gives good results.
SHRAPNEL--PLATE 120.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of Multiple Missiles.
The position of the femur is in outward rotation, as shown by the full shadow of the lesser trochanter and the vanishing of the greater trochanter behind the shoulder of the neck. The two larger missiles lie on the outer side of the bone and the others lie in front on the seat of fracture. The greatly deformed shrapnel balls and the slight chipping fracture of the femur indicate that the greater portion of the striking energy of the missiles was so dissipated in ricochet that but little force was left for attack on the bone.
The treatment in such cases is expectant and indication rarely arises for search for and removal of the missiles.
SHRAPNEL--PLATE 121.
LOWER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur, with Lodgment of the Missile.
The course of the shrapnel ball was from within outward, striking the femur with the energy of high (shrapnel) velocity, with fragmentation of the missile by impact on the bone. The largest fragment, by the distinct outline of its shadow, lies close to the plate and behind the bone; a smaller metal fragment has been carried to the outer border of the thigh, where it lies superficially; another fragment lies in the seat of fracture.
The position of fragments is faulty, as the indications for extension and abduction have not been wholly met, although this is a case from the well-conducted service of Gulhané Hospital.
The treatment in such cases is conservative and the results are good.
SHRAPNEL--PLATE 122.
LOWER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur, with Lodgment of the Missile.
The shrapnel ball, in its almost directly antero-posterior course from behind forward, has delivered the energy of high (shrapnel) velocity to the bone, which had absorbed it all in stopping the missile, with a resulting approach to a butterfly fracture with displacement of fragments.
The upper end of the lower fragment lies nearer to the plate than to the lower end of the upper fragment, with the deformed shrapnel ball lying behind the latter, closer to the plate.
The treatment in such cases is conservative, with good results to follow except as they may be imperiled by infection.
SHRAPNEL--PLATE 123.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of the Missile.
While the missile in this case may have been other than a shrapnel ball, the fracture is one produced by the impact of a missile delivering great striking energy, with a predominant cross-section factor in its composition. The fragments are due to the application of an energy in which the mass was distributed over a relatively large area on bone, which resulted in the displacement of the large fragments.
The treatment in such cases is conservative.
Results are favorable; infection is generally controlled.
SHRAPNEL--PLATE 124.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of Multiple Missiles.
The direct impact of two shrapnel balls, delivering all of their energy to the femur, resulted in a fracture with large fragments.
The exposure was made through a plaster splint, and shows a faulty position with progressing repair.
The treatment in such cases is conservative, but with respect for the indications to maintain proper position of the fragments.
SHRAPNEL--PLATE 125.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of the Missile.
The condition shown in the plate is the characteristic result of direct impact of a projectile of low velocity and great sectional area in which all of the energy is delivered to the bone against which it lodges.
The distinct outline and dense shadow of the deformed missile indicates its position to be behind the bone.
The callus formation indicates the favorable progress of repair, but with the fragments in faulty position.
The treatment in such cases is conservative, with proper respect to the principles of maintenance of normal relation of the fragments.
SHRAPNEL--PLATE 126.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of the Missile.
The course of the shrapnel ball was antero-posterior, with an impact on the shaft of the femur, which fragmented both the ball and bone through the imparting or the entire striking energy of the ball to the bone by the lodgment of the ball. The sharp outline and density of the shadows of the missile, in contrast with the dense shadows of the bone, indicate that the missile lies closer to the plate than does the bone, although the flattened ball does not permit a comparison between its shadow and the normal size of the ball.
The advanced stage of convalescence is shown by the formation of callous.
The treatment in such cases is conservative and the results are good if proper position can be maintained.
SHRAPNEL--PLATE 127.
LOWER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur.
The impact of the missile was delivered with the energy of high (shrapnel) velocity at close range, as is indicated by the signs of another shrapnel wound, just above the outer tuberosity (in the lower left corner of the plate), where a deposit of metallic particle is evidenced.
The fragmentation of the missile, through its contact with the bone, indicates the great striking force of a missile which ricocheted from the bone. The general distribution of metallic particles through a wound of this class indicates certainly that the missile was unjacketed, and the destructive forces show that its sectional area was relatively larger, i. e., a shrapnel ball.
The hard metal jacket of a rifle bullet would not give off its particles in contact with the bone unless it were so greatly deformed as to have almost entirely lost its jacket. In this state the energy of a rifle ball must be so greatly reduced, through the violence of ricochet, that it would not retain enough striking force to cause its disintegration on impact with the bone. Besides, some particles of the jacket could be identified, as they are always bent or twisted so that their character is recognized in the shadow.
SHRAPNEL--PLATE 128.
LOWER EXTREMITY.
Gunshot Wound of the Left Knee, with Lodgment of the Missile in the Joint.
The slight enlargement and moderate density of the shadow of the projectile indicates a position a short distance from the plate. A slight shadow dependent from the external condyle on the outside of the ball and a metallic marking just outside of the upper contour of the outer tuberosity indicate an injury to the joint and the path of the ball from above the outer tuberosity into the joint capsule.
The probabilities are that the ball lies between the head of the tibia and the patellar notch of the femur, but the absolute certainty of this deduction must be supported by an exposure in a lateral plane, which is shown in plate 129.
SHRAPNEL--PLATE 129.
LOWER EXTREMITY.
Gunshot Wound of the Left Knee, with Lodgment of the Missile in the Joint.
As the fibular shadow is about the normal size and clearly outlined, the fibular side of the leg lay next to the plate.
As the shadow of the ball is dense and not much enlarged, it must lie near the plate. A light shadow in front of the ball, which shows the anterior crucial ligament, and a metallic marking above the patella, suggests the path of the ball.
As this is a lateral projection of the same case that is shown in plate 128 in an antero-posterior projection, these conclusions are thus verified.
The missile lies in the joint capsule between the head of the tibia, in front of the spine, and the patellar notch of the femur.
As a foreign body in the knee joint which seriously interferes with its function, removal is indicated when surgical facilities are at hand.
The results in such cases are usually good.
SHRAPNEL--PLATE 130.
LOWER EXTREMITY.
Gunshot Wound of the Left Knee, with Lodgment of the Missile in the Joint.
The line of projection of the shadow is directed obliquely from behind, focussed on the internal aspect of the knee, with the fibula next to the plate. As the shadow of the shrapnel ball is much enlarged and not very dense, the ball must lie some distance from the plate and away from the fibular side of the joint. As the distances through the knee joint are about the same in all cases and as shrapnel balls are approximately the same size, it is evident that the ball lies farther away from the plate than it does in plate 129, where it is about the middle of a transverse line through the joint. It must lie, therefore, superficially between the head of the tibia and the internal condyle of the femur.
Removal is indicated under favorable surgical conditions. Infection of the joint may occasionally indicate drainage and removal as emergency treatment.
Results, except for infection, are good.
SHRAPNEL--PLATE 131.
LOWER EXTREMITY.
Gunshot Wound of the Knee, with Lodgment of the Missile.
That the knee is not fully extended is shown by the exaggerated outline of the tibial head.
The enlarged and only fair density of the shadow indicates that the shrapnel ball lies some distance away from the plate. As the bone is not injured, the missile must lie either in front of or behind the femur, and its enlarged shadow shows the position to be in front of the femur, just above the articular surface, and probably within the reflection of the capsular ligament.
A comparison with the size of the shadows of the balls shown in plates 128 and 130 will show this one to be greater than the former and less than the latter, and so it must bear about the same relation in the distance from the plate. This would account for the location in front instead of behind the femur.
The treatment is conservative, and removal is indicated when function is disturbed.
SHRAPNEL--PLATE 132.
LOWER EXTREMITY.
Gunshot Wound of the Knee, with Lodgment of the Missile.
The fibular side of the leg lay next to the photographic plate, as shown by the enlarged fainter outline of the internal tuberosity.
The shadow of the shrapnel ball is neither as normal in size as that of the external condyle nor as exaggerated as that of the internal condyle, and the position is probably neither as close to the plate as the former nor as far away as the latter.
The missiles lie about the middle of the anterior surface of the lower end of the femur, above the articular surface.
SHRAPNEL--PLATE 133.
LOWER EXTREMITY.
Gunshot Wound of the Right Knee, with Lodgment of the Missile.
The ball struck the outer condyle just above the articular surface with only enough energy to damage and slightly crack the bone. The injury to the bone and the metallic mark of the impact can be seen just above the outer border of the articular cartilage of the outer condyle.
SHRAPNEL--PLATE 134.
LOWER EXTREMITY.
Gunshot Wound of the Left Knee, with Lodgment of the Missile.
The outer tuberosity lay next to the photographic plate, with the knot in the localizing wire on the inside of the leg and farther away from the plate.
The line of projection is transversely through the tuberosities.
The shadow of the ball, as it is somewhat enlarged, not sharply defined, and of medium density, must lie about midway between the lines of the localizing wire or in the popliteal space just above and between the tuberosities, much nearer the popliteal surface than the bone. An accurate localization of the ball in a transverse line, however, would require an exposure of another plate in an antero-posterior line, but in this actual case the localization of the ball had to be made from this single plate, as only one exposure was made.
The ball struck the border of the popliteal space of the femur just above the tuberosity, without energy enough to cause a fracture, deform the ball, or even to leave, as a mark of contact, metal particles of the ball.
SHRAPNEL--PLATE 135.
LOWER EXTREMITY.
Gunshot Wound of the Left Leg, with Lodgment of the Missile.
The posterior surface of the leg lay next to the plate, as shown by the outline of the head of the fibula, but any estimate of distance from the plate, based on depth of the shadows, is of little value because there is no contrast between localizing-wire shadows in front of and behind the leg.
The slightly enlarged shadow of the ball indicates it to be farther from the plate than it would be if it lay behind the fibula. As the shadows of the metal fragments on the tibia are not sharp enough to indicate their position to be near the plate, the ball has lodged anteriorly between the tibia and fibula after ricocheting from the anterior surface of the tibia. The ball, being undeformed, struck the tibia with so little force that it barely penetrated the skin.
The reaction of infection in such wounds makes a diagnosis on physical examination difficult and indicates radiography.
SHRAPNEL--PLATE 136.
LOWER EXTREMITY.
Gunshot Wound of the Leg, with Lodgment of the Missile.
The leg lay with its posterior surface next to the photographic plate. The enlarged shadow of the ball and the blurred outlines of the metal fragments require them to be some distance from the plate and therefore on the anterior surface of the tibia.
The impact has been from within outward with so little energy that the ball only touched the internal border of the tibia and lodged beneath the skin.
Without the reaction of inflammation and infection, diagnosis could be made by palpation, but extensive swelling indicates radiography.
SHRAPNEL--PLATE 137.
LOWER EXTREMITY.
Gunshot Fracture of the Tibia and Fibula.
The fibular side of the leg lay next to the plate, as the distinct and not exaggerated outlines of the fibula can be seen in the dense shadow of the tibia. The wound, as indicated by the callous tissue, is shown in a state of repair, after the larger detached fragments of the fracture had been removed. The wound was caused by a missile carrying considerable energy. The small particles of metal marking the course of the missile show it was a shrapnel ball.
SHRAPNEL--PLATE 138.
LOWER EXTREMITY.
Gunshot Fracture of the Right Tibia and Fibula.
This plate shows a type of wound caused by a number of fragments of a shrapnel ball or other similar missile. The missile was deformed by a near-by ricochet, from which large and small fragments struck simultaneously and distributed themselves over a large area. The larger fragments carried enough energy to fracture the bone by transmitting all of their energy in lodgment and by possibly breaking up into smaller fragments.
In this case the energy of the missile was transmitted to the tibia, with fracture and great fragmentation of the bone. The fracture of the tibia was secondary, resulting from indirect violence, due to the loss of the support of the tibia.
SHRAPNEL--PLATE 139.
LOWER EXTREMITY.
Gunshot Fracture of the Right Tibia and Fibula.
The course of the missile was from within outward and from before backward, striking both the fibula and the tibia, with fragmentation and displacement of both bones.
The fibula lay next to the plate, as indicated by its distinct normal shadow and the exaggerated outline of the internal malleolus.
The trail of metal fragments is typical of a shrapnel ball with the energy of high shrapnel velocity, but any lead missile without a protective jacket, under like conditions, might have produced the same effect.
The treatment is conservative until some positive indication arising in the course of an infection directs interference.
SHRAPNEL--PLATE 140.
LOWER EXTREMITY.
Gunshot Fracture of the Left Tibia and Fibula, with Lodgment of the Missile.
As the heel lay on the plate it is easy to identity the tibia and fibula of the left leg.
The course of the ball from the internal malleolus across to the lower end of the tibia and fibula is well marked by the trail of metal particles left by the contact of the ball with the bones. The indistinctness of the shadows of the lead particles and of the ball and the very slight enlargement of the ball indicates a contact with the anterior surface of the tibia and of the fibula with lodgment of the ball beneath the skin at the anterior border of the lower end of the fibula. The remaining energy of the missile was almost entirely spent on the tibia, causing a long oblique fracture, so that the contact with the fibula resulted in a crack only, without the separation of a fragment.
The treatment in such cases is conservative, with the subsequent removal of the ball from its superficial location.
SHRAPNEL--PLATE 141.
LOWER EXTREMITY.
Gunshot Fracture of the Left Tibia, with Lodgment of the Missile.
The course of the ball was from without and behind, ranging upward and inward, striking the tibia on the outer border, and causing a splitting fracture without displacement of fragments. The missile was most probably deformed by ricochet before it struck the bone, as there is too little bone injury to account for the spattering and wide distribution of the fragments by the direct impact of an undeformed ball. Two metallic fragments lying over the fibula were probably additional missiles detached from the ball as it ricocheted near the wound.
The treatment in such cases would be conservative, while meeting the indications of infection.
SHRAPNEL--PLATE 142.
LOWER EXTREMITY.
Gunshot Fracture of the Left Fibula, with Lodgment of the Missile.
This plate furnishes another example of the fragmentation of a shrapnel ball by ricochet on a near-by object before striking the body.
A slight fracture of the fibula is seen (at the top of the plate) with the lodgment of multiple missiles over a wide area, without other injury to the bones.
The fragments seen through the shadow of the tibia lie nearer the plate than the smaller fragments on the fibula. As the largest fragment, lying below, shows a much enlarged semicircular outline, its position is not close to the plate and it must lie superficially on the inner side of the leg.
SHRAPNEL--PLATE 143.
LOWER EXTREMITY.
Gunshot Fracture of the Right Fibula.
This plate shows the right leg, because the calf always rests on the plate in the absence of a contraindication, which does not occur in this case, and because the slight angle of approach of the tibia and fibula identifies the relation of the lower end of these bones.
The nature of the fracture, without much fragmentation and with no displacements of fragments, indicates a slight striking energy of the missile, which was disintegrated by ricochet before striking the bone.
The fragments of a shrapnel ball, spattered on a near-by object, struck the leg in front over a wide area, as indicated by the fragments lying over the tibia and smaller ones lying on the inside of the bone. The larger metal fragment, on the fibula, is some distance from the plate, and probably lies in front of the bone, while the smaller ones, seen in sharper outline, lie behind.
SHRAPNEL--PLATE 144.
LOWER EXTREMITY.
Gunshot Fracture of the Left Fibula.
This is another example of the condition, shown in plate 143, in which a shrapnel hall or similar missile is disintegrated by ricochet before a fleeting the wound.
By comparison of the shadows of the missiles with the shadows of the portion of the localizing wire lying nearer the plate (shown more deeply and distinctly), and with the portion lying in front of the leg, it can be concluded that the fragments lie superficially in front of the bones.