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.
[Illustration: Plate 64.]
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.
[Illustration: Plate 65.]
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.
[Illustration: Plate 66.]
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.
[Illustration: Plate 67.]
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.
[Illustration: Plate 68.]
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.
[Illustration: Plate 69.]
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.
[Illustration: Plate 70.]
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.
[Illustration: Plate 71.]
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.
[Illustration: Plate 72.]
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.
[Illustration: Plate 73.]
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.
[Illustration: Plate 74.]
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.
[Illustration: Plate 75.]
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.
[Illustration: Plate 76.]
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.
[Illustration: Plate 77.]
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.
[Illustration: Plate 78.]
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.
[Illustration: Plate 79.]
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.
[Illustration: Plate 80.]
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.
[Illustration: Plate 81.]
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.
[Illustration: Plate 82.]
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.
[Illustration: Plate 83.]
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.
[Illustration: Plate 84.]
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.
[Illustration: Plate 85.]
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.
[Illustration: Plate 86.]
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.
[Illustration: Plate 87.]
SHRAPNEL--PLATE 87.
UPPER EXTREMITY.
Gunshot Fracture of the Humerus.
The missile struck the bone and caused a long, splitting fracture,
with some fragmentation of the proximal fragment.
The wound could have been caused by either a ricocheted rifle bullet
or by a deformed shrapnel ball, either projectile being the low
velocity of long range. These conditions are more common to shrapnel
wounds, but the appearance of the larger metal fragment leads to the
suspicion that it is a piece of the jacket of a rifle bullet.
The wound was not infected, and convalescence is well advanced, as is
indicated by the callous formation.
[Illustration: Plate 88.]
SHRAPNEL--PLATE 88.
UPPER EXTREMITY.
Gunshot Fracture of the Humerus, with Lodgment of the Missile.
The missile struck the shaft of the humerus from an anterior and
external direction and caused a long diagonal splitting fracture with
fragmentation, in which the bone absorbed all of the energy of the
missile at the seat of fracture. The missile lies in the anterior
surface of the humerus, in two fragments; the smaller, much less
distinct, is seen about an inch above the larger.
The wound is not infected, and convalescence is well established,
as is indicated by the callous formation, with overlapping of the
fragments.
The treatment in such cases is conservative and the results are
favorable.
[Illustration: Plate 89.]
SHRAPNEL--PLATE 89.
UPPER EXTREMITY.
Gunshot Fracture of the Humerus.
The course of the missile was from behind forward and outward,
striking the bone on the posterior surface, causing a fracture with
fragmentation, and lacerating the wound of exit with fragments of
bones and with its own deformation.
The wound of exit is indicated in the plate.
The wound is infected.
Fragments of the missile lie on the posterior surface of the bone, as
indicated by their dense shadow and distinct outline. The treatment in
such cases is conservative and the results are favorable.
[Illustration: Plate 90.]
SHRAPNEL--PLATE 90.
UPPER EXTREMITY.
Gunshot Fracture of the Left Humerus.
The course of the missile was transverse from without inward, with a
transverse fracture and fragmentation.
This wound might have been caused by either a shrapnel ball or a
deformed rifle bullet, but the distribution of the metallic fragments
rather indicate the course of a shrapnel ball.
The metallic fragments lie farther from the plate than the safety
pin of the dressing, which, therefore, lies behind the bone and the
fragments of the missile lie in front.
The treatment in such cases is conservative and the results are
favorable. The subsequent course may indicate interference for
mal-union.
[Illustration: Plate 91.]
SHRAPNEL--PLATE 91.
UPPER EXTREMITY.
Gunshot Fracture of the Left Humerus.
The course of the missile has been from without inward. The fragments
of metal marking the path of the missile lie farther from the plate on
the outer than on the inner side. This would indicate the former to be
in front of the bone and the latter to be behind. The wound could have
been caused by either a deformed rifle bullet or by a shrapnel ball,
but the distribution of metallic fragments along the track of the
missile rather indicates the agent to have been a shrapnel ball.
The case is similar in course and results to that shown in the
preceding plate 90.
[Illustration: Plate 92.]
SHRAPNEL--PLATE 92.
UPPER EXTREMITY.
Gunshot Fracture of the Right Humerus, with Lodgment of the Missile.
The missiles, shrapnel balls deformed by ricochet, were multiple, with
a course from without inward and diagonally downward. The streaks
of metal particles along the seat of fracture indicates the path of
a shrapnel ball or fragment from the point of impact to the lower
fragment of the fracture, where several deformed shrapnel fragments
are lodged. Multiple wounds by shrapnel are common.
The wounds of entrance were small. There was no wound of exit. The
wound was not infected. This is another evidence that does not defend
the inference that ricocheted missiles are prone to introduce elements
of infection into a wound.
The plaster dressing does not seem to meet the indications for support
of the fracture.
The treatment is conservative in such cases.
Results are favorable.
[Illustration: Plate 93.]
SHRAPNEL--PLATE 93.
UPPER EXTREMITY.
Gunshot Fracture of the Right Humerus.
The course of the missile was transverse, from without inward and
downward, striking the shaft of the bone squarely and producing
a characteristic “butterfly” fracture, with a separation of the
fragments.
The exposure was made with the ulnar side of the arm next to the
plate, indicated by the clear outline of the internal condyle and the
olecranon.
The nearly normal size of the shadow of the shrapnel ball shows it to
be near the plate, and therefore to lie on the inside of the humerus.
The irregular outline of the ball and the metallic fragments spattered
about indicate that the ball was deformed by the detachment of
fragments on direct impact with the bone. The wound is not infected.
The treatment is conservative in such cases and the results are good.
[Illustration: Plate 94.]
SHRAPNEL--PLATE 94.
UPPER EXTREMITY.
Gunshot Fracture of the Right Humerus.
The course of the missile was from behind forward, causing a
transverse fracture of the humerus with some fragmentation.
The wound is in a state of established convalescence, with
considerable separation of the ends of the large fragments and without
infection, shown by the formation of callus and by an attempt at union
in faulty position.
The trail of the metallic fragments of the missile from behind forward
and their location near the anterior surface of the arm indicate the
course of the missile, either a rifle bullet or a shrapnel ball--most
probably the latter, as the lead core of the rifle ball, protected by
the jacket, does not break up into as many small particles as does the
shrapnel ball. The missile was deformed by ricochet before striking
the bone.
The early treatment in such cases is conservative, although the
subsequent course may indicate interference for malposition. The
results are favorable.
[Illustration: Plate 95.]
SHRAPNEL--PLATE 95.
UPPER EXTREMITY.
Gunshot Wound of the Humerus, with Lodgment of the Missile.
The course of the missile was from before backward. The missile
consisted of two large fragments of a richocheted shrapnel ball,
almost spent in energy before striking the arm, as its penetration was
just enough to pass through the soft parts and strike the humerus,
causing a fissure without separation of fragments. The wound was clean.
The treatment in such cases is naturally conservative.