position with progressing repair.
The treatment in such cases is conservative, but with respect for the
indications to maintain proper position of the fragments.
[Illustration: Plate 125.]
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.
[Illustration: Plate 126.]
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.
[Illustration: Plate 127.]
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.
[Illustration: Plate 128.]
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.
[Illustration: 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.
[Illustration: Plate 130.]
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.
[Illustration: Plate 131.]
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.
[Illustration: Plate 132.]
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.
[Illustration: Plate 133.]
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.
[Illustration: Plate 134.]
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.
[Illustration: Plate 135.]
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.
[Illustration: Plate 136.]
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.
[Illustration: Plate 137.]
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.
[Illustration: Plate 138.]
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.
[Illustration: Plate 139.]
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.
[Illustration: Plate 140.]
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.
[Illustration: Plate 141.]
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.
[Illustration: Plate 142.]
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.
[Illustration: Plate 143.]
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.
[Illustration: Plate 144.]
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.
A slight fissure fracture of the fibula may be seen in the upper
portion of the plate.
[Illustration: Plate 145.]
SHRAPNEL--PLATE 145.
LOWER EXTREMITY.
Gunshot Fracture of the Fibula, with Lodgment of the Missile.
The fibular side of the leg lay next to the plate.
The sharp outline, great density, and normal size of the shadow of the
shrapnel ball shows the ball almost in contact with the plate.
The metallic particles marking the contact of the ball and the fibula,
at the seat of a diagonal fracture, without displacement of fragments,
are shown so distinctly that they must also be near the plate.
The course of the ball, therefore, was from without, ranging inward
and upward with the slight energy of long (shrapnel) range. The ball
lies on the fibular side superficially, just in front of the fibula.
[Illustration: Plate 146.]
SHRAPNEL--PLATE 146.
LOWER EXTREMITY.
Gunshot Fracture of the Right Fibula.
The plate exposed with the tibial side down shows the wound in the
course of treatment, with a drainage tube in position after the
detached fragments of several inches of the fibula have been removed
on account of infection. Several fragments of the missile are shown on
the lower fragment of the fibula.
Conservative treatment is evident and good results should follow.
[Illustration: Plate 147.]
SHRAPNEL--PLATE 147.
LOWER EXTREMITY.
Gunshot Wound of the Lower End of the Right Fibula.
As the heel lay next to the photographic plate, the right ankle is
easily identified. The clear shadows of even the very small metallic
particles show them also next to the plate and, therefore, on the
posterior surface of the external malleolus, where a shrapnel ball at
extremely low velocity struck and produced a slight fracture, or more
of a fissure, without separation of fragment.
The joint mortise is intact, as the line of fracture does not extend
to the articular surface.
The shrapnel ball in such cases would lie just beneath the skin or
escape through an adjacent wound.
[Illustration: Plate 148.]
SHRAPNEL--PLATE 148.
LOWER EXTREMITY.
Gunshot (Pott’s) Fracture of the Left Ankle.
As the heel lies next to the plate, the left ankle is easily
identified.
The course of the missile is shown by a metallic track from the
internal to the external malleolus, and by a point of greater contact
with the internal malleolus at the upper border of its articulation
with the astragulus, resulting in an oblique fracture, separating the
tip of the external malleolus.
At the point of first impact the posterior faciculus of the internal
lateral ligament was severed. The missile therefore passed directly
through the ankle joint, entering just behind the tip of the external
malleolus, coursing over the posterior portion of the superior tibial
articulation of the astragalus in front of the tendo Achillis to
strike the upper articular surface of the external malleolus, with
the resulting fracture. By this mechanism, the joint mortise has been
widened by outward displacement of the external malleolus, while
the rupture of the internal lateral ligament permitted the outward
rotation of the astragulus, thus producing rather faithfully,
by direct violence, a condition which might be called a
“simulated Pott’s fracture” of the first degree.
By the metallic path of the missile it is known that its soft metal
mass was not protected by a hard metal jacket; by the slight damage
done to the bone, which lay directly in its path, its velocity
and consequent energy are revealed as very slight; by the absence
of larger metallic fragments it is shown that the missile was not
deformed nor robbed of its energy through ricochet; and as only these
conditions can be furnished by a lead ball, undeformed and traveling
at low velocity, the missile was a shrapnel ball.
[Illustration: Plate 149.]
SHRAPNEL--PLATE 149.
LOWER EXTREMITY.
Multiple Gunshot Wound of the Leg.
This plate exhibits the characteristic marking of the metal particles
of a shrapnel ball scraped off by contact with the bone, showing the
course of the ball in relation to the bone.
The evidence that two shrapnel balls struck the tibia without
causing a fracture indicates that the velocity of shrapnel balls is,
sometimes at least, very low and that this low velocity may occur at
a comparatively short range from the point where the shrapnel balls
are discharged from the chamber or near the apex of the “cone of
dispersion.” Such multiple wounds are caused before the balls have
been so widely dispersed as when they arrive at the base of the “cone
of dispersion.”
[Illustration: Plate 150.]
SHRAPNEL--PLATE 150.
LOWER EXTREMITY.
Gunshot Fracture of the Left Astragalus, with Lodgment of the Missile.
The external border of the foot lay next to the plate, as is shown by
the articulation of the cuboid.
A fragment detached from the posterior inferior border of the
astragalus and several small metal particles lying behind the fragment
are in evidence.
The enlarged shadow of the ball indicates that it does not lie close
to the plate, and it must then lie at least as far away as the
internal surface of the calcaneus and at a depth from the sole that
can be measured on the plate.
[Illustration: Plate 151.]
SHRAPNEL--PLATE 151.
LOWER EXTREMITY.
Gunshot Fracture of Left Calcaneus.
The fibular side lay next to the plate, as shown by the shadow of the
fibula and the calcaneo-cuboid articulation.
As the metallic particles, showing the path of the missile, appear to
be next to the plate, the course of the missile was from the external
border of the tendo Achillis diagonally downward and forward, causing
only a slight fissure of the calcaneus. A missile, to have done so
little damage and to have left a metallic track showing its contact
with the bone, must have been unjacketed and of low velocity, and
therefore a shrapnel ball.
[Illustration: Plate 152.]
SHRAPNEL--PLATE 152.
LOWER EXTREMITY.
Gunshot Wound of the Heel, with Lodgment of the Missile.
The tibial side of the foot lay next to the photographic plate.
The normal size, great density, and sharp outline of the shadow of
the shrapnel ball show that it lay also close to the plate and about
an inch below the inside of the body of the calcaneus. No metallic
particles mark the track of the ball in this case, because the course
was parallel to the inner surface of the bursa without forceful, or
perhaps any, contact with the bursa, and passing through soft tissue,
only.
[Illustration: Plate 153.]
SHRAPNEL--PLATE 153.
LOWER EXTREMITY.
Gunshot Wound of the Heel, with Lodgment of the Missile.
That the inner border of the foot lay next to the plate is shown by
the articulation between astragalus, scaphoid, internal cuneiform, and
first metatarsal.
The metallic particles show the course of the ball from the posterior
calcaneo-astragaloid ligament to below the anterior inferior border of
the calcaneus.
As the shadow of the ball is enlarged and the shadow of the fragments
blurred, their position is not near the plate and their location is
therefore on the external plane of the calcaneus, with the ball lying
near the sole.
[Illustration: Plate 154.]
SHRAPNEL--PLATE 154.
LOWER EXTREMITY.
Gunshot Wound of the Foot.
The plate shows, in the wound of entrance, the metal particles
deposited by a shrapnel ball which passed out of the sole of the foot
without damage to the bone.