LOWER EXTREMITY.
Plate 47.
Rifle—Plate 47.
LOWER EXTREMITY.
Gunshot Wound of the Gluteal Region,
with Lodgment of the Bullet Near the Ischium.
Wound of entrance, over gluteal prominence on a transverse line through the great trochanter.
Wound of exit, none.
There was no bone injury in this case. The bullet, to have lodged in the soft parts after relatively slight penetration, must have struck the body at extreme range when its energy was almost spent in flight, for its normal outline indicates that it was not retarded by ricochet. The long axis is almost perpendicular to the plate. As the posterior pelvis was next to the plate, the fairly dense shadow shows the projectile was not far from the plate and behind the ischium.
The treatment is conservative; infection in such cases is extremely rare; and only pain or impaired function after many months of convalescence justifies operation for removal of the missile.
Plate 48.
Rifle—Plate 48.
LOWER EXTREMITY.
Gunshot Wound of the Thigh,
with Lodgment of the Bullet.
Wound of entrance, outer aspect of the thigh at the junction of the upper and middle thirds.
The slight penetration without bone injury and with slight deformity of the nose of the bullet indicates that the wound was caused by a ricochet shot at extreme range, after its energy was almost spent.
With the posterior aspect of the thigh next to the plate, the dense shadow and the nearly normal size of its outline indicate that the bullet was in the same relative position and that it lay posterior to the neck of the femur.
As such wounds are rarely infected, the treatment is conservative, and a search for the missile is only justified by serious infection, pain, or impaired function.
Plate 49.
Rifle—Plate 49.
LOWER EXTREMITY.
Gunshot Wound of the Right Thigh,
with Lodgment of the Bullet Behind the Femur.
There is no injury of the bone in this case, as the bullet lodged in the muscles posterior to the lower third of the femur without striking the bone. The lighter circular area of the larger end of the shadow of the projectile shows that its base is farther from the plate than its nose, which was probably flattened and bent by the ricochet which reduced its velocity so as to give it but slight power of penetration.
It is not easy to determine from inspection of the plate which side of the leg lay next to the plate.
With a history of the wound of the right thigh and with the outside of the leg next to the plate, the projectile must have lain near the plate on the outside behind the lower end of the femur, midway between the skin and bone.
The markings seen on the bone are not concerned with the wound, as the same effect in the plate is seen in the areas beside the bone.
The treatment is conservative; infection is rare.
Plate 50.
Rifle—Plate 50.
LOWER EXTREMITY.
Gunshot Wound of the Right Thigh,
with Lodgment of the Bullet Behind the Femur.
There is no injury to the bone. The large diameter, shortened length, and slight density of the shadow show the bullet to be some distance from and inclining toward the plate and lodged in the muscles behind the femur, nearer the side away from the photographic plate. It is difficult to identify the right or left thigh from the radiograph, but with the history of the wound in the right thigh and the outside of the leg next to the plate the ball would lie nearer the inside than the outside of the thigh, nearer the surface behind the femur. As the shadow shows irregular outline and the location of the bullet low velocity, the wound was caused by a ricochet shot at very long range.
The treatment is expectant and the course naturally favorable.
Plate 51.
Rifle—Plate 51.
LOWER EXTREMITY.
Gunshot Wound of the Thigh,
with Lodgment of the Missile.
As there is no injury to the bone, the bullet is not deformed. Its penetrating power was not great enough to carry it through the tissue so it must have struck the leg at extreme range when its energy was almost spent.
The actual length of the bullet is 1.25 inches; the length of the shadow is about 1.50 inches.
The increased length and the relatively slight density of the shadow indicate the bullet to be some distance from the plate. The case history places the wound in the right thigh, and the posterior surface of the leg lay next to the photographic plate. As the density of the shadow is not greater than the thickest portion of the bone, the bullet probably lies in front of the border of the outer tuberosity of the femur.
Although the surgeon’s diagnosis had to be made from the only available plate, there is something of a speculative element in these deductions, because if the reaction in the knee joint prevented the patient from extending the leg the increased length of the bullet shadow could be accounted for by this position, which would permit the bullet to lie behind the bone and yet far enough from the plate to account for the shadow enlargement. The nose of the bullet is at the epiphyseal line, which is shown in the femur.
Plate 52.
Rifle—Plate 52.
LOWER EXTREMITY.
Gunshot Fracture of the Upper Shaft of the Femur.
The course of the bullet was anteroposterior and pierced the axis of the shaft of the femur with three radiating lines of fracture, resulting from the perforating action of the bullet striking the bone at long range and with greatly reduced energy.
This plate shows the lateral separation of large fragments, which is typical of gunshot wounds of long range.
Such wounds are usually not infected.
Emergency treatment is antiseptic dressing and coaptation with extension and temporary splint, so that it may support the bone for transportation and may be easily removable at place of continued treatment.
In these cases with lateral separation of fragments, it is imperative to supplement extension with pressure in a line perpendicular to the long axis of the femur.
Plate 53.
Rifle—Plate 53.
UPPER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur
with Lodgment of the Bullet.
The course of the bullet was antero-posterior and diagonally inward from the antero-external border of upper third of the thigh. A thin longitudinal fragment was split off without transverse fracture.
The missile struck the thigh after its energy had been greatly reduced by ricocheting as a result of striking a resisting object which flattened its nose and “set up” its body, as shown by the wavy outlines of the shadows.
The dense and normal-size shadow shows the bullet to be near the plate and probably in the muscles superficially behind and below the lesser trochanter.
As the prominent outline of the lesser trochanter shows that the leg was in external rotation when the negative was made, it is evident that, with the rotation back to the anatomical position, the projection of the shadow of the bullet would fall close to or in line with the shaft of the femur; the position of the bullet is behind the femur.
The treatment is conservative, with no trouble to be expected from infection.
Plate 54.
Rifle—Plate 54.
LOWER EXTREMITY.
Gunshot Fracture of the Lower End of the Shaft of the Femur.
The course of the bullet was anteroposterior through the axis of the femur. Several large fragments which were not displaced were separated by the force of impact. The separation of the fragments and the overriding of the ends of the proximal and distal large fragments were due to bearing bodily weight or to muscular contraction.
The projectile causing the wound was moving with the velocity of mid range. The wound of exit was not lacerated.
The emergency treatment is antiseptic dressing and temporary splint immobilization. Permanent dressing, with extension and lateral compression, is the rule.
Infection in such cases is frequent owing to lack of facilities for proper dressing on the field.
Results in saving life and limb are generally good.
Plate 55.
Rifle—Plate 55.
LOWER EXTREMITY.
Gunshot Fracture of the Lower Third of the Shaft of the Femur.
The course of the bullet was diagonally anteroposterior, with a velocity near mid range, without causing much displacement of fragments.
The wound of entrance and exit would be almost the same in appearance.
Treatment and results would be similar to case shown on [plate 54]. Many of these wounds are infected, due, no doubt, to the difficulties of arranging a clean first-aid dressing and effecting satisfactory immobilization during the first stage of transportation.
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.
Plate 56.
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].
Plate 57.
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.
Plate 58.
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.
Plate 59.
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.
Plate 60.
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.
Plate 61.
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.
Plate 62.
Rifle—Plate 62.
LOWER EXTREMITY.
Gunshot Fracture of the Upper Third of the Tibia,
with Large Longitudinal Fragment.
The course of the bullet was anteroposterior and slightly diagonal from without inward through the shaft of the tibia.
The injury was due to the energy of impact of a bullet, in the high velocity of short range, striking the axis of the diaphysis, in which the greater part of its energy was expended in pushing away a wall of the canal.
Convalescence is well established without infection, as shown by callus formation.
The treatment in such cases is invariably conservative, with the removal of such fragments as may be detached by suppuration and sequestration.
Plate 63.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.