(40) Notch Fracture of the Crest of the Tibia
Range 'short.'
The raising of the margins of the notch suggests a perforation. Compare with figs. 51 and 57 in the text.
The treatment of these injuries differed in no way from that adopted in civil practice, given satisfactory surroundings. Suture might be indicated in some cases of transverse fracture, but this would only be necessary if the fragments were widely separated. The punctured fractures needed treatment as for simple wounds, combined with a short period of rest and pressure for the condition of hæmarthrosis. It was important not to prolong the period of rest beyond a week or ten days if the effusion was slight, in view of possible ulterior interference with range of movement in the knee-joint.
Fractures of the tibia.—Some remarks have already been made regarding fractures of the head of the tibia, and the importance of the overhanging prominent margins in the production of somewhat irregular injuries (p. 170). Putting these peculiarities on one side, the cancellous ends are subject to the type forms of injury; thus perforations either of the head of the bone or the malleolus were common injuries. The fractures of the shaft also deviated from the type in so far as the broad flat surfaces in the upper two thirds of the bone rendered it especially liable to the results of lateral impact, and to the production of the extreme wedge-shaped types of fracture. Plate XXII. illustrates the different result of a bullet striking the dense and strong spine at a low rate of velocity, a notch only resulting. If, on the other hand, the lateral surfaces were struck, a wedge with the base corresponding to the posterior surface was the most common injury, the spine in many cases remaining intact and maintaining the continuity of the bone. Wedge-shaped fractures of this bone were apt to show multiple secondary wave fissures concentric with the main line, and consequently free comminution. I saw several examples, the loose fragments being remarkably numerous. Plate XIX. is an example of an oblique fracture produced by a bullet which has ploughed across the bone, displacing large fragments anteriorly, but finely comminuting the bone in its course, and leaving small fragments of the mantle on its way. Plate XX. is an example of the rare condition of transverse fracture.
(41) Spurious Perforation of the Fibula
Moderate range, 'about 1,000 yards.'