(26) Comminuted Fracture of the Humerus
Range '250 yards.'
Impact oblique. Wound of entry 1 inch below the insertion of the deltoid; exit, on inner aspect of arm at a slightly lower level. The bullet probably struck the bone laterally, and drove out the central fragment.
Prolonged suppuration resulted, but the humerus healed well, and good movement of the elbow was preserved.
The effect of oblique impact together with high velocity is well illustrated. Had the resistance been greater, as in the case of the femur, a nearer resemblance to the effect seen in plate XV. would have been the result.
Of fractures of the hand I have little to say. In the case of the carpus, the slight degree of resistance offered by the bones rendered injuries of an explosive character rare. I never saw one. Fractures of the metacarpus, on the other hand, presented exactly the opposite features. The density of these small bones was well illustrated by the frequency with which the bullet suffered injury, even amounting to fragmentation, and the great comminution they themselves suffered. The breaking up of the bullet in these fractures was a curious feature, which may perhaps be explained by the tendency of the distal part of the limb to be driven in the course of the bullet, with the result of somewhat lengthening the period of contact of the projectile, or more probably by somewhat frequently occurring irregular impact. Plate XI. is a good example of an injury of this nature of moderate severity. The soft parts suffered much in these injuries, the tendons were torn and lacerated at the moment, and were very apt to acquire more or less permanent adhesion. This latter condition was sometimes to be improved by the removal of bone fragments, and I have freed tendons from actual clefts in the bones where they had been carried in by the bullet. In some cases very great deformity of the digits, due to shortening, developed, even when no fragments were removed beyond those blown away by the bullet.
One form of injury of some interest was multiple fracture of the phalanges produced by a bullet travelling in a course parallel to the length of the rifle when pointed by the patient. Occasionally several digits were lost.
Treatment of fractures of the upper extremity.—The general lines of this have already been foreshadowed in the general section, the remarks as to transport being applicable to all serious fractures of the shaft of the humerus, and this is the only one of the bones of the upper extremity on which anything special need be said, as the treatment of all the other fractures exactly coincides with that of ordinary civil practice.
