(32) Typical Stellate (Butterfly) Comminuted Fracture of the Femur
Range 'short.'
Wounds small, impact direct, very little fine comminution. The bone united without shortening of the limb.
Other tracks took a direction of longitudinal obliquity, and then implicated both epiphysis and diaphysis. Fig. 52, p. 169, shows an example, and also the peculiarity likely to be assumed by the exit aperture in the bone, especially if the bullet was travelling at a low rate of velocity, a considerable plate of the compact bone being driven out. In some cases these oblique tracks involved both femur and tibia. They will be referred to again under the heading of injuries to the joints, and some remarks will also be found there regarding the synovial effusion so often occurring into the knee-joint in cases of fracture of the shaft of the bone.
It may be of interest to insert here a few remarks as to the clinical characteristics of fractures of the femur. First with regard to the primary signs and symptoms. A very considerable degree of general or constitutional shock usually accompanied them, and this was perhaps more constant than in the case of any other injury in the body. This was, moreover, no doubt increased by the unfavourable conditions in which patients on the field of battle are situated in regard to transport. When the patients were brought into hospital some delay in the primary treatment was often necessary until reaction took place. Local shock to the part was also a prominent feature. Abnormal mobility was very free in the badly comminuted cases. Crepitus was often loose, and of 'the bag of bone' variety. The result of local shock and consequent flaccidity of the muscles was to reduce the development of primary shortening; in some cases of severe comminution this was practically nil during the first day or two, when, with return of tone in the muscles, it sometimes became very considerable. Swelling of the limb was often very great, and vascular injury definitely far more common than in the fractures of civil practice, in consequence, no doubt, not only of the number and sharpness of the fragments, but also of the force with which they were driven into the surrounding tissues. The exit segment of the track was out of all proportion in size to the entry, as a result of the propulsion of bone fragments through it. This often made the closure of the exit wound a very protracted event, the track continuing to discharge a small quantity of bloody serum and fragments of necrosed tissue for many weeks.
(33) Comminuted Fracture of the Femur
Range 'short.'