Range '300 yards.'
Wound of soft parts nearly transverse, entry on tibial aspect. The bullet crossed and grooved the posterior aspect of the tibia, but struck the fibula full. This is the only instance of a transverse cleft which came under my notice.
The wound suppurated, and a number of fragments of the fibula needed removal; hence the amount of callus present.
Cases in which operative fixation is indicated are rare, but a few oblique fractures may be treated with advantage in this manner if the conditions surrounding the patient admit of it. Screwing is generally preferable to wiring.
Lastly, we come to the cases in which primary amputation is necessary. I may say at once that I saw no case of wound from a bullet of small calibre in which this was indicated, and only one shell injury in which it was performed. I believe with small bullets that injury to the main blood-vessels is almost the only indication which is likely to be met with, and this by no means always indicates an amputation. First of all the question arises as to whether the wound in the vessel is caused by a bone fragment or by the bullet itself; reference to the chapter on blood-vessels would seem to prove that a bullet wound is by no means a necessary indication for amputation. Given favourable conditions, it might be treated locally by ligature at the time, while if hæmorrhage is not proceeding, developments should be awaited before proceeding to amputation. In the case of bone fragment punctures, secondary hæmorrhage is a more likely indication for amputation than primary.
Broadly, it may be laid down that very extensive injury to the soft parts is the only indication for primary amputation beyond primary hæmorrhage, and it may be added that the condition is rare with wounds from small-calibre bullets. If a primary amputation is necessary the observations as to the transport of fractured thighs are equally applicable. I never saw a primary amputation do well that was moved during the first week; sloughing of flaps or hæmorrhage followed as a rule, and often death.
Intermediate amputations were indicated in cases of septic infection and those of hæmorrhage; they seldom did well, and should be avoided if possible. Secondary amputations for sepsis or hæmorrhage were attended by fair results, but I can give no statistics. Unless extensive osteo-myelitis is evident, or very widespread cellulitis of the limb exists, I am strongly of opinion that the amputations when the fractures are above the middle of the thigh should be through the fracture, and not at the hip-joint, even if a subsequent secondary operation is risked.
(39) Perforation of the Shaft of the Tibia, and Incomplete Oblique Fissure extending from the lower part of The opening to the crest of the bone.