Splintered or Comminuted Fractures.
—Splintered or comminuted fractures refer to the formation of numerous bony fragments, which are often more or less loosened, sometimes completely so, occasionally dovetailed together, and often driven in or depressed. Such fractures are direct. It is possible to have comminution without depression; the latter makes it the more grave condition.
Fractures with absolute loss of substance may be made by gunshot injuries or by any extensive splintering or by a penetrating body. It is possible to have fracture of one table without that of the other, this being often true of the external table. In isolated fractures of the inner table there is often dislodgement of small fragments which may injure the dura and possibly produce later epileptic or irritative disturbance. When the external table is chipped off the diploë is exposed, and this with its wonderfully fine venous communications opens up a wide area to infection and subsequent pyemia.
Gunshot Fractures.
—Gunshot fractures are always depressed and almost invariably comminuted. The bullet of the modern army rifle possesses a great initial velocity, and the cranium struck by it will probably be disrupted into fragments, causing instant death. The majority of gunshot fractures of the skull seen in ordinary civil practice are due to revolver or pistol bullets from weapons of the prevailing type. In these instances there will usually be penetration, perhaps with perforation of the skull, and the formation thus of one or of two compound fractures, the wound of entrance being always comminuted and depressed, while fragments of bone may be scattered along the course of the bullet, which may also carry infectious material from without, such as hair, particles of hat, and the like ([Figs. 373] and [374]). (See also [Figs. 52], [53] and [54].)
Fig. 373
Fig. 374
Gunshot fracture of skull. (Helferich.)