71 08 
 
 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY 

 
 FRACTURES
 
 7108 
 
 FRACTURES 
 
 BY 
 
 LIEUT. COLONEL JOSEPH A. BLAKE, M.C.U.S.A, 
 
 CHIEF SURGEON AMERICAN MILITARY HOSPITAL NO. 2, A. E. F. 
 
 WITH FORTY ILLUSTRATIONS 
 
 D. APPLETON AND COMPANY 
 NEW YORK LONDON 
 
 1919
 
 COPYRIGHT, 1919, BY 
 D. APPLETON AND COMPANY 
 
 Printed in the Fnited States of America
 
 Uiomedfcal 
 lAmj 
 
 WE 
 
 PREFACE 
 
 This little manual is the outcome of a request made to 
 me by the late Dr. Lewis A. Stimson to write a chapter 
 on fractures for a book he was compiling for the Council 
 of National Defence but which did not materialise be- 
 cause of his sudden death. 
 
 In it I have attempted to put in as concise a form as 
 possible the conclusions formed as a result of my ex- 
 perience and observation since the beginning of the war 
 in hospitals largely devoted to the treatment of frac- 
 tures,, with the hope that the manual may be of some aid 
 to members of the Medical Corps who have not had 
 equal opportunities in war surgery, and that it may help 
 to alleviate the sufferings of our soldiers and diminish 
 the number of cripples who will become a charge upon 
 our country. Perhaps, also, suggestions arising from 
 it may lead to the realisation of further progress and 
 thus assist our surgeons to continue the advance so bril- 
 liantly begun by our French and British colleagues. 
 
 JOSEPH A. BLAKE. 
 
 624090
 
 CONTENTS 
 
 CHAPTER PAGE 
 
 I. MECHANISM AND VARIETIES OF GUN-SHOT FRAC- 
 TURES 3 
 
 II. REPAIR or FRACTURES 12 
 
 III. TRANSPORT AND OPERATIVE TREATMENT OF FRAC- 
 TURES IN GENERAL 20 
 
 IV. MECHANICAL, TREATMENT 35 
 
 V. DIAPHYSEAL FRACTURES 51 
 
 VI. FRACTURES AND WOUNDS OF JOINTS . 109
 
 LIST OF ILLUSTRATIONS 
 
 FIGURE PAGM 
 
 1. Extensive wounds of tibia and fibula by rifle ball with- 
 
 out complete fracture 4 
 
 2. Fracture of humerus by ball. Large and small frag- 
 
 ments 5 
 
 3. Fracture of femur by shell. Large fragments. 
 
 Faulty position due to lack of abduction of the 
 limb 6 
 
 4. Extensive comminuted fracture of femur by rifle ball. 
 
 Illustrating the flexion, abduction and rotation out- 
 ward of upper fragments observed in high diaphyseal 
 fractures of the femur 7 
 
 5. Double fracture of humerus by shell, suggesting a 
 
 combined direct and indirect violence .... 10 
 
 6. Fracture of tibia and fibula. Infected. Union with 
 
 exuberant callus and osteophytes after treatment 
 without traction in a bridged plaster splint . . 13 
 
 7. Fracture of tibia and fibula. Partial resection. 
 
 Large callus with opening caused by persistent use 
 
 of through and through drainage tube . . . . 14 
 
 8. Production of exuberant irregular callus about the 
 
 necrosed extremity of fragment in compound frac- 
 ture of the femur 17 
 
 9. Cutting periosteum elevator of Oilier . . .25 
 
 10. Suspension frame for fractures . . . . . .38 
 
 11. Detail of trolley bar for suspending the lower limb . 40 
 
 12. (A) Thomas traction arm splint. (B) Murray's 
 
 modification of the Thomas traction arm splint . 52 
 
 13. The Jones traction humerus splint 53
 
 x LIST OF ILLUSTRATIONS 
 
 FIGURE PAGE 
 
 14. The Thomas traction arm splint used as an ambula- 
 
 tory splint . 54 
 
 15. The Thomas traction arm splint used for bed treat- 
 
 ment of fracture of the humerus 55 
 
 16. Principles of suspension and traction for fractures of 
 
 the humerus 56, 57 
 
 17. Method of suspension for fracture of the humerus or 
 
 elbow 58 
 
 18. A simple method of producing traction and at the 
 
 same time regulating abduction . . . . .59 
 
 19. Position of extreme abduction and external rotation 
 
 necessary in the treatment of some fractures at the 
 surgical neck of the humerus 62 
 
 20. Method of using bent Thomas traction arm splint for 
 
 treating fractures of the radius and ulna ... 67 
 
 21. Suspension cradle for fractures of the radius and ulna, 
 
 and methods of installing traction and counter-trac- 
 tion .69 
 
 22. Van de Veld's splint for fractures of the forearm . . 70 
 
 23. Sinclair's splint for fractures of the forearm ... 71 
 
 24. Thomas traction leg splint 73 
 
 25. (A) Half-ring modification of the Thomas traction 
 
 leg splint. (B) Hodgen's leg splint. (C) Frame 
 used for suspension of fracture of the forearm . . 75 
 
 26. Method of attaching end of splint to stretcher sus- 
 
 pension 76 
 
 27. Method of applying the Thomas traction leg splint . 77 
 
 28. Method of treating high fractures of the femur with 
 
 the Hodgen's splint and traction by the Codavilla 
 (Steimann) pin or Besley tongs 83 
 
 29. Method of treating high fractures of the femur with 
 
 the half-ring Thomas splint 85 
 
 30. Method of suspension for fractures of both femora . 87
 
 LIST OF ILLUSTRATIONS . xi 
 
 FIGURE PAGE 
 
 31. Four methods of installing traction for fracture of the 
 
 leg 88 
 
 32. Ransohoff tongs 89 
 
 33. Hennequin's method in conjunction with Hodgen's 
 
 splint in the treatment of fracture of the femur . 91 
 
 34. Delbet's apparatus for ambulatory treatment of frac- 
 
 tures of the femur 96 
 
 35. Method of treating fractures of the tibia and fibula by 
 
 suspension and traction 105 
 
 36. Delbet's ambulatory splint for fracture of the tibia 
 
 and fibula 106 
 
 37. Method of cutting strips of crinoline for making the 
 
 plaster bands for Delbet's ambulatory splint for 
 fracture of the tibia and fibula 107 
 
 38. Method of treating infected wounds of the elbow joint 
 
 by suspension . 120 
 
 39. Molded plaster splint for immobilisation of the wrist. 124 
 
 40. Method of cutting thicknesses of crinoline to make 
 
 molded plaster splint for wrist 125
 
 SECTION I 
 GENERAL
 
 GUN-SHOT FRACTURES 
 
 OF THE EXTREMITIES 
 
 CHAPTER I 
 
 MECHANISM AND VARIETIES OF GUN- 
 SHOT FRACTURES 
 
 Definition: 
 
 A fracture is a solution of the continuity of a bone. 
 Fractures are divided into two groups: fractures of the 
 diaphyses and fractures of the epiphyses. In diaphyseal 
 fractures the false point of motion is more evident than 
 in epiphyseal fractures; there is a tendency to over- 
 riding and shortening, which is most marked in the case 
 of fractures of single bones, such as the humerus and 
 femur. In epiphyseal fractures the articulations are 
 frequently involved. Because of the difference in the 
 process of repair, and in the treatment necessitated, the 
 two groups will be described separately. 
 
 Wounds of bones: 
 
 A distinction should be made between fractures and 
 wounds of bones. A bone may be perforated, or a por- 
 tion of it broken off or removed by a missile, and its 
 continuity still remain intact (Fig. 1). Such a condi- 
 tion is more often observed in an epiphysis than in a 
 diaphysis. It frequently occurs that a missile penetrates 
 
 3
 
 4 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 or even perforates an epiphysis without causing a true 
 fracture; but usually, when a diaphysis is perforated, 
 
 
 
 FIG. 1. Extensive wounds of 
 tibia and fibula by rifle ball 
 without complete fracture. 
 
 any slight indirect violence is sufficient to break the 
 remaining bone. Nevertheless, shrapnel balls have per- 
 forated the shaft of the humerus without producing a 
 fracture.
 
 MECHANISM AND VARIETIES OF FRACTURES 5 
 
 As regards the epiphyses, it is often difficult to dif- 
 ferentiate between wounds and fractures, but it is better 
 
 
 
 FIG. 2. Fracture of humerus by 
 ball. Large and small frag- 
 ments. This fracture united in 
 23 days. 
 
 to confine the term "wound" to those injuries which do 
 not produce solution of continuity between important 
 parts of the bone. Wounds of the epiphyses frequently 
 occur without implication of the joints.
 
 6 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 Varieties of fractures: 
 
 All varieties of fractures are met with in war. Simple 
 fractures occur as often as in any other violent occupa- 
 
 FIG. 3. Fracture of femur by shell. 
 Large fragments. Faulty position, 
 due to lack of abduction of the limb. 
 
 tion, but they are caused more particularly by the explo- 
 sion of mines and shells. The essentially war fracture
 
 MECHANISM AND VARIETIES OF FRACTURES 7 
 
 FIG. 4. Extensive comminuted frac- 
 ture of femur by rifle ball. Small 
 fragments. Bad position. Had 
 been treated with a plaster splint. 
 Illustrates the flexion, abduction 
 and rotation outward of upper 
 fragments observed in high dia- 
 physeal fractures of the femur.
 
 8 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 is produced by the impact of relatively small missiles 
 traveling at a relatively high velocity and penetrating 
 or perforating the body or limbs. Such a fracture is 
 always compound, and, unless made by a rifle or shrap- 
 nel ball (which do not, as a rule, entrain clothing), is 
 a priori infected. 
 
 The effects produced by missiles upon bones are ex- 
 tremely diverse, and it is idle to try to classify them too 
 minutely. Occasionally a bone is broken transversely 
 or obliquely into two fragments, but it is much more 
 usual to find comminution. Such comminution may ex- 
 tend for a short distance only, the pieces being large 
 or small; or the bone may be shattered for a great part 
 of its length (Figs. 2, 3 et 4). Not infrequently the 
 fissures extend far enough to involve articulations. 
 
 It often happens that the bone is broken up into tiny 
 particles to which the velocity of the missile is imparted ; 
 these in turn tear their way through the soft tissues, 
 thus producing the so-called "explosive" effect. It is 
 largely to this destruction of the soft tissues that war 
 fractures owe their peculiar danger and their need of 
 special treatment. In fractures of the thigh, for in- 
 stance, there may be relatively small apertures of en- 
 trance and exit in the skin; yet when these openings 
 are enlarged the hand may be introduced and freely 
 moved around in a pulp of muscle filled with gritty 
 fragments of bone. This effect is seldom seen in an 
 epiphysis, however it may be shattered, because of the 
 less dense character of the bone. 
 
 Effects produced by different missiles upon the bones
 
 MECHANISM AND VARIETIES OF FRACTURES 9 
 
 cannot be classified arbitrarily. The lesions caused by 
 rifle balls depend in character upon the velocity of the 
 ball. Unless it is distorted or tumbling, as a result of 
 hitting some other object before wounding when it 
 acts like a shell fragment it usually produces a split- 
 ting fracture, or, in the case of the epiphyses, a simple 
 perforation. Yet rifle balls may cause extensive minute 
 comminution. Fragments of shell, on account of their 
 lesser velocity, are more apt, when causing fractures, 
 to become lodged in the bone; although they frequently 
 stop short at its surface and produce fracture by im- 
 pact instead of by penetration. As a rule, such frac- 
 tures are not comminuted. 
 
 Double fracture: 
 
 Double transverse fractures of a single bone, only 
 one of which communicates with the wound (Fig. 5), 
 are not infrequently observed. In these cases there is 
 often a history of a fall, suggesting a combined direct 
 and indirect violence. 
 
 Fractures by impact and fractures by penetration or 
 perforation: 
 
 As has been pointed out by Leriche, the question as 
 to whether the missile breaks the bone by impact simply, 
 or whether it enters or passes through the medullary 
 cavity, possesses great clinical importance. In the first 
 instance no infectious material is carried into the bone, 
 and the wound may be considered as a wound of the 
 soft parts so far as infection is concerned ; in the second, 
 if the missile penetrates the medulla or perforates the
 
 10 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 bone, any foreign matter upon it is generally caught 
 between the fragments. Cases in which the opening 
 
 FIG. 5. Double fracture of 
 humerus by shell, sug- 
 gesting a combined direct 
 and indirect violence. 
 
 into the medulla is small are particularly dangerous in 
 that, on account of retention of the products of infec- 
 tion, extensive osteomyelitis is apt to be caused. The
 
 MECHANISM AND VARIETIES OF FRACTURES 11 
 
 difference between the treatment of fractures by impact 
 and fractures by penetration will be considered later. 
 
 Infection: 
 
 Fractures produced by rifle balls, if the orifices of 
 entrance and exit are small, are considered as unin- 
 fected; when caused by shrapnel balls, judgment must 
 be used as to whether to consider them infected or not. 
 Generally, when the orifices in the skin are small and 
 punctate, they may be taken to be uninfected; but if 
 proper conveniences are at hand for the performing of 
 an aseptic operation no doubtful case should be allowed 
 to pass. 
 
 All fractures produced by shell, bomb or grenade 
 fragments must be regarded as infected. In the great 
 majority of cases clothing, hair, skin or other foreign 
 bodies are entrained by the projectile. This foreign 
 material is often found entangled in the bone splinters.
 
 CHAPTER II 
 
 REPAIR OF FRACTURES 
 
 The process of repair in fractures produced by mis- 
 siles does not differ in principle from that observed in 
 the ordinary fracture in civil practice; but with the 
 former, on account of extensive comminution and dis- 
 placement of small fragments, results having a far- 
 reaching effect upon the ultimate function of the mem- 
 ber may occur. Infection markedly influences repair, 
 and it is therefore well to consider the uninfected cases 
 first. 
 
 In the absence of infection there is no death of tis- 
 sue, at least in mass, and new bone is produced to a 
 varying extent by all the osteogenetic tissue, whether 
 attached to periosteum or bone fragments, or contained 
 within them. If there is no comminution the repair does 
 not differ from that of a similar simple fracture caused 
 by indirect violence, except that, as the periosteum has 
 usually not been stripped from the ends of the bones, 
 the repair takes place more normally and more rapidly. 
 In cases of extensive comminution (Figs. 2 and 3) the 
 new bone forms around and between all the fragments 
 as if cement had been poured in between them, and, as 
 the broken surfaces present a far greater area than 
 those of a non-comminuted fracture, the formation of 
 new bone is much increased and the site of union cor- 
 respondingly enlarged; the size and irregularity of the 
 callus depending upon the separation and distribution 
 
 12
 
 REPAIR OF FRACTURES 13 
 
 of the fragments. Osteophytic processes often extend 
 into the muscles, interfering greatly with their function 
 
 FIG. 6. Fracture of tibia and fibula, in- 
 fected; united with exuberant callus 
 and osteophytes. Had been treated 
 without traction in a bridged plaster 
 splint. 
 
 (Fig. 6). Nerves may be surrounded and included. 
 Pieces of bone entirely detached from the others and 
 projected into muscles do not, however, produce new 
 bone, but, as has been shown in cases of experimental,
 
 14 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 FIG. 7. Fracture of tibia and 
 fibula: partial resection. Large 
 callus with opening through it 
 caused by persistent use of 
 through and through drainage 
 tube.
 
 REPAIR OF FRACTURES 15 
 
 implantation of bone into tissues distant from bone, 
 are gradually absorbed. The tendency to excessive 
 bone production can be controlled to a certain degree 
 by proper treatment. Traction by stretching the mus- 
 cles tends to confine the fragments to normal limits, 
 and no drainage tubes or packing should be introduced 
 between them. Fig. 7 shows an opening produced 
 through a callus by a large drainage tube. Such holes 
 and cavities close but slowly, if they close at all. 
 
 Union of uninfected comminuted fractures usually 
 takes place very rapidly. Fractures of the humerus are 
 not infrequently united in three weeks and fractures 
 of the femur in from four to five weeks. 
 
 Infection not only delays union as a rule, but also, 
 by causing the death entirely or in part of fragments, 
 gives rise to obstinate sinuses leading to the dead frag- 
 ments or sequestra, which do not close until the dead 
 bone is removed and then often very slowly on account 
 of the irregular cavities left in the callus. Mild infec- 
 tion stimulates bone formation to a certain degree, and 
 the excessive growth of the involucrum about the ne- 
 crossed bone, thereby caused, frequently results in the 
 production of irregular and exuberant callus which in- 
 terferes greatly with the function of muscles and joints 
 in proximity to them. Furthermore, long-continued in- 
 fection kept up by the presence of dead bone and the 
 abscesses caused by the blocking of drainage by repar- 
 ative tissue leads to infiltration of the surrounding soft 
 parts by scar tissue, and this, added, to the incisions 
 which have to be made to afford drainage, has most 
 deleterious effects upon the function of the member.
 
 16 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 Typical osteomyelitis is exceptional in comminuted 
 fractures on account of the free drainage afforded to the 
 medullary cavity. Not infrequently a limited osteo- 
 myelitis is observed in transverse fractures and results 
 in the death and separation of the entire ends of the 
 fragments. This is particularly true of fractures in 
 which the periosteum is stripped from the ends of the 
 fragments, thus depriving them of their nutrition and 
 at the same time allowing infection to enter. Destruction 
 of the medullary artery is a frequent cause of extensive 
 necrosis. Occasionally a missile engenders fissures 
 which, on account of the elasticity of the bone, close, 
 entrapping foreign material and thus producing osteo- 
 myelitis. Fissures that close, however, rarely cause 
 extension of infection. It is rather the open fissure, 
 along which infection may extend but which does not 
 afford sufficient drainage, that gives rise to extensive 
 infection of the marrow cavity. Such fissures, extend- 
 ing through the epiphyses into the joints, may lead to 
 infection of the latter, necessitating amputation in order 
 to save life. 
 
 Insufficient drainage of the medullary cavity is a 
 cause of grave spreading of infection resulting in ex- 
 tensive death of bone, and this is why typical osteomye- 
 litis is more common in slight wounds and injuries of the 
 bones than in severer ones. Even deficient drainage of 
 the wounds of the soft parts increases the infection and 
 therefore prepares the way for the death of bone. 
 
 When necrosis of fragments situated centrally to the 
 forming callus occurs (as, for instance, the ends of the 
 main fragments), a flask-like callus is apt to form con-
 
 REPAIR OF FRACTURES 
 
 17 
 
 taining the sequestra in its cavity. As time goes on 
 this callus is added to peripherally and excavated cen- 
 trally, on account of the absorption going on about the 
 
 FIG. 8. Production 
 of exuberant ir- 
 regular callus 
 about the ne- 
 crosed extremity 
 of fragment i n 
 compound f r a c - 
 ture of the femur. 
 Note the absorp- 
 tion of the interior 
 of the callus about 
 the sequestrum. 
 (By the courtesy 
 of M. le Medecin- 
 Major R. Ler- 
 iche). 
 
 sequestra, and the flask is thus increased (Fig. 8) . This 
 produces a very troublesome condition, necessitating 
 resection of one side of the flask to permit closure of 
 the cavity 1 . 
 
 'Page 32.
 
 18 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 Repair in injuries of the epiphyses and in the short 
 bones differs from that observed to take place in the 
 diaphyses. There is no medullary cavity, and true 
 osteomyelitis does not occur. On the other hand, in- 
 fection leads to a troublesome osteitis, characterized by 
 fragmental death rather than necrosis en masse. 
 
 The peculiarly obstinate infection and suppuration 
 noticed in cancellous bone can be explained by the char- 
 acter of the lesions produced by projectiles. Such tis- 
 sue, when penetrated, has a tendency to close behind 
 the missile, which may either lodge or perforate. Along 
 the tract thus closed are scattered minute fragments 
 of infectious material, and about it is an extensive zone 
 of hemorrhagic contusion. Into this area the infection 
 may extend, giving rise to scattered foci of necrosis. 
 In continued infection the bony trabeculse become ab- 
 sorbed and the fatty tissue increases, so that the entire 
 epiphysis becomes softened. This softening is fre- 
 quently mistaken by the surgeon for necrosis, and he 
 may do irreparable injury by curetting out tissue which, 
 with the subsidence of infection and the resumption of 
 function, would again become firm. These cavities do 
 not fill with new bone, and may have to be levelled up 
 by the implantation of soft tissue such as fat. 
 
 Besides causing death of bone, injury to the nutrient 
 vessels of a bone has a marked influence upon repair, 
 especially in infected fractures. This is evidenced by 
 a rarefaction of the bone deprived of its nutrition and 
 a lack of new bone formation, and not infrequently by 
 non-union. Bone grafts do not take well in such 
 cases.
 
 REPAIR OF FRACTURES 19 
 
 Non-Union: 
 
 Non-union rarely happens in comminuted fractures, 
 and should not occur in non-comminuted fractures 
 properly treated. The author has never observed it in 
 comminuted fractures in which the fragments were not 
 removed; but it occurs frequently after improper re- 
 section of the fragments. 
 
 Union almost invariably occurs by means of the in- 
 volucrum, even in the presence of extensive necrosis of 
 the ends of the bones, if the fragments are kept in a 
 reasonably good position. If by mischance the involu- 
 crum should break, union usually recurs rapidly; but 
 occasionally, particularly in old cases in which efforts 
 toward repair seem to have exhausted themselves, defi- 
 nite non-union results. In such cases the extremities 
 of the fragments are found to be rounded and the 
 medullary cavity to be plugged by eburnated bone. 
 In such cases union will never take place until the tnds 
 of the fragments are resected or the continuity of the 
 medulla re-establishd by an inlay graft.
 
 CHAPTER III 
 
 TRANSPORT AND OPERATIVE TREAT- 
 MENT OF FRACTURES IN GENERAL 
 
 TRANSPORT 
 
 The first treatment to be applied to a gun-shot frac- 
 ture is the cutting away of the clothing, the painting of 
 the wound and skin about it with iodine and the appli- 
 cation of the first aid dressing. Then comes the most 
 important (and often greatly mismanaged) part, 
 namely, the transportation of the wounded man to the 
 dressing station and thence on toward the rear. 
 
 The question of transportation, so far as distance and 
 stages are concerned, depends largely upon the exigen- 
 cies of the military situation; but it has been amply 
 proved during this war that the less the transportation 
 the better for a fracture. 
 
 In every case traction should be applied to the limbs 
 in order to avoid laceration of muscles, vessels and 
 nerves by the sharp fragments, and to prevent over-rid- 
 ing and stripping of the periosteum. If traction be 
 efficiently applied harmful angulation at the site of 
 fracture cannot occur. 
 
 For the treatment of fractures during transport 
 splints and apparatus must be light and non-cumber- 
 some, for otherwise they cannot be taken to the advanced 
 posts. Moreover, they should be of such a nature that 
 they may be easily and quickly applied and not inter- 
 fere with the dressing of wounds. They should be de- 
 
 20
 
 FRACTURES IN GENERAL 21 
 
 signed to produce reduction and maintain alignment 
 of the bone fragments; treatment may then be con- 
 tinued with the same apparatus. It is difficult, how- 
 ever, to find an apparatus combining all these desid- 
 erata, and usually another is substituted at the hospital 
 in which the treatment is carried out. The various 
 splints will be described under the headings for each 
 fracture. 
 
 OPERATIVE TREATMENT 
 
 Primary operations: 
 
 No operation should be performed until the wounded 
 reach a place where formal aseptic surgical treatment 
 can be given except in case of hemorrhage, for which 
 neither a tourniquet nor a tampon should be used, but 
 the bleeding point caught by a forceps. The tourniquet 
 is provocative of gas gangrene and the tampon of in- 
 fection. When either has to be used the patient should 
 be a rush case for operation. 
 
 Every fracture should be operated with the exception 
 of those caused by a bullet in which both wounds are 
 punctate. The operation should be performed at the 
 earliest possible moment; it is not a question of days 
 but of hours, even minutes. Gas gangrene has been 
 known to set in three hours after injury, and the earlier 
 the operation the surer the prevention of this, tetanus 
 and the ordinary suppurating infections. 
 
 The operative technique is extremely important, for 
 upon the success of the primary operation in removing 
 the causes of infection depend the entire aftercourse of
 
 22 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 the wound and perhaps the life of the patient. With the 
 exception of special procedures in the case of wounds 
 and fractures of certain joints which will be treated 
 later, the operative treatment resolves itself into two 
 categories : that of the soft parts and that of the bones. 
 
 In general, wounds of the soft parts complicating 
 fractures are treated in the same manner as those of the 
 soft parts alone. The region is prepared by dry shav- 
 ing and cleansing with ether followed by a 3-5 per 
 cent, solution of iodine in alcohol. After excision of the 
 edges the wound is enlarged superficially so that the 
 whole of the deeper recesses are laid widely open to 
 view. The deep surfaces are then pared with scissors 
 or scalpel until healthy, unlacerated tissues are reached ; 
 the proper depth is determined by their color, and 
 especially by their contractile response. Some surgeons 
 employ a fixative stain, consisting of 5 per cent, methyl 
 blue and 20 per cent, formalin (i. e., half the commer- 
 cial 40 per cent., a weaker solution not being sufficient) , 
 to color the devitalized parts, but equally good results 
 are reported by those who use nothing. If the oper- 
 ation is methodically and correctly performed it is ob- 
 vious that when the whole of the superficies of the 
 wound surfaces is removed all foreign materials are 
 removed as well, so that theoretically there is no need of 
 X-rays to determine the presence of missiles ; but prac- 
 tically, an accurate localization by the X-ray gives val- 
 uable information in helping to determine the course 
 of the projectile and the approach, especially if counter 
 incisions have to be made. 
 
 Wounds treated in this way may be closed by pri-
 
 23 
 
 mary, delayed primary, or secondary suture. The term 
 primary suture is applied to the immediate closure of 
 wounds. When suture is performed after a delay of 
 two or three days because of doubt as to the removal of 
 contamination or because of the evacuation of the 
 patient (i. e., removal from observation), the term de- 
 layed primary suture is employed. If the operation to 
 close the wound has to be postponed, on account of in- 
 fection, until the formation of granulations, the term 
 secondary suture is used. In the latter case a second 
 excision of the wound, entailing a further sacrifice of 
 normal tissue, is necessary ; if this is not done the opera- 
 tion seldom succeeds, or results in the production of an 
 inordinate amount of cicatricial tissue. Primary or de- 
 layed primary suture is therefore obviously preferable 
 to secondary suture, and should always be done if pos- 
 sible. 
 
 Uncomplicated wounds of the soft parts may be suc- 
 cessfully closed by primary or by delayed primary 
 suture in 98 to 99 per cent, of cases; the structures in- 
 volved are, as a rule, of minor importance, and risks 
 may be taken that would be unwarrantable were the 
 wounds complicated by fractures. Nevertheless, most 
 fractures may also be closed in this way if certain points 
 in the operative technique are carefully observed; in- 
 deed, in many cases, as will be shown, they may be 
 sutured primarily with as much impunity as wounds of 
 soft parts alone. It is, as a general principle, however, 
 more prudent to practise delayed primary suture when 
 a fracture is present, on account of the difficulty of re- 
 moving foreign materials from among the bone frag-
 
 24 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 ments. Herein lies the importance of distinguishing 
 between fractures by impact and fractures by penetra- 
 tion. 
 
 In the former case the projectile does not enter the 
 medullary canal, and the wound may be sutured as 
 though it were an uncomplicated wound of the soft 
 parts. The stitches should be interrupted and spaced 
 sufficiently to permit a certain amount of drainage and 
 yet accurately approximate the tissues. A few strands 
 of silkworm gut are inserted to serve the double purpose 
 of draining the wound and providing a tell-tale as to 
 the bacteriological flora it may contain; they are re- 
 moved at the end of the second or third day and cul- 
 tured to determine whether the wound may remain 
 closed or should be re-opened. 
 
 If the missile has penetrated or perforated the bone, 
 however, the medullary canal must be considered to be 
 contaminated, and must be laid open and explored. To 
 do this it is nearly always necessary to remove some of 
 the fragments. Absolutely detached fragments should 
 always be removed, since they have become foreign 
 bodies and will surely necrose should infection super- 
 vene. Unhappily their removal seldom affords suffi- 
 cient exposure of the medulla, and therefore fragments 
 still attached to their periosteum must also generally be 
 cut away. The greatest care must be exercised in excis- 
 ing them, and only enough and no more should be re- 
 moved. Care should be taken to leave at least one or 
 more, if possible, to preserve the continuity of the shaft. 
 In other words, if a resection is done it should be lateral 
 and not transverse in character. When a piece has to
 
 FRACTURES IN GENERAL 
 
 25 
 
 be removed it must never be torn or pried away; it 
 must be cut out, leaving its outer layer adherent to the 
 periosteum. This can only be done by one instrument, 
 namely, the cutting periosteum elevator of Oilier (Fig. 
 9) . The edge of this rugine must be kept as sharp as a 
 
 FIG. 9. Cutting Periosteum 
 Elevator of Oilier. 
 
 razor, and several may have to be used during an opera- 
 tion; a number of them, of various sizes, should be at 
 hand. The fragment to be separated must be held 
 firmly in a bone forceps while its outer layer is sliced 
 off by lateral movements of the rugine. The medulla 
 having been sufficiently exposed, all loose fragments 
 and pulpified medulla should be removed, as the latter 
 is apt to be filled with particles of clothing. 
 
 In the case of fractures in which the missile has per- 
 forated the bone, comminution is frequently more 
 marked at the side of the bone opposite to the wound 
 of entrance and the soft parts there are more likely to 
 be filled with contaminated bone fragments and there- 
 fore to need more careful treatment than those on the
 
 26 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 side of entrance. Consequently, in such a case it is 
 wise to approach the medullary cavity from both sides 
 of the limb. 
 
 For fractures by penetration great judgment must 
 be exercised in practising primary suture, the nature of 
 the missile, the time elapsed since wounding, the char- 
 acter of the wound and its situation, as well as whether 
 the patient is to be kept under observation or evacuated, 
 must be taken into account. It is wiser for an inex- 
 perienced surgeon to practise delayed primary suture. 
 Certain fractures, such as those of the femur, which are 
 surrounded by thick muscles in which the anaerobic bac- 
 teria are apt to proliferate, should not be closed pri- 
 marily except under exceptionally favorable conditions. 
 If infection supervenes in a closed wound it is much 
 more violent in character than in an open one, and re- 
 sults in a far greater setback to convalescence. 
 
 If there is grave doubt as to whether the wounds are 
 infected (as, for example, in the case of delay before 
 operation exceeding eight hours the period during 
 which bacteria remain latent) it is better not only to 
 leave the wounds widely open but also to use a complete 
 Carrel installation so as to remove the wound secretions 
 as completely as possible during the first few days fol- 
 lowing the operation. 
 
 A fracture which is transported after operation is 
 more likely to become infected than one retained in the 
 service of the operator, and, consequently, as many 
 fractures as possible should be kept in the hospital 
 where they have been operated. If they must be evac- 
 uated, delayed primary suture may be done at the hos-
 
 FRACTURES IN GENERAL 27 
 
 pital in which the patient is ultimately retained. It is 
 extremely important that the series of hospitals through 
 which fractures pass should be in close relation with one 
 another so that the results of operations may be closely 
 followed. 
 
 Operations in infected cases: 
 
 In obviously infected cases successful primary suture 
 cannot be hoped for. Tissues which have already devel- 
 oped protection should not be excised, but all dead and 
 foreign material must be removed and free and efficient 
 drainage afforded. The incision should be free enough 
 to enable inspection of the entire wound by sight, but 
 the operation must be gently done and no indiscriminate 
 rooting with the fingers is permissible. 
 
 In cases of gas infection (B. Welchii), the incision 
 should be very free and all dead muscle removed. In 
 exceptional cases the entire muscle may have to be ex- 
 cised. In any case, the incisions should reach into freely 
 bleeding muscle. It is to be remembered that the gas 
 infection extends along a muscle and is often limited by 
 the muscle sheaths. Incisions should, therefore, be lon- 
 gitudinal, in the axis of the muscle, and never trans- 
 verse. 
 
 In infected fractures it is usually unwise to resect or 
 remove any attached fragments ; it is better to wait until 
 the dead or dying portions of bone are sequestrated. 
 
 All such wounds should be left freely open, with 
 gauze laid lightly in them. Paraffined gauze does not 
 stick and may be used, but ordinary gauze drains better 
 and should not be removed until it is loosened. It is
 
 28 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 sufficient to keep the exposed parts of the wound well 
 cleansed with soap and water, and hydrogen peroxide 
 if obtainable, afterward washing with alcohol or ether. 
 The use of drainage tubes is bad practice, for they only 
 drain locally and allow the surface of the remainder of 
 the wound to adhere and form pockets. If drainage 
 is indicated it is advisable to employ the Carrel method 
 of using many small tubes and intermittent irrigations. 
 It is obvious that an infected fracture must not be secon- 
 darily sutured until all dead bone is eliminated. 
 
 Resection: 
 
 Typical resection (i. e., removal of all the fragments) 
 of diaphyseal fractures is, in general, to be condemned. 
 Good results have been obtained by surgeons skilled in 
 the technique of resection, but it is not a procedure to be 
 recommended. The resection should be confined to the 
 removal of only sufficient bone to expose the medullary 
 canal (vide supra). 
 
 On the other hand, certain fractures of the joints 
 should be resected, so that every surgeon must familiar- 
 ize himself with the rules governing the operation or his 
 results will be failures. The greatest care must be 
 taken to preserve the periosteum as a continuous sheet 
 in so far as possible, or the consequences will be disap- 
 pointing. The elevator or rugine of Oilier (Fig. 9) 
 should be used for the purpose. The periosteum is sep- 
 arated but a thin shaving of bone is left adhering so 
 that the osteogenetic layer is well conserved. In using 
 the instrument the hand must be controlled so as to 
 avoid slips and tearing of the periosteum. The great-
 
 FRACTURES IN GENERAL 29 
 
 est care should be exercised in removing the muscular 
 attachments. 
 
 As a rule, the resection should not be unilateral ; that 
 is, the cartilage, at least, should be removed from the 
 other bones forming the articulation with the exception 
 sometimes of the glenoid cartilage in the shoulder. The 
 classical incisions should be made unless the wound 
 affords abundant access. 
 
 The wound is lightly packed with gauze; some sur- 
 geons prefer iodoform gauze, although it is not indis- 
 pensable, especially in clean cases. The packing is ar- 
 ranged so as to keep the periosteal tube from collapsing, 
 and is used for two or three weeks, being changed as in- 
 frequently as possible. Tubes have to be used in some 
 resections such as resection of the hip by the anterior 
 method, in which dependent drainage through a pos- 
 terior opening is necessary. 
 
 In infected cases the aim is to keep the ends of the 
 bones separated (even in the knee when ankylosis is 
 desired), until the infection has subsided. Too much 
 stress cannot be laid on removing all the cartilage in 
 infected cases, because it prevents repair and prolongs 
 suppuration. The after-care is most important and will 
 be considered with the treatment of fractures of special 
 joints. In general, where a return of function is sought 
 for, very early motion should be instituted, particularly 
 active motion by the patient, in order to maintain 
 the function of the muscles, and, by their contraction, 
 to pull out and mold the new bone to its proper 
 shape. 
 
 The indications for and technique of resections of the
 
 30 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 various joints will be considered under the heading of 
 each. 
 
 Internal fixation: 
 
 Systematic plating, banding and wiring of compound 
 fractures of war have had an extensive trial and are 
 almost universally condemned. In exceptional cases 
 this procedure may be practised when a fracture can- 
 not be retained in reduction by other means, but such 
 cases are rare. It is often a temptation to band or wire 
 long splintering fractures, but equally good results can 
 be obtained otherwise without the risks of the operation. 
 Internal fixation of an infected fracture is, as a rule, 
 bad surgery. 
 
 Operations for sequestra and bone sinuses: 
 
 Nearly every case of infected war fracture unites 
 with sequestra in the callus. The sinuses resulting 
 therefrom are difficult to close and often keep a soldier, 
 who is otherwise perfectly well, from active duty for 
 months and even years. They will not definitely heal 
 until the necrosed bone is removed, and this should 
 therefore be done at the earliest possible moment, not 
 only to enable the sinus to close but to avoid osteitis 
 and excessive formation of callus. 
 
 Judgment must be exercised as to when to operate. 
 If the operation is performed before the dead bone has 
 become separated it will be a failure, because the trau- 
 ma tism provoked in removing the necrotic portion leads 
 to further necrosis. There is also great danger of re- 
 fracturing weak unions.
 
 31 
 
 The moment to operate is when the dead portions 
 have been detached from the living, at which time they 
 can be picked out of the sinus with the least traumatism. 
 Usually this occurs in six weeks, but the time is influ- 
 enced by the amount of blood supply to the parts. In 
 weak unions it may often be wise to wait for the growth 
 of more callus, but it must be remembered that an area 
 of absorption is being created about the sequestrum and 
 the operation should not be postponed until disagree- 
 able cavities are formed. 
 
 The best way of determining the presence and loca- 
 tion of sequestra, if they cannot be felt by the probe, is 
 by X-rays. Stereoscopic plates should be taken by 
 which the sequestra can be localized standing out by 
 themselves surrounded by a clear interval between them 
 and the less dense callus. In this way their exact num- 
 ber and location can be determined and everyone sub- 
 sequently accounted for at operation. The trouble and 
 expense of stereoscopic plates are far less than those 
 of several operations and the cost of months of treat- 
 ment thereby entailed. 
 
 Operations for sequestra possess none of the excite- 
 ment of abdominal surgery but are even more difficult 
 and require the most painstaking care. As a rule the 
 sinus and scar are excised and the opening thus made 
 used as the approach unless the sequestrum has been 
 located on the other side of the bone, when an incision 
 over it should be made. The dissection is carried out 
 along the sinus and if the necrotic bone is within the 
 callus the periosteum should be carefully lifted. The 
 callus should be interfered with as little as possible. By
 
 32 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 efficient sponging the dead white sequestrum can be 
 seen and removed. Others, if present, should be sought 
 for in the same way; the stereoscopic plates being on 
 view so that their relations with one another may be com- 
 pared. Blind curettage of a bone sinus is bad practice. 
 
 The aniline antiseptic dyes methyl blue, gentian 
 violet, flavine or brilliant green may be used to stain 
 the sinuses and are of help, but they are not so reliable 
 as stereoscopic X-ray plates. It is difficult to obtain 
 penetration of the stain throughout the sinuses. 
 
 After removal of the sequestra, in the presence of a 
 reasonably clean field the ends of the incision may be 
 approximated, and drainage may be dispensed with un- 
 less evidently needed, when light gauze packing should 
 be employed. 
 
 Sometimes when the operation to remove sequestra is 
 deferred for too long a period, particularly when large 
 portions of the main fragments necrose, large cavities 
 are formed more or less completely surrounded by an 
 irregular callus. Such cavities, unless operated on be- 
 fore the medullary cavity of the main fragment is 
 plugged by new bone (thus stopping all regeneration 
 of bone from that source), are almost incurable and 
 sometimes demand amputation or wide resection of the 
 whole area including the condensed bone closing the 
 medullary cavity. A resection of this extent produces 
 crippling shortening, as a rule, unless a bone graft can 
 be used. If, however, the operation is performed at an 
 early date it will suffice to resect one wall of the cavity, 
 preserving the periosteum covering the resected callus 
 and thus allowing the soft parts to collapse and obliter-
 
 FRACTURES IN GENERAL 33 
 
 ate the dead space. In such operations all the old gran- 
 ulations and cicatricial tissue lining the cavity should 
 be carefully excised so as to allow the periosteum of 
 the side removed to come into direct contact with the 
 callus remaining on the opposite side. 
 
 Vicious union: 
 
 Many cases of vicious union demanding correction 
 come to base hospitals. They are often complicated by 
 dead bone and fistulas, and it is usually advisable to get 
 rid of the latter before revising the union. In some 
 cases with quiet sinuses showing no signs of active in- 
 fection, the dead bone may be removed and the fracture 
 revised at the same operation; but the wound, under 
 such circumstances, must not be closed. 
 
 The methods employed to revise fractures obviously 
 depend upon the site and the nature of the mal-union. 
 
 Internal fixation is seldom necessary. If the frag- 
 ments cannot be maintained in good relation by fixing 
 the limb in proper position, an inlay graft may be of 
 value. Repair of fractured callus is very rapid if it is 
 fairly recent. After several months, however, it loses 
 its vascularity and repair is slow, so that operation on 
 these cases should not be deferred. 
 
 Non-union: 
 
 In true non-union the ends of the bones become 
 healed over and the medullary cavity plugged with 
 dense callus. Union will not take place unless this 
 bone plug is cut away and the medullary cavity made 
 continuous. Non-union is generally caused by loss of
 
 34 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 substance (i. e., removal of a section of bone either by 
 the projectile or by the surgeon), and therefore, if all 
 the dense material forming the ends of the bones is cut 
 away, considerable shortening results. Hence bone 
 plating should not be used, for it is decidedly unwise to 
 put on a plate and leave a gap between the bone ends. 
 The treatment for these cases is an inlay graft by the 
 Albee method. The channel cut to receive it passes 
 through the dense ends and thus the medulla is made 
 continuous by means of the medullary surface of the 
 graft. The ends of the fragments are not removed, 
 and the bone is therefore not shortened by the opera- 
 tion. 
 
 Delayed union: 
 
 Delayed union is best treated by use of the member. 
 An ambulatory apparatus such as the Delbet (Figs. 34, 
 36 et 37) may be employed in the case of the lower 
 limbs. Injections of blood between the ends of the 
 fragments should be made in refractory cases.
 
 CHAPTER IV 
 
 MECHANICAL TREATMENT 
 
 Since the beginning of the war mechanical treatment 
 (i. e. the external fixation of fractures) has passed 
 through several phases. The tendency has led steadily 
 and progressively away from the methods of absolute 
 fixation by splints of wood, metal and plaster of Paris 
 toward methods in which the main principle is traction 
 (extension of the member in what may be called the 
 physiological direction and position). With this latter 
 method the old rule of fixation of the adjoining articula- 
 tions has passed into obscurity. 
 
 It by no means follows, however, that plaster of 
 Paris and other splints should be done away with en- 
 tirely. They are of the greatest value for certain con- 
 ditions, more particularly in some stages of convales- 
 cence and for late transportation. 
 
 The inadequacy even harmf ulness of plaster, 
 especially the circular forms, for fresh fractures, be- 
 came evident very early in the war. It constricted the 
 limbs, causing sometimes oedema, sometimes gas gan- 
 grene; or, on account of the rapid atrophy of the 
 muscles, the splints became so loose as to afford little 
 support. Pressure sores were common. Filth col- 
 lected under the plaster and abscesses hidden from 
 sight were formed. Dressings were difficult, even with 
 the most skillful bridging. The joints stiffened, and, in 
 
 35
 
 36 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 short, the condition of the fractured member became 
 deplorable. 
 
 The treatment which is finding greatest favor and 
 gradually becoming generalized is suspension of the 
 member combined with traction. A simple form of 
 splint acting as a cradle (such as Hodgen's for the 
 lower extremity) is used or no splint at all, and the 
 limb is suspended to an overhead frame with or without 
 a trolley attachment. Traction is applied by a weight 
 attached to a cord running over a pulley, or simply by 
 utilizing the weight of the patient. The limb is sus- 
 pended in a position of flexion, rotation or abduction 
 which as nearly as possible coincides with that of physio- 
 logical rest for the opposing muscles, i. e. those tend- 
 ing to cause deformity. This position of physiological 
 rest is a most important object to attain, for with it 
 little force is necessary to keep the fragments in place. 
 Unfortunately, on account of wounds, infection and 
 other complications, it is often impossible to accomplish 
 it, but it should always be the goal aimed at. 
 
 The great advantages of this system become at once 
 apparent to one who has struggled with other methods 
 the circulation is better, the wounds are accessible, 
 union is if anything more rapid, and, greatest boon of 
 all, the patient has no pain. Furthermore, the articu- 
 lations are seldom fixed and the muscles are always ac- 
 cessible for massage. 
 
 Suspension apparatus: 
 
 In order to suspend fractured limbs some sort of over- 
 head frame or apparatus is necessary. The original
 
 MECHANICAL TREATMENT 37 
 
 Balkan frame consists of a single horizontal bar, longer 
 than the bed, supported by two posts set on foot pieces 
 in order to make the apparatus stable and allow it at 
 the same time to be moved from one bed to another. 
 This frame has the disadvantage of having only one 
 bar, of being too low, of being heavy and clumsy and 
 only suitable for the lower extremity. 
 
 The frame shown in Fig. 10 by itself, and in use in 
 the figures illustrating the method of suspending the 
 different fractures, is free from most of the above de- 
 fects and has proved its practicability. It has the dis- 
 advantage of being difficult to attach to beds that are 
 not supported on legs at the corners; but this can be 
 overcome by nailing longitudinal bars of the length of 
 the bed to the feet of each pair of frames, and thus 
 fastening them together under the bed, or by simply 
 nailing the feet to the floor. The frame is furnished 
 by the Red Cross and described in the Army Splint 
 Manual, but in case of delay in obtaining a supply it 
 can readily be made by anyone having the slightest 
 knowledge of carpentry. 
 
 The apparatus consists of two similar frames, one of 
 which is tied to the foot and the other to the head of the 
 bed. Each frame is composed of two uprights united 
 by two cross members ; the lower one at the level of the 
 top of the mattress, the upper one far enough below the 
 upper ends of the uprights to avoid splitting of the 
 ends of the latter by the screws or bolts which are used 
 to fasten them together. The upper cross member is 
 notched, as shown in the diagrams, to receive the longi- 
 tudinal bars, which are also notched. Several extra
 
 38 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 notches, two outside and two inside of each upright, are 
 made in the cross member to receive the longitudinal 
 bars in the proper position over the limb to be sus- 
 pended. Only two notches are made in the longitu- 
 
 FIG. 10. Suspension frame for fractures. 
 
 dinal bars, the distance between them being the exact 
 length of the bed. The interlocking of the notches 
 prevents the longitudinal bars from slipping and makes 
 the entire frame rigid. 
 
 The end frames, as will be seen by the diagrams, are 
 made in the shape of a truncated "A", the uprights be- 
 low being separated slightly more than the feet of the
 
 MECHANICAL TREATMENT 39 
 
 bed, while the upper ends are closer together. Each 
 upright, E-F Fig. 10, is 2 metres (80 in.) long. The 
 upper cross piece, A-B, is 1 metre (40 in.) long. The 
 lower cross piece, C-D, is as long as the bed is wide, so 
 that at the level of the top of the mattress the separation 
 of the uprights is exactly the width of the bed. The 
 lower ends of the uprights are separated about 0.10 
 metre (4 in.) more than at the level of the mattress, 
 which brings the upper ends about 0.20 metre (8 in.) 
 nearer together. The pieces of the end frames are 
 fastened together with two screws or carriage bolts at 
 each point. Bolts are better for frames to be knocked 
 down for transportation. 
 
 The best material for the purpose is soft white pine 
 free from knots; this does not split and the eyes or 
 screws of the pulleys are easily inserted into it. Any 
 wood may be used, however. Using soft pine the 
 author has found material 0.021 metre (% in.) thick 
 and 0.05 metre (2 in.) wide for the uprights and lower 
 cross piece sufficient, while for the upper cross piece 
 and the longitudinal bars slightly wider material, 0.06 
 metre (2% in.), should be used. The longitudinal 
 bars are 2.65 metres (10 ft. 4 in.) long and project 
 over the ends of the frames so as to allow the weights, 
 to hang beyond the head and foot of the bed. 
 
 Suspension is effected by strong cord passing through 
 pulleys. The pulleys used are the ordinary iron ones 
 found in any hardware shop, furnished with a screw to 
 fasten in the wood or with a hook which is hooked into 
 a screw eye. 
 
 To permit the patient to move longitudinally in the
 
 40 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 bed, as in the change of posture from lying down to 
 sitting, it is advisable to have a short bar to which the 
 limb and weights are hung, and which moves on a trolley 
 attached to the longitudinal bar of the main frame. 
 This bar is made of a piece of wood 0.30 metre to 0.45 
 metre (12 in. to 15 in.) long (Fig. 11), in the bottom 
 
 FIG. 11. Detail of trolle}' bar for suspending the lower 
 
 limb. 
 
 of which are screwed the pulleys through which the 
 cords for the suspension pass. Two pulleys are screwed 
 into its upper side and run on an iron rod 10 millimetres 
 (% in.) thick. One end of this rod is bent and tied to 
 the main longitudinal bar, while the other is straight 
 in order to allow it to -engage the pulleys and is passed 
 through a hole in a piece of strap iron bent at right 
 angles, which is in turn fastened to the longitudinal bar 
 by two screws. In default of screw pulleys the iron 
 strap hooks furnished by the Red Cross and figured in 
 the Army Splint Manual may be used for attaching 
 the short bar (trolley) to the long longitudinal bar. 
 In practice it has been found that the trolley attach-
 
 MECHANICAL TREATMENT 41 
 
 ment is very important for suspending the lower, but is 
 superfluous for the upper extremity. 
 
 The best weights are cast from lead, weigh 500 
 grammes each, and are strung on an iron rod, but when 
 they hang over the patient in such a position that he or 
 the attendants may strike against them it is better to 
 use small bags of shot, each holding 250 grammes, 
 placed in a larger bag of strong muslin. These smaller 
 weights permit a more delicate adjustment for the arm 
 and forearm. Failing shot or lead, sand or stones may 
 be used. 
 
 For suspension of the arm a simple post with a hori- 
 zontal arm may be used, but the frames just described 
 are adapted for the treatment of all fractures. 
 
 In some of the English fracture services installed in 
 barracks an overhead frame is constructed as part of the 
 building. It consists of a pair of longitudinal bars, of 
 about 0.10 metre X 0.075 metre (4 in. X 3 in.) square 
 section. These pass over the beds at the level of the 
 eaves on each side of the barrack and extend the entire 
 length of the building. The bar nearer the wall is at 
 about 0.85 metres (2 ft. 6 in.) distance from it, and the 
 other at 2.25 metres (7 ft. 6 in.) ; the latter thus passes 
 directly over the bottom of each bed. Across these, 
 other bars, about 2.40 metres (8 ft.) in length, may be 
 placed for suspension of limbs. To provide for trac- 
 tion, such as that required for a fracture of the femur, a 
 post is used, the lower end of which is fitted into a step 
 in a board nailed to the floor in front of the foot of the 
 bed, and the upper pinned to the longitudinal bar over 
 it. A number of steps are cut in the board so that the
 
 42 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 post may be put into the position requisite to obtain the 
 desired abduction of the limb. The foot of the bed 
 may also be suspended from the bar, in order to obtain 
 the necessary traction if the foot is attached directly 
 to the post, or counter-traction if a weight and pulley 
 are used. 
 
 This overhead construction is to be recommended for 
 fracture services installed in barracks, but it must be 
 lower than the eaves or it is impossible to arrange the 
 suspensions without a stepladder. 2 metres (6 ft. 6 
 in. ) is the most convenient height. 
 
 Methods of attaching suspension and traction apparatus 
 
 to the limbs: 
 
 The several methods of suspension will be discussed 
 under the headings of the different fractures. 
 
 For direct attachment of the apparatus to the limb 
 several adhesive substances may be used. The most 
 convenient have been found to be Sinclair's 1 glue or 
 Heussner's 2 liquid glue, both of which are painted 
 
 1 Formula for Sinclair's glue (from the British- Medical 
 Journal, August 26, 1916, p. 301) : 
 
 Glue 50 parts 
 
 Water 50 " 
 
 Glycerine 2 " 
 
 Calcium chloride 1 " 
 
 Thymol . 1 " 
 
 2 Formula for Heussner's glue : 
 
 Resin 50 parts 
 
 Alcohol 90 0/0 50 " 
 
 Venice turpentine 1 " 
 
 Benzine 10 "
 
 MECHANICAL TREATMENT 43 
 
 directly on to the limb with a brush. Bands made of 
 Canton flannel and furnished with straps of webbing 
 for tying or buckling to the apparatus are then immedi- 
 ately applied. A supply of two sizes of these bands, 
 one for the leg and the other for the arm, should be 
 made and kept in stock ; they are readily trimmed to the 
 necessary size for any individual case and are more 
 easily applied than straps made of diachylon plaster, 
 although the latter is one of the best and least irritating 
 of the materials that can be used. If the flannel and 
 webbing bands are not at hand, however, stout muslin 
 or several layers of gauze may be employed. Rubber 
 plaster is liable to slip and should not be used. 
 
 Sinclair's glue, being an aqueous preparation, is well 
 borne by the skin. It adheres firmly. Sinclair does 
 not shave the skin but strokes the hairs upward in 
 applying the glue, which should be as warm as can be 
 supported. Heussner's preparation does not slip, but it 
 occasionally irritates. When using either glue the skin, 
 as for all impervious plasters, should be carefully 
 cleaned preliminarily by scrubbing with soap and water 
 and then removing all traces of the same with alcohol. 
 No antiseptic other than alcohol or ether should be 
 used. 
 
 Traction: 
 
 The most obvious object of traction is to overcome 
 longitudinal deformation, i. e. overlapping. It also to 
 a certain extent prevents lateral deformation, i. e. angu- 
 lation ; and if it is made in the proper direction, namely, 
 in that of the axis of the proximal fragment, the ten-
 
 44 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 dency to angulation is so slight as to make ordinary fixa- 
 tion unnecessary. In fact, as has already been stated, 
 the time-honored rule of fixing the adjacent articulations 
 no longer holds and in most instances may be disre- 
 garded. 
 
 There are two main methods of producing traction; 
 one by a force exerted continuously, as by weights and 
 springs, the other by a force exerted momentarily, the 
 resultant length being retained by fixation as in the or- 
 dinary application of the Thomas knee splint. In the 
 latter method there is no way of estimating the tractive 
 force, the only guide being the result obtained. Theo- 
 retically this would seem to be, and is thought by many 
 to be, the better method. The objection to it is that it 
 is difficult to maintain what has been gained without 
 producing discomfort* For instance, taking the 
 Thomas splint as an example, the length of the limb is 
 maintained by attaching the traction straps to the distal 
 end of the splint and consequently continuous pressure 
 is exerted by the upper part of the splint against the 
 pelvis. This pressure is sometimes insupportable. To 
 avoid it a weight may be attached to the end of the 
 splint by means of a cord running over a pulley, thus 
 substituting active traction for the passive traction of 
 the Thomas splint proper; or the same result can be 
 accomplished by attaching the splint to a fixed point 
 and using the weight of the patient (the bed being in- 
 clined) , as practised by Sinclair. By using the Thomas 
 splint in the manner described its great advantage of 
 being a self-contained traction splint permitting the 
 patient to be moved, as for operations or X-rays, is
 
 MECHANICAL TREATMENT 45 
 
 retained, and at the same time the objection of con- 
 stant pressure against the pelvis is obviated. If the 
 Thomas splint is used by itself, without traction on the 
 whole splint, care should be taken, in tightening the 
 traction from time to time, not to over-stretch the limb 
 and thus ruin the knee-joint. This may easily happen 
 on account of the impossibility of gauging the amount 
 of traction employed. The loose, weak knees so often 
 observed in convalescents after fracture of the femur 
 can be largely avoided by due regard to the principles 
 involved. Many surgeons commit the error, when us- 
 ing weights, of commencing with a comparatively small 
 one and adding to it until the desired effect is produced ; 
 not realizing that, on account of the process of repair, 
 each day makes the reduction increasingly difficult. In 
 this manner the weight is increased to an inordinate 
 amount and continued for an unnecessary length of 
 time. Consequently, if the traction is made through a 
 joint, the ligaments will be gradually stretched and the 
 joint may be irreparably damaged. The correct method 
 is to use a weight sufficient to reduce the fracture in the 
 first two hours and to then decrease it to the amount 
 just necessary to maintain the position. If traction is 
 applied in this way little trouble will be experienced in 
 regard to the joints. 
 
 Traction by means of elastics and springs is difficult 
 to control, is not well borne, and is in general unsatis- 
 factory. 
 
 Radiographic control: 
 
 It is impossible to treat fractures properly and intelli-
 
 46 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 gently without frequent radiographic observations. 
 This is particularly true of gun-shot fractures because 
 of the frequent dressings that are often necessary and 
 that cause disturbance of the mechanical treatment. 
 
 Radiographs should be taken directly after the splints 
 and apparatus have been applied and as often as is 
 necessary to verify the position and observe the course 
 of repair. 
 
 It is unwise and impracticable to move the patient to 
 the X-ray room, and there should therefore be a port- 
 able apparatus in every fracture service. In hospitals 
 where there are large wards near the radiographic de- 
 partment wires may be carried from the latter and ex- 
 tended throughout the length of the wards, and to these 
 the X-ray tube may be directly connected. 
 
 Nerve lesions: 
 
 All cases of fracture should be carefully examined 
 for injuries to the nerves before the anaesthetic is given 
 for the primary operation, so that they may be sutured 
 if possible at that time. 
 
 Due care must be taken in the after treatment of these 
 cases to prevent deformation, contractures and trophic 
 disturbances such as pressure sores. 
 
 When there is a lesion of the musculo-spiral nerve 
 the hand must be kept in the position of dorsiflexion so 
 that the flexor muscles may function. For this pur- 
 pose, especially during convalescence, the Jones cock-up 
 splint is excellent; it bandages to the flexor surface of 
 the forearm. Another good cock-up splint may be 
 made of thin sheet metal placed on the dorsum of the
 
 MECHANICAL TREATMENT 47 
 
 forearm and wrist and reaching just to the heads of the 
 metacarpals. A narrow band at the end of this passes 
 across the palm, holding the hand up. This band does 
 not interfere so much in grasping objects as the splint 
 placed on the flexor surface.
 
 SECTION II 
 
 SPECIAL FRACTURES
 
 CHAPTER V 
 
 DIAPHYSEAL FRACTURES 
 
 CLAVICLE AND SCAPULA 
 
 Fractures of the clavicle and scapula, when not in- 
 volving the shoulder joint, are treated as in civil prac- 
 tice. Either the Sayre, or the sling and body bandage 
 may be used. It is often impossible to use a typical 
 method on account of the position of the wounds. 
 
 The chief complications of these fractures are inju- 
 ries to the lung, brachial plexus and subclavian vessels. 
 
 HUMERUS 
 Transport: 
 
 Three splints are furnished by the Red Cross for 
 splinting the humerus for transport. These are, in 
 order of preference: Murray's hinged modification of 
 the Thomas traction arm splint (Fig. 12 A), the 
 Thomas traction arm splint (Fig. 12 B), and Jones' 
 humerus traction splint (Fig. 13). The unmodified 
 Thomas splint would be best were it not for the difficulty 
 of transporting a man with his arm extended at right 
 angles to his body. 
 
 Neither the Murray modification nor the Jones splint 
 afford abduction, and this is an objection to their use 
 for the continued treatment of high fractures. The 
 
 51
 
 52 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 Jones is a right and left splint and, moreover, several 
 sizes are necessary. 
 
 Failing these splints a fractured humerus may be 
 transported satisfactorily for a short distance by using 
 a sling and body bandage, provided that the axilla and 
 
 FIG. 12. 
 
 A. The Thomas traction arm 
 
 splint. 
 
 B. Murray's modification of the 
 Thomas traction arm splint. The 
 bars are hinged to the ring, thus 
 allowing the arm to hang by 
 patient's side. 
 
 side are well padded and that some form of coaptation 
 splint is used to prevent angulation. 
 
 In both the Thomas splint and Murray's modifica- 
 tion traction is made with the arm and forearm in a
 
 DIAPHYSEAL FRACTURES 
 
 53 
 
 straight line, i. e. with the elbow extended. It should 
 be effected by means of adhesive straps attached to the 
 skin of the forearm. In case these cannot be applied, 
 as, for instance, when there are wounds of the forearm, 
 a clove hitch may be taken with a bandage about a heavy 
 dressing of cotton placed on the wrist. In either case 
 
 FIG. 13. The Jones traction humerus splint. 
 
 the straps or the extremities of the bandage are tied 
 to the end of the splint after having been first placed 
 one over the other under the bars. Traction is then 
 made by twisting, % means of a short stick (Spanish 
 windlass ) . 
 
 In using the Jones humerus splint, traction is sup-
 
 54 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 posed to be effected by adhesive straps attached to the 
 skin of the arm, the elbow being flexed ; but in fractures 
 of the lower part of the humerus the straps obviously 
 cannot be used, and a hitch must be taken about the 
 elbow with a bandage. All such hitches must be pinned 
 in order to prevent their drawing tight and constricting 
 the parts. 
 
 FIG. 14. Thomas traction arm splint used as an ambulatory 
 splint. Abduction is maintained by bending another Thomas 
 splint to form a support. 
 
 Operative treatment: 
 
 Should be conducted as laid down for fractures in 
 general. When operated on before infection is estab- 
 lished, the musculo-spiral nerve, if divided, should be 
 sutured.
 
 D1APHYSEAL FRACTURES 
 
 55 
 
 Mechanical treatment: 
 
 Much ingenuity has been expended in devising 1 am- 
 bulatory splints for fractures of the humerus, but none 
 of them fulfill all the requirements, though they may 
 render excellent service after union has commenced and 
 deformation is no longer likely to occur. 
 
 FIG. 15. Thomas traction arm splint used for bed treatment 
 of fracture of the humerus. Traction is made by twisting 
 the bands by means of a nail. The splint may be suspended 
 as shown, or at its extremity alone. 
 
 Fractures of the upper half of the bone should be 
 treated by traction, rotation out and abduction, accord- 
 ing to the site. Fractures of the surgical neck usually 
 require extreme abduction and rotation out (Fig. 19). 
 This position brings the hand to a level above that of 
 the head a position extremely difficult to maintain 
 with an ambulatory apparatus. 
 
 Fractures of the lower half do not, as a rule, require 
 abduction and external rotation, and could be satisfac- 
 torily treated with the Jones splint were it not for the
 
 56 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 difficulty of arranging the traction in presence of low 
 wounds and of keeping the splint in place. The 
 Thomas splint can be employed for any fracture, and 
 may be used as an ambulatory splint when supported 
 
 FIG. 16. Principles of suspension and traction for 
 
 fractures of the humerus : 
 
 A. High fracture of the humerus for which adhesive 
 strips can be used for traction. 
 
 as shown in Fig. 14; but when it is utilized the patient 
 is generally kept in bed and the end of the splint sus- 
 pended (Fig. 15) . The objection to the Thomas splint 
 and its modifications is that the elbow is kept fixedly 
 extended and traction made through it, and on account 
 of the resulting stiffness the period of convalescence is 
 greatly lengthened by the time necessary to restore the 
 motion of the joint. Moreover, the ring interferes with
 
 DIAPHYSEAL FRACTURES 57 
 
 the dressings when the wounds are in the neighborhood 
 of the shoulder. 
 
 On the other hand, treatment by suspension and trac- 
 tion (without any splint), as carried out on the author's 
 
 Low fracture for which adhesive strips cannot be 
 used. In this case a band is placed about the arm 
 in the manner shown; in order to prevent its slip- 
 ping, and to keep the traction in the axis of the 
 humerus, the ends of the band are crossed over in 
 front and pinned on each side of the forearm. It 
 may be placed directly over the dressing covering 
 the wound ; when there is no wound dressing a thick 
 piece of cotton should be placed under it, but for 
 the sake of clearness neither dressing nor cotton has 
 been shown in the drawing. The spreaders which 
 should be used to prevent pressure of the band on 
 the epicondyles have also been omitted from the 
 drawing.
 
 58 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 service during the past three years, is adapted to all 
 fractures of the humerus, including those entering the 
 
 FIG. 17. Method of suspension for fracture of 
 the humerus or elbow. 
 
 Note the use of two bars over the arm, the ex- 
 ternal one being employed to support the 
 forearm and to maintain the abduction and 
 external rotation of the lower fragment. 
 The traction has been omitted from the 
 drawing. 
 
 shoulder and elbow (Figs. 16, 17, 18 and 19). As most 
 cases require abduction of the arm, the forearm and arm
 
 DIAPHYSEAL FRACTURES 
 
 59 
 
 are suspended in different planes in relation to the 
 longitudinal axis of the bed, so that two longitudinal 
 
 FIG. 18. A simple method for producing traction and 
 at the same time regulating abduction. The pulley 
 for the weight is attached to an upright fixed at the 
 end of a rough unplaned board which is slipped in 
 under the mattress. The desired abduction is obtained 
 by adjusting the position of the board. 
 
 bars must be used, the forearm being suspended to the 
 outer. The distance between the suspending bars is
 
 60 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 regulated to conform with the desired abduction and 
 the outward rotation of the lower fragment. 
 
 Traction must always be made in the axis of the 
 upper fragment. The position of the latter depends 
 upon the site of fracture and the preservation of the 
 attachments of the muscles, and varies greatly. Its 
 exact situation can only be determined by means of 
 X-rays; the apparatus for treatment should be adjusted 
 until the lower fragment is in line with the upper frag- 
 ment. Generally speaking, the higher the fracture the 
 greater the abduction and outward rotation of the upper 
 fragment In rare cases the pectoral may adduct the 
 upper fragment, and the deltoid draw the lower frag- 
 ment upward on its outer aspect. 
 
 In the lower fractures traction may usually be made 
 in the axis of the bed and the traction pulley attached 
 to a cross barjon the frame at the foot of the bed. If 
 more abduction is necessary the method illustrated in 
 Fig. 18 may be used. By this device any desired abduc- 
 tion can be obtained except for fractures of the surgical 
 neck, in which the fractured surface of the upper frag- 
 ment may look almost directly upward. In these frac- 
 tures the arrangement illustrated in Fig. 19 has been 
 found efficient and surprisingly comfortable. 
 
 The weight necessary for traction varies with the 
 musculature of the arm. It is generally from 1,500 to 
 2,000 grammes. 
 
 If no direct suspension of the arm is made the frag- 
 ments tend to bow backward. To prevent this a broad 
 sling, nearly equal in width to the length of the humerus, 
 is placed under the arm, which is then suspended as
 
 DIAPHYSEAL FRACTURES 61 
 
 shown in Figs. 17 and 18. By using two narrow slings 
 it is possible to vary the suspending force on each frag- 
 ment as desired ; this is often an advantage, but it neces- 
 sitates careful attention as regards the position of the 
 slings and the weight attached to each, and for this 
 reason a single^ broad sling is more practical. This 
 should be attached to a stick as long as its width to pre- 
 vent it from wrinkling. Eyelets made in the ends of 
 the sling slip over hooks on the stick and permit it to be 
 easily undone for dressing purposes. 
 
 The weight attached to the sling should just balance 
 that of the arm proper, while the amount attached to 
 the forearm should correspond to the weight of the 
 latter. If a heavier weight be applied to the forearm 
 the fragments will tend to bow backward, and con- 
 versely, if the weight be lighter they will tend to bow 
 forward About 1,500 grammes are necessary for 
 each (i. e. arm and forearm) . 
 
 The slings may be made of Canton flannel backed 
 with muslin to give them rigidity and prevent wrinkling, 
 but when continued irrigation or wet dressings are em- 
 ployed they are best made of rubber sheeting. 
 
 The method of arranging the adhesive strips for sus- 
 pension of the forearm is shown in Fig. 16. The strips 
 are applied to the sides of the limb and must not overlap 
 (i. e. encircle it) on account of the danger of constric- 
 tion in the event of swelling of the member. The pieces 
 of webbing attached to them are fastened by buckles to 
 a spreader made of thin board, 0.125 metre (5 in.) long 
 X 0.10 metre (4 in.) wide, to the center of which a cord 
 is fixed. To the ends of this spreader are attached
 
 62 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 bands of elastic webbing, 0.02 metre (% in.) wide; 
 these support a round bar of wood at a height which puts 
 
 FIG. 19. Position of extreme abduction and external rotation 
 necessary in the treatment of some fractures at the surgical 
 neck of the humerus. 
 
 it just within reach of the fingers, so that the patient 
 can pull it down into the grasp of the hand and thus
 
 DIAPHYSEAL FRACTURES 63 
 
 exercise the fingers an arrangement which is of special 
 value if the musculo-spiral nerve has been injured. 
 
 Traction to the lower fragment of the humerus is 
 most efficiently made by means of adhesive or glued 
 strips. When wounds are present below the middle of 
 the arm, however, they cannot be applied unless such 
 wounds happen to be in the antero-posterior plane of 
 the limb. To overcome the difficulty a band of muslin 
 0.08 metres (3 in.) wide can be passed about the arm 
 and elbow, somewhat in the manner of the Hennequin 
 hitch for fractures of the femur. The center of the 
 band is applied to the back of the arm just above the 
 elbow, and the ends, after crossing in front, pass to each 
 side of the forearm as shown in the illustration (Fig. 
 16) ; they are then pinned back to the middle portion 
 of the band, so as to pass along the sides of the elbow 
 and bring the traction into the axis of the humerus, as 
 otherwise the band would tend to force the lower frag- 
 ment forward. As an alternative, a band like a wristlet 
 may be placed just above the elbow and side-straps at- 
 tached to it; it is convenient to have these made so that 
 they can be laced on. Either variety may be placed 
 directly over the dressing on the wound, but if such 
 dressing does not extend to the elbow the latter should 
 be well padded with absorbent cotton. 
 
 Patients should be encouraged to move the elbow, 
 wrist and fingers actively, and they should be passively 
 moved and massaged daily. 
 
 No splints of any kind are applied to the arm, and 
 although the patients move freely in bed, lying down 
 and sitting up (even out of bed in a chair), there is no
 
 64 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 pain and union takes place rapidly without deformity. 
 
 As soon as union is firm the patient is allowed to get 
 up with his arm in a sling ; this must be removed several 
 times a day, however, and the patient encouraged to ex- 
 ercise all the motions of the shoulder and elbow joints. 
 
 In fractures treated by suspension firm union has 
 been repeatedly observed within 25 days in uninfected 
 cases, and patients have been able to use their arms in 
 four weeks from reception of the wound. In cases of 
 delayed union caused by loss of bone or infection there 
 has been no tendency to the production of pseudarthro- 
 sis, as might be supposed would result from the absence 
 of fixation. On the contrary, union has appeared to 
 be more rapid, which is explained by the preservation, 
 during the treatment, of function and normal circula- 
 tion. 
 
 RADIUS AND ULNA 
 
 Fractures of the forearm are extremely difficult to 
 treat. In fractures of both bones, on account of the 
 usual comminution and projection of splinters into the 
 tissues, cross union or interference of callus is apt to 
 occur. Moreover, because of the numerous muscles 
 and tendons it is difficult to secure adequate drainage 
 and infection may cause lamentable loss of function 
 from sloughing of tendons and from cicatricial fusions. 
 
 Transport: 
 
 Murray's modification (Fig. 12 B) of the Thomas 
 traction arm splint is the best splint for transport. 
 Traction is applied by one of the methods illustrated in
 
 DIAPHYSEAL FRACTURES 65 
 
 Fig. 21 or by a hitch with a bandage over a cotton dress- 
 ing about the wrist. The ends of the strips are simply 
 passed about the bars of the splint and tied to its end 
 (as already described for fractures of the humerus), 
 and the traction is tightened by twisting the strips. The 
 traction should be arranged so as to keep the hand 
 supinated. A bandage is placed about the splint and 
 arm. 
 
 Operative treatment: 
 
 Fractures of the radius and ulna, although not so 
 dangerous to life as others, are the most dangerous of 
 all as regards loss of function. The losing of the use of 
 a hand is much more serious than that of a leg, and the 
 surgeon must not only aim at preserving a forearm and 
 hand but at preserving their functions also ; this cannot 
 be the case if all the tendons and nerves are embedded 
 in a cicatricial mass, and such fractures should therefore 
 receive the earliest possible attention in order to avoid 
 infection. Rifle ball fractures with punctate orifices 
 are the only ones which should not be operated upon. 
 
 Were it not for the fact that non-union of these bones 
 is common after resection, primitive resection of their 
 fractures would have fuller indications than in the case 
 of breakage of any other diaphysis. 
 
 When operating before the establishment of infection 
 the incisions should be free and the dissection carefully 
 carried down between the muscles and tendons. All 
 fragments driven into the muscles must be carefully 
 sought for and removed, and those which have remained 
 attached should be pressed back into place if possible.
 
 66 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 The muscles and tendons should be trimmed and re- 
 paired, or cross sutured if long segments have been de- 
 stroyed. Fine chromicized gut should be used; plain 
 cat -gut will not hold, and heavy chromicized gut will 
 have to be removed if suppuration should occur. Nerves 
 should be sutured if possible. The wounds should be 
 partially closed; tight suturing of the fascia must be 
 avoided. Drainage tubes should never be used, as they 
 produce sloughing of the tendons by pressure. 
 
 When infection is already established the operation 
 should be confined to providing drainage and removing 
 detached bone and foreign bodies, especially clothing. 
 Projectiles themselves do not provoke suppuration un- 
 less clothing is attached to them, and therefore, if they 
 are small and not easily located, the operation should 
 not be prolonged to find them. For drains vaselined 
 gauze should be used. 
 
 Mechanical treatment: 
 
 Traction is exceedingly important in the treatment of 
 fractures of the radius and ulna, even when only one 
 bone is broken. This is especially true of fractures of 
 the lower part of the radius, as in these cases abduction 
 of the hand due to shortening of the radius is apt to 
 occur, causing marked loss of function. 
 
 It is wiser to treat these patients in bed until repair 
 is well advanced, particularly if the fracture is infected. 
 By keeping the patient in a reclining position, with the 
 arm and forearm suspended, the circulation is greatly 
 improved and repair hastened. 
 
 The entire limb may be placed in a Thomas arm
 
 DIAPHYSEAL FRACTURES 
 
 67 
 
 splint and suspended. It will be found better to use 
 independent traction by weight and pulley (Fig. 21) 
 than to attach the traction strips to the splint, as in the 
 
 FIG. 20. Method of using bent Thomas traction 
 arm splint for treating fractures of the radius 
 and ulna. Traction is made by a glove glued 
 to the hand, and counter-traction furnished by 
 a band around the arm and splint just above 
 the elbow. 
 
 latter case the arm will have to rest at right angles to 
 the body. On account of the carrying angle of the el- 
 bow, it is usually advisable to bend the Thomas splint 
 at the elbow (Fig. 20). The Jones humerus traction 
 splint may be used instead of the bent Thomas, but it 
 generally needs considerable re-bending and adjust- 
 ment.
 
 68 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 The simple cradle shown in Figs. 21 and 25 C has 
 been found satisfactory. It consists of two parallel 
 steel rods, 0.009 metre (% in.) thick and 0.40 metre 
 (16 in.) long, fastened together by two bows of rod 
 0.004 (3/16 in.) thick, so that the distance between the 
 parallels is about 0.15 metre (6 in.). This distance 
 can be easily regulated by bending the bows. 
 
 No matter what splint is used the forearm is sup- 
 ported in the same manner as for the lower extremity, 
 on pieces of 10 centimetre (4 in.) flannel bandage 
 doubled across the bars and fastened at one side with 
 clips or pins. When wet dressings are used these bands 
 should be made of perforated rubber sheeting. Care 
 should be taken to keep such bands or slings taut and 
 smooth so that the limb is evenly supported. 
 
 Traction is effected by means of glued or adhesive 
 strips (Fig. 21 A), or by Sinclair's method of gluing a 
 cotton glove on to the hand (Fig. 21 B). This clever 
 and very satisfactory arrangement consists of an ordi- 
 nary cotton glove to which small curtain rings are 
 attached at the tips of the ringers by means of cotton 
 tape, the latter being sewed along the entire length of 
 the fingers to reinforce them. A narrow cord is then 
 laced through the rings and over a round stick which 
 acts as a spreader and thus equalizes the tension on the 
 fingers. The spreaders should be long enough to en- 
 gage with the bars of the splint, so as to prevent the 
 hand from turning and to maintain it in supination. 
 
 Counter-traction is provided for, when the bent elbow 
 position is adopted, by a hitch about the forearm at the 
 bend of the elbow and over a cotton dressing, as shown
 
 DIAPHYSEAL FRACTURES 
 
 69 
 
 in Fig. 21 ; or, when a bent Thomas splint is used, by 
 attaching the cord directly to the splint. A weight of 
 
 
 FIG. 21. Suspension cradle for fractures of the radius and 
 ulna, and methods of installing traction and counter-trac- 
 tion. 
 
 A. Traction by means of glued or adhesive strips for high 
 fractures. A spreader is used, to which the traction strips 
 are attached. 
 
 B. Sinclair's method of using a cotton glove glued to the 
 hand. Note the manner of attaching the rings to the fingers 
 of the glove by means of cotton tape, and the equalizing of 
 tension by lacing the cord through the rings and over the 
 spreader. Counter-traction is made by the band hitched 
 about the forearm at the bend of the elbow. The dressing 
 of cotton which should be placed under this band has been 
 omitted from the sketch for the sake of clearness. 
 
 from 1,000 to 1,500 grammes is usually sufficient for 
 traction. 
 
 The consensus of opinion is in favor of treating frac-
 
 70 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 tures of the forearm and particularly those of the 
 radius, with the hand in full supination, both on account 
 of the danger of cross union and because the movement 
 of pronation is then more easily acquired in case of in- 
 complete ankylosis of the radio-ulnar articulation. The 
 hand is much more useful in the supinated position, 
 
 FIG. 22. Van de Veld's splint for fractures of the forearm. 
 
 since it is brought into the pronated position by abduc- 
 tion of the elbow. This last point must be borne in 
 mind during the treatment of the fracture in order that 
 the mistake may be avoided of over-supinating the hand 
 when suspending the arm with the elbow abducted from 
 the body ; for, when the arm is abducted to a right angle, 
 the hand is in full supination when the thumb is point- 
 ing upward and the palm is directly mesally.
 
 DIAPHYSEAL FRACTURES 
 
 71 
 
 When repair is well under way and the condition of 
 the wound permits, an ambulatory splint is desirable. 
 If traction is still necessary a bent Thomas arm splint 
 may be used and the traction cords attached to the end 
 of the splint (Fig. 20). In this case it is well to use 
 an elastic cord to take up the slack of the bandages 
 
 FIG. 23. Sinclair's splint for fracture of the forearm. 
 
 which fasten the arm into the splint. When traction 
 is no longer required the best splints are then the Van 
 de Veld and Sinclair (Figs. 22 and 23). These are 
 alike in principle. The Van de Veld consists of two 
 pieces of wooden splint board, of which one lies on the 
 palmar aspect of the forearm and the other on the 
 lateral aspect of the arm, the two being connected by an 
 adjustable metal hinge at the elbow. The Sinclair is 
 made of metal, and the two pieces are fastened together
 
 72 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 by a curved rod. With both, pronation is prevented 
 by the arm piece being on the outside of the arm. 
 
 Circular plaster splints should never be used for frac- 
 tures of the forearm because the circular turns draw 
 the bones together. 
 
 Repair is fairly rapid in fractures of the forearm, and 
 the bones should unite within three or four weeks. It is 
 exceedingly important that the fingers be moved twice 
 daily throughout treatment, and the splints should never 
 pass beyond the heads of the metacarpals. Active mo- 
 tion of the fingers must also be encouraged ; a few days 
 of fixation often produce irreparable stiffness. 
 
 METACARPUS AND PHALANGES 
 
 Gun-shot fractures of these small bones are nearly 
 always accompanied by loss of substance and, in the 
 case of the phalanges, generally demand amputation. 
 In some instances resection of portions of the hand is 
 necessary. Such operations are atypical and cannot be 
 described. In general, on account of the serious aggra- 
 vation of the wounds by infection, it is wise to remove 
 all lacerated tissues and strive for asepsis; by acting in 
 this way plastic operations and tendon sutures may be 
 successful which could never be performed later. 
 
 In cases not needing resection, fractures of the meta- 
 carpals may be treated by bandaging the hand. over a 
 rubber ball a little larger than the ordinary tennis ball. 
 Some cases are benefited by traction; this can be at- 
 tached by gluing on glove fingers (Fig. 21) and plac- 
 ing the arm in one of the traction splints for the forearm. 
 When traction is employed the hand should be sup-
 
 DIAPHYSEAL FRACTURES 73 
 
 ported on a ball in order to preserve the normal curve 
 of the bone. 
 
 FEMUR 
 
 Gun-shot fractures of the femur are the most serious 
 of all fractures of the limbs. The mortality is high: 
 firstly, from hemorrhage and shock; secondly, from 
 acute infection (particularly gas gangrene) ; and 
 thirdly, from chronic sepsis and its complications. In 
 all cases convalescence is long and average results are 
 poor. 
 
 FIG. 24. Thomas 
 
 traction leg splint. 
 Transport: 
 
 Traction during transport is absolutely essential.
 
 74 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 The Thomas traction leg splint (Fig. 24), or the half 
 ring modification (Fig. 25 A) should be used. The 
 ring of the regular Thomas splint is passed over the 
 limb, and for this reason is made much larger than that 
 of the ambulatory splint. 1 The half-ring model is ap- 
 plied to the back of the limb and is held in place by 
 a strap which passes over the groin. Ordinarily three 
 sizes of the regular Thomas splint are furnished, but 
 only one size of the half -ring modification is supplied. 
 For transportation from the field the splints are 
 applied over the clothing and before the wounds are 
 dressed. Traction is then attached to the foot, over 
 the boot, either by means of the gaiter which is issued 
 with the splint, or, better, by Pouliquen's method of 
 using a bandage, as follows: 2 lengths of 0.075 metre 
 (3 in.) bandage, each 1 metre long, are applied to the 
 ankle by the middle of each, one to one side of the ankle, 
 the other to the other side; the ends are then carried 
 across the foot, one in front over the instep and the 
 other behind over the heel: when drawn upon the ends 
 hug the foot snugly and do not slip. The ends of the 
 gaiter straps or of the bandage are passed over and 
 under the bars, and tied about the notch at the end of 
 the splint. In tying them the full strength of the sur- 
 geon must be exerted in order to crowd the ring well 
 up against the pelvis and pull the leg down into the 
 splint. If the traction is insufficient a stick or nail a 
 little longer than the width of the splint should be 
 passed between the straps at the end of it and twisted 
 in the manner of the Spanish windlass. The clothing 
 is then cut from about the wounds and they are dressed. 
 
 'Page 94-
 
 DIAPHYSEAL FRACTURES 
 
 75 
 
 A piece of coaptation or wire splinting is placed behind 
 the limb (Fig. 27), care being taken to pad it well at 
 the back of the knee. By taking hitches with a band- 
 age about the bars of the Thomas splint, a sort of sling 
 suspension is formed and at the same time the leg is 
 
 FIG. 25 
 
 A. Half-ring modification of the Thomas traction leg 
 splint. On account of the hinge the splint can be 
 used for either limb. 
 
 B. Hodgen's leg splint. 
 
 C. Frame used for suspension of fracture of the fore- 
 arm. 
 
 prevented from moving forward in the splint. Several 
 turns of the bandage should be passed around both 
 splint and limb, as shown in the illustration, and a figure 
 of eight made about the foot so as to support it com- 
 fortably. On the stretcher the limb should be sus- 
 pended as shown in Figs. 26 and 27. If the patient 
 is to be evacuated in a Ford ambulance the stretcher 
 suspension must be placed over the middle of the leg
 
 76 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 in order to raise the foot enough to clear the tailboard 
 of the car. 
 
 Traction by the gaiter or by a hitch over the boot is 
 merely provisional, however, and only to be employed 
 for short trips. The use of the gaiter, even with a 
 
 FIG. 26. Method of attaching end of 
 splint to stretcher suspension. If the 
 patient is to be transported in a Ford 
 ambulance the stretcher suspension 
 must be placed over the middle of the 
 leg so as to raise the foot above the tail 
 board of the car. (From the British 
 Army Instructions.) 
 
 heavy cotton dressing under it, is unsatisfactory for the 
 strong tension necessary for fractures of the thigh, as 
 it is apt to cause pressure sores, especially above the 
 heel. At the time of operation permanent traction for 
 treatment should be provided. This may be applied 
 by means of adhesive or glued strapping, the Codavilla
 
 DIAPHYSEAL FRACTURES 77 
 
 pin or the Ransohoff tongs; but if the patient is to be 
 evacuated again strapping must be used. 
 
 If wounds preclude the use of the Thomas splint in 
 the case of high fractures, the long Listen splint should 
 be employed. There is no provision in the Liston 
 
 FIG. 27. Method of applying the Thomas traction leg splint. 
 The splint is passed over the clothing and the traction is 
 applied before the wound is dressed. The clothing is then 
 cut from the region of the wound ; it is dressed, and a coap- 
 tation splint, well padded under the knee, is placed behind 
 the limb. The bandage is then applied so as to prevent any 
 motion of the limb either backward or forward, and to form 
 a figure of eight about the foot. The end of the splint is 
 hung to the stretcher suspension so as to prevent lateral 
 swaying. (From the British Army Instructions.) 
 
 splint, as supplied, for traction, but this can be pro- 
 vided by attaching the foot to the lower end of the 
 splint and then taking up the counter-traction by pass- 
 ing a padded cord from the upper end between the 
 thighs as a perineal band. Failing the Liston splint,
 
 78 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 the same object may be attained by utilizing one side of 
 a Bradford frame or a stretcher pole. 
 
 The combination of the long Listen splint and the 
 Delorme aluminium gutter splint with traction, devised 
 by Pouliquen, is extremely efficient for transport as it 
 provides both fixation and traction. 
 
 When a patient with fracture of the femur has to be 
 evacuated after the primary operation, a Thomas splint 
 should be used and the traction strapping freshly and 
 carefully arranged. A wire foot piece as shown in Fig. 
 27 (but reversed) should be applied to the splint and 
 the foot bandaged to it, in order to prevent foot drop. 
 The slings and bandages about the splint must be very 
 carefully adjusted so as to avoid, in so far as possible, 
 the slightest motion at the site of fracture. It is ex- 
 tremely unwise to transport these cases before union 
 has commenced, as the slightest fresh traumatism (so 
 easily caused) may light up infection. 
 
 Occasionally it may seem best to use plaster of Paris 
 splinting for transport, particularly in cases of high 
 fracture and fracture of the neck in which a position 
 of abduction should be maintained. These splints are 
 difficult to put on and must be accurate to be efficient. 
 In order to maintain abduction the pelvis must be fixed 
 and the sound limb therefore included in the splint, and 
 the latter should also extend up over the lower ribs on 
 each side of the body. To avoid the suffering caused to 
 the patient by keeping him too long on the pelvic rest, 
 it is wise to cut out forms of fifteen to twenty thick- 
 nesses of crinoline for the parts of the splint which must 
 be strongest (i. e. one piece for the abdomen, groin and
 
 DIAPHYSEAL FRACTURES 79 
 
 anterior parts of the thigh, and another and longer 
 piece for the side of the body, outer side of the thigh and 
 the leg). These forms should be impregnated with 
 plaster cream and bandaged on with the ordinary plas- 
 ter bandages. It is well to bandage in a cross stick to 
 keep the thighs apart. 
 
 Operative treatment: 
 
 AMPUTATION. As the function of the lower ex- 
 tremity is essentially that of weight bearing, unless 
 there is hope of retaining a strong limb it is wiser to am- 
 putate than to run the risk of a prolonged and often 
 stormy convalescence. Consequently the surgeon 
 should not take chances in fractures of the thigh that 
 would be perfectly justifiable in fractures of the upper 
 extremity, the preservation of the slightest portion of 
 which is of value. 
 
 The indications for amputation may be divided into 
 two groups: the first, for immediate amputation; the 
 second, for amputation after infection has become estab- 
 lished. Immediate amputation should be done for (1) 
 extensive loss of groups of muscles, especially if the 
 sciatic nerve is severed, (2) division of both femoral 
 and internal saphenous veins, (3) excessive comminu- 
 tion of the greater portion of the shaft 20 centimetres 
 or more, (4) shock, when it is deemed that the patient 
 will not survive the primary operation described below, 
 since amputation is shorter and less shocking and the 
 convalescence quicker. The indications for amputa- 
 tion in the case of established infection are (1) injury 
 to the femoral artery or vein requiring ligation, (2)
 
 80 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 gas gangrene when more than one group of muscles is 
 extensively involved, (3) extensive fracture of the dia- 
 physis communicating with the knee joint when the 
 latter is also suppurating, (4) multiple wounds threat- 
 ening life, (5) incurable chronic osteomyelitis. The 
 drifting policy should not be followed in septic cases; 
 amputation should be done before visceral degeneration 
 takes place. 
 
 PRIMARY OPERATIONS. The primary operation is 
 long and severe, and the patient must have recovered 
 from shock before it is undertaken. Nitrous oxide oxy- 
 gen anaesthesia should be used. The wounds should 
 be enlarged so as to obtain free access to their deepest 
 parts transverse incisions should be avoided if pos- 
 sible. Flexion of the thigh on the pelvis relaxes the 
 muscles and facilitates retraction. The danger of in- 
 fection is largely due to the extensive destruction of 
 muscles and consequently great care must be taken to 
 remove all devitalized tissue. Greater attention than 
 usual should be paid to the perfection of hamiostasis on 
 account of the depth of the wounds and the consequent 
 danger of retention of blood. 
 
 Dependent counter-drainage should be provided in all 
 operated fractures. The drainage incision should be 
 made at the outer border of the biceps and should extend 
 to above the site of fracture, so as to avoid pocketing 
 when the thigh is flexed. 
 
 Immediate suture of the wounds is not to be recom- 
 mended except in selected cases. Up to the time of 
 writing primary suture of the wounds has succeeded in 
 only about 15 per cent, of fractures of the femur. They
 
 DIAPHYSEAL FRACTURES 81 
 
 should be left for delayed primary or secondary suture. 
 
 Mechanical treatment: 
 
 SPLINTS. The splints furnished for treatment of 
 fractures of the femur are the Thomas leg traction, the 
 half -ring Thomas (already described) and the Hodgen's 
 (Fig. 25 B). This latter is essentially a suspension 
 splint, and is right and left. The angle at the knee may 
 be changed by bending to suit the requirements of in- 
 dividual cases. The splint is shown in place in Figs. 
 28 and 33. The suspension cords are arranged in two 
 sets; the proximal cord passes upward and across the 
 patient to the head frame on the opposite side, prevent- 
 ing the patient from sliding and the splint from tilting. 
 It is usually better balanced if the distal cords are 
 attached one approximately opposite the malleoli and 
 the other just proximal to the knee. The main cords 
 should be attached to the bridles by knots that cannot 
 slip, as otherwise the splint may rotate. Hodgen's 
 splint is well adapted for treatment of high fractures 
 of the femur in which the wounds preclude the use of 
 the Thomas. It is more apt to become displaced than 
 the Thomas and half-ring splints, in which the ring 
 helps greatly in keeping the apparatus in position, and 
 when in use much attention has to be given to the sling 
 bands at the proximal end to keep them taut and in 
 place. 
 
 Either the Thomas full ring or half -ring splints may 
 be employed, though the latter will be found to be the 
 more convenient. The bars may be bent at the knee to 
 suit the requirements of the case. Even when treating
 
 82 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 a fracture in the straight position of the limb, as in Fig. 
 29, the bars should be bent a little (about 10). This 
 angulation aids in preventing the knee from sagging 
 backward and in maintaining the normal anterior bow- 
 ing of the femur. 
 
 The Thomas splints possess the great advantage of 
 intrinsically maintaining traction. Ordinarily, during 
 treatment, this feature is not made use of traction being 
 applied to the end of the splint in order to prevent the 
 painful counter-pressure of the ring and for other rea- 
 sons to be mentioned later 1 ; but if it should be necessary 
 to remove the patient from his bed, as, for instance, for 
 a radiogram when no portable apparatus is available, or 
 for operation or evacuation, traction may be kept up by 
 simply twisting the traction straps. The Thomas 
 splint, therefore, should be used in preference to any 
 other if the hospital does not possess a portable radio- 
 graphic outfit or if there is a possibility of having to 
 evacuate the patient before consolidation of his fracture. 
 
 The weight for suspension should just balance that 
 of the limb and consequently varies with the case. 
 
 In some instances the sound limb may have to be sus- 
 pended in abduction in order to maintain abduction in 
 the injured one; although, ordinarily, the patient can be 
 prevented from occupying a position in the axis of the 
 fractured bone by a band about his body fastened to the 
 opposite side of the bed. When both limbs are sus- 
 pended, or when the patient has to be raised high up 
 to give access to wounds of the buttock, a sling made of 
 one of the bands for the Bradford frame should be
 
 DIAPHYSEAL FRACTURES 
 
 83 
 
 passed under the body. A stick to act as a spreader 
 is fastened to each end of the sling, and cords are at- 
 
 FIG. 28. Method of treating high fractures of the femur with 
 the Hodgen's splint and traction by the Codavilla (Stein- 
 mann) pin or Besley tongs. Abduction is obtained by plac- 
 ing the pulley for the traction cord on an outrider, and 
 outward rotation by tilting the splint. 
 
 The suspension attachment for preventing foot-drop has not 
 been drawn. 
 
 (The more proximal of the distal suspension cords should have 
 been attached to the splint at the proximal side of the knee.
 
 84 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 tached to the stick by means of stout hooks. These 
 cords pass over pulleys on the longitudinal bars to coun- 
 terpoises. The patient, by pulling on the latter (which 
 he can do readily himself) can be suspended clear of 
 the bed without changing the relative position of the 
 limbs, which, since they are counterpoised, go up also 
 (Fig. 30). This is even more convenient than an 
 apparatus by which the entire patient is suspended, 
 such as the hammock devised by Sinclair. 
 
 Counterpoised suspension of the limb, such as has 
 been described, is much safer and more comfortable for 
 the patient than fixed suspension. It is well to suspend 
 the limb to a trolley (as illustrated in the cuts) which, 
 even if not automatic, is easily shifted by the attendant 
 when the patient changes his position in the bed. 
 
 FOOTDROP. Support of some kind must be provided 
 for the foot in treating all fractures of the lower extrem- 
 ity. This may be attached to the splint itself, but on 
 account of the variations in the length of the limb due to 
 the influence of traction a fixed support is unsatisfac- 
 tory. 
 
 The arrangement shown in Figs. 29, 31 A et B, and 
 33 has given great satisfaction. It consists of a piece 
 of Canton flannel, or several thicknesses of gauze, glued 
 to the sole of the foot and extending beyond the ends 
 of the toes. From this end a cord passes upward and 
 cephalad over a pulley on the trolley to a weight of 
 500 grammes. This holds up the foot without fixing 
 the ankle, which the patient is instructed to move at 
 frequent intervals. When the limb is to be put in a
 
 DIAPHYSEAL FRACTURES 
 
 85 
 
 position of outward rotation, the material should be 
 glued on the sole obliquely, so that the cord passes up 
 at the mesal aspect of the great toe. 
 
 FIG. 29. Method of treating high fractures of the femur with 
 the half-ring Thomas splint. Note the manner of obtaining 
 abduction and flexion at the hip, also the attachment to pre- 
 vent foot drop. The traction weight is not applied directly 
 to the traction straps but to the splint and consequently 
 draws the latter away from the tuberosity of the ischium. 
 The traction straps are also attached to the splint and hold 
 it in place. 
 
 TRACTION. One of the most important and vexing 
 problems is the best manner of applying traction. 
 Broadly speaking, there are three methods; the choice
 
 86 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 between which is generally limited by the position of 
 the fracture, the size and location of the wounds com- 
 plicating it, and the occurrence of other wounds or frac- 
 tures in the same limb. The first and most common 
 method is to attach the tractive force to the skin, either 
 by applying bands of Canton flannel or of gauze by 
 means of Sinclair's or Heussner's glue, 1 or, better, by 
 using the well-known moleskin or diachylon plaster. 
 Ordinary adhesive plaster is valueless on account of its 
 slipping. When moleskin plaster is used the end of 
 each band is cut into three strips a wide central piece 
 which is applied straight, and two lateral narrow bands 
 which are applied in opposing spirals avoiding the front 
 and back of the knee. The bands are adjusted from 
 just above the ankle to above the knee if possible. Sin- 
 clair prefers gluing the strips only as far as the knee 
 (vide infra). The chief disadvantages of this method 
 are : that the knee must be kept in an extended position, 
 that the force is applied mainly through the ligaments 
 of the knee (which become stretched and thus entail a 
 longer convalescence), and that irritation of the skin 
 (more often observed in infected cases) is caused. The 
 bands cannot be applied solely to the thigh above the 
 knee because the tractive force is then chiefly trans- 
 mitted by the skin and fascia to the pelvis. The advan- 
 tages of bands are their cheapness, safety and ease of 
 application. 
 
 The second method is to make traction on the bones 
 themselves. This is accomplished directly by Ranso- 
 hoff's tongs (Fig. 32) or the Codavilla pin (Fig. 28) 
 through the condyles of the femur ; and indirectly by the 
 
 'Page 42.
 
 DIAPHYSEAL FRACTURES 87 
 
 Codavilla pin through the head of the tibia or the os 
 calcis, or by the stirrup of Finochietto (Fig. 31 C), 
 
 FIG. 30. Method of suspension for fractures of both femora, 
 showing systems of applying additional suspension at the 
 site of fracture in order to prevent backward angulation of 
 the fragments, and also a method of counterpoising the 
 weight of the body of these cases. 
 
 which is a steel band passed over the os calcis in front 
 of the tendo-achillis. The use of the Codavilla pin or 
 the Ransohoff tongs through the condyles of the femur 
 is the most perfect of all methods because it permits 
 the placing of the limb in an absolutely correct position
 
 88 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 FIG. 31. Four methods of installing traction for frac- 
 ture of the leg: 
 
 A. With a gaiter. (For the sake of clearness, the cot- 
 ton dressing, which should first be placed about the 
 ankle, has been omitted.) 
 
 B. With traction straps. 
 
 C. With the stirrup of Finochietto. 
 
 D. With Sinclair's skate.
 
 DIAPHYSEAL FRACTURES 89 
 
 and acts directly upon the fragment without fixing or 
 injuring the knee. With it a weight of six kilos will 
 produce as much effect as fifteen kilos attached by the 
 ordinary adhesive bands. The objection to it is the 
 fear of infection at the site of the pin or tongs, especially 
 in infected fractures, but present experience seems to 
 prove that the tongs at least may be employed with 
 impunity. The Codavilla pin may be used through 
 
 FIG. 32. Ransohoff's tongs. 
 
 the head of the tibia with equal efficiency, and additional 
 injury to the femur is thus avoided, but this system has 
 the disadvantage of stretching the ligaments of the 
 knee. By using the Codavilla pin through the os calcis, 
 or Finochietto's stirrup, no advantage is gained over 
 the adhesive band method except those of direct action 
 on the skeleton and avoidance of irritation to the skin, 
 but one of them may be employed when wounds of the 
 leg prevent the use of any other method. 
 
 In the third method of effecting traction the knee is 
 strongly flexed and the tractive force is applied about 
 the latter or against the back of the calf. This is ordi- 
 narily accomplished in two ways. By Hennequin's 
 method (Fig. 33) the limb is surrounded to the height 
 of the middle of the thigh by a very thick dressing of 
 non-absorbent cotton, bandaged on very snugly with a
 
 90 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 narrow bandage. The knee must be kept in flexion 
 while the dressing is applied, and it is well to put a wet 
 crinoline or very thin plaster of Paris bandage over all 
 to keep the dressing in place. A figure of eight hitch 
 is then made about the thigh and knee by means of a 
 sheet folded several times so as to make a band 1.50 m. 
 (60 in.) long and at least 0.15 m. (6 in.) wide. Henne- 
 quin cut away the mattress to allow a place for the foot, 
 but this is not necessary when the limb is slung in a wide 
 Hodgen's splint. Hennequin's is probably the best 
 method for high fractures of the femur when the Coda- 
 villa pin cannot be used. It is obvious that it cannot be 
 employed for low fractures because of the interference 
 of the bandage with the wound. 
 
 The alternative manner is to bandage the leg to a well 
 flexed Hodgen's splint and make the traction on the 
 latter. This method affords access to wounds in the 
 lower part of the thigh for dressing purposes, but it has 
 a great disadvantage in that it is exceedingly difficult, 
 when it is adopted, to make sufficient traction on the 
 splint without causing unbearable pressure on the calf 
 just below the bend of the knee, particularly in the 
 early part of the treatment when it is necessary to ex- 
 ercise strong traction to overcome the spasm of the 
 muscles. In the later stages, however, when only slight 
 traction is required to hold what has already been 
 gained, the system is fairly satisfactory. It will be re- 
 ferred to later in describing the treatment of low frac- 
 tures. When strong pressure is made against the calf, 
 the head of the fibula should be padded to avoid pres- 
 sure upon the peroneal nerve.
 
 DIAPHYSEAL FRACTURES 
 
 91 
 
 In the case of coexistent fractures of the thigh and 
 leg the traction has to be divided, because, if enough 
 traction to reduce the fracture of the femur be applied 
 below the fracture of the leg, the latter will be over- 
 stretched. If the fracture of the leg is low there may be 
 room enough above it to glue bands by which traction 
 for the femur can be made, while traction for the frac- 
 ture of the leg may be effected by one of the methods 
 described under that heading. In such a case the 
 
 FIG. 33. Hennequin's method in conjunction with Hodgen's 
 splint in the treatment of fracture of the femur. 
 
 weight placed on the femur should be equivalent to the 
 difference between the weight for the femur proper and 
 the weight placed on the leg, the limb being in the 
 straight position. For example, if 15 kilos were the
 
 92 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 weight to be applied for the fracture of the femur and 5 
 kilos for that of the leg, 10 kilos should be placed OR 
 the straps above the leg fracture. If there is not 
 enough room on the leg for glued straps and there are 
 no wounds on the lower part of the thigh, a collar of 
 plaster of Paris may be placed around the latter, care- 
 fully modelled about the condyles of the femur, to which 
 the traction for the femur may be attached. This plas- 
 ter should be modelled directly on to the skin ; if a band- 
 age be placed under it it is apt to become wrinkled and 
 cause pressure sores. In most cases of double fracture, 
 it is better, if possible, to place the limb on a splint 
 bent to an angle of 135 at the knee (as for treatment 
 of fractures of the leg Fig. 35) and to use a Codavilla 
 pin or Ransohoff tongs for the traction on the femur. 
 The amount of traction for fracture of the thigh 
 varies with the musculature of the member, the manner 
 in which traction is made (whether directly upon the 
 bone, i. e. skeletal traction, or on the skin) , and the 
 position of the limb. If the hip and knee are flexed the 
 muscles which produce overlapping are relaxed, and not 
 half as much weight as that required in the straight posi- 
 tion of the limb is needed. If traction is made by glued 
 or adhesive straps fastened to the leg and thigh the knee 
 cannot be strongly flexed and much of the tractive force 
 is transmitted through the skin and fascia. With the 
 knee in the extended position a weight of 16 to 18 kilos 
 is usually necessary for the first few days, while with the 
 flexed position of the knee and with skeletal traction by 
 means of the Codavilla pin or Ransohoff tongs, a weight 
 of 8 to 9 kilos is generally sufficient and may be too
 
 DIAPHYSEAL FRACTURES 93 
 
 much, particularly if the weight of the limb is more than 
 counterbalanced by the suspension weights (Fig. 28). 
 
 As has already been said, the initial traction should 
 be sufficient to overstretch the muscle in the first few 
 hours or at least in the first day. A radiograph should 
 then be taken, and if the overlapping has entirely dis- 
 appeared the weight may be diminished by one-third. 
 Two or three days later another radiograph should be 
 taken, when, if the reduction has been well maintained, 
 the weight may be gradually decreased to that just 
 sufficient to maintain it, as determined by frequent 
 radiographic examinations. 
 
 Counter-traction is furnished by the weight of the 
 patient, the foot of the bed being raised. If traction is 
 made with the knee extended, the foot of the bed will 
 have to be raised about 30 cm. (12 in.) ; while if made 
 with the knee flexed, half this distance will be found 
 ample. 
 
 The patient's head and shoulders should be raised if 
 possible, for there is distinct danger of pulmonary com- 
 plications from hypostatic congestion in feeble and sep- 
 tic cases. 
 
 When traction is made by springs, by the use of the 
 Thomas splint on the Thomas principle (i. e. by twist- 
 ing the traction straps), or by attaching the straps to a 
 post and utilizing the weight of the patient, it is ex- 
 tremely difficult, if not impossible, to gauge and regu- 
 late the amount of traction actually employed; the 
 tendency is to use too much traction over too long a 
 period and thereby to endanger the integrity of the 
 ligaments of the knee.
 
 94 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 Late treatment: 
 
 The normal length of time for consolidation of frac- 
 tures of the femur is about eight weeks. Exception- 
 ally this is reduced, especially in comminuted, non-in- 
 fected fractures, such as those caused by rifle bullets in 
 which the fragments of bone have not been removed. 
 In these cases firm union may be accomplished in six 
 weeks. There are many cases, however, in which, al- 
 though consolidation may occur in the ordinary period, 
 the union is weak either from loss of substance or in- 
 sufficient callus. In other cases union is delayed, and, 
 although apparently firm to the examining hands, the 
 bone will angulate when weight is put upon it. This 
 bending may be very gradual and increase during a 
 period of several months ; it is more frequently observed 
 after secondary operations done to reduce mal-union. 
 In such instances the callus may be very large and give 
 a false sense of security. 
 
 Even if a fracture unites normally there is danger 
 of the patient's falling and re-breaking it. Refrac- 
 tures of the femur have been so common as to make the 
 French Service de Sante prohibit the use of crutches. 
 
 To avoid such accidents and deformations and to 
 permit the patient to use his limb at the earliest possible 
 moment, an ambulatory splint should be fitted to all 
 cases. The most satisfactory is the Thomas knee splint. 
 In the British army the fitting of these splints is termed 
 "calipering," and all fractures of the femur are "cali- 
 pered" before being sent home. 
 
 The Thomas splint used for this purpose differs from 
 that employed for transportation and treatment in re-
 
 DIAPHYSEAL FRACTURES 95 
 
 gard to the size of the ring, which is much smaller. The 
 ring must fit closely to the thigh so that the weight, 
 when the patient is walking, is borne on the tuberosity 
 of the ischium. Eleven sizes of the splint are neces- 
 sary to fit all cases, the internal circumference of the 
 bare ring varying by inches from 16 in. to 26 in. The 
 size for the average thigh has an internal circumfer- 
 ence of 21 in., and ten splints of this dimension will be 
 used as against nine each of 20 in. or 22 in., seven each 
 of 19 in. or 23 in., five each of 18 in. or 24 in., three 
 each of 17 in., or 25 in., and one each of 16 in. or 26 in. 
 In measuring for a splint the circumference of the thigh 
 is taken at the gluteal fold and two inches added to it, 
 one for the obliquity of the ring and the other for the 
 thickness of the padding. The latter should be four 
 inches in circumference at the inner side of the ring and 
 taken to nothing at the outer. The bars of the splint 
 are made of three-eighths inch iron rod, and the inner 
 bar is one-third of the internal circumference of the 
 ring shorter than the outer. To caliper a patient the 
 ring is slipped over the leg and forced firmly up against 
 the ischium, and a mark is made on one of the bars at 
 the level of the sole of the bare foot. The bars are 
 then cut off 2^X> inches below this mark. The patient's 
 boot having been re-soled and heavily re-heeled, the 
 terminal l^ inches of the bars are bent inward at a 
 right angle and fastened into holes bored into the heel, 
 that on the inner side of the heel being 1 inch behind 
 the one on the outer side in order to provide for the 
 outward rotation of the foot. 
 
 If angulation has occurred during the late treatment
 
 96 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 of a fractured femur and the callus is not absolutely 
 firm, the Delbet splint will be found to be of distinct 
 value. This splint or apparatus (Fig. 34) consists of 
 three metal uprights, two of which are welded to a 
 pelvic ring resembling in principle that of the Thomas 
 splint but incomplete, and the other attached to the 
 ends of the ring segment by means of a strap. Each 
 upright consists of a rod telescoping into a tube and 
 
 FIG. 34. Delbet's apparatus for ambula- 
 tory treatment of fractures of the femur. 
 (By the courtesy of M. le Medecin-Major 
 R. Leriche). 
 
 fitted with a spiral spring and suitable stops for regulat- 
 ing the tension of the spring or blocking it. The lower 
 ends of the rods are embedded into a plaster collar about
 
 DIAPHYSEAL FRACTURES 97 
 
 the lower part of the thigh and bearing on the femoral 
 condyles. This collar is connected, as shown in the 
 illustration, by two lateral splints, with two other col- 
 lars, one just at and below the tuberosity of the tibia, 
 the other just above the ankle and bearing on the mal- 
 leoli. The apparatus is essentially an ambulatory one, 
 and Delbet's patients are up and walking within a few 
 days from reception of their injury. It is used more 
 commonly for late treatment, and the tendency to angu- 
 lation (which is almost always outward) can be over- 
 come by increasing the force of the spring on the adduc- 
 tor side of the thigh. 
 
 In cases in which the callus is soft, either the calipers 
 or the Delbet apparatus may have to be worn for 
 months. 
 
 Mechanical treatment of special fractures of the femur: 
 
 FRACTURE OF THE NECK OF THE FEMUR. These 
 fractures practically always involve the articulation, 
 and will be considered later with fractures of the hip 
 joint. 
 
 FRACTURE OF THE UPPER THIRD OF THE FEMUR. 
 Such cases are not infrequently complicated by injury 
 to the pelvis. The wounds of the soft parts are large, 
 or have to be made so in order to explore the fracture 
 and to effect drainage; they are often situated posteri- 
 orly, which makes them difficult to dress, and it is fre- 
 quently impossible to use the Thomas splint because 
 of them. Antero-posterior wounds being in the region 
 of the femoral vessels and of the anterior crural and 
 sciatic nerves, large drainage tubes should never be
 
 98 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 used in such cases. If additional drainage is necessary 
 the incision should be made behind the great trochanter, 
 well to the outer side of the sciatic nerve. The position 
 assumed by the upper fragment is that of marked ab- 
 duction, rotation out and flexion, the flexion being more 
 accentuated when the lesser trochanter remains attached 
 to it. To bring the lower fragment effectively into line 
 the limb should be suspended in marked abduction and 
 rotation out, with the knee flexed. The best way of 
 accomplishing this is to use the Codavilla pin or the 
 Ransohoff tongs. In these cases the best arrangement 
 of the suspension frame is that shown in Fig. 28. The 
 necessary position for the limb is best grasped by flex- 
 ing one's own hip and knee and rotating the limb out- 
 ward, when it will be seen that the leg assumes a posi- 
 tion midway between the antero-posterior and trans- 
 verse planes of the body, and that when the limb is 
 well abducted the foot lies in the median plane of the 
 body. To maintain the splint and limb in this position 
 of outward rotation, the bridles (i. e., the cords fixed 
 directly to the splint and to the bights of which the sus- 
 pending cords, are tied) must be arranged so that the 
 parts attached to the inner bar of the splint are much 
 shorter than those attached to the outer. It may even 
 be necessary to fix a guy line to the foot and pass it over 
 a pulley (fastened to the opposite longitudinal bar) to 
 a sufficient weight. The weight for skeletal traction at 
 the outset should be about 8 kilos (18 Ibs.). 
 
 When the pin or tongs cannot be used the Hennequin 
 method may be employed with the limb in the same posi- 
 tion and a commencing weight of 10 kilos (22 Ibs.)
 
 DIAPHYSEAL FRACTURES 99 
 
 (Fig. 33) . If, for any reason, neither the Codavilla pin 
 nor the Hennequin method can be used, the limb is put 
 on a straightened Hodgens splint (traction being made 
 by straps passing well above the knee or by the Fino- 
 chietto stirrup) and placed in the position of abduction, 
 rotation out and flexion at the hip, the knee of course 
 being extended (Fig. 29). With this arrangement the 
 initial weight must be at least 14 to 18 kilos (30 to 40 
 Ibs.), because the hamstrings must be stretched and the 
 weight of the limb overcome. 
 
 When a straight splint is used the other limb may 
 have to be suspended in like abduction in order to main- 
 tain abduction in the injured one. This is seldom nec- 
 essary, however, when the flexed position of the knee 
 is employed. 
 
 With all the above methods the foot of the bed is ele- 
 vated and the patient's head and shoulders should be 
 raised on pillows. 
 
 FRACTURE OF THE MIDDLE OF THE FEMUR. In these 
 the wounds are at the middle of the thigh and do not 
 interfere materially with the use of any method except 
 the Hennequin. The position assumed by the upper 
 fragment is abduction if the fracture is above the ad- 
 ductor longus insertion; otherwise it is nearly straight, 
 moderately flexed and rotated out. These cases are 
 the easiest to treat because the position of the fragments 
 is controlled by the lateral pressure of the muscles when 
 strong traction is made. 
 
 As has been emphasized by Sinclair, due regard must 
 be given, in treating all fractures of the shaft, to repro- 
 ducing the normal anterior curvature of the femur. If
 
 100 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 traction is applied in the axis of the bone, the best re- 
 sult that can be hoped for is a perfectly straight bone; 
 generally, however, a position of backward curvature 
 will be obtained. This is particularly true in fractures 
 below the middle of the shaft. The best way to over- 
 come the tendency of the fragments to backward sag- 
 ging, is to apply the tractive force in a line below the 
 axis of the femur and to place a support behind the 
 fragments so that the pull will be made against the sup- 
 port, thus forcing the fragments forward. This is ac- 
 complished by means of a bent splint, the bend being 
 about 4 cm. above the knee joint. The angle varies 
 slightly with the case, but should be about 160. A 
 Thomas splint will be found the most satisfactory. The 
 ordinary muslin or flannel slings are used, but they 
 should be doubled behind (particularly just below the 
 point of fracture) so as to afford an unyielding sup- 
 port. The limb, when suspended in such a splint, is in 
 a position of flexion at the hip and moderate flexion at 
 the knee. Traction may be made in the axis of the leg 
 by glued bands, in which case the splint does not have 
 to be bent so much as when the tongs are used directly 
 upon the femur. In the latter case the axis of traction 
 must be higher in order to clear the leg, which in turn 
 necessitates a position of greater flexion of the femur. 
 
 It is obvious that when traction is thus made against 
 a supporting band attached to the splint, the fraction 
 should not be applied to the end of the splint but rather 
 directly to the limb, and that the splint should be held 
 against the limb. The method of suspension should 
 therefore be that shown for the Hodgens splint (Figs.
 
 DIAPHYSEAL FRACTURES 101 
 
 33 et 35). A supplementary sling, attached by a cord 
 to a weight, may also be used to correct the position of 
 the fragments (Fig. 30). 
 
 The Thomas splint thus used is merely a cradle for 
 suspension, but should the patient have to be moved 
 from his bed it is only necessary to attach the traction 
 straps or cords to the end of the splint to bring the 
 Thomas principle into play. 
 
 FRACTURE or THE LOWER THIRD OF THE FEMUR. 
 In very low fractures of the shaft, if. the method just 
 described does not suffice to overcome the strong tend- 
 ency of the lower fragment to become flexed backward 
 by the pull of the gastrocnemius, the Ransohoff tongs 
 have been used successfully in the following way. They 
 are applied, as usual, to the upper part of the lower 
 epiphysis, but instead of making traction below, the 
 traction is made above the axis of the femur, thus act- 
 ually tilting the fragment upward. Care should be 
 taken to obtain the elongation necessary before raising 
 the axis of traction, as otherwise the upper end of the 
 lower fragment may engage behind the lower end of 
 the upper and reduction be impossible. 
 
 If the tongs cannot be used on account of the prox- 
 imity of infected wounds, and complete reduction of 
 the backward angulation has not been obtained by the 
 other method, the following procedure should be tried. 
 While the union is still soft, the splint should be flexed 
 to a full right angle and the leg bent to suit. The knee 
 will have been somewhat stiffened by the long traction 
 and the bending will therefore take place at the frac- 
 ture. Traction is then made on the splint at the knee
 
 102 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 and transmitted to the back of the calf. If strong trac- 
 tion has been used from the beginning of treatment the 
 muscles will have been stretched so that only moderate 
 force will be necessary. This method has given satis- 
 factory results during the last two years. 
 
 TIBIA AND FIBULA 
 
 Fractures of the fibula alone are of little consequence, 
 as the tibia acts as an efficient support for the broken 
 bone. Fractures of the tibia alone are splinted by the 
 fibula, which prevents over-riding to any great extent, 
 though it cannot obviate (especially in cases of loss of 
 substance) a tendency to incurvation. Fractures of 
 both bones tend to overlap and also be interlock in bad 
 positions, and are often difficult to reduce; moreover, 
 repair in the leg seems more indolent than elsewhere 
 in the body, and these fractures sometimes unite very 
 slowly and imperfectly. The lack of soft parts over 
 the tibia possibly accounts for some of such cases of 
 delayed union, sluggishly granulating wounds and dis- 
 agreeable scars. 
 
 Transport: 
 
 The problem of transport is simple. The fragments 
 are easily fixed by any splint, but it is advisable to use 
 the Thomas on account of the traction it affords, which 
 does much to prevent laceration of the muscles, tendon 
 sheaths and skin as well as to obviate over-riding and 
 interlocking. It is applied in the same manner as for 
 fractures of the femur, except that the leg should be 
 well bandaged into the splint. If the fracture is in the
 
 D1APHYSEAL FRACTURES 103 
 
 region of the ankle the boot should be removed and 
 the anklet placed over the dressing. In these cases care 
 should be taken to support the foot, and for this pur- 
 pose the Cabot leg splint may be tied to the Thomas 
 if a foot rest is not at hand. 
 
 At the initial operation the fracture should be re- 
 duced if possible, as these fractures, above all, need 
 direct instrumental intervention to effect proper re- 
 duction ; if done at once a secondary operation will often 
 be avoided. All projecting fragments which might 
 produce pressure necrosis of the overlying skin should 
 be carefully pushed back in place; if it is not possible 
 to do this it is better to remove them. 
 
 If the fracture has already become infected, however, 
 an operative reduction should not be attempted, as very 
 disagreeable suppuration of the muscle planes and ten- 
 don sheaths is apt to be provoked on the breaking down 
 of the barriers to infection which have been formed. 
 
 Primary and delayed primary suture have been quite 
 successful in treating fractures of the leg. On account 
 of the better conservation of the tendons, primary su- 
 ture is preferable to secondary suture, especially in 
 low fractures. 
 
 Mechanical treatment: 
 
 All wounds and fractures of the leg repair far more 
 quickly if the limb be suspended. Traction is neces- 
 sary in fractures of both bones. 
 
 The best method is to suspend the limb in a Hodgens 
 or Thomas splint bent to 135 (Fig. 35). The center 
 of suspension should be below the knee. A cord
 
 104. GUN-SHOT FRACTURES OF EXTREMITIES 
 
 attached by a bridle to the thigh part of the splint 
 passes back to a pulley on the head frame on the oppo- 
 site side from the fracture and provides counter exten- 
 sion. Traction is made in a straight line to the foot 
 frame. Frome 6 to 7 kilos (13 to 15 Ibs.) are sufficient 
 to commence with for fractures of both bones ; half this 
 amount should be used for fractures of the tibia alone. 
 The weight must be rapidly diminished. If there is no 
 tendency toward overlapping half the amount, or less, 
 is enough. The effect of the traction should be verified 
 by X-rays. 
 
 In high fractures the weight may be attached to glued 
 straps (Fig. 31 B). In low fractures the Sinclair skate 
 (Fig. 31 D) or the Finochietto stirrup (Fig. 31 C) 
 should be used. The gaiter method (Fig. 31 A) is not 
 suitable for strong, continued traction even when a 
 heavy dressing is placed beneath, for in spite of every 
 care pressure sores will form at the dorsum of the foot 
 and at the attachment of the tendo-achillis when it is 
 employed. It is, however, valuable as a supplementary 
 traction and can be used in conjunction with glued 
 straps. The Sinclair skate consists of a half -inch board 
 longer than the foot and 9 cm. wide. In this a central 
 slot is cut (as clearly shown in the illustration) in which 
 slides a bolt with a winged nut. The bolt passes 
 through a hole in the center of a piece of strap steel 
 15 cm. long. This steel crosspiece serves for the attach- 
 ment of the traction cords, and, resting on and across 
 the bars of the splint, also acts as a regulator of the 
 position of the foot. When it is clamped toward the 
 heel the traction dorsiflexes the ankle, and conversely,
 
 DIAPHYSEAL FRACTURES 
 
 105 
 
 when clamped toward the toes plantar flexion is pro- 
 duced. Moreover, as the bar rotates on the bolt, the 
 rotation of the foot may be controlled. Eight or ten 
 notches, 1 cm. apart, are cut on each side of the board 
 and serve to prevent the slipping of the lacing cord 
 
 FIG. 35. Method of treating fractures of the tibia and fibula 
 by suspension and traction. The limb is suspended in a 
 Hodgens splint bent to an angle of about 135. Traction in 
 this case is made (as shown) with straps glued on to the leg. 
 
 which fastens it to the glued straps. The straps are 
 made beforehand of Canton flannel or tape with small 
 curtain rings sewed to their ends. They are glued to the 
 sides of the foot as shown in the illustration and must 
 not overlap on the dorsum. The board is padded so as 
 to conform to the sole of the foot and is laced on either
 
 106 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 by a continuous cord or by separate cords for each pair 
 of opposed rings. 
 
 Another form of skate devised by Sinclair consists of 
 a plaster sole lined with saddler's felt, which is accu- 
 rately modelled to the sole of the foot and glued to 
 same. A piece of strap iron bent to a shape resembling 
 a right-angled letter omega is embedded by its feet 
 into the bottom of the plaster sole. The free portion of 
 the omega iron has a slot in it corresponding to and serv- 
 ing the same purpose as the slot in the wooden skate. 
 The plaster skate is used when wounds of the foot pre- 
 vent the use of the wooden one. 
 
 Obviously, fractures of the tibia and fibula may be 
 treated in a Thomas splint, but being straight it is not 
 so satisfactory. If the patient is to be evacuated, how- 
 ever, the Thomas splint should be used in order that 
 traction may be kept up during transport. 
 
 Ambulatory treatment of fractures of tibia and fibula: 
 
 As has already been stated, delayed union is not un- 
 common in fractures of the tibia and fibula. In such 
 cases it is important that the function of the leg should 
 
 FIG. 36. Delbet's ambulatory splint for 
 fracture of the tibia and fibula. (By the 
 courtesy of M. le Medecin-Major R. Ler- 
 iche.)
 
 DIAPHYSEAL FRACTURES 
 
 107 
 
 be resumed, as the increased circulation and trauma- 
 tism at the ends of the bones caused thereby greatly 
 aids in hastening union. A certain amount of weight 
 
 5 
 
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 V ,".-.,. . . .:,,;, : ~zEj 
 
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 K:fi5-<?^:^ : - ^.?---v- ft*.. :,.:.':-J 
 
 ^'. -,- ', ..-.;-. 
 
 
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 3 *-7 t 
 
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 b'....-,' ..-"'.^ /J^ </n 'V/' . .;"'-: '- 
 
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 12ZES "L EZ2 EHE 
 
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 '* ,;': - v -;'.. i ,n ^..,.,,,, - ..., 
 
 to***' 
 
 
 FIG. 37. Method of cutting strips of crino- 
 line to make the plaster bands for Delbet's 
 ambulatory splint for fracture of the tibia 
 and fibula. 
 
 A. Upper band. 
 
 B. Lower malleolar band. 
 
 C. and D. Lateral bands with folds 10 
 cm. long at inferior extremity. 
 
 E. Lower band for the malleoli with notch 
 cut in heel piece for heel. (By the cour- 
 tesy for M. le Medecin-Major R. Leriche). 
 
 should be borne on the leg, but the fracture must be sup- 
 ported and angulation prevented. The Delbet leg 
 splint, the tibia and head of the fibula above and against
 
 108 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 the malleoli below, thus preserving the length of the 
 leg. To be successful the splint must be skillfully 
 applied. In such cases patients with simple fractures 
 can walk in three or four days after reception of their 
 injury. The plaster is put directly on the vaselined or 
 talcum-powdered skin. Recent fractures are reduced 
 by attaching a weight of 25 kilos to the foot, and the 
 splint is applied while the traction is still attached.
 
 FRACTURES AND WOUNDS OF JOINTS 
 
 General: 
 
 Experience during this war has unequivocally proved 
 that the ideas formerly prevalent concerning the ex- 
 treme susceptibility to infection of the synovia were 
 erroneous. At the present time most of the wounds 
 of joints are being closed successfully, and it has been 
 found that if they suppurate the infection is, as a rule, 
 confined to the periarticular tissues or at least com- 
 mences there. In proof of this assertion it is frequently 
 observed that part of a joint may be infected while the 
 rest of it, although continuous with the infected portion, 
 remains free. 
 
 It has also been remarked that the presence of for- 
 eign bodies or materials in joints brings about infec- 
 tion and encourages its progress. This is not only true 
 of carriers of infection, such as shell fragments and 
 clothing, but also of objects considered surgically clean, 
 such as drainage tubes. In support of this it has been 
 found that cases of suppurative synovitis, which, by the 
 older treatment of drainage by tube, would have ended 
 in the loss of the joint, if treated by simple, free inci- 
 sions and a mild irrigation to wash out the pus recover 
 rapidly and satisfactorily. 
 
 The rules for treatment of wounds of the joints are, 
 therefore, exceedingly simple. Recent, contaminated 
 
 109
 
 110 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 wounds should be treated as already described for 
 wounds of the soft parts accompanying fractures. All 
 foreign bodies should be removed, contaminated and in- 
 jured synovia cut away, especial attention given to re- 
 moving small, loose fragments and all infected bone, 
 and perfect hamiostasis made. The synovia should 
 then be closed by cat-gut sutures, and wounds of the 
 periarticular structures either closed by primary or left 
 for delayed primary or secondary suture. When there 
 is injury to the bone communicating with the exterior 
 through the joint, it is well to expose the bone wound 
 by an incision over it so that in case of infection the 
 bone will drain directly to the surface and not through 
 the joint. The worst and most persistent suppurations 
 of the joints are those caused by infection of the bones 
 forming them, so that every precaution should be taken 
 in the way of removing all causes of infection in the 
 bone wounds and isolating them from the joint cavity. 
 
 In treating joints already infected free incisions so 
 planned as to not only drain the joint but, above all, the 
 wounds of the bones, should be made. No drains of any 
 sort should be used, but the wounds leading into the joint 
 should be kept open until all drainage from it ceases. 
 At the time of operation the joint may be irrigated out. 
 The value of subsequent irrigation is questionable. If 
 made, the greatest gentleness should be observed so as 
 not to injure the synovia. It is probable that normal 
 saline or isotonic sodium bicarbonate solution is as 
 good as any fluid for irrigating purposes. 
 
 The indications for radical operative procedures on 
 the bones, such as excision, vary with the different joints
 
 FRACTURES AND WOUNDS OF JOINTS 111 
 
 and will be considered under the heading of each. 
 Post-operative treatment of wounds of the joints de- 
 pends largely upon the extent of injury to their archi- 
 tecture and also upon their normal functions; for the 
 elbow, for example, free movement may be desirable 
 at the expense of strength, while stability at the cost of 
 mobility is usually preferable for the knee. These ques- 
 tions will be discussed later, in detail, for each joint. A 
 general line of treatment may, however, be mapped out 
 for wounds implicating the synovia alone or accom- 
 panied by slight or moderate injury to the bones. 
 Early mobilization is beneficial in these cases, as -has 
 been demonstrated by Wilhelm, who commences mobili- 
 zation on the day following operation even when mild 
 infection is present. The passive motion carried out 
 for the first two or three days is at once followed by 
 active motion, and patients with wounds of the knee 
 or ankle are walking by the third or fourth day. When 
 begun early and carried out consistently, motion and 
 use of a joint are not painful. If it is infected it is of 
 course left open, but without drains; Wilhelm claims 
 that drainage is improved by the motion. The func- 
 tional results of his method are far better and more 
 rapid than those obtained by the old fixation treat- 
 ment. 
 
 SHOULDER 
 
 In a large number of fractures of the shoulder all 
 three bones humerus, scapula and clavicle are in- 
 volved. Wounds at the point of the shoulder often pre- 
 sent loss of substance with a wide laying open of the
 
 1 1 2 GUN-SHOT FRA CTURES OF EXTREMITIES 
 
 joint. In such cases the origin of the deltoid is fre- 
 quently destroyed. Wounds involving chiefly the head 
 of the humerus are deep, as the joint is here surrounded 
 by heavy muscles; they are consequently prone to an- 
 aerobic infection. 
 
 The deltoid muscle is the principle abductor of the 
 arm, as well as the one which supports its weight. If it 
 ceases to act the humerus descends and the motions of 
 the shoulder are lost or much weakened. Great care 
 should be taken to preserve it and its nerve, the circum- 
 flex, which passes backward around the neck of the 
 humerus in a line 5 to 6 cms. below the border of the 
 acromion process. 
 
 Transport: 
 
 Traction is not indicated, and the sling and body 
 bandage method is therefore the best for fixation for 
 transport from the field. For transport after operation 
 one of the methods described for ambulatory treatment 
 (page 106) may be used. These cases, however, should 
 not be transported until convalescent: 
 
 Operative treatment: 
 
 Punctate bullet wounds should not be operated on. 
 All others should receive surgical treatment as early as 
 possible. 
 
 If sufficient access for exploration is not afforded by 
 enlarging the wounds, or if they cannot be enlarged on 
 account of their position, the incision for typical resec- 
 tion should be made at the anterior border of the deltoid 
 and the joint opened at the outer side of the bicipital
 
 groove and tendon. After this approach counter-drain- 
 age is made, if necessary, posteriorly above the circum- 
 flex nerve. The drains should be introduced only as 
 far as the joint and should not enter it. 
 
 All missiles lodged in the humeral epiphysis, even if 
 the wounds do not implicate the joint, should be re- 
 moved with the possible exception of rifle balls, which 
 are usually innocuous. A diligent search for bits of 
 clothing must be made, as, if such foreign bodies are 
 not removed the joint is apt to become involved in the 
 subsequent infection of the bone. 
 
 In cases of fracture typical resection should be 
 avoided except when the head of the humerus is smashed 
 into small pieces. Ordinarily the surgeon must be con- 
 tented with the removal of spicular and irregular por- 
 tions of bone which would be likely to interfere with the 
 function of the joint. The cartilage should not be re- 
 moved unless the joint is already infected. 
 
 In early operations, when there is every reason to ex- 
 pect an aseptic evolution of the wound, the latter may 
 be loosely closed; but, as a rule, it is better to simply 
 close the synovia and leave the wound of the superficial 
 parts for delayed primary or secondary suture. In re- 
 cent wounds, in which infection is already established 
 particularly in fractures extending into the diaphysis 
 of the humerus with much comminution the surgeon 
 should, on account of the great danger to life and limb, 
 be less conservative of bone and work for an absolutely 
 free drainage. Large openings should be made, a free 
 sub-periosteal resection done, all the cartilage of the 
 articulation removed, and the wounds left open.
 
 1 1 4- GUN-SHOT FRA CTURES OF EXTREMITIES 
 
 In later, suppurative cases, where the danger of an 
 explosive infection is past but in which abscesses form 
 from extension along the muscles, the surgeon should 
 limit himself to free drainage of these extensions and 
 not resect. 
 
 Mechanical treatment: 
 
 If the after-treatment is not carefully followed 
 most resections of the shoulder will result in a flail artic- 
 ulation which renders the limb almost useless. The 
 same condition is apt to follow any injury or treat- 
 ment causing paralysis or over-stretching of the deltoid 
 muscle. Temporary inhibition of the muscles activat- 
 ing the joints is a peculiarity of all joint injuries. The 
 period of inhibition is usually proportional to the trau- 
 matism and may last for many weeks. In the case of 
 the shoulder it is extremely important to keep the 
 humerus in contact with the glenoid cavity and to sup- 
 port the arm until the muscles have regained their tone. 
 Moreover, the danger of a flail joint being so great 
 after resection, it is better to play for complete anky- 
 losis which gives a strong and useful member if the an- 
 kylosis is good. The position to be sought is one of ab- 
 duction to 90 and rotation out. The movements of 
 the scapula on the thorax will then allow the arm to be 
 approached to the side and the hand to pass the median 
 plane. If, on the other hand, ankylosis takes place with 
 the arm at the side, the movements of the scapula will 
 not compensate in the slightest degree, and the arm will 
 remain fixed to the side of the body. Furthermore, if 
 ankylosis is not complete, a range of motion from ab-
 
 FRACTURES AND WOUNDS OF JOINTS 115 
 
 duction to adduction is far more easily acquired, on 
 account of the greater power of the adductor muscles 
 and because the weight of the arm does not have to be 
 overcome. Hence the adducted (i. e., arm at side) posi- 
 tion is absolutely contraindicated. 
 
 During the first weeks after reception of the injury 
 the arm should be suspended as for high fracture of the 
 humerus, but no traction should be employed. The 
 correct position for suspension is for the humerus to be 
 at 90 with the body and midway between the coronal 
 and sagittal planes. For the later stages of treatment an 
 aeroplane splint may be used, or the arrangement of 
 Thomas splints shown in Fig. 14. If wounds at the 
 shoulder interfere with the ring of the arm splint a 
 Thomas leg splint may be used, the ring being slipped 
 over the opposite arm and the chest being between the 
 bars. Traction must not be employed. It is better, 
 however, to keep the arm suspended until ankylosis or 
 return of function takes place. Suspension allows of a 
 certain amount of motion continuously at the articula- 
 tion and favors a return of normal movement. It also 
 facilitates massage, and the patient, being able to move 
 the arm, regains control of it much more rapidly. 
 
 These cases should never be allowed a sling. If the 
 patient must be up before function has returned he 
 should wear a corset and a hinged support for the arm. 
 
 ELBOW 
 
 Fractures of the elbow joint, even if infected, are not, 
 as a rule, dangerous to life, but are difficult to treat on
 
 116 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 account of the tightness and irregularity of the articu- 
 lation. 
 
 Transport: 
 
 Murray's modification of the Thomas arm splint 
 (Fig. 12 B) or Jones' humerus splint (Fig. 13) may 
 be used. With the former, the arm being in the straight 
 position, a slight amount of traction is indicated, but 
 with the latter none is required. 
 
 Operative treatment: 
 
 Any fracture involving the joint surfaces is apt to 
 result in ankylosis more or less complete. The loss of 
 the movements of flexion and extension is not so serious 
 as the loss of pronation and supination of the forearm. 
 The worst result that can happen is a flail articulation, 
 and this often follows injudicious resection. 
 
 In deciding upon the treatment to be adopted in any 
 individual case, the surgeon must not only consider the 
 extent of the injury but also the occupation of the pa- 
 tient in civil life and the result which will be most de- 
 sirable for him. 
 
 Complete resection of the elbow, performed by sur- 
 geons who are familiar with the technique and the very 
 important after-treatment, generally gives excellent re- 
 sults as regards motion and to a certain extent as re- 
 gards power; but occasionally it fails, producing a flail 
 articulation. It is therefore exceedingly doubtful 
 whether complete resection should be recommended to 
 the average surgeon who does not follow the after-treat- 
 ment himself. Partial and atypical resections are often
 
 FRACTURES AND WOUNDS OF JOINTS 117 
 
 sufficient to prevent infection, and as they generally 
 become ankylosed during repair they are probably bet- 
 ter operations for laborers or others needing a power- 
 ful arm. 
 
 It is very difficult to lay down strict rules. When 
 possible, the question should be put before the patient; 
 and the surgeon, after explaining the situation fully to 
 him as to probable and possible results, both good and 
 bad, should be led by his wish. 
 
 Early operations: 
 
 NON-INFECTED CASES. (a) Perforating bullet 
 wounds with punctate orifices should not be operated 
 upon, no matter what the extent of fracture. 
 
 (b) In wounds opening the joint but without frac- 
 ture or lodged foreign bodies, the synovia should be 
 sutured and the soft parts closed by primary or delayed 
 primary suture. 
 
 (c) In wounds with lodged foreign bodies and slight 
 splintering of the joint surfaces, the foreign bodies and 
 bone splinters which enter the articulation and might 
 interfere with its function should be removed, together 
 with all lacerated and contaminated tissue The syno- 
 via should be closed if possible and the soft parts treated 
 accordr g to indications. 
 
 (d) If there is a loss of substance on one side of the 
 bearing surface (the trochlear, for example), resection 
 is indicated if lateral deviation is probable. 
 
 (e) If most of the joint is smashed, one must decide 
 between complete resection in the hope of getting a 
 movable joint, and simple drainage or partial resection
 
 118 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 with ankylosis in view. The nature of the operation 
 will depend upon the extent of comminution. 
 
 CASES IN WHICH INFECTION is ESTABLISHED. 
 Arthrotomy in generally the best operation for all 
 cases except those in which there is extensive comminu- 
 tion at the ends of the bones, when resection should be 
 performed. Resection is the best and quickest method 
 of terminating infection, but if it means extensive re- 
 moval of bone (for fractures may extend halfway up 
 the humerus or down the forearm and it is difficult to 
 draw a limiting line) it is better for the patient to suf- 
 fer a long course of suppuration and retain a stiffened 
 arm than to have a flail forearm. 
 
 When enlargement of the wounds does not afford 
 sufficient drainage, the typical incision for arthrotomy 
 should be made along the outer border of the olecranon. 
 This will drain the entire articulation and, together with 
 enlargement of the original wounds, should suffice. On 
 account of the superficiality of the elbow no tubes are 
 necessary. 
 
 Resection: 
 
 The Oilier incision is best, as it gives access and good 
 drainage, and the ends of the bones are not so apt to 
 project through the wound during the after treatment 
 as with the letter H incision. The incision passes down- 
 ward, from the commencement of the external epicon- 
 dylar ridge, along its posterior border, to its tip, then 
 obliquely downward and inward to the middle of the 
 base of the olecranon process, and straight downward
 
 FRACTURES AND WOUNDS OF JOINTS 119 
 
 along the posterior border of the ulna. The operation 
 must be entirely sub-periosteal, even to conserving the 
 periosteum of the minutest fragments. For the hu- 
 merus the section of the bones should pass through the 
 epicondyles, but it may sometimes be necessary to go a 
 little higher; for the ulna, just so as to remove the ar- 
 ticular surface of the coronoid process; for the radius, 
 through the neck. Hemi-resections do not succeed. All 
 the cartilage must be removed from all the bones. The 
 head of the radius must be removed, or supination will 
 be lost. The wound is merely filled very lightly with 
 sterile gauze, which should not be removed until the 
 eighth or ninth day. 
 
 Amputation: 
 
 Amputation should never be performed for injuries 
 to the elbow if the pulse is present at the wrist, even if 
 more than one of the nerves is divided. 
 
 Mechanical treatment: 
 
 All wounds of the elbow do better by suspension than 
 by any other form of treatment. The joint, although 
 at rest, moves slightly, and if there is any chance what- 
 ever of escaping ankylosis this chance will be pre- 
 served. For injuries not requiring resection the fore- 
 arm and arm are suspended as for fractures of the lower 
 end of the humerus, but no traction is used. When in- 
 fection is present a slight separation of the joint sur- 
 faces is desirable and the arm should be hung by the 
 forearm alone (Fig. 38). If greater separation of the 
 joint surfaces is required, the suspending pulley is
 
 120 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 shifted nearer to the foot of the bed, thus increasing 
 traction. As infection subsides the pulley is moved 
 toward the head of the bed until the desired amount of 
 flexion at the elbow is obtained, and the weight of the 
 upper arm is also suspended, so that the patient may 
 
 FIG. 38. Method of treating in- 
 fected wounds of the elbow 
 joint by suspension. Note that 
 the upper arm is not supported. 
 
 make attempts at motion and thereby possibly prevent 
 ankylosis. 
 
 In complete resections entire restoration of the joint 
 is the goal aimed at. In order to avoid stretching the 
 muscles and separating the ends of the bones, the limb
 
 FRACTURES AND WOUNDS OF JOINTS 121 
 
 should be slung as for fracture of the humerus (Fig. 16) , 
 but without any traction. There will be enough un- 
 conscious motion for the first week, but after that 
 time the forearm should be flexed and extended a little 
 more each day, preferably by the patient himself and 
 never so as to cause lasting pain. Active motion must be 
 encouraged throughout the period of convalescence for 
 two reasons: to improve the nutrition of the muscles, 
 and to mold the new articulation; the latter being ac- 
 complished by the pulling of the muscles on the perios- 
 teum. 
 
 If suspension is not available, a double gutter splint 
 with hinged side pieces forming a joint at the elbow may 
 be used. The hinges permit the necessary motion. 
 Non-articulated splints should not be employed. 
 
 A thorough course of sun treatment is particularly 
 valuable to these cases, both for healing the wounds 
 and for preserving the tone of the muscles. 
 
 WRIST 
 
 Wounds and fractures are seldom confined to the car- 
 pus alone, and usually either the inferior radio-ulnar 
 articulation or the metacarpus is also involved. It is 
 consequently necessary to consider all the articulations 
 as one as far as treatment is concerned. 
 
 Gun-shot injuries in the region of the wrist, although 
 not, as a rule, dangerous to life, are particularly serious 
 in regard to loss of function, especially if the wounds 
 become infected. The tendons about the wrist are fre- 
 quently lacerated or divided; and if infection occurs
 
 122 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 they become irreparably embedded in cicatricial tissue 
 when not destroyed in the infective process. It is there- 
 fore imperative that all injuries likely to become in- 
 fected be operated upon at the earliest possible moment 
 to remove not only foreign bodies but also pieces of 
 bone which, if infection should ensue, would give rise 
 to protracted suppuration. As the wrist is seldom cov- 
 ered by clothing, pieces of fabric are seldom entrained 
 into it by projectiles, but fragments of shell or grenade, 
 however minute, are apt to cause infection which some- 
 times develops in a peculiarly slow and insidious way. 
 
 Transport: 
 
 Flat splints should never be used for injuries of the 
 wrist and hand. An efficient splint for transport may 
 be made of the wire ladder splinting furnished by the 
 Red .Cross. 
 
 Operative treatment: 
 
 As a movable wrist is out of the question once sup- 
 puration is established, resection is indicated in all cases 
 of fracture of the carpus except those showing bullet 
 wounds with punctate orifices. The resection should 
 not be typical, as for tuberculosis, but should gener- 
 ally be confined to the fractured bones with due regard 
 to the lateral deformities which may ensue. The semi- 
 lunar and scaphoid should not be removed and the 
 cuneiform left, for instance, as a crippling distortion 
 would result. When the extremity of the radius has 
 been destroyed or removed the head of the ulna should
 
 FRACTURES AND WOUNDS OF JOINTS 123 
 
 be resected. In general, the trapezium and trapezoid 
 on one side and the uncif orm on the other should be pre- 
 served. 
 
 If the wound and fracture involve the metacarpus 
 and the carpus (particularly if the tendons of the cor- 
 responding finger are affected, as, for example, the os 
 magnum, the third metacarpal and tendons of the mid- 
 dle finger) a good operation is to amputate the middle 
 finger and split the hand right down to the carpus, re- 
 moving all the fractured bones. The halves of the hand 
 can be at once reunited if the wound is clean, or sutured 
 secondarily if it is infected. 
 
 For extensive resections of the carpus the incisions 
 for approach are two : an external incision which fol- 
 lows the radial border of the extensor indicis, commenc- 
 ing at the level of the line joining the styloid processes 
 and extending to the middle of the second metacarpal; 
 and an internal incision which commences just above the 
 styloid process of the ulna and passes down well to the 
 inner side of the extensor minimi digiti to 2 cm. (1 in. ) 
 above the lower end of the fifth metacarpal. The ten- 
 dons should be carefufly retracted after dividing the 
 posterior annular ligament. 
 
 If the lower ends of the radius or ulna are resected 
 the periosteum should be preserved with the greatest 
 care in order to obtain restitution of the extremities of 
 the bones. As for the carpals themselves, bony restitu- 
 tion is not so important, for a cicatricial wrist is to be 
 desired; but the sub-periosteal method should be 
 used in order to avoid injury to the overlying tissues.
 
 124 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 Mechanical treatment: 
 
 After extensive resection the hand has to be immo- 
 bilized in a position of dorsal flexion until repair is es- 
 tablished, in order to avoid the tendency to displacement 
 toward a position of palmar flexion due to the greater 
 strength of the flexor muscles. This should be done by 
 means of a molded plaster splint (Figs. 39 and 40). 
 By using this splint the thumb as well as the palm is 
 well supported and the fingers can be moved. 
 
 FIG. 39. Molded plaster splint for immobili- 
 zation of the wrist. (By the courtesy of M. le 
 Medecin-Major R. Leriche). 
 
 When wet dressings have to be employed, as in infected 
 cases, the original plaster splint should be carefully re- 
 moved at the first dressing and another applied. If the 
 first is in good condition it should be thoroughly dried 
 and then impregnated with melted paraffin; it can sub- 
 sequently be used for a long time without becoming 
 softened by the dressing solutions. As an alternative, 
 if sheets of gutta-percha can be had, they may be heated 
 in hot water and the splint molded out of them. 
 
 For later treatment, when absolute fixation is not
 
 FRACTURES AND WOUNDS OF JOINTS 125 
 
 necessary, one of the cock-up splints may be used to 
 advantage. 
 
 After extensive resections passive and active motion 
 should be limited to the fingers until repair is well ad- 
 vanced. After limited resections passive and active 
 motions of both wrist and fingers should be commenced 
 at the end of a week. 
 
 FIG. 40. Method of cutting thicknesses of crinoline to 
 make molded plaster splint for wrist. (By the cour- 
 tesy of M. le Medecin-Major R. Leriche). 
 
 HIP 
 
 On account of its depth in a mass of heavy muscles, 
 its close relation to the cavity of the pelvis and the or- 
 gans contained therein, and the great danger of anae- 
 robic infection, gun-shot injuries of the hip joint are ex- 
 tremely serious. It is probable that only exceptional 
 cases reach the surgeon, the greater number being killed 
 immediately or dying of hemorrhage and shock. Of 
 those who do live to reach the surgeon, many succumb 
 from complicating injuries to the intestine or bladder, 
 an^i others from rapid development of infection due to 
 the favorable field for the growth of anaerobes afforded 
 by the lacerated muscles.
 
 126 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 In no class of cases is early operation more impera- 
 tively demanded to save life, yet more often prevented 
 on account of shock. 
 
 Transport: 
 
 Fractures of the hip joint are transported in the same 
 manner as fractures of the upper part of the shaft of 
 the femur. 1 
 
 Cases should remain at the hospital in which they are 
 operated until consolidation is established. As extreme 
 abduction is necessary throughout their treatment, if 
 they must be transported they should be put in a splint 
 which will maintain such a position, and the double 
 plaster of Paris spica should therefore be used. 
 
 Operative treatment: 
 
 Bullet wounds with punctate orifices should not be 
 operated upon, but such cases must not be evacuated 
 until all danger of infection is past. 
 
 All other wounds should receive operative treatment 
 as soon as the patient's condition permits. The nature 
 of the operation will depend upon the character of the 
 injury and whether infection is already established or 
 not. 
 
 OPERATIONS BEFORE EVIDENT INFECTION. For 
 wounds of the joint without bone injury, or those 
 merely complicated by grooving of the bone or embed- 
 ding of projectiles therein, the treatment should be as 
 for any other joint wound. Primary suture should not 
 be attempted, however, the wound being left open for 
 delayed primary or secondary suture. 
 
 'Pages 73-79.
 
 FRACTURES AND WOUNDS OF JOINTS 127 
 
 If there is extensive comminution of the head and 
 neck of the femur, even if it extends down the shaft, 
 complete sub-periosteal resection of all the fragments 
 should be made on account of the great danger, if in- 
 fection should supervene, of continued and perhaps 
 fatal suppuration amidst them. The cartilage of the 
 acetabulum should be removed in nearly all cases, be- 
 cause, as there is no hope of regaining an articulation, 
 firm ankylosis is the result to be sought for, and also 
 because suppuration, if it should occur, is prolonged by 
 the presence of the cartilage. When the os innomina- 
 tum has been pierced by the missile, the bone fragments 
 and projectile should be removed, even if an ischio-rectal 
 or an abdominal incision has to be made. 
 
 For resections and extensive operations on the joint, 
 the approach from in front should be selected as easier 
 and causing less traumatism to the muscles. The pos- 
 terior route would at first sight seem preferable be- 
 cause it affords dependent drainage, but it destroys 
 the attachment of the muscles to the trochanter and 
 digital fossa (which will be the most important muscles 
 in preventing dislocation of the femur on the dorsum 
 ilia during after-treatment). It is therefore better not 
 to enlarge existing posterior wounds except in so far as 
 is necessary to trim and clean them. The best incision 
 is one which commences at the antero-inferior spine of 
 the ilium and passes outward and downward toward 
 the great trochanter, following in general the direction 
 of the neck of the femur. This incision is deepened 
 between the rectus femoris mesally and the tensor fascia 
 femoris laterally. The capsule of the joint is split longi-
 
 128 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 tudinally and then cut away transversely at its attach- 
 ment to the acetabulum. If the neck has not been frac- 
 tured it can be cut with a large bone-cutting forceps or 
 by a gigli saw, and the head removed. 
 
 Drainage, if the original wound does not open pos- 
 teriorly, should be made by a stab wound at the border 
 of the glutens maximus. Two small drainage tubes 
 should be inserted, but only as far as the cavity left by 
 the removal of the bone. The anterior wound should 
 be left open for delayed primary or secondary suture. 
 
 OPERATIONS DURING EVIDENT INFECTION. The same 
 remarks apply as for non-infected cases except that the 
 indications for resection are more pronounced. In- 
 juries to the bones likely to prolong infection, such as 
 fissured fractures, should be treated by typical resec- 
 tion. If the bone injury is slight resection may be post- 
 poned as perhaps unnecessary. In such cases the cap- 
 sule should be fully opened; drainage tubes must never 
 be passed through it, however, but should go just to its 
 level. 
 
 Mechanical treatment: 
 
 In cases where there is no complete fracture the limb 
 should be suspended in flexion of the hip and knee and 
 in moderate abduction and traction. This is most easily 
 accomplished by means of a Hodgen's splint and the 
 Hennequin method of making traction (Fig. 33). 
 Such a position is best for drainage and is the most 
 convenient for patient and attendants. A traction pull 
 of five or six kilos should be sufficient.
 
 FRACTURES AND WOUNDS OF JOINTS 129 
 
 In cases of fracture by rifle ball which have not been 
 operated upon, and in cases of resection, a position of 
 extreme abduction is indicated, in the first to prevent 
 coxa vara, and in the second to keep the end of the 
 femur in the cavity of the acetabulum and to compen- 
 sate for shortening. In non-resected cases a certain 
 amount of flexion at the hip is permissible, but not in 
 resected cases. The non-resections need strong trac- 
 tion, but the resections should have only slight traction. 
 The limb should therefore be suspended on a straight 
 splint (the straightened Hodgen's is usually the most 
 convenient ) , and only slightly elevated from the bed ; 
 a traction pull of from 16 to 18 kilos to commence with 
 being applied for the non-resected cases and of from 
 4 to 5 kilos for the resected cases. To maintain abduc- 
 tion the sound limb must also be suspended in marked 
 abduction. 
 
 In the resected cases, as soon as the danger of infec- 
 tion is past and the wounds are healing, it is advisable 
 to put on a double plaster of Paris spica; this need not 
 be carried below the knees. 
 
 Amputation: 
 
 As disarticulation at the hip joint is an exceedingly 
 shocking operation, and more so than resection, the 
 latter is sometimes preferable as a primary operation, 
 even when the injury to the bones is so extensive as to 
 make restoration of the function of the limb ques- 
 tionable. 
 
 There are also cases in which the pelvis, as well as the 
 hip, is infected, and in which a disarticulation would not
 
 130 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 benefit the pelvic condition. For these, resection and 
 drainage would seem the lesser risk. In most infected 
 cases of severe and extensive injury to the soft parts and 
 femur, however, amputation at the hip is advisable. 
 
 KNEE 
 
 Wounds of the knee have aroused more interest and 
 controversy than those of any other articulation. No 
 other joint demonstrates so vividly the course of nor- 
 mal repair or infection, and it is generally accepted as 
 the type as regards the results of different treatments. 
 In the early months of the war nearly all wounds of the 
 knee became infected, and in a very large proportion 
 amputation was performed. The usual treatment for 
 an infected knee was to insert through and through 
 drains into multiple incisions, and suppuration con- 
 tinued until the cartilage disappeared, after which the 
 bones could become covered with granulations and re- 
 pair gradually took place. The patient, during this 
 long period, was subjected to all the dangers of severe 
 sepsis, and finally emerged (if he did emerge) without 
 the limb or with a stiff knee, and his viscera shattered 
 by amyloid degeneration. It was soon discovered that 
 resection, by removing the cartilage and affording free 
 drainage of all the recesses of the joint, hastened resolu- 
 tion and repair. The greatest improvement in treat- 
 ment (and, in fact, a milestone in the treatment of all 
 joints) was the discovery that by a proper surgical 
 (i. e., operative) cleaning of the wounds the joint cavity 
 could be closed with even more impurity than wounds 
 of soft parts, and that infection could be eliminated in
 
 the great majority of cases. More recently, observa- 
 tions in a number of cases of suppurating knees in the 
 service of the author have tended to prove that in such 
 cases simple incisions, sufficient to open the recesses 
 of the joint but without the use of drains, lead to rapid 
 decline of the infection and repair without destruction 
 of the joint. 
 
 Anatomically the joint is complicated. Besides the 
 main bursa extending upward under the quadriceps ex- 
 tensor muscle, there are a variable number of bursae in 
 the popliteal space in relation with the popliteus and 
 gastrocnemius muscles, which may or may not be in- 
 volved in an infection of the joint. Usually they escape 
 until the joint becomes more or less disorganized. If 
 they become infected they are apt to cause abscesses 
 which dissect their way into the calf unless opened at an 
 early date. The popliteal nerves and vessels lie directly 
 behind the joint, and incisions to open the popliteal 
 bursae must be made by careful dissection. If drain- 
 age tubes are used in these cases there is great danger 
 of secondary hemorrhage from pressure ulceration. 
 
 Transport: 
 
 All injuries of the knee should be transported from 
 the field in a Thomas splint with traction. A well pad- 
 ded, posterior board or wire ladder splint should be 
 used in addition, to support the joint. For late trans- 
 portation, the Thomas splint is good for ordinary cases ; 
 for cases which have been resected a plaster of Paris 
 splint, extending from the foot to the waist, should be 
 employed.
 
 132 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 Operative treatment: 
 
 Operative treatment varies greatly with the extent of 
 injury to the joint, and also with the absence or pres- 
 ence of infection. The normal knee, in everyday life, 
 is more subject to accident than any other joint; in 
 other words, it is inherently weak. It is important, 
 therefore, that the treatment should be directed toward 
 preserving strength and avoiding any sacrifice of liga- 
 ments or tendons. On the other hand, if part of the 
 bone, sufficient to destroy the bearing surface of the 
 joint, has been lost, it is impossible to restore it; and in 
 order to obtain a strong and useful limb it is advisable 
 to resect, as an ankylosed knee is better than a weak and 
 deformed one and one subject to recurring accidents. 
 
 As the type of operation to be performed depends 
 chiefly upon the anatomical lesions, the cases will be 
 grouped accordingly, and not by the absence or pres- 
 ence of infection, the only exception being perforating 
 bullet fractures and wounds with punctate orifices 
 which should not be operated. 
 
 (a) Wounds entering the articulation, with or with- 
 out lodged projectiles, but without injury to the bones. 
 These should be pared and excised as usual, the foreign 
 bodies removed, the synovia sutured if the operation 
 takes place at an early date, and the superficial wound 
 closed by primary or delayed primary suture. If the 
 projectile has passed across the joint, the latter should 
 be opened at the opposite side so as to provide sufficient 
 access to not only extract the projectile but to inspect 
 the cavity and remove all contaminated tissue. If ob- 
 viously infected the wounds should merely be left open,
 
 FRACTURES AXD WOUXDS OF JOINTS 133 
 
 and if the joint has been distended with pus incisions 
 should be made at each side of the thigh into the upper 
 part of the quadriceps bursa and each side of the patella 
 tendon. No tubes should be used. 
 
 (b) Lodged projectiles in the epiphyses but not en- 
 tering the joint. These should be removed and the tract 
 carefully excised. If the joint is full of blood it should 
 be opened and washed out with normal saline. Unless 
 it is infected the opening into it should be sutured. The 
 original wound should be left for delayed primary su- 
 ture. If the joint is infected secondarily from a pro- 
 jectile lodged in an epiphysis it is usually best, on ac- 
 count of the infection being established in the bone, to 
 resect the joint. 
 
 (c) Fractures involving only a small portion of the 
 bony surfaces and not endangering the future relations 
 of the bones. In early cases, before infection, the loose 
 fragments should be removed and the joint closed. If 
 the joint is infected and the wounds of the bone can- 
 not be isolated from the joint and drained directly to 
 the exterior, it is wiser to resect. 
 
 (d) Fractures with loss of substance destroying the 
 bearing of the joint (one condyle of the femur, for in- 
 stance, or one tuberosity of the tibia) . These should be 
 resected whether infected or not. 
 
 (e) Comminution of the joint. These cases should 
 be resected or amputated. 
 
 (f) Fractures with extensive fragmentation. These 
 usually demand amputation. 
 
 (g) Cases in which simple drainage has been made 
 without causing the infection to subside and with
 
 1 :34 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 marked signs of general sepsis persisting. These are 
 best treated by resection or amputation, depending 
 upon the strength of the patient. If there is doubt it is 
 advisable to amputate. 
 
 Technique of resection: 
 
 The resection should always be as conservative as 
 possible, and just enough bone removed to obtain a 
 good surface for apposition. In cases without fracture 
 the cartilage can be removed from the posterior aspect 
 of the condyles after taking the saw cut. The patella 
 should usually be excised. The saw cut should be made 
 so that when the sawed surfaces are in apposition the 
 knee will be flexed to about 10. It is not necessary 
 to excise the synovia; the cartilage is the structure that 
 retards and restricts repair. In clean cases the bones 
 should be fixed in apposition with nails, and the wound 
 closed. Resections in infected cases should be left open, 
 and the ends of the bones kept separated by traction 
 until the infection disappears. 
 
 Delayed or fibrous union occurs sometimes after re- 
 sections of infected joints and necessitates a secondary 
 resection. This should not be done until the wound has 
 been healed for a sufficient time to eliminate the danger 
 of post-operative infection. As these secondary resec- 
 tions, and other late resections for demority, do not 
 always unite well it is very good practice to put in an 
 inlay graft. If this is done failure will seldom occur. 
 
 There are some things which should not be done in 
 operations on the knee. The patella ligament should 
 never be divided unless during resection, for the knee
 
 135 
 
 in most instances will have to be resected later; if suffi- 
 cient access is unattainable by means of curved lateral 
 incisions, the patella and its tendon and ligament may 
 be split longitudinally. Extended experience has 
 proved that the method of treating infected knees wide 
 open in flexion is undesirable. It is bad practice to 
 drain through the popliteal space; it is much better to 
 resect. 
 
 Mechanical treatment: 
 
 All cases, with the exception of non-infected resec- 
 tions, are best treated by suspension in a Hodgen's or 
 Thomas splint bent to 165 at the knee, and just enough 
 traction to steady the limb a weight of 3 to 4 kilos is 
 sufficient. It is, however, impossible to immobilize a 
 limb sufficiently after resection of the knee by suspen- 
 sion without a firm support behind the thigh and leg 
 to prevent displacement and angulation. This can be 
 accomplished by means of a molded plaster splint ex- 
 tending from the gluteal fold to the foot. The splint 
 should be removed when hard and dried, and paraffined 
 as has already been described in dealing with the wrist. 
 A gutta-percha splint is equally suitable. With this 
 rigid support suspension in a Hodgen's splint has given 
 excellent results. Resections for infection should be 
 treated with enough traction to keep the ends of the 
 bones apart until the infection disappears, when they 
 should be allowed to approximate. Non-infected resec- 
 tions, and those in which infection has subsided, should 
 be immobilized as absolutely as possible in order to 
 promote firm union. For this purpose a plaster of
 
 136 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 Paris splint extending from the foot to above the hip 
 joint should be used. 
 
 ANKLE 
 
 The calcaneo-astragalar articulation will be studied 
 in this group, because no definite separation can be 
 made between fractures of the two articulations. 
 
 In considering the treatment of injuries of this re- 
 gion, and also those of the anterior tarsus and metatar- 
 sus, two main points must be kept in view: firstly 
 (orthopedic), the conservation of the function of the 
 foot; secondly, the peculiarities of the course taken by 
 infection. The orthopedic question is dealt with in 
 the description of the operations for each region. 
 
 Infections of the short bones are apt to take a slow 
 and insidious but persistent course, the infective osteitis 
 gradually extending and involving the articulations and 
 adjacent bones. Unless treated vigorously by remov- 
 ing enough of the bone or bones to afford free drainage, 
 suppuration is apt to persist for months and may, from 
 absorption of bone, destroy the usefulness of the foot 
 or necessitate amputation. The surgeon will conse- 
 quently do well to anticipate this irregular destruction 
 by a resection on orthopedic principles which will 
 arrest the infection and provide a useful foot. More- 
 over, particularly in wounds of the anterior tarsus, in- 
 fections are apt to take a very violent course, involving 
 the sole of the foot and ascending the tendon sheaths 
 so much so that wounds of the foot are not only exceed- 
 ingly dangerous to the member but to life itself. This
 
 FRACTURES AND WOUNDS OF JOINTS 137 
 
 explains what might otherwise seem extraordinarily 
 radical operations for wounds of this region. 
 
 Transport: 
 
 The Cabot posterior wire splint should be used for 
 transport from the field. For late transport some form 
 of plaster of Paris splint is desirable. 
 
 Operative treatment: 
 
 As the ankle joint, on account of the tight mortise 
 formed by the malleoli, is very difficult to drain, it is 
 often better to remove the astragalus than to await a 
 prolonged and problematic recovery by simple drain- 
 age, all the more so because the orthopedic result after 
 removal of the astragalus is excellent. On the other 
 hand, it is extremely important to preserve the malleoli 
 and the mortise between them, as well as the os calcis 
 which should never be removed in toto. In infected 
 fractures of the malleoli above or of the os calcis be- 
 low, therefore, the astragalus, when it is necessary to 
 obtain drainage, should be sacrificed, even if little in- 
 jured, in order to preserve the other bones. In primary 
 operations for wounds or projectiles lodged in the astra- 
 galus, if it is found, in curetting out the bone, that the 
 posterior part of the body has to be removed to such an 
 extent as to destroy its form and bearing power, the 
 whole bone should be excised. On the other hand, par- 
 tial resections of the head give good orthopedic results. 
 
 Most fractures of the astragalus should be treated 
 by total excision, even if caused by rifle balls and pre- 
 sumably uninfected.
 
 138 GUN-SHOT FRACTURES OF EXTREMITIES 
 
 In wounds and fractures of the os calcis resections 
 should be as limited as possible, and the tuberosity and 
 plantar surface should never be removed. The gap 
 caused by removal of the astragalus gives sufficient room 
 to treat more conservatively fractures of the malleoli 
 above and of the os calcis below. 
 
 The incisions for excision of the astragalus are made 
 on both sides of the foot. The outer and more impor- 
 tant begins from 5 to 6 cm. .(2 to 2% in.) above the 
 extremity of the external malleolus and passes down- 
 ward along the anterior border of the fibula, curving 
 gently forward in the direction of the interval between 
 the fourth and fifth toes to end at the cuboid. It is 
 deepened to the outer side of the peroneus tertius and 
 anteriorly to the peroneus brevis. From its center a short 
 straight incision is carried backward and downward to 
 the tip of the external malleolus; this exposes the in- 
 ferior tibio-fibular, the tibio-astragalar and the astra- 
 galo-navicular articulations. The internal incision, 
 about 6 cm. (2^> in.) long, curves along the front of 
 the internal malleolus to its tip ; from the center of this 
 incision another is carried forward and slightly down- 
 ward to the navicula, but does not cross the tibialis an- 
 ticus. This opens the tibio-astragalar and the astragalo- 
 navicular articulations and only divides the extreme 
 anterior fibers of the internal lateral ligament. The 
 astragalus should be removed sub-periosteally with the 
 sharp periosteal elevator, carefully avoiding any in- 
 jury to the over-lying soft parts. The gaping wound 
 should be very lightly filled with gauze from each side. 
 No through and through drainage should be used.
 
 FRACTURES AND WOUNDS OF JOINTS 139 
 
 For exposure of the os calcis the incision is made on 
 the outer side of the foot in the shape of the letter L, 
 the vertical portion being at the anterior border of the 
 tendo-Achillis and the horizontal parallel with the sole 
 at the junction of the thin skin with the thick skin of 
 the sole. This affords plenty of room for all operations 
 upon the calcis, particularly in conjunction with the 
 original wounds. 
 
 Mechanical treatment: 
 
 For simple drainage of the ankle, and for all atypical 
 operations, suspension in a Hodgen's splint with a slight 
 traction by means of Sinclair's skate (Fig. 31 D) is 
 by far the best treatment. 
 
 The after-treatment of resections of the astragalus 
 by suspension is more difficult, on account of the tend- 
 ency to displacement of the foot, but it is advisable to 
 use suspension and traction in infected cases until the 
 infection is arrested. For clean cases of resection the 
 best method is to employ a plaster of Paris splint reach- 
 ing from the toes to the knee. This, of course, has to 
 be removed at every dressing, but in clean cases the 
 dressings are so infrequent that this is no great incon- 
 venience. Increased comfort will be afforded to the 
 patient if the limb in the splint be suspended. 
 
 Old fistulas of the astragalus and vicious union of 
 the ankle and foot are best treated by astragalectomy. 
 The position of the foot must be carefully watched 
 after excision of the astragalus. At first the foot hangs 
 loosely, but as repair takes place it gradually becomes 
 drawn up against the tibia and fibula. If the splint is
 
 140 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 not properly applied the foot may be displaced too far 
 forward or backward and become useless; there is also 
 a tendency to inward rotation, which must be met and 
 corrected. A firm cicatricial union should be sought for 
 rather than a new articulation; early movements are 
 not indicated, therefore, nor should the patient attempt 
 to walk until cicatrization is complete, i. e., three or 
 four months on an average. Much attention must be 
 given to the toes in order to prevent incurvation; they 
 must be massaged daily and their active motion en- 
 couraged. When repair is sufficiently advanced to per- 
 mit walking, a shoe with lateral steel braces extending 
 up the leg should be fitted in order to prevent lateral 
 deviation of the foot. 
 
 As has already been stated in regard to the ankle and 
 posterior tarsus, operations for fractures of this region 
 should be performed at the earliest possible moment to 
 avoid infection, with its deplorable consequences, not 
 only to the articulations and tendons of the foot, but to 
 life itself. 
 
 Transport: 
 
 As for fractures of the ankle. . 
 
 Operative treatment: 
 
 The question as to amputation or resection in these 
 cases is decided by the amount of destruction of the soft
 
 FRACTURES AND WOUNDS OF JOINTS 141 
 
 parts, tendons and skin. Even extensive injuries in- 
 volving the greater part of the tarsus can be treated by 
 resection with good orthopedic results if sufficient soft 
 parts remain. 
 
 The nature of the resection will depend on the extent 
 of injury transversely. For wounds and fractures of 
 single bones, partial resection and ablation of all torn 
 tissues and foreign bodies suffices as a rule, when it is 
 done primarily and before infection is established. 
 After infection has set in the affected bones should be 
 entirely removed. When the bones are fractured trans- 
 versely across the foot, resection of the entire anterior 
 tarsus, with partial resection of what metatarsals may 
 be injured, gives excellent results. Resections of the 
 bones at one side of the foot are not so satisfactory on 
 account of the tendency to lateral deviation, and they 
 should not be performed unless at least half or more 
 of the tarsus is preserved. For more extensive injuries 
 it is best to resect the entire tarsus, removing the astra- 
 galus but always leaving the os calcis. 
 
 Injuries to the metatarsus, if severe, may be treated 
 by resection combined with disarticulation of the corre- 
 sponding toes. 
 
 For resection of the tarsus the incisions already de- 
 scribed for the astragalus and os calcis, and the typical 
 incisions for navicula, cuboid and cuneiforms advised by 
 Oilier, are used in conjunction with the original 
 wounds. The incisions for resection of the anterior tar- 
 sus are four in number: one passing along the inner 
 border of the foot from the tubercle of the navicula to 
 the articulation of the cuneiform with the first metatar-
 
 GUX-SHOT FRACTURES OF EXTREMITIES 
 
 sal; a second passing close to the outer border of the 
 extensor hallucis, uncovering the navicula and passing 
 between the internal and middle cuneiforms; a third 
 passing between the extensor tendons of the fourth and 
 fifth toes and opening the articulation between the ex- 
 ternal cuneiform and the cuboid; and a fourth passing 
 along the superior border of the peroneus brevis and 
 uncovering the cuboid. It is not necessary to remove 
 the heads of the metatarsals or of the astragalus in re- 
 sections of the anterior tarsals. The large cavity left 
 by extensive resections should be gently filled with 
 gauze, which, in the clean cases, should not be removed 
 for eight or ten days. 
 
 When the wounds involve the sole, threatening in- 
 fection of the tendon sheaths or already infected, a suc- 
 cessful method of treatment has been to split the foot 
 longitudinally, by a dorsal and plantar incision, the two 
 joining in the commissure between the toes. The halves 
 of the foot are then separated, and the bones resected 
 if necessary; when infection is present the former are 
 kept apart until it has subsided. These incisions, by 
 laying open the dense tissues of the sole, have been very 
 efficacious in limiting infection and have, at the same 
 time, given satisfactory functional results. Such a lon- 
 gitudinal splitting in the sagittal planes is less destruc- 
 tive than another which has been recommended ; namely, 
 a splitting of the sole away from the bones by incisions 
 along the border of the foot. These splitting proce- 
 dures require a secondary operation for closure, unless 
 the wound is so clean at the primary operation as to 
 warrant its being done at that time.
 
 FRACTURES AND WOUNDS OF JOINTS 143 
 
 Mechanical treatment: 
 
 Resections of the tarsus have to be immobilized for 
 a long time to prevent deformity by cicatricial and 
 muscular contraction. The posterior molded plaster 
 splint is the best. 
 
 An orthopedic shoe should be worn and weight 
 should not be put on the foot until sensitiveness has 
 disappeared.
 
 INDEX 
 
 Albee graft for non union 33 
 
 Amputation for fracture of elbow 119 
 
 Amputation for fracture of femur 79 
 
 Amputation for fracture of hip 129 
 
 Angulation, in fracture of femur 95 
 
 Ankle, treatment of fractures of 136 
 
 Astragalectomy, for fractures of ankle and tarsus 137 
 
 Astragalectomy, for mal-union of foot and ankle 139 
 
 Balkan frame 37 
 
 Ball method for treating fractures of metacarpals 72 
 
 Ball rifle, fractures usually uninfected 11 
 
 Ball rifle, lesions produced by 9 
 
 Ball shrapnel, infection in fractures caused by . 11 
 
 Bandage method, Pouliquen's 74 
 
 Barrack frame, for suspension and traction 41 
 
 Bomb, fractures usually infected 11 
 
 Bone fragments, explosive effect of 8 
 
 Bone grafts, ineffectual when nutrient vessels are injured .... 18 
 
 Bone grafts, inlay 19, 33, 134 
 
 Bone sinuses, operations for 30 
 
 Bone sinuses, stains for .32 
 
 Bone splinters, gradually absorbed when detached 13 
 
 Bones, distinction between fractures and wounds of 3 
 
 Bones, effects produced by missiles upon 8 
 
 Cabot's splint . 103, 137 
 
 Callus, control of exuberant . 15 
 
 Callus, repair of fractured 33 
 
 Callus, flasklike . . . ..'' . 17, 32 
 
 Carrel tubes for doubtfully clean wounds 26 
 
 Carrel tubes for drainage 28 
 
 Clavicle and scapula, treatment of fractures of 61 
 
 Codavilla pin 76, 83, 86, 92, 98 
 
 Coexistant fractures of thigh and leg 90 
 
 Delayed primary suture, definition of 22 
 
 Delayed primary suture, for fractures by penetration ..... 23 
 
 Delayed union, Delbet apparatus for .......... 34 
 
 Delayed union in fracture of knee . . 134 
 
 Delayed union, injection of blood for 84 
 
 Delbet apparatus for delayed union 34 
 
 Delbet femur splint, for ambulatory use 96 
 
 Delbet femur splint, for angulation . 95 
 
 Delbet leg splint, for ambulatory use . 106 
 
 Drainage tubes for infected fractures 27, 28 
 
 Drainage Tubes, Carrel's 26, 28 
 
 Elbow, treatment of fractures of 116 
 
 Elbow, sun treatment for fractures of 121 
 
 Femur (fracture of), advisability of amputation for 79 
 
 Femur (fracture of), angulation in 95 
 
 145
 
 146 INDEX 
 
 Femur (fracture of), danger of pulmonary complications subsequent 
 
 upon , . . . 93 
 
 Femur (fracture of), Delbet's ambulatory spl'nt for 97 
 
 Femur (fracture of), Hennequin's method for 89 
 
 Femur (fracture of), plaster of Paris collar for 92 
 
 Femur (fracture of), supplementary sling for suspension of sound 
 
 limb in . 81 
 
 Femur (fracture of), transport of 73 
 
 Femur (fracture of), with coexistent fracture of leg 90 
 
 Femur (fracture of), re fracture of 94 
 
 Fibula and tibia, treatment of fractures of 102 
 
 Finochietto's stirrup 86, 99, 104 
 
 Fixation, internal, bad practice 30 
 
 Fixation, internal, seldom necessary for vicious union 33 
 
 Fixation, internal, unnecessary for non union 33 
 
 Foot drop 84 
 
 Fractures", by impact 24 
 
 Fractures, by penetration or perforation 24 
 
 Fractures, characteristics of diaphyseal and epiphyseal 3 
 
 Fractures, coexistant, of thigh and leg 90 
 
 Fractures, definition of 3 
 
 Fractures, distinction between wounds of bones and 3 
 
 Fractures, double 9 
 
 Fractures, repair of infected 15 
 
 Fractures, radiographic control of 46 
 
 Fractures, the essentially war 6 
 
 Fractures, varieties of 6 
 
 Frame, for suspension and traction 36 
 
 Frame, for suspension and traction in barracks 41 
 
 Function, harmful effects of infection upon 15 
 
 Gaiter method unsuitable for strong traction 104 
 
 Gas infection, extension along muscles 27 
 
 Glove method, Sinclair's 68, 71 
 
 Glue, Huessner's 42 
 
 Glue, Sinclair's 42 
 
 Grafts, inlay bone 19, 33, 134 
 
 Grenade, fractures usually infected 11 
 
 Hammock, Sinclair's 84 
 
 Hennequin's method for fracture of femur 89 
 
 Hennequin's method for fracture of hip 128 
 
 Heussner's glue 42 
 
 Hip, treatment of fracture of 126 
 
 Hip, treatment of fracture of, Hennequin's method for 128 
 
 Humerus, treatment of fracture of 61 
 
 Immobilization of fractured wrist 124 
 
 Infected fractures 27 
 
 Infection, due to open fissures 16 
 
 Infection, gas 27 
 
 Infection, harmful effect upon function 15 
 
 Infection, in cancellous bone 18 
 
 Infection in fractures caused by different missiles 11 
 
 Infection, operations in presence of 27 
 
 Infection, synovia not particularly susceptible to 109 
 
 Infection, use of Carrel's tubes for 26, 28 
 
 Inlay graft . 19, 33, 134 
 
 Internal fixation, bad practice 30 
 
 Internal fixation, seldom necessary for vicious union 33 
 
 Internal fixation, unnecessary for non-union 33
 
 INDEX 147 
 
 Knee, treatment of fracture of 130 
 
 Knee, loose joints caused by wrongly applied traction 45 
 
 Mai union 33 
 
 Mai union of foot and ankle 140 
 
 Medulla, danger of small openings into 10 
 
 Metacarpus and phalanges, treatment of fractures of 72 
 
 Metatarsus and tarsus, treatment of fractures of 140 
 
 Missiles, effects produced upon bones 8 
 
 Nerve lesions 46 
 
 Non union 33 
 
 Oilier incision, for resection of elbow 118 
 
 Ollier's periosteum elevator 25, 28 
 
 Operations in infected cases 27 
 
 Operations for sequestra and bone sinuses 30 
 
 Operations, primary, necessity of early 21 
 
 Operations, primary, technique 21 
 
 Operations, primary, usefulness of X-ray in , 22 
 
 Osteitis in epiphyses and short bones 18 
 
 Osteomyelitis 16 
 
 Periosteum Elevator (Oilier) 25, 28 
 
 Phalanges, treatment of fractures of 72 
 
 Pin, Codavilla's 76, 83, 86, 92, 98 
 
 Plaster of Paris, collar for fractured femur 92 
 
 Plaster of Paris for fractured wrist 124 
 
 Plaster of Paris for resected astragalus 139 
 
 Plaster of Paris for transport of fractured ankle 137 
 
 Plaster of Paris for transport of fractured femur 78 
 
 Plaster of Paris for transport of fractured knee 131 
 
 Plaster of Paris for transport of fractured hip 126 
 
 Plaster of Paris unsuitable for treatment of fresh fractures ... 35 
 
 Plates, stereoscopic, for location of sequestra 31 
 
 Pouliquen's Bandage Method 74 
 
 Primary operations, necessity of early 21 
 
 Primary operations, technique of 21 
 
 Primary operations, usefulness of X-ray in 22 
 
 Primary suture, definition of 23 
 
 Primary suture, for fractures by impact 24 
 
 Primary suture, for fractures by penetration or perforation ... 24 
 
 Primary suture, for fractures of femur 80 
 
 Primary suture, for uncomplicated wounds of soft parts .... 23 
 
 Primary suture, in presence of fractures 23 
 
 Radius and ulna, treatment of fractures of 64 
 
 Ransohoffs tongs 77, 86, 89, 92, 98, 101 
 
 Refracture of femur 94 
 
 Repair of fractures, different in epiphyses and diaphyses .... 18 
 
 Repair of fractures, in extensive comminution 12 
 
 Repair of fractures, influence of infection on ... ... 12 
 
 Repair of fractures, process of 12 
 
 Repair of fractures, process of stimulated by mild infection ... 15 
 
 Repair of fractures, radiographic control of 46 
 
 Resection, general technique of 28 
 
 Resection, of diaphyseal fractures 28 
 
 Resection, of fractured elbow 116, 118 
 
 Resection, of fractured hip 127, 129 
 
 Resection, of fractured joints 28 
 
 Resection, of fractured knee ... 133 
 
 Resection, of fractured tarsus and metatasus 140 
 
 Resection, of fracture, wrist 122
 
 148 INDEX 
 
 Resection, partial, for fractured ankle 137 
 
 Resection, secondary 134 
 
 Rifle ball, fractures usually uninfected 11 
 
 Rifle ball, lesions produced by 9 
 
 Scapula, treatment of fractures of 61 
 
 Scar tissue, infiltration of soft parts by 15 
 
 Secondary resection 134 
 
 Secondary suture, definition of 23 
 
 Sequestra, contained in flasklike callus 17, 32 
 
 Sequestra, location of 31 
 
 Sequestra, operations for 30 
 
 Sequestra, sinuses reading to 15 
 
 Sequestra, stereoscopic plates for location of 31 
 
 Shell, fractures must be regarded as infected ........ 11 
 
 Shell fragments, lesions produced by 9 
 
 Shoulder, treatment of fractures of Ill 
 
 Shrapnel ball, infection in fractures caused by 11 
 
 Sinclair's glove method for fractures of forearm 68 
 
 Sinclair's glove method for fractures of metacarpals 72 
 
 Sinclair's glue 42 
 
 Sinclair's hammock 84 
 
 Sinclair's skate for traction in low fractures of leg 104 
 
 Sinclair's skate for use in presence of foot wounds 106 
 
 Sinclair's splint for forearm 71 
 
 Sinuses, bone . 30 
 
 Skate method, Sinclair's 104, 106 
 
 Sling, supplementary for suspension of sound limb in fracture of 
 
 femur 82 
 
 Spanish windlass twist 53, 74 
 
 Splints, Cabot leg 103, 137 
 
 Splints, "Caliper" 94 
 
 Splints, Delbet's ambulatory famur 96 
 
 Splints, Delbet's ambulatory leg 106 
 
 Splints, Delorme's aluminium gutter 78 
 
 Splints, double gutter, for fractured elbow 121 
 
 Splints, for transport of fractured humerus 51 
 
 Splints, Hodgen's 36, 81, 90, 99, 100, 103, 128, 135, 139 
 
 Splints, Jones' cock-up arm .... - 46 
 
 Splints, Jones' traction humerus 51, 67 
 
 Splints, Listen 77 
 
 Splints, metal cock-up, for drop wrist 46 
 
 Splints, Murray's modification of Thomas traction arm . . 51, 52, 64 
 
 Splints, Plaster of Paris, for hip 126, 129 
 
 Splints, Plaster of Paris, for knee 130, 13o 
 
 Splints, Plaster of Paris, for wrist . 124 
 
 Splints, Sinclair, for forearm 71 
 
 Splints, Thomas ambulatory, or knee .' 94 
 
 Splints, Thomas, for use in absence of portable X-ray ..... 82 
 
 Splints, Thomas half-ring leg . . . 74, 80 
 
 Splints, Thomas traction arm 52, 66, 69 
 
 Splints, Thomas traction leg ... 74, 78, 80, 100, 102, 103, 131, 135 
 
 Splints, Van de Veld '.' / '70, 71 
 
 Splints, wire ladder, for wrist .....'; 122 
 
 Stains, for bone sinuses ......;. 32 
 
 Stereoscopic plates, for location of sequestra . . . . . . . . 31 
 
 Stirrup, Finochietto's 86, 99, 104 
 
 Sun treatment, for fractures of elbow . ......... 121 
 
 Suspension of sound limb, in fractures of femur 81
 
 INDEX 149 
 
 Suspension and traction, advantages of . 36 
 
 Suspension and traction, barrack frame for ........ 41 
 
 Suspension and traction, description of method 36 
 
 Suspension and traction, for fractured astragalus . ; 139 
 Suspension and traction, for fracture of elbow . . . . *. . .118 
 
 Suspension and traction, for fracture of femur 80 
 
 Suspension and traction, for fractured hip 128 
 
 Suspension and traction, for fractures of humerus 57 
 
 Suspension and traction, for fractures of knee 135 
 
 Suspension and traction, for fractures of leg 103 
 
 Suspension and traction, for fractures of radius and ulna .... 66 
 
 Suspension and traction, frame for 36 
 
 Suspension and traction, metohds of attaching apparatus to limbs . 42 
 
 Suspension and traction, trolley bar for 40 
 
 Suspension and traction, weights for 41 
 
 Suture, delayed primary, definition of 23 
 
 Suture, primary, definition of 23 
 
 Suture, primary, for fractures by impact 24 
 
 Suture, primary, for fractures by penetration or perforation ... 24 
 
 Sutue, primary, for fractures of femur 80 
 
 Suture, primary, for uncomplicated wounds of soft parts .... 24 
 
 Suture, primary, in presence of fractures 23 
 
 Suture, secondary, definition of 23 
 
 Synovia, not extremely susceptible to infection 109 
 
 Tarsus and metatarsus, treatment of fractures of 140 
 
 Tibia and fibula, treatment of fractures of . . . 102 
 
 Tongs, Ransohoff's 77, 86, 89, 92, 98, 101 
 
 Traction, for coexistent fractures of thigh and leg 90 
 
 Traction, for fracture of femur 84 
 
 Traction, methods of producing 43 
 
 Transport of fractures 20 
 
 Treatment of fractures, ankle 136 
 
 Treatment of fractures, clavicle and scapula 51 
 
 Treatment of fractures, elbow .115 
 
 Treatment of fractures, femur 73 
 
 Treatment of fractures, femur, lower third of 101 
 
 Treatment of fractures, femur, middle third of 99 
 
 Treatment of fractures, femur, neck of 97 
 
 Treatment of fractures, femur, upper third of 97 
 
 Treatment of fractures, hip 126 
 
 Treatment of fractures, humerus 51 
 
 Treatment of fractures, knee 130 
 
 Treatment of fractures, metacarpus and phalanges 72 
 
 Treatment of fractures, radius and ulna 64 
 
 Treatment of fractures, shoulder Ill 
 
 Treatment of fractures, tarsus and metatarsus 140 
 
 Treatment of fractures, tibia and fibula 102 
 
 Treatment of fractures, wrist 121 
 
 Trolley bar, for suspension and traction . 40 
 
 Twist, Spanish windlass 53, 74 
 
 Ulna, treatment of fractures of 64 
 
 Union, delayed by infection 15 
 
 Union, delayed, Delbet apparatus for 34 
 
 Union, delayed in fracture of knee 135 
 
 Union, delayed injections of blood for . 34 
 
 Union, non 33 
 
 Union, non, inlay graft for 33 
 
 Union, vicious 33
 
 150 INDEX 
 
 Union, vicious, internal fixation unnecessary for 33 
 
 Union, vicious, of foot and ankle ........... 139 
 
 Weights, for suspension and traction 41 
 
 Windlass t^st, Spanish 63, 74 
 
 Wounds of bones ..<......... 3 
 
 Wounds of joints , 109 
 
 Wrist, treatment of fractures of, 121
 
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