DIAGNOSIS OF OSSEOUS LESIONS OF THE DIAPHYSES.
The diagnosis should rest on two points:
(1) General diagnosis of the osseous lesion;
(2) diagnosis of the group and of the variety.
1. GENERAL DIAGNOSIS.-- Pain, loss of all power in the limb, change in its length or in its shape, abnormal mobility, all these points can be of use to us in fractures by firearms, as they are in ordinary fractures, in establishing a general diagnosis; but as many of these signs very often are wanting, we are obliged to look for others. The following are the signs we consider of the greatest importance. They are:
Shock (comminuted and very comminuted fractures).
Pain evoked by pressure at a distance or on the supposed line of the fissures.
Angular prominence of the terminal extremity of the large splinters, easily felt in the superficial foci (tibia, ulna, clavicle), and sometimes in bones situated more deeply, even in the femur.
Position of the wounds in direct relation to the superficial bones (hand, foot, tibia, ulna, clavicle).
The relation of the track in the soft parts to the position of the bones.
The enlarged dimensions of the aperture of exit in the skin and in the clothing compared with the aperture of entry (short and middle range firing).
The spread-out form of certain orifices made by soft lead bullets.
Swelling profuse haemorrhage (the bone becoming a regular enormous collection of blood). This sign has not been sufficiently dwelt upon.
Escape of small oily drops (comminuted fractures of the big long bones).
The presence of free splinters in the canal of exit, at the level of the cutaneous orifice, or that of the clothes. This is a favourable sign.
A special change of shape of the projectile (lateral change of shape, bending back of the point), even when the aperture of entry shows from its appearance and its dimensions that the bullet has entered from point-blank firing, and had not been deflected nor had its shape altered.
Extensive crepitation which is obtained by bringing the splinters together; or localised crepitation, obtained by slight compression exercised in the direction of the aperture of exit in the bone. These are quite harmless proceedings, very different to the highly reprehensible plan of seeking for crepitation by moving the whole of the bone, or by rotating the fragments; this, indeed, is still worse, for this rotation easily renders complete an incomplete fracture, and gives rise to displacements which are difficult to correct.
These, then, were the signs we brought forward. They well maintain their value, and very often the military surgeon is unable to obtain others. Under favourable conditions, at the rear, radiography, the generalisation of which becomes more and more necessary, much simplifies nowadays the general diagnosis.
When in doubt, we should act as if the fracture existed, and a more or less rapid examination, or one carried out subsequently, will either confirm or nullify the diagnosis.
2. DIAGNOSIS OF THE GROUP AND OF THE VARIETY--
(I) Contact Fractures.--We have given as principal signs of these fractures: absence of aperture of exit, absence of very small oily drops, absence of free splinters in the canal of exit, and, the best sign of all, absence of perforation of the bone or of indentation, this having been proved by direct exploration.
Here radiography has furnished precise indications and simplified research after these last two valuable signs. In fact, radiography has completed the clinical history of this group.
It shows in these contact fractures with large splinters-- The absence of splinters in the canal of exit, and, above all, the PATHOGNOMONIC SIGN: the SHARP WEDGE OF THE TWO FRAGMENTS, upper and lower. In no other kind of fracture caused by firearms is this sign to be found.
(2) Fractures by perforation.-- Radiography settles the diagnosis of fractures by perforation of one wall of the bone.
Fractures by perforation of the two walls of the bone are recognised by the rectilinear track in the axis of the bone, by the enlargement of the aperture of exit in the soft parts and in the clothes, by the presence of free splinters close to the cutaneous aperture of exit or else in the track of exit, by multiple orifices (explosive fire), by the change in shape of the point of the bullet, by splitting up of those bullets that have an envelope, by the localised crepitation in the focus of free splinters near the aperture of exit in the bone.
Thanks to these signs, the diagnosis of the lesion is generally easy. Radiography has made it still easier by disclosing (1) when there is no solution of continuity, the ROUNDED OR OVAL PERFORATION the diaphysis has sustained in the first wall that has been pierced, the more irregular but as easily demonstrated loss of substance in the second wall; (2) when there is solution of continuity, and even considerable displacement of the fragments, the INDENTATION presented by the superior and inferior cuneiform fragments; finally (3) in both cases the PRESENCE OF NUMEROUS FREE SPLINTERS, either lying in the canal of exit or moved into a new position.
(3) Fracture by Groove.--These fractures were very difficult to diagnose before the advent of radiography. The circular nature of the track, occasionally the slight change of shape of the bullet (lateral parts and apex), the small free splinters in the canal of the wound and especially the verification by the finger of a peripheric osseous groove, were the signs met with.
Radiography renders the FOLLOWING PATHOGNOMONIC SIGN perfectly clear: PERIPHERIC INDENTATION in the osseous track of hard lead bullets with an envelope (German and Austrian bullets). These tracks are rendered evident by small seed-like particles of lead when the bullet has become separated from its covering.
Comminution is easily recognised. It is shown--(1) By multiplied loud, fine crepitation of free splinters, very different with regard to sensation and to sound from the extensive crepitation, more muffled and not multiplied, caused by the friction of the long adherent splinters. (2) By the presence of a large number of splinters. We must also remember that in war surgery grave comminution and a solution of continuity are not synonymous.
Not only has radiography thrown light on the general diagnosis of these fractures, and allowed us to establish the diagnosis of the different groups, but every day it enables us to identify metallic foreign bodies, whole bullets that have lost their shape or become subdivided, and have been arrested in the osseous focus or in the neighbouring soft parts after having caused the fracture of the diaphysis.
We have already described many of these changes of shape, but in doing so we always had before our eyes the changes of shape that result from contact with hard soil before reaching the human body. Now we have to deal only with those that result from contact with bone.
Changes of Shape in Bullets that have struck Bones. - 1. Soft lead bullets that have caused FRACTURES BY CONTACT are flattened out, and often take on the shape of the bones they have struck. According to the bone it has reached, the bullet is flattened or concave.
2. It is the same thing with hardened lead bullets that have an envelope. The change of shape consists especially in flattening of the apex, with or without separation from the envelope; but in these cases, again, the surface is flat or concave.
3. With bullets composed of one piece, such as the D bullet, the change of shape is insignificant. In PERFORATIONS, both soft lead bullets and hardened lead bullets with an envelope become flattened are compressed, and become bent from the apex to the base. The flattened surface of the apex is rendered irregular. The increase of diameter, consequent on the compression, results in enlargement of the bony aperture of exit, in the liberation of more splinters, and also in enlargement of the aperture of exit in the soft parts.
Though less marked, the changes of shape in the D bullet are analogous, but do not present any notable irregularity in the surface of the turned-back apex.
With GROOVES, the changes in the shape of the bullets are insignificant.
Foreign Bodies derived from the Clothes.--Diagnosis of foreign bodies derived from the clothes is rendered certain by inspection of the clothes which at the aperture of entry show loss of substance, and indicate the number and the dimensions of the pads, consisting of pieces of clothing, that are in the wound. The surgeon should never forget to make this examination. The enlarged aspect of the aperture of entry WILL ALONE determine the probability of the sojourn of these infecting bodies in the focus; on the other hand, increase in size of the apertures of exit is a sign that makes us presume the existence of a lesion of bone.