WOUNDS OF THE UPPER LIMBS
The new tactics in warfare, which embody prolonged firing from improvised trenches, render the different segments of the upper limbs particularly vulnerable, the result being that wounds of these parts are seen at present with a frequency formerly absolutely unknown. The respective positions of the forearm and of the left arm during firing make these two segments especially liable to simultaneous wounds. The hands also are very frequently hit ; and at the time of bursting of shrapnel the fingers are often wounded because they are unprotected on the knapsack, that they hold up to protect the head (French soldiers).
Wounds of the Hand and Fingers.
The hand is the most exposed part of the upper limb. Its lesions are more than 10 per cent. of the wounds of the limb (Ferraton). They are rarely isolated. Concomitant lesions frequently take effect on the head, the face, or the chest.
Wounds of the hands and fingers are antero-posterior, more often postero -anterior, sometimes transverse, exceptionally axial or longitudinal.
Wounds of the Soft Parts. - The fleshy parts of the thenar, of the hypothenar, of the metacarpal spaces, even of the fingers, are furrowed, sometimes perforated by bullets.
Osseous Lesions. - The phalanges, even the second and third, may be indented or perforated. In spite of their small size, they present the typical lesions of fractures of the long bones. On a level with the articulations, radiography shows the epiphysial lesions, perforations with or without separation of small lateral wedges of bone.
On the metacarpals, Which really are long bones with compact tissue, we see, on the diaphysis, oblique or transverse contact fractures, also grooves and perforations, with typical radiating fissures. Perforation of the diaphysis, with its two principal lateral splinters and a few subdivided splinters either free or adherent, are the most common lesions. The splinters are short, rarely displaced. The grooves or the perforations of the epiphyses are typical, and the radiating fissures cuneiform.
In the lesions from postero-anterior firing, the free splinters are forced towards the palm of the hand. They are very difficult to get at. When the firing is antero-posterior, they are superficial; and when they have been forced onwards, they will be found to have notably increased the extent of the cutaneous perforation. When the range is short, the soft parts of the dorsum of the hand almost present the characteristics of explosive fire.
If hit transversely, the hand and the fingers nearly always show multiple fractures, which belong to the same type, with, however, the peculiarity that the lesion often increases in size from the first to the last fingers, from the first to the last metacarpal bones through which the bullet has passed.
Complications .- Haemorrhage is the most-important and frequent primary complication of these wounds. It is specially profuse when the projectile has penetrated the palm above the horizontal line, starting from the ulnar border of the hand, and going to the inferior border of the thumb in forced abduction (line of E. Boeckel). In this case one of the palmar arches, sometimes both of them, might be wounded. A diagnosis may be made of a lesion of the deep arch, if the wound corresponds to the bases of the thenar and hypothenar eminences.
Metallic foreign bodies and displaced splinters constitute the second immediate complication. A bullet may stop in a phalanx. The hand being bare, there are no foreign bodies derived from the clothes.
Opening of the sheath of the flexor proprius pollicis, and also of the common sheath, which is prolonged to the extremity of the little finger, renders these sheaths liable either to the simple infection of reaction or to suppuration, as well as to the opening up of the sheaths of the finger muscles. Between Boeckel's line and the lower palmar fold of flexion there is a region in which no sheath is reached.
Treatment - After an application of iodine, a simple dressing is sufficient. The palmar splint, to secure immobility, only seems to be of use when the bones of the metacarpus are very much displaced. However it is a good plan to often keep up extension of the fingers on account of their tendency to flex and to remain flexed.
After temporary compression, Boeckel's incision and the median palmar incision of Delorme will allow the surgeon to ligature the two ends of the indented or divided palmar arches. Let us remind medical men that our incision extends from the centre of the. heel of the hand to above the commissure of the index and middle fingers. By the dorsal route one may, perhaps, after removal of the splinters and of the heads of the metacarpal bones, reach the deep palmar arch.
Our median palmar incision is the best for removal of foreign bodies from the palm, as also for opening deep abscesses. Opening abscesses of the sheaths is carried out either by a thenal incision that opens the sheath of the flexor proprius, or by a hypothenal incision (internal palmar incision); finally, if necessary, by radio-ulnar incisions.
Phlegmonous reactions of the sheaths seem to us much less grave than formerly, and unlikely to necessitate the extensive freeing of the radio-carpal ligament that has been proposed.
Baths of tepid boiled water are always useful in phlegmonous inflammation. Hydrogen peroxide also renders signal service in these cases.
Conservatism is indispensable in wounds of the hand, and, at first, should be pushed to its extreme limits. But care must be taken to employ passive motion to both the wounded and the sound fingers as soon as possible, to avoid the stiffness which is so frequent, so regrettable, and so often ascribed to surgical inaction.
However, if, at the beginning, conservatism should be, so to speak, excessive, because the smallest particles of the hand, even if much lacerated, can be of the greatest utility, yet subsequently there must be no hesitation in ridding the patient of any one of the middle fingers that happens to be irretrievably ankylosed, both in flexion or in extension, so that it is not only useless, but also troublesome and in the way. Too extensive and too weak terminal cicatrices, as well as painful cicatrices, may also render amputation necessary.
Total removal of the splinters, trimming the metacarpal fracture by means of resection, are condemned. It may give rise to pseudarthrosis.
Ferraton has very justly said, in speaking of the treatment of the most serious traumatisms (bursting of shells), the most extensive mutilation of the hand and fingers never can bring about such functional troubles as those that would be caused by total loss."
Self- Mutilation. - In all wars, even during the present one, the question has been raised of self-mutilation carried out on the hand and fingers. A faint-hearted soldier obtains at the price of self-mutilation the safety of a life which probably was not even threatened.
In such a case the skilful surgeon must act up to his strict duty. He owes the truth - all the truth-to the commanding officer; but in order that he may pronounce his verdict, on his soul and conscience, the truth must show itself very clearly; and when he feels the slightest doubt, he must refrain from coming to a conclusion of mutilation.
The frequency of wounds of the fingers and of the hand must not be used as an argument. This frequency is normal in battle during the present wars, as the bare hand is very much exposed to bullets.
Diagnosis is based on the verification of a palmo-dorsal wound, especially at the extremity of the index and middle fingers; but mutilation may take place in the palm, as we have already seen. The wound in such a case would still be palmo-dorsal. This sign may lead us to a presumption. In battle, wounds of the fingers and hand are generally dorso-palmar.
Formerly a sign that led to presumption was again drawn from the state of the wounds, which were reduced to pulp, irregular, split up; whilst wounds received from a distance are regular. On the other hand, it must be confessed that wounds inflicted for self-mutilation can be regular, and accidental lesions reduced to pulp and lacerated.
The real indication is furnished by the burnt appearance of the aperture of entry. Around the wound, even in all the palm, if this last has been traversed, the epidermis is dry and black, the edges of the discoloration being INCRUSTED WITH GRAINS OF POWDER. Even when this has disappeared, grains will be found in the derma.
Chemical analysis of the grains in the epidermis would perhaps remove our last doubts. We are studying this The presence of other wounds is in favour of the man's innocence.
Considering the gravity of the disciplinary decisions that proceed from the surgical verdict, it is indispensable that -
1. In conformity with tradition, the verdict should be given by a mixed Commission, composed of surgeons of high rank who are perfectly acquainted with the characteristics of war traumatisms, of a few staff officers, and of the Provost Marshal and his officers.
2. The verdict should be given on a pretty near date to that of the reception of the wound; then all signs are very distinct.
Wounds of the Wrist.
Wounds of the wrist are not very frequent. They are 7 to 8 per cent. in the total of wounds of the limbs.
An inferior, horizontal line passing approximately through the superior and external prominence of the metacarpal bone of the thumb, and a superior line cutting through the forearm at two fingers' breadths above the styloid process of the radius, give the limits of the wrist.
Wounds of this part are antero-posterior - these are rare; or Postero-anterior, which are more frequent, especially on the left side; finally, axial, especially on the right. We can easily understand this if we think of the position of the soldier when firing.
Wounds of the Soft Parts - The soft parts may alone be hit. We have to consider - Tendinous lesions, with penetration of the sheaths; wounds of the vessels and of the nerves.
Osseous Lesions.-When the bones are hit, the lesions differ according to whether the projectile has taken effect on the carpus or on the inferior radio-ulnar extremities.
On the carpus we see indentations on the edges, extensive furrows on the surface, perforations, generally simple, all revealed by localized pain, difficulty of movement; radiographic pictures are rarely conclusive, especially with regard to the relationship of the track to the affected bones. Speaking anatomically, these lesions are simple.
Extension or limitation of the damage on the inferior radio-ulnar extremities are governed by the seat of the lesions. The line of the epiphysis and diaphysis rises only a centimetre above the point of the styloid process of the radius.
Below this line the furrows, grooves, and perforations are of the epiphysial type - that is to say, circumscribed; above they are epiphysial-diaphysial - that is to say, often radiated by fissured tracks which limit more or less completely wedges that have an articular basis, or large splinters.
From a practical point of view, and in an aseptic wound, these fissures do not constitute a complication.
Diagnosis.-In such a superficial articulation the diagnosis of bony lesions is easy. Localized pain make us suspect fissures, radiography sometimes shows them. Equally easy is the diagnosis of arterial (ulnar, radial) and nervous lesions (median, ulnar, radial).
Treatment - Haemorrhage is easily arrested by compression; afterwards by direct ligature, which is indispensable in these cases as a safeguard against a relapse of the bleeding, facilitated by the extensive palmar and dorsal anastomoses.
Possible infection of the sheaths would necessitate dorsal incisions, lateral incisions on the line of the ulnar and radial arteries, or median palmar incisions. Being an uncovered region, the wrist is but little complicated by the presence of infecting foreign bodies.
Conservatism is the rule, even in the most serious traumatisms produced by explosive fire. Immobility is obtained by a palmar splint. Removal of splinters from the carpus, even in infected cases, is rarely of any use, by reason of the limitation of the damage. Clearing out the wound would only be necessitated by persistent osteitis.
Lesions of the wrist are rarely grave. Passive movements of the articulation and of the fingers should be begun early.
Wounds of the Forearm.
The forearm extends from the superior limit of the wrist to a transverse line, passing two fingers' breadths below the fold caused by the flexion of the elbow.
The proportion of these wounds is not as yet completely established. It is said that they represent a tenth of the total lesions of the limbs.
The tracks may be classed as antero-posterior, postero-anterior (these are the most often seen), transverse, which are pretty frequent, and also the most serious (fracture of both bones), and finally axial.
Wounds of the Soft Parts.- Nothing particular can be said on this subject.
Osseous Lesions.-With regard to osseous lesions, they belong to the diaphysial type. They are contusions, cracks, fissures, sometimes revealed by radiography, sometimes by the presence of localized pain (back of ulna); contact fractures, often transverse and oblique, or with large splinters; grooves, with their well-known lines of fissures; fractures by perforation, the most usual.
The adherent splinters are relatively short. The total. length of the osseous focus is 4, 6, 8, 10 centimetres. The free splinters are 1 to 2 centimetres longer. Not only in fractures of but one bone, but even in fractures of both bones, there is not always a tendency to an axial or a lateral deviation. But it is a mistake, and we have seen others make it, to treat these fractures by the application of a simple dressing, however thick and permanent it may such a proceeding exposes the wounded man to useless pain, to consecutive displacements most regrettable, in reference to the preservation of the shape and the usefulness of the limb. A last reason for the employment of an apparatus is that, whilst rendering the dressing easy, it at the same time safeguards the limb from any circular constriction which would be unfavourable to its vitality.
Complete fractures of the ulna generally show less displacement than those of the radius.
Treatment. - Immediate immobility of the forearm can be obtained by a sling, by any splint, by bandages with a straw splint.
We must be careful in applying the dressing not to exert too strong a circular or interosseous constriction, as this might cause gangrene.
Immobilization should be obtained with the forearm in the position of supination; the fragments then will be in good position. In half pronation or in complete pronation, these fragments cross one another, and their extremities are directed towards the axis of the interosseous space (Ferraton).
Our hollowed out metallic splint with valves insures the easy application of the dressings, it enables us to exercise supervision, to push back towards the axis, if necessary, the lateral splinters when they are displaced from the centre, besides, in our hollowed out splint, supination is the natural position.
The splint should be long enough to include part of the arm and the hand, so as to immobilize both the elbow and the wrist.
Antero-posterior or lateral deviations (the last are the most serious, especially of the ulna) are the result of the fragments over-riding, and should be prevented. Pseudarthrosis exposes the limb to the same danger, and pseudarthroses are not rare in the forearm. They are nearly always consecutive to unjustifiable removal of splinters, therefore we must absolutely abstain from doing this, at least at first.
In fractures of both the radius and the ulna, as a consequence of the isolated synostosis of the upper fragments, then of the lower, the movements of pronation and of supination are lost.
In order to reach wounded vessels we must make use of the classical incisions. They should also be utilized in searching for foreign bodies, and in opening purulent collections.
Conservatism must be pushed to its extreme limits. This is the occasion to repeat that whatever the extent of a traumatism due to a bullet, conservatism should be carried out as long as there is no confirmed gangrene.
PROGNOSIS is generally very good, even when the fracture is of a complicated type. For this reason we should most carefully endeavour to obtain a perfect ultimate result.
We need not stop to consider the consecutive nervous and osseous complications.
Wounds of the Elbow.
The elbow is the region comprised between two transverse lines passing at two fingers' breadths, 4 centimetres above and below the fold of flexion.
Its wounds represent one-tenth of the lesions of the upper limb, and 3 per cent. of the total.
The tracks of the bullets that reach it are nearly always antero-posterior, more rarely Postero-anterior or transverse.
Wounds of the Soft Parts. - The only point of interest in wounds of the soft parts lies in lesions of the vessels, haemorrhage from the brachial, from its venae comites, from the superficial veins, and in lesions of the nerves (median, ulnar, radial).
The classical incision for ligature brings the surgeon on to the brachial artery. If it has been divided, the only efficacious plan, in order to prevent blood coming back through the inferior end, is to ligature both ends.
Osseous Lesions. - Osseous lesions should be studied on every bone of the part.
With reference to the elbow, as in dealing with all joints, we have concisely laid down what damage is caused by bullets on the extremity of the humerus, on the radius, and on the ulna.
On the epicondyle and epitrochlea, which are but superadded epiphyses, the grooves, perforations, and abrasions that we see are limited lesions.
On the trochlea and the condyle, the damage caused by bullets whose track is situated below the, epicondylo-condylar line is limited. It is rare for this damage to extend above this line. With regard to the nature of the lesions, they are clean fractures, furrows, perforations, abrasions ; the perforations are nearly always not, or but little, comminuted. From transverse fire the lesions are more important. Generally they are simple.
When the bullet penetrates on the level of the epitrochlear-epicondylar line or below it, the lesion is of the epiphysial-diaphysial type - that is to say, the perforation is accompanied by more or less complete fissured tracts, which are prolonged as much as 5, 6, 7 centimetres above the intervening line, forming nearly always two lateral splinters, which, lower down, enclose a large subperiosteal adherent fragment represented by the condyle and the trochlea. The fracture, whether incomplete or complete, is therefore supracondylar. A secondary fissured tract may make it supra- and inter-condylar.
On the other hand, if the firing, instead of being median, is lateral, only one fissure is found which limits an adherent internal or external condylar fragment.
A bullet that penetrates to the limit of the olecranial and coronoid cavities - that is to say, to two fingers' breadths from the epitrochlear-condylar line - causes a typical diaphysial fracture.
The head of the radius, the coronoid process of the ulna, the upper half of the olecranon, are composed of pure superadded epiphysial tissue. Their lesions are limited.
The bullet that penetrates below the head of the radius to the base of the olecranon, and, a fortiori, below it, gives rise to one or two radiating cuneiform fissures, with a superior base and an apex descending to 3 centimetres below the intervening line.
Diagnosis - The diagnosis, clinically based on the relations of the track to the osseous extremities with which the projectile comes into contact, is at first easy, before the rapid swelling that comes on in this region has set up. But it is necessary, in order that the diagnosis may be precise, for the two segments of the elbow to be replaced, at any rate in the surgeon's mind, in the position they occupied at the moment of the traumatism. Pain, revealed by pressure on the course of the fissures, is a good sign. Radiography will complete the first data.
Treatment. - All bony lesions of the elbow, when caused by bullets, should be treated at first by conservatism, whatever be the comminution, whatever the extent of the damage to the soft parts, even if the brachial artery is involved and the nerves contused. We have proved this in an admirable example we brought before the Academy of Medicine.
At first a sling, a short time afterwards a hollowed out valvular metallic splint, which takes as points of support the arm above and the forearm below, leaving the elbow free, will insure immobilization. A plaster apparatus is not as advantageous as this splint. It is more prudent to secure this immobilization even when there is no abnormal mobility.
Superficial antisepsis with immobility generally suffices to secure recovery. When there is suppuration, the necessary incisions must be made at once.
Superficial and anterior abscesses are opened by the incision that is utilized for ligature of the brachial artery, posterior ones by an axial incision, which, if necessary, will also open the bursa of the olecranon, where suppuration is often started by a slight lesion.
To get to the joint we must have recourse to a posterior, median, supra-olecranal incision, or to a lateral internal short incision skirting the inner border of the triceps and stopping below at the epitrochlea, so as not to wound the ulnar nerve ; finally, to the lateral external curved incision used for resection.
Removal of perfectly free and infected fragments can be accomplished through these incisions, and drainage can be established from one wound to the other.
1f, by reason of the grave nature of the lesions and the slowness of the cure, we apprehend ankylosis, the limb must be placed in a position of flexion at a slightly acute angle, in preference to a barely acute one or to a right angle (Ferraton). The first position is the only one that allows the patient to carry his hand freely to his mouth. The forearm will be in a position midway between pronation and supination; the hand should have the thumb upwards.
Ankylosis is relatively frequent after bullet wounds, for the elbow is a very tight ginglymus that stiffens quickly, and rapidly loses its action without passive movements. Therefore, when there is no suppuration, we must not wait too long before beginning these movements.
Atypical resection should be exceptional; it must only be undertaken at a subsequent period if there is prolonged osteitis.
Wounds of the Arm. From the elbow, whose limits we have given, the region of the arm extends above to a horizontal line which should just touch the inferior border of the pectoralis major.
Wounds of the arm, like those of the forearm and of the elbow, are sometimes isolated, sometimes complicated by simultaneous lesions of the neighbouring parts-the head, the thorax, the abdomen.
Wounds of the soft parts do not call for any special practical consideration. They are sometimes extensive both in front and behind the limb when caused by large shell fragments.
Osseous lesions of the diaphysis of the humerus are typical. They are contusions; longitudinal fissures; fractures by contact, either transverse or oblique, with large splinters; grooved fractures, with their well-known fissures; fractures by perforation, of which the type with two lateral splinters, more or less subdivided, is habitual. In this last lesion the focus of free splinters, that are generally short, usually corresponds to the bony focus of exit, and extends but little.
Splinters adherent to the periosteum are from 6 to 8 centimetres long. The close relationship of the musculo-spiral nerve (in French, radial) to the diaphysis of the humerus is the cause of this nerve often being contused or torn in the fractures.
Treatment - Conservatism is the rule in all fractures of the humerus by bullets.
If immobilization is well insured by Champenois's hollowed out splint, or by a hollowed out metallic splint framed on Hennequin's model, it will be found that application and renewal of the dressings with these apparatus are less easy than with the hollowed out valvular metallic splint. Preference, then, should be given to this last apparatus.
In some fractures of the upper fourth of the humerus, which one has but little power over the superior fragment as it has a tendency to abduction, reduction and regular maintenance of reduction is only obtained by also giving the inferior segment an inclination to abduction. This position is maintained by a big triangular pad fixed against the thorax, with its apex in the axilla, and against which the apparatus and splints rest. These cases are rare.
In complete fractures of the lower part, the point of the inferior fragment has often a tendency to fall forwards. The fracture is reduced by a localized external compression.
In the largest majority of cases, maintenance of the reduced fracture in an axial apparatus will suffice, for the displacement of the fragments is either non-existent, or -ver3 moderate and easily reduced.
Whether the axial or lateral displacements are to reduced or are non-existent, the whole limb must not be too much moved.
The lateral splinters, the free splinters, must not be re. moved at once, but should be carefully brought nearer the extremities of the fragments, whilst resting in the apparatus through pressure exerted by elastic tampons of cotton-wool applied perpendicularly to the course taken by the projectile, Repeated radiographic examination will give the requisite information on the result obtained, and on the one that we must still hope for.
When the wound is properly treated and suppuration has been trivial, recovery is generally very rapid-often it is obtained in nearly as short a time as would be necessary for the consolidation of a simple fracture.
In infected foci purulent collections should be at once opened by lateral incisions - either the internal incision along the internal border of the biceps is employed, or the external incision along the external border of the triceps. The musculo-spiral must be avoided.
We have nothing special to say with regard to lesions of the arteries or of the nerves, to aneuryms, to liberation of the musculo-spiral, which is so often included in callus, to the removal of foreign bodies, to foci of persistent osteitis which we get at by lateral incisions carried to the level of the intermuscular septa. Let us remind surgeons that the external incision, in order to avoid the musculo- spiral, must stop below at 10 centimetres from the epicondyle, and also that subsequent ligature of arteries generally necessitates free incisions.
Wounds of the Shoulder.
Wounds of the Soft Parts. - Amongst the wounds of the shoulder we only have now to study those in the region of the deltoid, of the axilla, and of the articulation. Lesions of the clavicle and of the body of the scapula have been described in the chapter on wounds of the chest.
2.9 per cent. of the wounded men are hit in the shoulder.
Bullet wounds of the axillary or deltoid regions present nothing in particular. Fragments of large projectiles sometimes give rise in these localities to very extensive loss of substance, without, however, opening the joint.
Opening of, the large subdeltoid serous bursa is of no importance so long as the wound remains aseptic. When it is infected (shrapnel bullets, shell fragments, deflected bullets), a rapidly developed abscess is the result.
A bullet may pass between the acromion and the articulation without opening the joint.
We should only be saying the same things over again if we dwelt on the characteristics and the prognosis of lesions of the axillary artery and vein. These large vessels give rise to formidable primary and secondary haemorrhage, to arterial and arterio-venous haematomata, that necessitate, in the hands of an experienced surgeon, subsequent difficult operations. Primary or secondary haemorrhage must be treated by direct ligature. Indirect ligature of the subclavian fails in two-thirds of the cases.
The nerves of the brachial plexus, the circumflex nerve, are, like the important arteries, either wounded separately or at the same time as the bones.
Osseous Lesions. - On the superior extremity of the humerus, the growing or epiphysial cartilage, that differentiates lesions of the head of the bone from those of the remainder of the articular extremity, corresponds to the anatomical neck. The tuberosities are superadded parts that are developed from special bony points, and that retain their individuality with regard to their wounds.
HEAD OF THE HUMERUS
1. Bullets that, above the cartilage of. the anatomical neck, reach the head of the humerus, cause furrows, hollowing out, simple perforations, or may break it up. This last is rare, but even in such cases the fragments remain in contact.
2. If the projectile penetrates at the level of the anatomical neck about its centre, the head of the bone is separated from the shaft by a fissure, but nevertheless it remains very adherent, thanks to the fasciculi of fibrous tissue about it and the periosteum.
3. If the penetration of the bullet has taken place near the greater tuberosity. This latter is separated by a wedge-shaped fissure, with the base uppermost, but the fragment, which has fixed limits, is very adherent.
4. Under the anatomical neck, on the surgical neck, the lesion is epiphysial-diaphysial; the fissures may be extended.
5. The greater tuberosity is excavated as by a groove, superficially perforated or deeply perforated. The lesion is limited to the tuberosity when the firing has been antero-posterior. If it has been transverse, the bullet has followed an epiphysial-diaphysial track, and has led, on the head of the bone and on the diaphysis, to the formation of two large lateral splinters.
6. The lesser tuberosity may be abraded.
GLENOID CAVITY - In the glenoid cavity we observe furrows, simple or fissured, perforations. The fragments are nearly always held in place by the insertions of the capsule.
Diagnosis - Lesions of the shoulder-joint, by reason of the great thickness of the soft parts covering it, and of the extensive swelling which sometimes very rapidly invades the region, should be diagnosed especially by taking into account the seat of the wounds and their relationship to the points occupied by the extremity of the humerus and by the epiphysial-diaphysial line. Wounds of the glenoid cavity can only be suspected without the help of radiography.
We have given very precise data for insuring the diagnosis of lesions of the upper end of the humerus.
IN FRONT - By moderately strong pressure we can recognize the tip of the coracoid process in the deltoid-pectoral space. From this tip we drop a vertical line. The inferior limit of the anatomical neck of the humerus is, on this vertical line, a finger's breadth below the coracoid tip and a little internal to it.
If from the most prominent, the most external, part of the acromion we draw a line which ends at the point previously fixed, the resulting oblique line gives the direction and the seat of the anatomical neck.
With the arm falling vertically, we can make out the rounded head of the humerus above this line; the lesser tuberosity and the diaphysis are below it.
AT THE BACK - If we unite the same acromial point to the prominent angle of the scapula, with the arm falling vertically, we mark out the line of the anatomical neck.
Its inferior limit is where the preceding line intersects a vertical line dropped from the acromio-clavicular articulation, which canbe recognized by the prominence of the outer extremity of the clavicle.
If the line of the neck be carried backwards, we make out, above it the head, and below it the remainder of the humerus, in the same way as in front.
With these data, confirmed by radiography, it is easy to recognize the bony points that have been wounded. Our anatomical and pathological knowledge will indicate the character, the limits, and the extension of the lesions.
Treatment. - Conservatism is the rule in lesions of the shoulder. It is primarily applicable in nearly all injuries caused by bullets, even in the most serious ones.
Amputation would only be justifiable in confirmed gangrene. Immobility is at first obtained by a sling and by fixing the arm to the body. Subsequent immobility and keeping in position necessitate the employment of other methods. A hollowed out splint is one of the best apparatus.
The ordinary hollowed out splints made of iron wire are detestable; their equilibrium is unstable, they get out of place, forcing the patient to stiffen himself to keep them from falling off, or to constantly hold them up with his hand; besides, they do not allow an easy application of dressings. Hennequin's hollowed out plaster splint, Champenois's splint, and, above all, our hollowed out splint with valves, lengthened out when necessary, in certain cases, in order to cover over the whole shoulder, are preferable.
Extension is necessary in some fractures of the surgical neck, but these cases are rare. Our apparatus, which exerts counter-extension in the axilla and extension on the elbow, realizes these desiderata with great simplicity.
A few notches are made in the part of its upper edge which rests in the axilla; the flaps thus formed, that correspond to the armpit, are evenly turned down and well padded A spica bandage of the neck and the axilla is then put on it firmly fixes the apparatus above, and gives it a power of counter-extension. Extension is made on the elbow by bandages.
In infected wounds, abscesses under the deltoid must be opened in front by the anterior vertical deltoid incision used in excision, carried a little outside the deltoid pectoral line. Behind a symmetrical incision may be made, but it must not descend more than 4 centimetres below the acromion, so as to avoid wounding the circumflex nerve.
Collections of pus in the axilla are incised behind the inferior border of the pectoralis major; periscapular collections along the spinal border of the scapula, and the incision is followed, when necessary, by freeing of the bone with the finger.
Removal of splinters that cause intolerable suffering will be done through the same routes.
Atypical excision is quite allowable, but only at a future period and in cases of persistent osteitis.
The grave disturbances caused by shell fragments may necessitate a disarticulation. We must bear in mind that a disarticulation of the shoulder can be done by placing the knife almost exactly under the acromion (Ledran), and in this way that an excellent stump can be made. The typical intrascapular thoracic disarticulation is, so to speak, never indicated.
Wounds of the lower limbs