Volkmann splint may also be used. If, however, both bones have been broken and there is overriding of the fragments, extension must be applied. When the injury lies in the upper half of the calf, adhesive plaster strapping attached to the Thomas splint or to the iron bar incorporated in a plaster dressing extending to the pelvis, gives effective extension. In

FIG. 22.-Tracing of roentgenogram of the patient illustrated in Fig. 23. a, One week after the injury. b, Three and a half months later. those instances, however, where the fracture lies near the ankle-joint, it is impossible to secure the necessary traction by adhesive plaster and then recourse must be had either to a nail driven through the lower extremity of the tibia, to the bonetongs, or to the wire method referred to on page 36. The surgeon must not rest content until he has applied sufficient traction to overcome the shortening. The danger of infection which may be urged as an argument against the insertion of

any instrument directly into the bone, becomes minimal if careful asepsis be exercised.

If there are extensive wounds of the soft parts, as was the case in the patient whose roentgenogram-tracing is shown in Fig. 22, the fenestrated plaster dressing reinforced by iron bands can be used to great advantage. To prevent sagging of the calf backward, it is held by a gauze bandage (see Fig. 23) in which it rests comfortably as in a hammock.

FIG. 23. A fenestrated plaster dressing for severe compound fracture of the tibia. The backward sagging of the bone is prevented by the gauze bandages in which the leg is suspended as in a hammock. For the roentgenogram of this case see Fig. 22.

Injuries to the Ankle. When wounds are present on both the internal and external aspects of the joint, with a drainage. opening on the posterior surface, these are, in my experience, the most difficult of all gunshot injuries of the bones to splint properly. Even the ingenious crab splint of Jones fails to meet the requirements of these extensive lacerations. The only method I have found of avail is the fenestrated plaster dressing reinforced by iron bands, as shown in Fig. 24. The padding and plaster are applied as described on page 25, then the iron band, bent as indicated in the figure, is fastened in place by another layer of plaster bandages. The loop of metal projecting beyond the toes serves for the attachment of the adhesive plaster strips which keep the foot from slipping backward.

The problem is as easy in the cases where there is a clean wound as it is difficult in the extensive lacerations. Any one of several methods may be employed to hold the foot at right angles and fix it in this position: the crab splint, the Volkmann, the moulded plaster, or the wooden splintconsisting of two boards nailed together at right angles and suitably padded.

The iron band

Adhesive plaster

FIG. 24.-Diagram illustrating the dressing applicable to severe injuries to the ankle joint which require free incisions not only laterally but posteriorly. The iron band is incorporated in a plaster dressing which encircles the upper two-thirds of the calf and the metacarpal region of the foot. The adhesive plaster prevents a backward sagging of the foot.

Injuries to the Metatarsal Bones and to the Toes.-Little can be accomplished by a splint, since, except in very extensive injuries which usually demand amputation, it seldom occurs that more than one or two bones are shattered, and those not injured act as effective internal splints. Drop foot is prevented and the patient rendered more comfortable by a well padded external support which holds the foot at a right angle to the leg.

CHAPTER II

INJURIES TO THE NERVES

Lesions of the peripheral nerves complicate so large a percentage of gunshot injuries to the extremities that no examination of a wounded soldier is complete unless the surgeon tests the function of the nerves that may have been injured. This neurological examination is important even at the front, since the treatment of the nerve injury should begin as soon as the patient reaches medical hands. A splint for the nerve is frequently fully as important as a splint for the fractured bone, and just as the bone injury must be treated at the front, so, too, the nerve injury should be properly cared for without delay. It is therefore necessary for every surgeon to have at his fingers' ends the simple tests for nerve injuries. I am led to give these in detail, because experience in approximately 100 cases of gunshot injuries of the peripheral nerves has shown that the classical descriptions are in some instances inaccurate.

Symptoms of Injury to the Peripheral Nerves.-1. Musculospiral Nerve. The patient is unable to extend the hand at the wrist, to extend the proximal phalanx of the four fingers, or to extend the thumb. Extension of the two distal phalanges is possible owing to the action of the interossei and lumbricales which insert into the extensor tendon just proximal to the first interphalangeal joint. Supination is weakened and, in cases of injuries to the musculospiral near the axilla, extension of the elbow is also weakened. Total paralysis of the triceps occurs only as the greatest rarity, because that branch to the inner head known as the ulnar collateral pursues a separate course and is therefore not encountered by the projectile which has injured the parent trunk.

The sensory disturbance varies markedly from case to case. In not one instance did I see an anesthesia corresponding to

the distribution of the sensory branches of the nerve, that is, over the dorsum of the thumb, second, third, and half of the fourth finger. Usually the anesthetic area is not larger than a fifty-cent piece, and is located on the dorsum of the hand near the base of the thumb. Very often, however, even the most careful tests fail to reveal any sensory disturbance whatever.

2. Ulnar Nerve.-Injuries to this nerve are peculiarly variable in the extent of the motor symptoms. In some cases there is a very marked interference with the flexion of the fingers; in other instances, there is no appreciable disturbance except a slight weakening of the fourth and fifth fingers. The only

motor symptom that is constantly found is the inability to spread the fingers wide apart, due to the paralysis of the dorsal interossei. Even this symptom must be viewed critically since the long extensor tendons enable the patient to spread the fingers somewhat apart. In contrast to the variability of the motor symptoms, is the constancy of the sensory disturbance. There is regularly anæsthesia over the entire little finger, the ulnar half of the fourth finger, and the ulnar border of the hand. In cases where the injury to the nerve occurs a short distance above the wrist, the anesthetic area is present only on the palmar surface, owing to the fact that