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Prognosis.-In gunshot injuries the operator cannot hope for primary union and healing of the graft in all cases. series of forty bone grafts successful healing occurred in 65 per cent. This average would probably have been distinctly bettered had I realized from the outset the necessity of postponing the operation for several months after every indication of infection had disappeared, since in the last 20 cases, in which this rule was closely observed, healing occurred in 90 per cent. (See Figs. 53 and 54.)

CHAPTER VI

JOINT INJURIES

This book is concerned essentially with gunshot wounds. Therefore, I shall not deal with those traumatic injuries to joints which are frequently seen in times of peace, such as sprains, lesions of the semilunar cartilages, dislocations, etc., nor with diseases of joints, although, of course, the soldier is more liable to these joint troubles than the civilian. The military surgeon must be as well acquainted with their treatment as with that of gunshot injuries.

Nor are we concerned with the immediate surgical treatment of gunshot injuries to the joints—the technic of drainage, methods of resection, etc. In passing, however, I want to emphasize one important fact relative to the treatment of infected gunshot wounds of the hip with involvement of the femoral head: Effective drainage can be secured only by resecting the femur. That this operation is not a crippling one is evidenced by Fig. 55, which shows the result after resection of the head, neck and a part of the great trochanter. From the orthopedic point of view the after-treatment is of importance. To prevent the shortening which injudicious posture would cause, the thigh should be abducted sufficiently to prevent the trochanter from slipping upward. A plaster spica is not necessary, since the position is easily maintained by traction in the abducted direction.

When discussing the work at the front, the position in which to immobilize gunshot injuries to the joints, was considered in detail. In the base hospital, the immobilization should be continued until all danger of infection has subsided.

In employing methods of mobilizing joints, it is important to distinguish between those cases in which there has been destruction of the joint cartilage and those in which the limitation of motion is due merely to adhesive bands. In the case of the latter, vigorous methods are possible, which if applied to the former would result disastrously. I shall consider first:

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Fig. 55.—Result six months after excision of the head, neck and portion of the great trochanter of the left femur due to extensive gunshot injury of the hip. Shortening of only 1 inch. Voluntary flexion and abduction almost to the normal range. Patient able to walk four hours without fatigue.

Treatment of Adhesive Bands, Either Within or in the Immediate Proximity of the Joints, in cases uncomplicated by infection. Under these circumstances, it is safe to rupture the adhesions. Although an anæsthetic is useful in securing muscular relaxation and in sparing the patient pain, in many instances it is preferable, from the patient's point of view, to avoid the risk of anæsthesia. Whether with or without an anæsthetic, the methods employed are the same.

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Fig. 56.-Schede splints for the after-treatment of injuries in the neighborhood of joints. By simply changing the position of the intermediate bar, the splints can be used to produce either extension or flexion. The traction is exerted by means of a stout cord, which the patient himself easily learns to adjust.

Steady force is applied to the extremity first in one direction, then in another until the adhesive bands are ruptured; the bone should be protected during this procedure by a splint or by the hand of the operator. The work is not to be considered complete until joint motion is free in all directions.

For each joint, certain grips are of particular value in breaking up the adhesions. For a knowledge of this medical jiujitsu, I am particularly indebted to Sir Robert Jones. In breaking up adhesions in the neighborhood of the shoulder, the scapula should be fixed by an assistant, who grasps the patient firmly from the opposite side of the body. The operator grasps the humerus a short distance above the condyles, and with one hand steadying the head in the axilla forcefully and

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Fig. 57.—The Schede splint applied to an injury on the anterior aspect of the elbow joint. The traction exerted by the cord gradually overcomes the flexion contracture.

gradually abducts. When motion with the scapula fixed is possible to 90°, the assistant should let go, so that the full range of abduction can be tested. With the scapula again fixed, rotary movements are performed, and with the arm abducted 90° it is brought forward and then forced backward. One carefully executed motion in each direction suffices to break up the adhesions.

At the elbow, the most usual adhesion is one preventing extension. The surgeon brings the patient's upper arm against

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