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be avoided is an overstretching of the injured muscle which will result in an inability to abduct the arm. It must therefore be fixed in the abducted position by one of the methods already outlined.
FIG. 30.-Shell injury to the right side of the neck and of the back. type of injury requires a plaster dressing holding the head toward the left side, otherwise a torticollis will result or an elevation of the right shoulder.
Injuries to the Pectoralis Major.-In the case of this muscle, the abducted position should be used, otherwise the arm will be bound closely to the body by the formation of scar tissue.
Biceps and Brachialis Anticus.-Injuries of these muscles, too, tend to result in contractures; therefore the arm must be kept extended. I have not found it advisable to hold the arm in the position of complete extension but rather to keep it at
an angle of about 160°, since otherwise the two portions of the flexor muscles are drawn excessively far apart and the union between them is too weak to be effective.
Triceps. Here, too, the position should not be one of extreme flexion nor of extreme extension, but about midway between the two (140°).
FIG. 31.-Plaster dressing applied after severe injury to the right side of the neck. The window necessary for dressing the wound has not as yet been cut. Immobilization in this position is necessary to prevent development of torticollis, or of an elevation of the shoulder with a consequent scoliosis.
Flexor Muscles of the Forearm.-In injuries to these muscles the tendency to flexion contracture of the fingers is very marked and should be prevented by a light splint which holds the fingers extended.
Extensor Muscles of the Forearm.-In sharp contradistinction to the flexor muscles, there is no tendency whatever to contracture. Instead, the fingers and hand drop and the
patient later is unable to extend them. The splint therefore must hold the hand and fingers extended.
Injuries in the Palm or on the Dorsum of the Hand.-As a rule, one projectile severs both the flexors and extensors and there is nothing to do except immobilize in the mid-position. If the extensors alone are divided, or the flexors alone, then the
Elevation of the left shoulder due to gunshot injury in the neighborhood of the left trapezius muscle. A deformity of this type tends to occur when an immobilizing dressing, as shown in Fig. 31, is not applied.
fingers should be splinted so as to bring the tendon ends as near together as possible; that is, in the case of the flexors, by bending the fingers; in the case of the extensors, by keeping them extended.
In very rare cases of gunshot injuries it is possible to perform an immediate suture of divided tendons. The methods of tendon suture are described on pages 171 and 175. Here it is simply important to emphasize the necessity of splinting the
fingers after such a suture in the position of maximum relaxation so as to avoid tension on the line of suture.
Injuries to the Tendons of the Fingers.—There is usually very little to gain by a splint because the tendons become hopelessly adherent to the shattered bone. In rare instances, where the tendon alone is injured (this applies particularly to the extensors) I have found it helpful to splint the part in such a way as to bring the tendon ends together.
Injuries to the Gluteal Muscles. In extensive injuries to these muscles it is well to abduct the thigh about 30° and keep it slightly hyper-extended, since otherwise the muscles tend to become weak and unable to keep the pelvis level when the patient is standing on the injured leg. That is, the same phenomenon is likely to occur after their injury as is found in cases of congenital dislocation of the hip where, owing to the elevation of the trochanter, the muscles are working at a mechanical disadvantage (Trendelenburg's sign).
Injuries to the Flexors of the Hip.-These muscles, on the contrary, tend to contract when injured, and a flexion contracture will probably result unless the thigh is kept fully extended.
Quadriceps Extensor.-The calf must be held extended, otherwise there will be a weakness of the extensor muscle.
Injuries to the Hamstring Muscles.-These tend to flexion contracture, and the knee must therefore be kept extended.
Injuries to the Gastrocnemius and Soleus Muscles. In this type of injury, the foot rapidly assumes the position of equinus unless it is held at right angles by an appropriate splint (see Fig. 29).
Injuries to the Extensor Muscles of the Foot.-These are quickly overstretched when injured and the foot should therefore be held in the position of maximum dorsal flexion.
Injuries to the Skin Produced by Extensive Burns.-These will be considered chiefly in the second part of the book, where the work of the base hospital is given in detail. At the front, immobilization should follow the rules laid down for injuries to the muscles and tendons of the corresponding portions of the body.
TRANSPORTATION OF THE WOUNDED
The transportation of the soldiers from the front to the base hospitals, although one of the most important problems of modern warfare, hardly falls within the scope of this book. From the orthopedist's point of view, the most important element in the success of the transportation lies in the effectiveness of the fixation method applied by the surgeon at the
FIG. 33.-a, Tapson's spring clip. b, Showing use of Tapson's spring clip. front. The most approved methods of transport will fail entirely if the surgeon has not done his work properly, and even the most cumbersome and old-fashioned vehicle will suffice if the part has been so splinted as to keep the injured limb absolutely at rest.
To bring the wounded from the trench to the bandage place or Hospital, a particularly ingenious device has been suggested