296

Injury, 6, 296-305

Analysis of fractures treated in the Royal Victoria Hospital, Belfast, in 1972, with special reference to gunshot wounds and bomb blast injuries J. W. Calderwood Royal

Victoria

Hospital,

Belfast

Summary

The total number of patients admitted to the Fracture Unit in the Royal Victoria Hosoital in 1972 is recorded and classified according to cause. Fractures resulting from gunshot wounds and bomb injuries are examined more closely together with associated injuries and complications. These groups are compared briefly with the open fractures resulting from road traffic accidents. Treatment of fractures in gunshot wounds and bomb injuries is discussed. Reference is made to the mechanisms of injury by gunshot and explosions.

hospital. These 2 incidents were on a scale comparable to the Old Bailey explosion in London on 8 February, 1973, when 19 patients were admitted to St Bartholomew’s Hospital from a total of 160 people injured (Caro and Irving, 1973).

INTRODUCTION

CIVIL disorder on a large scale in the British Isles has been unknown in recent times until its advent in Northern Ireland in August, 1969. Belfast has been involved to a large extent in this disorder. The Royal Victoria1 Hospital, as the main accident hospital in Belfast, is in the unique position of being close to the areas which are frequently involved in various aspects of disorder, and consequently has taken the majority of the casualties. During the three years from August, 1969 to 1972 the hospital used its disaster drill on 46 occasions. This is in comparison with 42 disasters recorded in the United Kingdom as a whole over a period of 20 years (Rutherford, 1973). In 1972 the peak month occurred when on 4 March, 25 patients were admitted out of 83 patients injured by an explosion in the Abercorn Restaurant, and two people were dead before arrival at hospital. On 20 March, 17 patients were admitted out of 127 people injured in an explosion at Donegall Street, and 4 people were dead before arrival at

Fig. 1.-Age/sex relationship the Fracture Unit in 1972.

of patients admitted to

These casualties have required the skills of many of the surgical and medical disciplines which are present in the 780-bed hospital. Among the surgical specialities in the Royal Victoria Hospital, is the Fracture Unit, which has 45 beds for inpatients and a Fracture Clinic for outpatients. The purpose of this paper is to record the types of cases admitted during a selected period as inpatients to the Fracture Unit in the Royal Victoria Hospital and to show the work involved, and the problems presented by the arrival of large numbers of cases with gunshot wounds and bomb injuries to what was already a busy

Calderwood

: Analysis of Fractures

297

fracture unit. The fracture cases recorded are, of course, only some of the casualties admitted to the Royal Victoria Hospital.

most common cause of fractures was still domestic falls, occurring predominantly in females. (Eddy, 1972; Editorial, Lancet, 1972).

MATERIAL

CAUSE

The year 1972 has been taken for this analysis, with follow-up for one year, or to discharge from review if this occurred earlier.

Causes of injury were divided into gunshot, bomb explosion, road accident and others. Of the total of 181 patients in the road accident group there were 103 car occupants, 57

Table /.-Causes of fractures with percentages each group and male/female incidence Cause

No.

Gunshot Bomb injury Road accidents Fall Occupational Sports Miscellaneous Total

110 41 181 224 33 15 22 626

% of total 17.5 6.5 29 36 5 2.5 3.5 100

in

Male

Female

102 31 128 65 33 15 15 389

8 10 53 159 7 237

Tab/e //.-Severity

,i,e, /

cause

Fig. 2.-Cause

GW.lld

Kceri

Lxplorinn

524 102 417 209 110* 41* 42

* 72 per cent open fractures requiring admission.

During the year 626 people were admitted with fractures. Patients were often admitted to other wards initially, and later transferred to the fracture unit as soon as beds were available, unless their fractures were of little importance in comparison with their other injuries. Of these 626 patients there were 391 males and 235 females. Ages ranged from 9 to 99 years. Fig. 1 shows the age/sex distribution of the cases. The usual male predominance in the younger groups is accentuated by the large number of gunshot wounds which occurred in these groups, as might be expected. Among older persons the

ALC

and causes of fractures

Fractures Major Minor Closed Open Caused by gunshot Caused by bombs Caused by road accidents

ADMISSIONS

F-11I

(see Table I and Fig. 2)

pedestrians, 19 motor cyclists and 2 pedal cyclists. The group of other causes is subdivided as follows: Falls-these were mainly domestic, but included falls outside the home when these were not the results of road accidents or occupation; Occupational-these were mostly industrial injuries; Sports and Miscellaneous-of the total of 22 patients in this group there were 9 cases from common assault, 3 from aeroplane crashes, 3 pathological fractures, 2 from a fight, 2 from a twisting injury, and 3 for which there was no known cause of injury. As some of these patients with fractures were admitted because of other injury or because of

ckc”pa~,oll”l

iporh

OflIe,

W”“,?d

OF

INJURY

of injury with male/female

WITH

MALE FLMALE

INClDENCt

incidence in patients admitted to the Fracture Unit in 1972.

injury: the British Journal of Accident Surgery Vol. ~/NO. 4

298

Table ///.-Gunshot

wounds

Fractures

injuries, and for comparison to look open fractures resulting from road (Table II).

No.

briefly at accidents

Upper limb 2 Clavicle 2 Scapula 12 Humerus 2 Epicondyle Radius 10 4 Ulna Radius and ulna 3 Carpals 1 Fingers, including metacarpals 18 Lower limb Head of femur 1 lntertrochanteric region 2 Shaft of femur 17 Condyle of femur 3 Patella 3 Tibia 18 6 Fibula Tibia and fibula 9 Tarsals 3 8 Metatarsals and toes Pelvis Iliac crest 2 Pubic ramus 2 Spine Tl 1 Tll 1 Ll 2 L2 and 3 1 +soft-tissue injury lumbar spine region 2

Gunshot wounds Table ZZZshows the 133 fractures sustained by 110 patients with gunshot wounds. Associated with these fractures notable injuries occurred locally at the site of the gunshot wound in 19 patients. These are listed in Table IV.

disease, their fractures were classified as major or minor according to whether or not the fracture itself required the patients to be treated as inpatients. It is proposed to look more fully at the fractures sustained from gunshot wounds and bomb

Paraplegia occurred with all the gunshot wounds of the spine, except for one patient with fractures at L2/L3 level in whom paralysis affected the left leg only. Exploration of the spine was carried out and a prolapsed intervertebral disc removed, but there was no neurological recovery. Two patients with paraplegia had no fracture of the spine, the missile had passed close to the lumbar spine, but through soft tissues only. Twenty-four patients had other serious injuries which were usually caused by further gunshots, (Table V). Treatment is also listed. In a few cases a bullet entering the chest or abdomen had already passed through an upper limb. In addition to the injuries listed in Table V, three patients sustained severe closed head injuries, one of them died after 24 hours. There were also two patients who sustained fractures of the facial bones.

Tab/e V.-Associated major gunshot injuries in patients with fractures

Site of gunshot

Head Chest Abdomen

Bladder

Table /l/.-Associated injuries occurring locally at the site of the gunshot wound Injury Nerve injury

Paraplegia Monoplegia Vascular injury

Site Nerve to supra- and infraspinatus Ulnar nerve Radial nerve Digital nerve Sciatic nerve Lateral popliteal nerve Saphenous nerve

Femoral artery and vein Femoral vein

wound

No.

1 2 2 1 1 1 1 6 1 2 1

No. of cases 4 8 10

2

Treatment Exploration Thoracotomy Laparotomy 1 suture of ruptured liver 1 nephrectomy 1 hemicolectomy 1 repair of jejunum 2 partial resections of colon with colostomies 1 repair of perforated colon with colostomy 1 appendicectomy 2 cases without visceral injury Exploration and repair

Bomb injuries Table VI shows the fractures received as a result of bomb injuries in 41 patients. In this group of

Calderwood

: Analysis of Fractures

299

patients there were 62 fractures and 12 traumatic amputations. Associated major injuries are shown in Table VII, together with a note of treatment. Table V/.-Bomb

injuries

Fractures

MO.

Upper limb Clavicle Humerus Radius and ulna Ulna Fingers Lower limb Femoral shaft Tibia and fibula Tibia Malleolus Tarsals Toes, including metatarsals Traumatic amputations Humerus Forearm Hand Thigh Through knee Below knee

1 4 1 1 7 8 10 4 7 4 15 1 2 : 1 4

In addition to these injuries almost all patients admitted after bomb injuries suffered from partial loss of hearing. Many patients quickly recovered, but 11 remained moderately deaf. Tab/e l///.-Associated major injuries by bombs in patients with fractures Injury

No.

Severe head injury Perforating chest injury Blast lung

2 2 4

Perforating abdominal injury

2

Vascular injury

1

Fracture of maxilla Fracture of mandible Perforating eye injuries

1 3 5

Treatment Burr holes Thoracotomy Positive pressure respiration 1 laparotomy and bowel resection 1 nephrectomy Vein graft of popliteal artery Wiring Suture

Several others continued to complain of a slight defect. Severe and extensive laceration was almost alwayspresent,and such wounds often constituted

major injuries in themselves. The fractured limb received the most severe laceration, but in 17 patients there were also extensive wounds on other limbs, and often all four limbs were involved. Eight patients had multiple lacerated wounds of the face and scalp. In many of these cases there were also severe burns. As shown in Table VII one patient sustained an injury to the popliteal artery. This became apparent only after 3 days, when a false aneurysm of the popliteal artery was diagnosed. A vein graft was inserted, but ischaemia later developed Table V///.-Open road accidents

fractures caused by

No.

Fractures Upper limb Humerus Ulna Fingers Lower limb Femur Patella Tibia and fibula Malleolus Tarsals

1 4 1 3 2 29 1 1

and amputation below the knee was necessary. The wound leading to the damaged vessel was only 6 mm in length, which emphasizes the need to remember the possible complications of puncture wounds of the limb. Open fractures road accidents

resulting

from

Table VZZZ shows the 42 open fractures caused by road accidents in 40 patients. One below-knee amputation was carried out.

FOLLOW-UP

The period of follow-up was one year, or to discharge from review if this occurred earlier. Not all patients were available for follow-up at the Royal Victoria Hospital because the admission of large numbers of patients to the fracture unit made it necessary to transfer some of those already treated to other hospitals for convalescence when they were fit to be moved. Soldiers were usually transferred to the Military Hospital after their early treatment. Civilian patients were transferred to hospitals in Belfast, or outside, if this was convenient for the patient. Of the 110 patients with 133 fractures by

300

Injury: the British Journal of Accident Surgery Vol. ~/NO. 4

gunshot,22with27fracturesweretransferredtothe Military Hospital for convalescence. Six patients with 7fracturesweretransferred to other hospitals, and 2 patients died. There were, therefore, 80 patients with97 fractures who attended forreview. Of these patients, 35 attended for six months or more,and13attendedforoneyearormore.Theincidence of infection and the particular complications of fractures are derived from these 80 patients.

Fig. 3.-Gunshot wound of right forearm immobilized by primary internal fixation using a Rush pin in the ulna.

Fig. 4.-Gunshot wound of the right humerus showing abundant new bone formation 10 months after injury.

Of the 41 patients with bomb injuries, 30 were available for review, these had 47 fractures. Nine were transferred to other hospitals and 2 died. Nineteen patients were reviewed for six months to one year, and 10 attended for one year or more. The incidence of infection is calculated on 41 patients because none with noteworthy infection was transferred, whereas the incidence of complications of fractures is calculated on the 30 patients available for review. In 40 patients with open fractures caused by road accidents, 7 patients were transferred to other hospitals, and 2 died. This left 31 patients with 33 fractures who attended for review. Ten of these patients attended for six months to one year, and 11 others attended for one year or more. As with bomb injuries, no patient with a noteworthy infection was transferred to another hospital within three weeks of admission. The

incidence of wound infection is, therefore, based on all 40 patients, whereas the incidence of complications of fractures is based on the 31 patients who were available for late assessment. TREATMENT Gunshot wounds As a general policy, all fractures caused by gunshot were treated by careful exploration and This often excision. necessitated extensive incisions, because the entry and exit wounds were frequently only l-2 cm in diameter. Wide resection of badly damaged soft tissue was carried out, muscle being cut back until it showed free bleeding and twitched when cut or pinched. On some occasions up to a kilogram of damaged tissue required removal. Grossly contaminated soft tissue was also excised, as were the edges of the skin wounds. The wounds were left widely

Calderwood : Analysis of Fractures

Fig. 5.-Fracture of the right femur following a bomb injury, showing comminution and gross contamination with foreign bodies.

Fig. 6.-Traumatic to a bomb injury.

open for drainage in spite of the underlying fractures, and delayed primary suture was carried out after 5 to 7 days. Wounds treated in this way were very often surprisingly clean and healthy at the time of delayed primary suture. All patients received antibiotics, usually ampicillin/flucloxacillin 500 mg six hourly, and occasionally cephaloridine 500 mg six hourly, or some other antibiotic, Tetanus toxoid was routinely given. Among the cases recorded there were 6 patients whose wounds were sewn up at the original operation. In all these cases sutures had to be removed because the patients’ temperatures remained elevated, and they became very ill. In a few cases in which comminution of the bone was extreme, primary internal fixation was carried out to stabilize the limb (Fig. 3), but most fractures were reduced with general anaesthesia and placed in plaster-of-Paris or a splint. In the lower limb, where fractures were very unstable, skeletal traction was often used, a Steinmann’s pin being inserted through the tibia or the OS calcis. In most cases this gave a satisfactory result. However, even without internal fixation, some fractures showed satisfactory bony union

in spite of gross comminution and the presence of foreign bodies (Fig. 4). It is interesting to note that massive swelling occurred after gunshot wounds, especially those of the thigh. This was presumably an effect of the shock waves and temporary cavitation of the soft tissues adjacent to the track of the missile. One hundred and eighty five general anaesthetits were given to 110 patients with gunshot wounds in the first two weeks after their admission.

amputation

of the right hand due

Bomb injuries In the treatment of bomb injuries the main problem was often the soft-tissue damage associated with the fractures. Laceration and extensive soft-tissue damage were often major injuries in their own right. Contamination of these wounds was severe. Fragments of metal and wood, pieces of clothing and road dirt made it very difficult to obtain a clean wound. Extensive excision of damaged tissue was almost always necessary. In many cases loss of skin caused difficulty in covering the fracture sites so that they required release incisions, or skin flaps had sometimes to be used in spite of the contamination.

Injury: the British Journal of Accident Surgery Vol. ~/NO. 4

302

Such wounds were at first left widely open for drainage, and split-skin grafts or pinch grafts were frequently carried out after a suitable interval. Again the fractures were placed in splints or plaster-of-Paris. Occasionally skeletal traction

Tab/e /%.-Complications by gunshot

Complication

Delayed

union

Non-union

of fractures

Site

Radius Ulna Humerus lntertrochanteric fracture of femur Shaft of femur Tibia and fibula

Osteomyelitis Deep venous thrombosis Fat embolism

caused

No.

Incidence (per cent)

1 2 1

3

Complication

Delayed

union

Non-union

Osteomyelitis

of fractures

Site

5.1 2

3 1

3.7 1.2

Tibia and fibula Femur Humerus Ulna Radius and ulna Tibia and fibula

caused

No.

3 1 1 1 1 2 4

Road accidents Open fractures from road accidents were treated by excision and exploration, but the wounds were closed wherever possible, except in very few cases in which there was gross contamination of the deep tissues. The fractures were splinted and antibiotics and tetanus toxoid given.

Table X/.-Complications road accidents

Complication

l 1 2 2

was used if this was practicable in the presence of the wounds. Antibiotics were prescribed in all cases, and tetanus toxoid was given. Fig. 5 shows large pieces of foreign material present around the fracture in a patient who was injured by a bomb. This femur united satisfactorily in 5 months. Table X.-Complications by bombs

particularly after the first 10 days, had dressings changed without anaesthesia.

Incidence (P er cent)

8.5

10.6 8.5

As shown in Table VI there were 12 traumatic amputations. These injuries were treated by excision and exploration. The amputation stump was trimmed to allow good skin cover. Fig. 6 shows a traumatic amputation of the right hand. One hundred operations were necessary on the 41 patients who suffered bomb injuries. These figures do not indicate the number who,

Delayed

union

Non-union Fat embolism Osteomyelitis

of fractures

Site

Talus Tibia and fibula Tibia and fibula

caused by

No.

1 3 4 3 1

Incidence (per cent)

12.1 12.1 9 3

RESULTS, including complications (see Tables IX, X and Xl) In the 3 groups of open fractures analysed, those caused by gunshot showed the best results in that delayed union occurred in 3 per cent, and nonunion in 5.1 per cent. This is compared with fractures caused by bombs, which developed 8.5 per cent delayed union, and IO.6 per cent non-union, and open fractures from road accidents which had 12,l per cent delayed union, and 12.1 per cent non-union. Except for one fractured humerus, which had firm fibrous union, bone grafting was carried out and union was obtained in all cases of non-union. The fact that there was a lower incidence of non-union after bomb injuries than after road accidents, was probably because bombs were so destructive and often led to amputation. In the 41 patients with bomb injuriesthere were 12 traumatic amputations, and 5 further amputations were carried out within a few days of admission, making a total of 17 amputations in 41 patientsan incidence of 41 per cent. Some of these patients had 2 amputations of limbs, and one had 3 amputations. In the 40 patients involved in road accidents, there was one amputation-an incidence of 2.5 per cent. There was no amputation of limbs injured by gunshots.

Calderwood

WOUND Gunshot

: Analysis

of Fractures

INFECTIONS wounds

All wounds were so contaminated as to be potentially infected at the time of injury, and this presented a serious problem in 25 per cent of the 80 cases available for assessment three weeks or more after injury. In 18 patients, wounds required more than three weeks to heal, and in 8 of them more than two months. There were also 2 patients with chronic osteomyelitis whose wounds had not healed after one year. Bomb injuries

As the wounds were severely contaminated and multiple foreign bodies were often present in the soft tissue, healing was very slow because of infection in many cases. Tn 22 patients wounds had not healed after three weeks. Eight patients had unhealed wounds after two months. This includes 4 patients with chronic osteomyelitis who had discharging wounds nine months to one year after admission. Besides these 22 patients with serious infection, one patient with 2 traumatic below-knee amputations subsequently required mid-thigh amputations. One patient with a below-knee amputation later had amputation through the knee performed. Three patients not listed under ‘ Traumatic amputations ’ in Table VI later required belowknee amputations, and one other patient had a mid-thigh amputation performed four days after admission. These amputations were all carried out because of gross infection. One other patient with a below-knee amputation on the left, developed gas gangrene in the right leg, wh.ich was the site of severe soft-tissue damage. There was no fracture present in this limb, which was amputated through the thigh, but the patient developed renal failure and died 11 days after admission. In all, 70.7 per cent of 41 patients developed serious wound infection. Road accidents

Nine patients had wound infections which were not healed after three weeks, and because of infection one patient required a below-knee amputation one week after admission. There was, therefore, a total of 10 patients out of 40 with serious wound infections-an incidence of 25 per cent (see ‘ follow up ‘.) DISCUSSION

In gunshot wounds injury to the tissues of the body is caused by 3 factors: the passage of the missile through the tissues, shock waves and

303

temporary cavitation (Hopkinson and Marshall, 1967). At low velocities, the main injury is caused only by the transit of the missile, so that unless important structures are directly injured by the missile, damage is slight. However, at higher velocities, shock waves and temporary cavitation assume a greater importance, temporary cavitation causing most damage. The tissues surrounding the missile track become irreversibly damaged, and at operation badly damaged muscle is evident to a variable extent. Larger blood vessels, by virtue of their elasticity, may survive the stretching and shearing forces which occur, and nerves may also survive, but may temporarily lose function due to rupture of the axis cylinders. High-velocity missiles can cause fractures without touching the bone. This is because the bones are rigid and cannot move aside when cavitation occurs. With very high velocities the soft tissues may be expanded to such an extent that their limit of elasticity is exceeded so that they are very extensively damaged. This type of injury has been described as being explosive in character (Howland and Ritchey, 1971). It must be distinguished from wounds caused by missiles that explode. Infection of wounds by gunshot may be caused by bacteria being carried into the wound by the bullet, or on in-driven clothing. The missile is not rendered sterile by the heat generated by its speed. Temporary cavitation also draws in infection from the surface of the body and from clothing, so that the track is infected. The position of the wound is, therefore, important relative topotential infection. In this series of patients it was noted that several developed gross swelling after injury. This was seen especially after gunshot wounds of the thigh. More swelling occurred than is usually seen with fractures of the femur from other causes. This presumably resulted from an explosive type of injury from a high-velocity bullet. Similarly, as already noted, two patients received only soft-tissue injury close to the lumbar spine, yet they developed paraplegia. This could be explained by the effect of the shock waves on the contents of the vertebral canal. Among the patients who suffered gunshot wounds there were some whose injuries were by high-velocity weapons such as the Armalite rifle, and others by a low-velocity weapon such as a sub-machine gun or revolver. When injury was by a high-velocity weapon the bone was often grossly fragmented (Fig. 7). When the bullet, or fragment of bullet was still present. it had

Injury:

Fig. 7.-Grossly comminuted fracture of tibia, due to a high-velocity gunshot wound.

the

the British Journal

of Accident

Surgery

Vol. ~/NO. 4

Ieft

usually been fired from a low-velocity gun (Fig. 8). However, on occasions a low-velocity missile passed completely through a limb, causing bony damage. Factors causing injury as a result of a bomb explosion were :

Fig. 8.-Comminuted fracture of the left tibl ia with fragmentation of the bullet due to a low-\ iel ocity gunshot wound.

Fig. 9.-Chest radiograph showing interstitial due to blast injury from bomb explosion.

oedema

1. The direct injury resulting from flying metal and other hard fragments, including glass. 2. The blast wave of the explosion. 3. Burns from the flash of the explosion. 4. Indirect violence resulting from the persons being thrown against surrounding objects. Fig. 5 shows the presence of foreign bodies, including metal. The difficulty of cleansing wounds containing such material has already been mentioned. The sudden pressure changes of the blast wave are responsible for the loss of hearing found in so many of these patients. The effect of this blast is more dramatically shown in the lung changes which occur, as shown in Fig. 9, producing the condition known as ‘ blast lung ’ (McCaughey et al., 1973). Osteomyelitis was surprisingly infrequent after gunshot wounds, as shown by the incidence of 2 per cent. It was, however, more frequent with bomb injuries where the incidence was 8.5 per cent, and undoubtedly was related to the greater contamination of the wounds in these cases. As noted under ‘ results ‘, infection was notably frequent after all 3 types of injury-25 per cent of gunshot wounds, 70.7 per cent of bomb injuries, and 25 per cent of road accidents. The success of the treatment of these wounds in the long term was undoubtedly owing to the

Calderwood:

Analysis

of Fractures

305

policy of adequate exploration and excision of all dead and grossly contaminated tissue, leaving the wounds widely open initially, and carrying out delayed primary suture in 5 to 7 days. In fractures caused by gunshot, delayed union occurred in 3 per cent, and non-union in 51 per cent. After bomb injuries there was delayed union in 12.1 per cent, and non-union in IO.6 per cent. After road accidents, delayed union was 12.1 per cent, and non-union 12.1 per cent. It has already been pointed out that in bomb injuries these figures have been influenced by the high proportion (41 per cent) of amputations in this group of patients. Another important factor is that in gunshot wounds, 20 per cent of the fractures involved the tibia, in bomb injuries 22 per cent involved the tibia, while in road accidents 69 per cent involved the tibia. This would also partly explain the high incidence of delayed union and non-union after road accidents, compared with bomb injuries in which a higher incidence might be expected because of the gross soft tissue damage and contamination which was often present. In gunshot wounds, although soft tissue damage was often great, contamination was much less than in bomb injuries.

excision

followed

by delayed

primary

suture.

Acknowledgements I am most grateful to Mr R. I. Wilson, Mr J. H. Lowry, and Mr P. H. Osterberg for permission to carry out this study on the patients under their care, and I am particularly indebted to Mr R. I. Wilson for his helpful criticism and advice. I am also indebted to the secretarial staff at the Royal Victoria Hospital, Musgrave ParkHospital and Belfast City Hospital for their willing co-operation.

REFERENCES

CARO, D. and IRVING, M. (1973), ‘The Old Bailey bomb explosion ‘, Lancet, 1,1433. EDDY, T. P. (1972). ‘ Deaths from domestic falls and fractures ‘,Br. J: hev. Sot. Med., 26, 173. Editorial (1972), ‘ Deaths from domestic falls ‘, Lancer, 2, 1351.

CONCLUSION

HOPKINSON,D. A. W. and MARSHALL,T. K. (1967), ‘ Firearm injuries ‘, BY. J. Sttrg., 54,344. HOWLAND, W. S. JR. and RITCHEY, S. J. (1971), ‘ Gunshot fractures in civilian practice-an evaluation of the results of limited surgical treatment ‘, J. Bone Jt. Surg., 53A, 47. MCCAUGHEY,W., COPPEL, D. L. and DUNDEE,J. W. (1973). ‘ Blast iniuries to the lungs _ ‘. Anaesfhesia,

The success of the treatment of fractures caused by gunshot and bombs is dependent to a great extent on the primary treatment. It is absolutely essential that these injuries, which have extensive tissue destruction and are grossly contaminated, should initially have careful exploration and

RUTHERFORD, W. H. (1973), ‘Experience in the accident and emergency department of the Royal Victoria Hospital with patients from civil disturbances in Belfast 1969-1972, with a review of disasters in the United Kingdom 1951-1971 ‘, Injury, 4,189.

Requests for reprints should

be addressed tot--J.

W. Calderwood.

i8,2:’

Esq.,

10 Harberton

Park,

Belfast,

BT9

6TS,

N. Ireland.

Analysis of fractures treated in the Royal Victoria Hospital, Belfast, in 1972, with special reference to gunshot wounds and bomb blast injuries.

The total number of patients admitted to the Fracture unit in the Royal Victoria Hospital in 1972 is recorded and classified according to cause. Fract...
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