CHAPTER II. DISLOCATIONS OF THE STERNAL END OF THE (Part 2)

clavicle is composed largely of compact tissue, the cancellous bone being confined to the extremities. The compact Fig. 6. — Diagram shoAving the relations of the brachial plexus to the first rib and clavicle. Section of clavicle removed. tissue is particularly heavy in the region of the oblique line where the coraco-clavicular ligaments are attached. The clavicle is subcutaneous throughout and easily palpated. It should be noted that the acromion stands directly external to the \ Fig. 7. — Fracture of the clavicle with overriding deformity in a child. outer end of the bone, as well as behind it. The rounding of the outer aspect of the shoulder is caused by the head of the humerus beneath the deltoid, and not by either clavicle or acromion. Any portion of the clavicle may be broken, but by far the most common site of fracture is in the outer end of the middle third and 14 FRxVCTURES AND DISLOCATIONS is decidedly oblique. Fracture in this region is usually the result of indirect violence and is almost always produced by a fall on the shoulder. Trauma sustained in this way more often produces a Fig. 8. — Fracture of the clavicle in its inner third. No deformity, Fig. 9. — Green-stick fracture of the clavicle. dislocation of the shoulder in adults, while in children fracture is more common because the clavicle is relatively weaker. Incom- plete fracture is common in children. Fractures in either the FRACTURES OF THE CLAVICLE 15 inner or outer third are comparatively rare and usually the result of direct violence. Muscular action is sometimes, though rarely, responsible for fracture of the clavicle. It should be remembered that fracture internal to the coraco- clavicular ligament completely destroys all bony and ligamentous Fig. 10. — ^Fracture of the middle third of the clavicle with the usual deformity — up- ward displacement of the inner fragment. Fig. 11, — Fracture of the clavicle with the usual deformity. connection between the scapula and sternum, but when the break occurs through, or external to, this ligament, a heavy bond is main- tained between the inner fragment and the shoulder blade. Simultaneous fracture of both clavicles is occasionally seen as a result of transverse crushes of the shoulders. Symptoms. — The patient complains of pain immediately follow- ing the accident, and there is almost complete loss of function 16 FRACTURES AND DISLOCATIONS Fig. 12. uacture of the outer end of the clavicle (rare). Fig. 13. — Comminuted fracture of the clavicle with overridinj as a result of pain and of the disturbed mechanism of the shoulder. Swelling usually develops within a few hours and obliterates the supra- and infra-clavicular fossae. The surgeon can hardly fail to recognize the obliteration of these fossae if the opposite shoulder is inspected and compared. If the inner fragment is free of the coraco-clavicular ligament the deformity will be so pronounced that the nature of the injury should be recognized by inspection alone. The shoulder is displaced inward, forward and downward, the injured member is supported with the opposite hand and the head FRACTURES OF THE CLAVICLE 17 is inclined to the injured side to relax the pull of the sterno-mastoid. The patient is unable to draw the shoulder forward, as shown in normal cases in Figs. 27 and 28. The inner fragment is usually Fig. 14. — Fracture of the right clavicle about twenty minutes after the accident. The injiiry was sustained by a fall on the shoulder. Note the swelling in the region of the fracture and the slight falling of the shoulder. The manner in which the patient grasps and supports the injured member is characteristic. If need be the diagnosis might be made by inspection alone. Palpation reveals abnormal mobility and crepitus at the site of fracture. Fig. 15. Fig. 1( Figs. 15 and 16. — Front and side views of fracture of the clavicle with moderate deformity. Note the prominence produced by the outer end of the inner fragment. Photographs taken about thirty minutes following the accident. displaced upward and can, as a rule, be palpated and moved without difficulty. The nearer the fracture is situated to the inner third of the bone the more pronounced will be the angle of upward 18 FRACTURES AND DISLOCATIONS displacement. The distance between the supra-sternal notch and the acromion process is decreased on the injured side; in other words the shoulder is shortened. When the fracture lies through Figs. 17 and 18. — Fracture of the right clavicle at about its middle. Note the prominence of the outer end of the inner fragment. Photographs taken about twenty minutes following the accident. Fi2. 19. Fig. 20. iurv ^'NotP^^tbrilH^T"J/^.^^''-^ •''^ L^^'^^^i'^^ ^^°^ twenty-four hours following in- sula and i^fv.rL f^i"*^ i^^ '""^^'r^t^ shoulder and the swelling which obliterates the lirj,eri^t£'if7o'A'^Z t'7..cZr!s'irt^l:^r ^'^ ^^^-^^^ displacement of the or external to the coraco-clavicular ligament the deformity will usually be too slight to recognize by inspection, and the patient will FRACTURES OF THE CLAVICLE 19 not show the usual anxiety in supporting the injured member. Pain, local tenderness and less pronounced loss of function will, however, be present. If the surgeon fixes the shoulder with one hand, the fingers of the opposite hand will detect abnormal mobility Figs. 21 and 22. — Fracture of the left clavicle with pronounced upward displace- ment of the inner fragment which is not bound down by the coraco-clavicular ligament. The following points are significant in making a diagnosis from inspection alone: Contour of shoulder normal, axis of arm normal, shoulder as a whole slightly lowered and patient grasps forearm. Deformity of clavicle plainly visible as well as palpable. Photographs taken a few minutes following the accident. Fig. 23 Figs. 23 and 24. — Delayed union of clavicle due to poor approximation of frag- ments. The inner fragment is above and anterior to the external fragment. This de- formity is chiefly the result of the action of the clavicular attachment of the_ sterno- mastoid. Fracture nearer the median line than usual. Injury the result of direct violence. Patient first seen by author six weeks after the accident. by alternate forward and backward pressure on the clavicle, in the region of the fracture. The middle third of the clavicle is free from heavy muscular attachments and can be grasped without diffi- culty in testing the integrity of the bone. When the normal 20 FRACTURES AND DISLOCATIONS Fig. 25. — Fracture of the left clavicle in an elderly woman some days following the accident. Note the ecchymosis in the region of the fracture and the obliteration by swelling of the supra- and infra-clavicnlar fossae. Falling of shoulder not apparent because elbow is supported by the arm of the chair. Fig. 26. — Fracture of right clavicle with pronounced deformity following improper treatment. This case (according to the historv given bv the patient) was treated by means of a plaster cast of the shoulder and the deformity recognized only when the dressing was removed some weeks later. Function of shoulder much impaired and symptoms of brachial ple.xus irritation present. This condition is a striking example of what may follow treatment which is not based on proper principles FRACTURES OF THE CLAVICLE 21 shoulder is thrown forward this middle third stands out promi- nently as shown in Figs. 27 and 28. Ecchvmosis usually develops within the first day or two and is almost pathognomonic of fracture. In children the fracture is often incomplete and the symptoms are much less pronounced. Local tenderness and pain are present but the child may not show any perceptible disturbance in the use of the arm and hand. Move commonly, however, there is a disin- Fig. 27. Figs. 27 and 28. — These two pictures were taken to demonstrate the manner in which the outlines of the clavicles may be brought out by throwing the shoulders for- ward. This movement not only brings out the outline of the bone but shows whether or not the clavicle is properly performing its function. If the clavicle is fractured the action of the shoulder will be qiiite different when the patient is requested to throw the shoulder forward. In adipose and well-muscled persons it is more difficult to see the outline of the clavicle, yet the signs and symptoms of fracture are almost always sufficiently pronounced to form a diagnosis if the examiner is observant and systematic. clination to use the hand of the injured side and the patient will cry out when the arm, forearm or shoulder is manipulated. Local swelling is usually present. When the fracture is complete the symptoms will be more pronounced though deformity is almost always slight in children. Fracture of the clavicle is rarely compound and injury to the structures passing beneath the clavicle are rare, considering the frequency with which the clavicle is fractured. If the brachial plexus or axillary artery is injured symptoms of paralysis or nerve irritation or disturbance in the circulation of the upper extremity will develop. Crepitus is a sj-mptom which can almost always be elicited in 22 FRACTURES AND DISLOCATIONS fractures of the clavicle, except in the incomplete form occurring in children. Diagnosis. — There is, as a rule, little difficulty in recognizing fracture of the clavicle if the region of the shoulder is carefully examined. The diagnosis is based on the symptoms just given. Incomplete fractures in children, and fractures of the outer end of the bone are most likely to be overlooked. In establishing a diagnosis of fracture of the clavicle it is not sufficient to note the presence of a break in a given region^ but the entire shoulder should be examined to exclude associated lesions. The clavicle should be palpated from end to end; occasionally the fracture is multiple. The spine of the scapula and the acromion should be palpated and the condition and position of the upper end of the humerus should be determined. The circulation of the forearm should be exam- ined and the reflexes noted. Treatment. — Reduction of the deformity in fractures of the clavicle is usually a simple matter, being accomplished by pulling the shoulder outward, upward and backward. The deformity recurs, however, as soon as the parts are released. Correction of the displacement, therefore, is useless prior to the application of retentive dressings. Innumerable dressings have been devised for maintaining the fragments in reduction, but only those which have proven most satisfactory wall be considered. The modified Sayre adhesive plaster dressing will be found most satisfactory in the largest number of cases and is applied with three strips of adhesive plaster, each about four inches wide and long enough to encircle the trunk one and a half times. Zinc-oxide plaster should be used as it is less irritating. Before the adhesive is applied the axilla should be cleansed, and the arm and chest sponged with alcohol and thoroughly dried. ^A folded towel should be placed in the axilla or a few layers of gauze secured in position to prevent the arm from coming in contact with the chest. If the upper extremity is immobilized and skin is allowed to come in contact with skin, cutaneous irritation is almost sure to follow and may be severe. A light folded towel or folded gauze should also be placed about the middle of the arm before the first strip of adhesive is applied. The first stnp of adhesive encircles the arm (the loop being secured with a safety pin) half way between the shoulder and FRACTURES OF THE CLAVICLE 23 elbow; the strip is then continued under tension, across the back, under the opposite arm and on to the chest anteriorly. This strip of adhesive, when in place, should pull the arm well backward. The portion of the dressing encircling the arm should be equi- distant from the shoulder and elbow ; neither above nor below this point. The second strip begins behind the shoulder, extends down the back of the arm, under the elbow, along the dorsal surface of the forearm and hand, and over the opposite shoulder. As this strip passes under the elbow the adhesive should be split and a generous padding of cotton placed in position to prevent irrita- Fig. 29. — Fracture of the right clavicle with the usual symptoms. The following figures show the application of a modified Sayre's dressing to this case. tion at the point of the elbow. As the end of the strip is being attached to the opposite shoulder the hand should be raised on the chest and the elbow pulled forward. This second strip pulls the elbow forward (thus displacing the shoulder backward with the middle of the arm fixed by the first strip) and raises the entire arm. "When these two straps are in position the shoulder is pulled upward, backward and outward, thus meeting the requirements for reduction of the displaced fragments. A third strip of adhesive plaster is then passed horizontally around the chest and arm to fix the arm to the side. Instead of this strip a body-swathe may be used to steady the member. This dressing, when properly applied, immobilizes the shoulder most satisfactorily. The author has found, however, that the patient usually complains of the confinement of the hand which often shows considerable irritation 24 FRACTURES AND DISLOCATIONS Jeig. 30. Fig. 31. K II Fis. 33. Author's modification of a Sayre"s dressing applied to the fractured clavicle shown in Fig. 29. In this dressing the hand is not included, which is a gi-eat comfort to the patient and does not render the dressing less effective. Sayre's dressing will meet the indications better in the greatest number of cases. When employed in the treatment of children, special care should be 'taken in watching for signs of irritation to the delicate skin. (See Figs. 37 and 38. — The Taylor brace, which is of great advantage in the treatment of children.) Fig. 30. — First strap of adhesive encircles the arm backward. rm and then the body, pulling the Fig. 31. — Second sti'ap of adhesive passing down the posterior aspect of the arm, under the elbow and over the opposite shoulder. Fig. 32. — Third strap of adhesive which passes down the outer side of the arm, under the elbow and under the hand to the opposite shoulder. Fig. .33. — Another view of the dressing showing the attachment of the straps poa teriorly. FRACTURES OF THE CLAVICLE 25 where it comes in contact with the adhesive. To obviate this the author has been in the habit of dividing the second strip into two narrow strips applied as shown in Figs. 32 and 33. The first strip passes down the posterior aspect of the arm, under the elbow, and then diagonally across the forearm so that it passes above the hand and over the opposite shoulder. The second strip passes down the outer side of the arm, under the elbow on its outer aspect, and then diagonally across the forearm in the opposite direction so that it passes below the hand and over the opposite shoulder. The hand is thus left exposed and free from irritation, and the patient may move it at will, thus relieving the discomfort of the cramped position without in any way disturbing the fixation. (See Figs. 29 to 33.) In some instances, especially when the fracture is in the inner half of the bone, additional direct pressure may be Fig. 34. — Mohr's figure-of-eight. Fig. 35. — Shows the turns used in Vel- peau's bandage. necessary to prevent upward displacement of the inner fragment. This is accomplished by means of pads of gauze or cotton held in position by strips of adhesive. AVhen adhesive plaster is not available Mohr's figure-of-eight, Velpeau's bandage or a posterior figure-of-eight with the turns passing behind the shoulders will serve the purpose as an emergency dressing. These dressings, however, are all too insecure to be relied upon in permanent fixation of the clavicle. The recumbent position will almost invariably maintain the frag- ments in good position when all forms of ambulatory treatment prove inefficient. The patient should be placed on a firm narrow bed, the arm secured to the side by means of a swathe, and a small firm pillow placed between the scapula? and fixed in position on 26 FRACTURES AND DISLOCATIONS the back by means of strips of adhesive. Multiple fracture of the clavicle or simultaneous fracture of both clavicles can be success- fully treated by this method. (See Fig. 36.) The test of any dressing is the position occupied by the fragments and the absence of undue constriction of the arm and forearm. No matter what method is employed either the presence of deformity or strangulation of the upper extremity is a condition which calls for correction and indicates the inefficiency of the dressing. In adults, especially large persons, considerable strength is necessary in the dressing to maintain the proper position of the Fig. 36. — In difficult cases recumbent treatment will give good results when other methods would fail. This photograph was taken about tive years after fracture of both clavicles (one clavicle in two places) and fracture of the first and second ribs on both sides. Recumbent treatment was employed. At the time this photograph was taken it was impossible to determine by palpation the former positions of the fractures in the clavicles. upper extremity, and accordingly the points of greatest pressure (the middle of the arm and the point of the elbow in Say re's dressing) should be particularly well padded. Taylor's brace (see Fig. 37) is especially well adapted to frac- tures of the clavicle in children, and allows freedom of motion of both arms. Sayre's dressing, however, will answer the purpose very well, though the delicate skin of a child must be closely watched for irritation when adhesive plaster is employed. Operative Treatment.— Nearly all cases of fractured clavicle can be successfully treated either by Sayre's dressing or the recumbent method and hence operative intervention is rarely