Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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having recovered, however, the diagno-
sis could not be determined by • actual

Since among surgeons some difierence
of opinion seems to exist as to the prac-
ticability of overcoming the displacement
in certain fractures of the clavicle, it is
proper that I should defend the accuracy
of my own observations by a reference
to the observations of others.

In nine of eleven cases reported by ^J*»»p^«'«d«rtriM i^adne; noaxii-
Stephen Smith, one of the surgeons at *'^
Bellevue Hospital, New York, more or less deformity remained after

> New York Journ. of Medicine, May, 1857.
* Erichsen, Surgery, Amer. ed., p. 205.

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the cure was completed. In the two remaining cases the actual results
are unknown.'

Chelius remarks : "Setting of this fracture is easy, yet only in very
rare cases is the cure possible without any deformity." « » * »
" It is considered, also, that the close union of the fracture of the collar-
bone depends less on the apparatus than on the position and direction
of the fracture (therefore, in spite of the most careful application of
this apparatus, some deformity often remains)."*

Velpeau, in a lecture given in 1846, and published in the OasseUe
dee ffdpitaux, declares that with all the bandages imaginable, in the
case of an oblique fracture at the junction of the outer third with the
inner two thirds, we cannot prevent deformity.

Vidal observes: "Fracture of the clavicle is almost always followed
by deformity, whatever may be the perfection of the apparatus and the
care of the surgeon."'

" Hippocrates has observed that some degree of deformity almost
always accompanies the reunion of a fractured clavicle ; all writers
since his time have made the same remark ; experience has confirmed
the truth of it."*

Turner remarks as follows: "As to the reduction of this fracture, it
must be owned the same is often easier replaced than retained in its
place after it is reduced; for its ofiSce being principally to keep the
head of the scapula, or shoulder, to which, at one end, it is articulate,
from approaching too near, or falling in upon the sternum, or breast-
bone, it happens that, on every motion of the arm, unless great care
be taken, the clavicle therewith rising and sinking, the fractured parts
are apt to be distorted thereby. Besides, even in the common respira-
tion, the costss and sternum aforesaid, where the other end of this bone
is adnected, together with the motion of the diaphragm, rising and
falling, especially if the same be extraordinary, as in coughing and
sneezing, are able to undo your work, not to mention the situation
thereof, less capable of being so well secured by bandage as many
others. All which, duly considered, it is no wonder that upon many
of these accidents, although great care has been taken, these bones
are sometimes found to ride, and a protuberance is left behind, to the
great regret particularly of the female sex, whose necks lie more ex-
posed, and where no small grace or comeliness is usually placed."*

Says Johannis deGorter: "Bestituiter facile tractis huraeris a min-
istro posterius, dum simul suo genu locate ad spinam dorsi, dorsum
sustentet minister, nam tunc chirurgus folis digitis claviculam fractam
reponere potest. Difficilius autem in reposita sede reti^ietur, sed loca
cava supra et infra claviculam spleniis implenda."*

Says Heister, writing only a little later: "The reduction of a broken

" New York Joum. Med., May, 1857, p. 882.

s System of Surgerv. By J. M. Chelius, of Heidelberg, with notes by South.
First Amer. ed., vol. i. pp. 603, 605.

* Vidal (de Cassis), Paris ed., vol. ii. p. 105.

* Treatise on Fractures and Luxations. By J. P. Desault. Edited by Xav.
Bichat, and translated by Charles Caldwell, M.D. Philadelphia, 1805, p. 9.

» The Art of Surgery, b^; Daniel Turner, vol. ii. p. 256. London ed., 1742.

* Johannis de Gorter ; Chirurgia Repurgata, p. 79. Lugduni Batavorum, 1742.

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clavicle is not very hard to be eflFected, especially when the fracture is
transverse; nor is it anusual for the hameruS; with the fragment of
the clavicle, to be so far distorted as not to be easily replaced with
the fingers; bul the difficulty is much greater to keep t/ie bone in its
place when the fracture is once redxjtced, especially if the hone voas broken

Amesbury, after having exposed the ineflScacy of all previous modes
of dressing, and especially of the figure-of-8 bandage, Desault's, Boy-
er's, and an apparatus recommended by Sir Astley Cooper, proceeds
to describe his own apparatus and to affirm its excellence. It is, how-
ever, not much unlike a multitude of others, and is liable to the same

M. Mayor, of Lausanne, thinks that up to this day no successful
mode of treatment has been devised. ''Here everything appears as
yet so*Iittle determined, that each day sees some new propositions and
different procedures," etc. He believes, however, that in his simple
handkerchief bandage, with straps across each shoulder, the indica-
tions are most fully accomplished and the most successful results are
obtained. • If, however, it were to be treated without apparatus, the
horizontal position, lying upon the back, would, in the end, make the
most perfect unions.^

Says M. Malgaigne : " The prognosis, considering the trivial charac-
ter of this fracture, is sufficiently difficult. For, little as may be the
displacement, the surgeon ought not to promise a reunion without de-
formity; and certain successful results, proclaimed from time to time,
betray, on the part of those who relate them, the most extravagant

M. N^laton having spoken of the various plans which have been
suggested to retain this bone in place, and of their inefficiency, comes
at last to speak of the handkerchief bandage of M. Mayor, and re-
marks: —

"This apparel is .very simple; but neither will it remedy the over-
lapping." *****< Of all the apparels which we have passed
in review, there is, then, not one which fills completely the three in-
dications usually present in the fracture of a clavicle. None of them
oppose the displacement; they have no effect, with whatever care
they may be applied, but to maintain immobility in the limb. We
think, then, that it is useless to fatigue the patient with an apparatus
annoying, and, perhaps, even painful; a simple sling, secured upon
the sound shoulder, will be sufficiently severe. Nevertheless, as this
does not assure so complete immobility as the bandage of M. Mayor,
it is to this that we think the preference ought to be given in all cases
of fractures of the clavicle, whether accompanied with displacement
or not, whether they occupy the middle or the external part of the

1 Heister^B Surgery, vol. i. p. 184. London ed., 1768.

» Treatment of Fractures, by Joseph Amesbury, vol. ii. p. 527. London ed., 1881.

' Nouveau Systeme de D^ligation Chirurgicale, par Mathias Mayor, de Lausanne,
p. 884, etc. (also Atlas, plate 3 figure 28). Paris ed., 1838.

* Traits des Fractures et des Luxations, par J. F. Malgaigne, tome premier, p.
473. Paris ed., 1847.

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clavicle. If the fracture presents no displacement, we shall obtain a
cure which will leave nothing to be desired. If there is a tendency to
displacement, the consolidation will be effected with a deformity more
or less marked; but since this deformity is inevitable, at least with
adults, whatever may be the apparel which we employ, it is evident
that the apparatus which causes the least constraint ought to have the
preference. We may remark, farther, that this union with deformity
in no wise impairs the free exercise of all the movements of the mem-

" The venerable gentleman who stands at the head of American
surgery, and whose manipulations with the roller approach very
nearly to the limits of perfection, informed us, in 1824, that he had
never seen a case of fractured clavicle cured by any apparatus, with-
out obvious deformity."* .

I need not say that the " venerable gentleman" to whom Dr. 'Coates
refers in this passage was the late Dr. Physick, of Philadelphia.

Dr. Gross says that, according to his experience, " fractures of the
clavicle are seldom cured without more or less deformity, whatever
pains may be taken to accomplish the object."^ •

Treatment. — If evidence were needed beyond that which has been
furnished, of the difficulty of bringing to a successful issile the treat-
ment of this fracture, it might be supplied, one would think, by a
reference merely to the immense number of contrivances which have
been at one time and another recommended.

A catalogue of the names only of the men who have, upon this
single point, exercised their ingenuity, would be formidable, nor would
it present any mean array of talent and of practical skill.

All these surgeons, however, have admitted the same indications of
treatment, viz., that in order to a complete restoration of the outer
fragment, which alone is supposed to be much displaced, we are to
carry the shoulder upwards, outwards, and backwards. But as to
the means by which these indications can be most; easily, if at all, ac-
complished, the widest differences of opinion have prevailed ; and, in
the debate, it may be seen that while, on the one hand, no invention
has wanted for both advocates and admirers, on the other hand, no
method has escaped its equivalent of censure.

Hippocrates, Celsus, Dupuytren, Flaubert, Lizars, Pelletan, and
others, directed the patients to lie upon their backs, with little or no
apparatus. S. Cooper and Dorsey also recommend that the patients
should be confined in this position during most of the treatment ; and
from the account given by Dr. Lente, it will be understood that a
similar plan is generally adopted in the New York City Hospital.
''But this result (deformity) rarely happens when the patient has
strictly followed the directions of the surgeon, as to position especially,

1 Elements de Pathologie Chirurgicale, par A. N^laton, tome premier, p. 720.
Paris ed., 1844.

« Reynal Coates, Amer. Med. Joum., vol. xviii. p. 63, old eeries. It is probable
that Dr. Physick here referred to complete and obliqae fractures of the middle
third, or that Dr. Coates has forgotten the precise language employed on this occa-

» Gross, System of Surgery, vol. ii. p. 155, 1869.

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for it is by position, more than by any other remedial means, that a
good result is to be eflFected.

Nearly the same method we find recommended by Alfred Post, in
1840, then one of the surgeons of that hospital ; the arm being merely
kept in a sling and bound to the side, with the patient lying upon his
back. Dr. Post mentions a case treated in this manner, which termi-
nated with very little deformity ;* and I have myself treated many
cases by this plan, with more than average success.

Kecently, Dr. Edward Hartshorne, of Philadelphia, has published,
in the second volume of the Pennsylvania Hospital Reports, 1869, a
very ingenious argument in favor of the supine position, in which he
seems to have demonstrated that the special efficacy of this plan
depends upon the pressure made upon the angle of the scapula. In
order \o accomplish this, and to place the scapula in the position most
favorable for the reduction of the clavicle, the back should rest upon
a broad, firm, and unyielding mattress, and not upon a pillow between
the shoulders, which latter has the efiect rather to defeat than to pro-
mote the indication ; the head should be slightly raised so as to relax
the sterno-cleido-mastoid muscles and somewhat extend the trapezius;
the arm and forearm of the injured side should be flexed, resting across
the chest, with the hand reaching over the sound shoulder, as recom-
mended by Velpeau in the use of his dextrine apparatus, or it should
be placed at right angles with the body, as recommended by Dupuytren.

It is scarcely necessary to say that the absolute immobility required
by the posture treatment must always limit its application, and render
its general employment impossible. Dr. J. A. Packard, of Phila-
delphia, regards the scapula, also, as the bone upon which the resto-
ration of the clavicle chiefly depends ;
and he finds in the serratus magnus Fig. 45.

the especial obstacle to this restora-

Dr. Eve, of Nashville, Tenn., and Dr.
Eastman, of Broome County, N. Y.,
have also employed this method suc-
cessfully f while Malgaigne declares it
to be the most reliable means of obtain-
ing an exact union.

Albucasis, Lanfranc, Guy de Chau-
liac, Petit, Parr, Syme, Skey, Brun-
ninghausen, Parker, and very many
others, especially among the English,
have preferred, in order to carry the
shoulders back, a figure-of-8 ; while
Desault, Colles, South, and Samuel
Cooper have represented this bandage FigureH>r-s.

as useless, annoying, and mischievous.

> N. Y. Journ. of Med., vol. ii. p. 226.

• Packard, New York Journ. of Med., 1867.

• Bost. Med. and Surg. Journ., vol. Ivi. p. 468.

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Heister, Chelius, Miller, Breffield, Keckerly,* Coleman,* Hunton,'
prefer, for this purpose, some form of back-splint, extendiDg* from
acromion to acromion, against which the shoulders may be properly
secured. Parker says that splints of this kind, with a figure-of-S
bandage, are *' better than all the apparatus ever invented," while Mr.
South gives his testimony in relation to all dressings of this sort as
follows: ''I do not like any of the apparatus in which the shoulders
are drawn back by bandages, as these invariably annoy the patient,
often cause excoriation, and are never kept long in place, the person
continually wriggling them off to relieve himself of the pressure."

Fox,* Brown,* Desault, and others bring the elbow a little forwards,
and then lift the shoulder upwards and backwards. Wattman and
Lonsdale carry the elbow still farther forwards, so as to lay the hand
across the opposite shoulder; while Guillou carries the hand and fore-
arm behind the patient, and then proceeds to lift the shoulder to its

Thus Desault, Fox, and Wattman accomplish the indication to carry
the shoulder back, by lifting the humerus while the elbow is in frord
of the body, and Guillou accomplishes the same indication by lifting
the humerus when the elbow is a little behind the body. Chelius also
says : " The elbow, as far as possible, is to be laid backwards on the

Sargent, who believes that with Fox's apparatus " the occurrence of
deformity is the exception," and not the rule, and prefers it to all
others, has treated three cases by Guillou's method, and is perfectly
satisfied with its operation. HoUingsworth, of Philadelphia, has also
treated one case successfully by Guillou's method, and adds his testi-
mony in its favor.

But how shall we explain these equal results from opposite modes
of treatment 7 Is the indication to carry the shoulders back, which
Fox sought to accomplish by pressing the elbow upwards and back-
wards, as easily attained by pressing the elbow upwards and forwards?
Or are we not compelled to infer that there has been some mistake as
to the precise amount of good accomplished by the apparatus in
either case ? Moreover, Ooates,* Keal, and others instruct us that the
only safe and proper position for the humerus is in a line with the
side of the body, and that it must neither be carried forwards nor

Paulus jEgineta, Boyer, Desault, Pecceti, Liston, Fergusson, Samuel
Cooper, Erichsen, Miller, Skey, Levis, Dorsey,' Gibson,^ Fox, H.

> Keckerly, Amer. Joum. Med. Sci., vol. xt. p. 115 ; also, m^ Report on De-
formities after Fractures, in Trans, of Amer. Med. Assoc, vol. viii. p. 440.

> Coleman, New York Joom. Med., second series, yol. iii. p. 274, from New
Jersey Med. Rep.

' Hunton, ibid.; also, New Jersey Med. Rep., vol. v. p. 146.

• Fox, Liston's Practical Surgery, Amer. ed., p. 47.

• Brown, Sargent's Minor Surgery, p. 132.

« Ooates, Amer. Joum. Med. Sci., vol. xviil. p. 62.
y Dorsey, Elements of Surgery, vol. I. p. 183.

• Gibson, Institutes and Practice of Surgery, vol. i. p. 271.

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H. Smith,^ Norris,* Sargent, Eastman,* recommend an axillary pad ;
while Richerand, Velpeaa, Dupuytren, Benjamin Bell, Syme, deny its
utility, or affirm its danger. Dr. Parker has seen one patient in whom
paralysis of the arm resulted from the pressure upon the brachial
nerves, in the attempt " to pry the shoulder out ;" and I have myself
recorded another.

Cabot, of Boston, Massachusetts, has recommended a mould of gutta
percha laid over the front and top of the chest.*

Desault's plan, which took its origin, as Velpeau thinks, in the
spica of Glaucius, under various modifications, is recommended by
Delpech, Cruveilhier, Lasere, Flamant, Samuel Cooper, Fergusson,
Liston, Cutler, Physick, Dorsey, Coates, and Gibson; while by Vel-
peau, Syme, Colles, Chelius, Samuel Cooper, and Parker it is regarded
as inefficient and troublesome. Says Mr. Cooper: "In this country,
many surgeons prefer Desault's bandages; but I do not regard them
as meeting the indications, and consider them worse than useless.''

The dextrine bandages, or apparatus immobile, of Blandin, Velpeau,
and others, constitute only another form of the bandage dressing of
Desault. In this connection it ought to be noticed that Velpeau does
not regard the employment of this apparatus, or of any other demand-
ing great restraint, as imperative. In his great work on anatomy,
referring to the fact that when the bone is broken and overlapped,
the patient is still able, in many cases, to move the arm freely, he
remarks : " Do not these cases give support to the opinion of those
who admit that fractures of the clavicle do not actually require any
other apparatus than the simple supporting bandage ?" " It is neces-
sary to observe," he adds, " that by thus acting we do not prevent an
overlapping,"* etc.

More recently. Dr. E. M. Moore, of Bochester, in a paper read
before the New York State Medical Society, in 1871, has called atten-
tion to what he terms the " Figure-of-8 from the elbow," by which he
proposes to render tense the clavicular fibres of the pectoralis major,
and at the same time draw the scapula backwards towards the spine.
He is thus able, he affirms, to overcome the action of the sterno-cleido-
mastoid, which lifts the sternal fragment ; and to carry the acromial
fragment outwards and upwards.

These ends are accomplished by placing the arm in the following
position. The end of the middle finger resting upon the ensiform
cartilage, while the elbow is pressed against the side of the body.
In order to maintain it in this position, we may employ a single
band, two and a half yards long by eight inches wide — in the ac-
companying wood-cut a shawl is substituted — the centre of which,
cravated, eight or ten inches wide, is laid against the point of
the elbow and folded around the arm ; the extremity which appears

» H. H. Smith, Practice of Surgery, p. 854.

> Korria, Liston's Practical Surg., Amer. ed., p. 46.

* Eastman, Apparatus for Fractured Clavicle, by Paul Eastman, Aurora, 111.;
Boston Med. and Surg. Joum., vol. xxiii. p. 179.

* Cabot, Bost. Med. and Surg. Jonrn., vol. lii. p. 282.
» Velpeau, Anatomy, Amer. ed., vol. i. p. 242.

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Fig. 46. in front is now carried up-

wards over the front of the
corresponding shoulder,
obliquely downward across
the back to the opposite
axilla, and through the
axilla to the front. The
other extremity emerging
behind, between the elbow
and the body, is carried
obliquely upward to the
sound shoulder, and for-
ward over this shoulder, to
be tied to the opposite ex-
tremity of the shawl com-
ing from the axilla. The
forearm is then flexed at
an acute angle, and sus-
pended by a narrow sling
passing under the wrist.
Dr. Lewis A. Say re, of this city, has for some time employed an
apparatus for dressing broken clavicles, by which he proposes, also,
t|0 render tense the clavicular attachments of the pectoralis major,
and thus secure more effectually the depression of the sternal frag-
ment, while at the same time the
Fig. 47. shoulder is lifted and carried back.

Two strips of adhesive plaster are
prepared, each about three and a half
inches wide, for an adult; one long
enough to encircle, first the arm, and
then the body completely; the other
of sufficient length to reach from the
sound shoulder, over the point of the
elbow of the broken limb, and across
the back obliquely to the point of
starting. Maw's moleskin plaster, or
some plaster equally strong, is to be

The first strip is looped around the
arm just below the axillary margin and
pinned, or stitched, with the loop suffi-
ciently open to avoid strangulation.
The arm is then drawn downward and
backward until the clavicular portion
of the pectoralis major is put suffi-
ciently on the stretch to overcome the
sterno-cleido-mastoid, and thus draw the sternal fragment of the
clavicle down to its place. The strip of plaster is then carried com-
pletely around the body, and pinned or stitched .to itself on the back.

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The second strip is then applied, commencing on the front of the
shoulder of the sound side, thence it is carried over the top of the
shoulder, diagonally across the back, under the elbow, diagonally
across the front of the chest to the point of starting, where it is
secured by pins or thread. A longitudinal slit is made in the plaster,
to receive the point of the elbow.

Fig. 48. Fig. 49.

Before laying the plaster across the elbow, an assistant must press
the elbow well forward and inward, and it must be held firmly in
this position until the dressing is completed. It will be now seen
that the arm has been converted into a lever, whose fulcrum is the
loop of adhesive plaster at the lower margin of the axilla; and upon
this it is believed that in a great measure the efficiency of the appa-
ratus depends. It is scarcely necessary to say that if the plaster
becomes loosened, it should be promptly readjusted.

1 have seen a number of broken clavicles treated by this method,
and I am prepared to affirm its general efficacy ; but I cannot say
that the proportion of cases in which overlapping has resulted is
less than by the method which I have myself generally adopted, and
which will be described hereafter. Under both plans I have seen
some very satisfactory and some very unsatisfactory results; and if
for any reason I found it inconvenient to adopt my own plan, I should
resort to Dr. Sayre's in preference to any other.

The sling, in some of its forms, is employed by Bicherand, Hu-
berthal, CoUes, Miller, Fox, Stephen Smith,' H. H. Smith, Bartlett,^

» Stephen Smith, New York Joum. Med., vol. ii. 8d series, p. 384 (May, 1857).

2 Bartlett, my ''Report on Defor.," etc., Appendix ; also, Bost. Med. and Surg.
Jonrn., vol. li. p. 404.

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Pig. 60.

Levis,' Dugas,^ Benjamin Bell, Bransby Cooper, Earle, Chapman,
Keal, and by a large majority of the English surgeons.

No apparatus, perhaps, has been so generally employed, among
American surgeons, as that form of the sling introduced by Dr.

George Fox into the Pennsylvania Hos-
pital in 1828.

Sargent says of it : " Fractures of the
clavicles, treated by this apparatus, are
daily dismissed from the Pennsylvania
Hospital, and by surgeons in private
practice, cured without perceptible de-

Norris, in a note to ListorCs Practical
Surgery^ afl5rms that " the chief indica-
tions in the treatment of fracture of the
clavicle are perfectly fulfilled by the
use of this apparatus."

H. H. Smith, in his Minor Surgery,
declares that Fox's apparatus accom-
plishes "perfect cures" in very many
cases, and that it is " a very rare thing
for a simple case to go out of the house
(Pennsylvania Hospital) with any other
deformity save that which time cures,
viz., the deposition of the provisional
callus." He has also repeated substan-
tially the same opinion in his larger
work, entitled Practice of Surgery,

Such testimony in favor of any
dressing demands respectful attention ;

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 23 of 100)