Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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and I shall not be. regarded as detract-
ing from the respect due to these authorities, when I express my
belief that it is in deference to the distinguished reputation of the
surgeons who have during the last thirty years had charge of the
services in that hospital, and who have been so loud in its praise,
that the use of this apparatus has, with us, become so general. I
believe, also, that, in some measure, this general preference is due
fairly to the intrinsic excellence of the dressing. But I must be per-
mitted to express a doubt whether it has made deformities of the
clavicle " the exception, instead of the rule," with us. I have used
this dressing oflener than any other form, and yet my success has by
no means been so flattering as has been the success of these gentle-
men. I have seen others employ it, also, and with pretty much the
same result. Nor ought it to be forgotten that, in Great Britain, by
far the greater majority of surgeons emplov an apparatus essentially
the same. I have seen it in many of the hospitals^ and Mr. Bicker-
steth, one of the surgeons of the Liverpool Infirmary, informed me,



K 6ARTLvrr*8 Apparatot.— "For an
axillary pad, roll a strip of woollen
llaDQel, four or five inches wide, aronod
the axillary strap, to the sice required.
The apparatus may be used for either
side by changing the attachment of the
•ling." (BaHUti)



» Levis, H. H. Smith's Practice of Surg., p. 865.
1860, p. 428.



Am. Joum. Med. Sci., April,



« Dugas, Report on Surgery.



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FRACTURES OF THE CLAVICLE.



199



in 1844, that it had been in use with Fig. 51.

them as long as thirty years. All that
has justly been said against the English
mode of dressing by slings, is equally
true of this; and whatever has been
affirmed of the danger of using an axil-
lary pad applies as much to this as to
any other mode of using the same.

I believe, however, that in the Penn-
sjlvania Hospital the axillary pad em-
ployed is not so large, and especially
not so thick, as that recommended by
Desault, and in this respect it is plainly
an improvement ; but then, in the same
proportion that it is made less thick, it
is less powerful to accomplish the indi-
cation in question ; and if it merely fills
the. axillary space, then it is no longer
a fulcrum upon which the arm is to
operate as a lever. •

Regarding, then, the importance of
this question to the interests of surgery,
and observing the wide differences of
opinion which are entertained here and
elsewhere as to the real value of this
dressing, is it asking too much of these
gentlemen that they will present us
some more precise statistical testimony ?
It will be observed that its advocates
have claimed for it what is not to-day,
at leasts claimed for anv other apparatus, viz., that it is capable of ful-
filling " perfectly" all the indications of treatment. By which it must
be^intended to say, that, in addition to both of the other indications,
that also which has always heretofore been found so difficult, if not
impossible, the carrying out of the shoulder, is in a majority of cases
perfectly accomplished — the clavicles are not shortened.

If it is intended, however, to say that a shortening is not generally
prevented, but only that no unseemly projection of the fractured ends
will he found to result, I reply, that then it does not answer all the
indications ; and I beg, further, to say that my experience has con-
vinced me that the absence or presence of such a projection, after
union, is due much to the circumstances of the fracture, as to whether
it is more or less oblique, and still more especially to the degree ot
roundness or emaciation of the patient, rather than to any form, or
part, or condition of the apparatus. It will be found more distinct
in oblique fractures than in transverse, and much more marked in thin
persons than in plump or fat persons, and more so in muscular than
in non-muscular. In short, I affirm that such a projection has oc-
curred as often under my observation, when this dressing has been
used, as it has when other forms have been employed.



George Fox*8 Apparatni "condlsts of a
llrmly staffed pad of wedge shape, and
about half as loDg as the hamerns, hav-
ing a band attached to each extremity o
its upper or thickest margin ; a sHng to
suspend the elbow and forearm, made of
strong muslin, with a cord attached to
the humeral extremity, and another to
each end of the carpal portion ; and a
ring made of muslin stuffed with cotton
to encircle the sound shoulder, and
serve as means of acting upon and re-
ceiving the sUng." (Sargent.)



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200 FRACTURES OF THE CLAVICLE.

Finally, while I deprecate incautious assumptions in regard to the
capabilities of any form of dressing for broken collar-bones, a dispo-
sition to which is manifested by more than one advocate of special
plans, I am ready to bear my humble testimony in favor of that one
of whose claims I have taken the liberty to speak so freely, and which
is usually known in this country by the name of Fox's apparatus,
consisting essentially of a sling, axillary pad, and bandages to secure
the arm to the chest, and to which the stuffed collar is a convenient
accessory, but which admits of various modifications, answering the
same ends. Among the considerable variety of dressings which I
have used, this, either with or without such slight modifications as I
shall presently suggest, has seemed to me most simple in its construc-
tion, the most comfortable to the patient^ the least liable to derange-
ment (if I except Yelpeau's dextrine bandage), and as capable as any
other of answering the several indications proposed.

No apparatus *is better able to answer the first indication, namely,
"to carry the shoulder up," and thus to bring the fragments into line.
If, as not unfrequently happens, the outer end of the inner fragment
is also carried a little upwards and forwards, it may be, in some
measure, replaced by inclining* the head to the injured side, or by a
carefully adjusted compress and bandage. But it is not probable that
any patient will consent to remain a long time in a position so un-
natural and constrained ; nor is it very easy, as the experiment will
show, to maintain a steady pressure upon this portion of the broken
clavicle.

The second indication, " to carry the shoulder back," is certainly
much more difficult of accomplishment than the first ; and it does not
seem to me to be fully met by the sling dressing ; but until some mode
is devised less objectionable than any I have yet employed, or than
any the mechanism of which I have seen described, I see no alterna-
tive but to trust to that action of the muscles attached to the scapula,
by which, as Desault first explained, when the shoulder is lifted per-
pendicularly, it is also in some degree carried backwards, and that,
too, it has occurred to me frequently to observe, just as much as when
the upward pressure is made with the elbow placed in front of the
body.

It is my belief, however, from the evidences now before us, that the
third indication, " to carry the shoulder out," still remains unaccom-
plished ; that it cannot be claimed for this, or for any other apparatus
yet invented, that, in a certain class of cases which I have sufficiently
indicated, constituting a vast majority of the whole number, it is able
to prevent a riding of the fragments. Nor, seeing the difficulties in
the way, and the amount of talent which has been already devoted to
their removal, have I much confidence that this end, so desirable, and
so diligently sought, will ever be attained. Yet it is presumptuous,
perhaps, to say what the skill and ingenuity of a profession whose
labors never cease, may not hereafter accomplish.

Having already expressed my preference for the sling, I have only
to add what I consider necessary modifications in the form of this
dressing recommended by Dr. Fox.



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FRACTURES OF THE CLAVICLE. 201

Dr. Coates, in the excellent paper already referred to/ calls attention
to the danger of making too much pressure upon the brachial artery
and nerves, when the axillary pad is used, and the arm is, at the same
time, carried forwards upon the body. In bringing the elbow for-
wards so as to lay the forearm across the body, the humerus is made
to rotate inwards, and the brachial artery and nerves are brought into
more direct apposition with the pad. The same objection must hold,
only in a greater degree, to M. Gaillou's method of carrying the fore-
arm across the back.

The humerus ought then to be permitted to hang perpendicularly
beside the body, and thus the nerves and bloodvessels will be removed
in a great measure, yet not entirely, from pressure. The pad (to be
employed only as a part of the retentive means, and not as a fulcrum)
should be no thicker than is necessary to
fill completely the axillary space when the ^S- 53.

elbow is made to press snugly against the
side of the body.

I find it necessary also to secure the arm
to the body by two or three turns of a
roller, applied always lightly and with
great care, so that its pressure shall be in
no degree painful or uncomfortable.

The stuffed roller is by no means an
essential part of the apparatus, and I fre-
quently suspend the broken arm by a sling
passed in the ordinary manner about the
neck and over the shoulders.

In cases of partial fracture' accompanied
with a persistent bend in the line of the
axis of the bone, it is proper to make some
attempt, by moderate pressure directly upon
the salient fragments, to restore them to
place ; but I confess that I have never yet
sQCceeded in accomplishing anything in The Author's Apparatas.

this way. Nor is it a matter of much con-
sequence, I imagine, since, as I have already explained when speaking
of partial fractures in general, the line of the axis of the bone will
eventually, at least in a majority of cases, be completely restored.

The only treatment which seems then to be indicatea, and the only
treatment which I have of late adopted in these cases, is to place the
hand and forearm of the child in a sling, or I direct the mother to
make fast the sleeve to the front of the dress in such a way that the
child cannot use the arm until the union is consummated. Even this
precaution I have several times omitted, with no injury to the patient.

For a more full consideration of partial fractures of the clavicle, I
beg to refer the reader to the chapter on " Partial Fractures," &c.

1 Amer. Joum. Med. 8ci., yoL xyiii. p. 62.
* See chapter on Incomplete Fracture.
14



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202 FBACTURES OF THE SCAPULA.



CHAPTER XIX.

FRACTURES OF THE SCAPULA.

Fractures of tbe scapula may be divided into those which occur
through the body, the neck, the acromion, and coracoid processes.

§ 1. Fraotubks of the Body of the Scapula.

Under this title I propose to consider not only fractures of the
" body/' properly speaking, but also fractures of the angles and of the
spine.

Causes, — It is usually broken by the fell of some heavy body directly
upon the bone, or by some severe crushing accident^ by the kick of a
horse, by a fall upon the back — in short, by direct causes alone, and by
such causes as operate with great violence.

Malgaigne says that a Doctor Heylen has recently published a case
of this fracture which he believes to have been the result of muscular
action, occurring in a man forty-nine years old. The case, however,
is not stated so clearly as to relieve us entirely of a doubt as to the
nature and cause of the accident

I have myself recorded six cases Which have been under my treat-
ment ; and I think I have observed in the course of my hospital prac-
tice three or four other examples of fractures of the body or spine of
the scapula not caused by firearms. There are two cabinet specimens
of fracture of the body of the scapula below the spine in the Pennsyl-
vania Medical College, and two involving the spine. Dr. Mlitter had
in his collection a fracture of the posterior angle, and Dr. March had
a specimen of fracture of the body. I believe also that in the collec-
tion of the late Dr. Charles Gibson, of Richmond^ there were one or
two specimens of this fracture. I know of no other museum speci*
mens in this country except my own of partial fracture, described in
the chapter on Partial Fractures.

BavatOD, after a practice of fifty years, declared that he had never
seen a fracture of the scapula except as it had been produced by fire-
arms. Among 2858 fractures reported from Hdtel Dieu during a
period of twelve years, onlv four examples of fracture of the scapula
are recorded ; and at Middlesex Hospital, Lonsdale has noticed, among
1901 fractures, only eight of the body of the scapula.

The infrequency of this fracture is no doubt due in a great measure
to the elasticity of the ribs, to the mobility of the scapula, and to the
softness of the muscular cushion upon which it reposes.

Symptoms. — Since this bone is seldom broken except by great
force directly applied, the usual signs of fractures are likely to be con-



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FRACTURES OF THE BODY OF THE SCAPULA. 208

cealed by the speedy ocoarrence of swelling. It is for this reason that
it becomes necessary, generally, that the examination should be made
with great care before we can safelydetermine upon the diagnosis. I
have more than once had occasion to correct the diagnosis of other prac-
titioaers, who believed they had discovered a fracture of the scapula.

When, however, the line of the fracture has traversed the spine,
and any considerable displacement has occurred, one ought to recog-
nize the fracture easily by

merely carrying the finger Fig. 63.

along the crest.

If the fracture has oc-
curred through the body,
below or above the spine,
or through either of the |
angles, the displacement
may not be so easily recog-
nized. The surgeon ought
then to trace carefully with
his fiDger the outlines of the
scapala, and this he will be
able to do more satisfactorily
if he places the scapula in
such positions as elevate its
margins and render them
more prominent. In ex-
amining the posterior angle,
the hand of the injured limb
may be placed upon the op-
posite shoulder, the forearm
being carried across the front
of the chest; but in search-
ing for a fracture below the
spine, the forearm ought to ^^^^^^ ^^ ^^^ ^^.^^^^ ^^^^^ ^, ^^^^^^ ^^^^ ^..^^^

be Jaid across the back. MOUer'. coUeoUon, sp«ciineii C. No. 187.

Crepitus, which is not
always present, owing to the fact that the fragments overlap com-
pletely, or because they have been widely separated by the action
of the muscles, may generally be detected by placing the palm of the
hand upon some portion of the scapula, so as to steady the fragment
upon which it rests, while the arm is moved backwards and forwards,
and in various other directions, until their broken surfaces are brought
into contact.

Some degree of embarrassment in the motions of the shoulder and
arm must always result from this fracture ; sometimes this embarrass-
ment is very great, but it ought not to be considered ever as diagnostic
of a fracture, since it may be produced equally by a severe contusion ;
and even when it is accompanied with a fracture, it is due rather to
the contusion than to the fracture.

Pathology, Seat, Direction, <tc. — Of incomplete fractures of the sca-
pula, I have already mentioned that I have seen one example.



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204 FRACTURES OP THE SCAPULA.

Malgaigne thinks that he has seen one case of incomplete fractarcr
which occurred in a man who was injured by the fall of a heavy block
of stone, upon his back ; but as the patient recovered, his diagnosis
must remain doubtful. I know of no other recorded examples.

Complete fractures occur most often below the spine, and they are
generally oblique or transverse, sometimes nearly longitudinal.

Fractures involving the spine are noticed occasionally, but I am
not aware that any one has ever seen a specimen of a fracture of the

spine alone, although many surgeons have
Fig. 54. spoken of them.

I have mentioned one example of a frac-
ture of the posterior angle as being in the
cabinet of Dr. Mutter, of Philadelphia.
Malgaigne seems to doubt its existence,
but speaks of it as a fracture which sur-
geons have " imagined."

Occasionally the bone is broken into
more than two fragments.

As a result of the fracture there is usually
more or less displacement; generally, if
the fracture is below the spine and trans-
verse, and especially if its direction is ob-
lique from before backwards and down-
wards, the inferior fragment is displaced
T^ . #.1. v^ A . forwards, or forwards and upwards, by the

Fraetnresof the bodf, and acromion . ' , • ^ • "^ r

procoM of the teapau. actiou of the scrratus major anticus, or or

the teres major, while the superior frag-
ment is inclined to fall backwards, aiid sometimes it is carried upwards
and backwards, following the action of the rhomboideus major.

In cases of comminuted fracture, and occasionally in simple frac-
tures, the direction of the displacement is reversed, or altogether
changed, so that the lower fragment, instead of being in front, is behind
the upper fragment ; and instead of overlapping, the two fragments
are more or less drawn asunder. These are deviations which are not
easily explained, but which depend, perhaps, rather upon the direction
of the blow than upon the action of the muscles.

In a few cases there is no displacement in any direction, although
the crepitus with mobility sufficiently demonstrates the existence of a
fracture.

Prognosis. — If displacement actually has taken place, it will be found
very di^cult, as we shall see when we come to consider the treatment,
to hold the fragments in apposition until a cure is completed ; so that
they are pretty certain to unite with a degree of overlapping, or other
irregularity.

Lonsdale, Lizars, Chelius, N^laton, Gibson, Malgaigne, and others
have spoken of the difficulty or impossibility generallv of keeping
these fragments in place. N^laton and Malgaigne, indeed, confess that
they have never succeeded ; Gibson declares that it is scarcely possible;
while Ohelius affirms that if the fracture is near the angle, the cure is
always effected with some deformity.



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FRACTUEBS OP THE BODY OF THE SCAPULA. 205

But then it is not probable that the patient will ever suffer any
serious inconvenience from this irregular union of the fragments, since
the perfection of its function depends less upon any given form or size
than in the case of almost any other large bone ; and if, as has been
observed by Lonsdale, the free use of the arm is not recovered for some
time, or if, as has been noticed by B. Bell, a permanent stiffness results,
these should be regarded as due to the injury which those muscles
have suffered which envelop the scapula, or to some injury of the
ligaments and muscles which surround the shoulder-joint.

In some few examples upon record, the bone has been so commi-
nuted, and the soft parts adjacent so much injured, that suppuration
and necrosis have ensued. And in one case of gunshot fracture of
the scapula, attended with much comminution, and resulting in ne-
crosis, 1 have had occasion to remove the entire scapula.

Treatment. — In the treatment of this fracture, the first object with all
surgeons has been to restore the fragments to place, and this they have
chiefly sought to accomplish by position ; after which they have en-
deavored to immobilize the fragments by bandages, &c.

In seeking to accomplish the first indication, they have placed the
shoulder and arm in a great variety of postures. Nearly all seem to
have regarded it as of some importance that the shoulder should be
elevated, so as to relax the muscles attached to the upper and back
part of the scapula, and thus permit the upper fragment to fall down-
wards and forwards.

If we confine our remarks first to fractures through the body, and
do not include fractures of the inferior angle, this indication is the
only one which Ndlaton and Mayor have sought to accomplish, and
for this purpose they employ a simple sling; while Amesbury, Listen,
Lonsdale, S. Cooper, South, Skey, Miller, Pirrie, have added to the
sling a bandage or roller, which is made to inclose snugly the body
and arm.

Erichsen uses the body bandage alone, as in fractures of the ribs,
while B. Cooper, Lizars, and Tavernier employ a bandage which in-
closes not only the body, but also the arm ; neither of these last-men-
tioned surgeons recommends a sling, or any other means to elevate
the arm.

Johannes de Gorter advises that a sling shall be used, but that the
elbow shall be lifted away from the side of the body, so as to relax
the deltoid. Chelius and Desault recommend the same position, but
with the addition of an axillary pad, whose apex shall be directed
upwards, secured in place with appropriate bandages.

Pierre d'Argelata used also an axillary pad, but instead of a wedge
he recommended a simple roll ; and instead of lifting the elbow away
from the body, he directed that the elbow should be secured against
the side, making use of the axillary roll as a fulcrum.

Petit and Heister advised that the elbow and forearm should be car-
ried forwards upon the front of the chesty and secured in this position.

In the treatment of no other fracture perhaps have surgeons differed
more widely as to the indications than in this, since, as we have seen,
some recommend the elbow to be carried from the body, and some



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206 . FRACTURES OF THE SCAPULA.

that it shall be made to approach the body ; one directs that tbe elbow
shall fall perpendicularly beside the chest, a second prefers that it shall
be carriea a little back, and a third that it shall be brought well for-
wards. In one thing alone have they nearly all agreed, namely, that
the elbow shall be lifted ; and generally also it has been recommended
that the arm, forearm, and body shall be confined by sufficient band-
ages to insure quietude. It might be proper to conclude, therefore,
that the sling and bandage constitute all of the apparatus which is
necessary or useful ; and that it is relatively unimportant whether the
elbow is near or remote from the body, or whether it is in front of, or
behind, or beside the chest.

Such, indeed, is the conclusion to which we have ourselves arrived;
yet if, in relation to the position of the elbow, a choice were to be
expressed, we would give the preference to that in which the arm is
laid vertically beside the body, or, perhaps, with the elbow a little
inclined backwards, so as to relax as completely as possible the teres
major.

It is quite probable, however, that no single position will be found
of universal application ; and perhaps it would be more safe to advise
the surgeon in any given case first to reduce the fragments as com-
pletely as possible by manipulation, and then to place the arm in such
a position as, upon careful experiment in this particular instance, he
shall find enables him to best retain them in place.

If, however, the fracture is such as to have separated the inferior
angle from the body, it will be well to follow the advice of Boyer and
of others, and to place a compress in front of the inferior angle, to
resist the greater tendency to displacement in this direction. This
compress will more effectually accomplish this indication if the roller
with which it is secured to the body, and with which we seek to im-
mobilize the scapula and chest, is turned from before backwards, or
in a direction of antagonism to the action of the muscles which pro-
duce the displacement.

Desault, with Ghelius and Bransby Cooper, has recommended also,
in the case of a fracture through the angle, that the forearm should
be acutely flexed upon the arm, and that the hand should be placed in
front of the chest, upon the sound shoulder, a position which is always
irksome, and sometimes insupportable, and which does not offer ia
any case sufficient advantages to render it worthy of a trial.

§ 2. Fragtubes of the Neck of the Scapula.

If by the '' neck" of the scapula, surgeons mean that slightly con-
stricted portion of this bone which is situated at the base of the glenoid
cavity — and it is to this portion, we believe, that anatomists have
generally applied the term " neck" — then its fracture is certainly very



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 24 of 100)