Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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to the boy the necessity of changing his occupation, and advised him
to go into the country; but as he was unable to do so, little hope was
entertained of his recovery.^

> B. Cooper's ed. of Sir Astley Cooper, &c., op. cit., p. 447.



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524 DISLOCATIONS OF THE CLAVICLE.

§ 3. Dislocation of one Cartilage upon Another.

The cartilages on the sixth, seventh, and eighth ribs are furnished
at their lower borders with a true arthrodial joint, by which they
articulate w'ith the corresponding cartilages. This arrangement some-
times extends to the fifth and ninth ribs.

A displacement of these articulations may take place when one
falls upon hia back, striking upon some projecting body, so that the
chest is suddenly thrown forwards; in consequence of which the
upper margin of the lower cartilage is depressed and entangled be-
hind the lower margin of the upper. The inferior cartilage is, there-
fore, the one which is displaced rather than the superior, although
this latter being made prominent by the pressure of the other from
behind, seems alone to be displaced. Boyer, Martin, and Malgaigne
have each reported one example.

It is probable that the contraction of the pectoral and abdominal
muscles has a chief agency in the production of these dislocations, and
that they are not solely or directly due to the shock of the accident.

The treatment consists in pressing firmly upwards and backwards
against the inferior margin of the upper, or overlapping rib, so as to
disengage it from the lower, when by its own elasticity it will resume
its natural position. The reduction might also be aided by a full in-
spiration.



CHAPTER V.

DISLOCATIONS OF THE CLAVICLE.

Of 46 dislocations of the clavicle observed by me, 9 belonged to the
sternal end and 87 to the acromial. Of those belonging to the sternal
end, 7 were dislocations forwards, forwards and upwards, or forwards
and downwards, and 2 were upwards. I have never met with a dis-
location backwards. Of the acromial dislocations, the whole number
were dislocations upwards, or upwards and outwards.

§ 1. Dislocation Forwards at the Sternal End.

Causes. — This accident is generally caused by a fall upon the point
of the shoulder, in consequence of which the sternal end of the cla-
vicle is driven forcibly inwards and forwards. It is probable, also,
that the blow which produces the dislocation is received rather upon
the anterior and outer face than exactly upon the extremity of the
shoulder. A sudden eftbrt of the muscles, as in the attempt to
balance a weight upon the head, or to throw the shoulders backwards
when under drill, has been known also to produce this dislocation.
In one example it was occasioned by placing the knee against the
spine and drawing the shoulders forcibly back. Various other acci-



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DISLOCATION FORWARDS AT THE STERNAL END. 525

dents, the philosophy of whose agency is not so easily explained, are
said to have produced the same result; but it is not improbable that
in many of these cases the precise manner in which the injury was
received has not been correctly understood or reported.

Mr. Fergusson has once seen this displacement in a newly-born
infant, which had happened during birth. It could be replaced with
ease, but immediately slipped out again when left to itself. " Nothing
was done ; a new joint formed, and the child afterwards possessed as
much power in thia one arm as in the other."^

Symptoms. — The head of the bone, unless the person is exceedingly
fat, or great swelling has supervened, can be distinctly felt and seen
in front of the sternum; the corresponding shoulder falls a little back;
the head inclines also sometimes to the same side; the movements of
the arm are embarrassed, and accompanied almost always with an acute
pain at the point of dislocation. The clavicular portion of the sterno-
cleido-mastoid muscle presents an unusually sharp and projecting
outline, and a careful measurement indicates, if the dislocation is
complete, a sensible approach to the
acromion process toward the centre Fig. 280.

of the sternum. If now the surgeon
places his knee against the spine, and
draws the shoulders back, the pro-
jection of the clavicle in front dimin-
ishes or disappears ; if he carries the
shoulder up, it descends; and if he
depresses the shoulder, it ascends.

The simplicity and uniformity of
the symptoms which usually charac-
terize this accident will generally pre-
vent the possibility of a mistake ; but
Pinel mentions the case of a man who

having presented himself at one of the Dislocation of the stemal end forwardi.

hospitals of Paris, suffering under this

dislocation, the surgeon-in-chief thought it a tumor of the bone, and
advised the application of a plaster ; and, on the other hand, a patient
presented himself to Velpeau, who had been treated for a dislocation,
when the bone was only expanded by disease.

I have myself also seen a fracture so near the sternal end of the
bone as not to be easily distinguished from a dislocation.

Pathology. — In complete anterior luxation of the clavicle, the cap-
sular ligament suffers a complete disruption, and also the anterior
with the posterior sterno-clavicular ligaments. The rhomboid and
interarticular ligaments suffer more or less, according to the extent of
the displacement. The interarticular cartilage may retain its attach-
ment to the sternum, or it may be carried forwards with the clavicle.
The head of the bone lies immediately underneath the skin and in
front of the sternum; and generally it is found to have descended a
little upon its anterior sur^ce. Bicherand saw a case in which the

> Fergusson, System of Practical Surgery, Amer. ed., 1853, p. 203,



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526 DISLOCATIONS OP THE CLAVICLE.

sternal extremity of the bone was placed three inches below the top
of the sternum.

Wherever the bone lies it carries with it the clavicular fascicalus
of the sterno-oleido-mastoid muscle.

li'ecUTnerU. — Not one of the seven forward dislocations of the
clavicle at the sternal end seen by me has been completely redaced,
or if reduced they have not been retained in place. In the following
example the reduction, although faithfully attempted, was never
accomplished.

Mr. H., of Buffalo, set. 45, was thrown by a horse, suffering at the
same moment a fracture of the leg and a forward dislocation of the
left clavicle at its sternal end.

Prof. James P. White, with whom I was in consultation, made
several attempts to reduce the dislocation by placing the knee against
the spine and pulling the shoulder forcibly back, and the same eflbrts
were repeated by myself, but without accomplishing the redaction.
We also endeavored to reduce it by pressing directly upon the pro-
jecting bone and by placing a pad in the axilla, using the arm as a
lever as recommendea by Desault, and with no better result.

This patient was tolerably muscular, but while we were manipu-
lating he was very much enfeebled by the shock of the accident.

Finding that it was impossible to reduce the dislocation by any
moderate amount of force, and believing that if we were to succeed
we could not retain the bone in place, and the more especially because
his left side was so much bruised that he could not bear an axillary
pad or bandages of any kind, we desisted from any further attempts.

Two years later I examined the shoulder and found the clavicle
still unreduced, and its position unchanged. When he carries the
shoulder forwards or backwards, there is a corresponding motion at
the sternal end of the clavicle. The arm is not quite as strong as the
other, and its freedom of motion is slightly impaired.

I have also in my museum the cast of a case of complete forward
dislocation at this point; which accident occurred in a lad twelve
years old, who had fallen into a cellar on the 20th of Aug. 1856. The
late Dr. Lewis and Dr. Dayton, both excellent surgeons, had examined
the arm, and dressings had been applied with a view to maintain the
reduction; but on the fifth day after the accident I found the bone
displaced; nor do I think reduction was ever afterwards maintained.

A lad was brought into the Buffalo Hospital of the Sisters of
Charity, with a dislocation of the same character, on the 25th of Sept.
1858, who had been run over by a wagon on the same day. Dr. E.
P. Smith, one of the surgeons of the hospital, attempted faithfully to
reduce it, but was unable to do so. Five days after, I found the bone
out and quite movable. All apparatus having been removed, we laid
him Upon his back in bed, and kept him in this position three weeks.
He was then dismissed with no change in the appearance of the bone,
but he could move the arm as well as before the accident.

Other surgeons have not met with, or at least they have not men*
tioned, any cases in which the reduction of this dislocation was attended
with difficulty, nor am I prepared to explain the difficulty which was



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DISLOCATION FORWARDS AT THE STERNAL END. 527

experienced in my own (Mr. H.), and in Dr. E. P. Smith's case. Pro-
tably they ought to be regarded as exceptions to the general rule.
Sut most surgeons have testified to the difficulty of retaining it in
place when reduction has been fairly accomplished. Chelius says
"there commpnly remains more or less deformity," and Malgaigne
says that " it is difficult and rare to cure it without deformity."

Nevertheless, Desault(or, rather, his pupil Bichat, who has published
his lectures), who always speaks very confidently of his ability to retain
either broken or dislocated bones
in their places, says that he Fig. 281.

'^ almost always obtained com-
plete success" with his appara-
tus. It is remarkable, however,
that of the three examples fur-
nished by Bichat to confirm this
statement, all of which were
treated by Desault himself, one
recovered after a long time with
a "very perceptible protuber-
ance in front of the sternum,"
one with a " very slight protu-
berance," and in the other the
" swelling was almost gone" on
the twentieth day, and we are
left in doubt as to whether the
reduction was any more com-
plete than in either of the other
cases.^ Bicherand and Guersant
succeeded no better with De-
sault's dressings.'

Other surgeons have made sirAgtleyCooper'gftppftrfttMfordi«loc»tedcUTlcle.

similar claims for their own

forms of apparatus, but experience still continues to show that a com-
plete retention of the dislocated bone is seldom to be expected.

Sir Astley recommends an apparatus, the construction and appli-
cation of which are illustrated by the accompanying sketch, the object
of which is to draw the shoulders back, and at the same time, by the
aid of two pads or cushions in the axill89, to carry the shoulders out-
wards. The dressing is then completed by placing the ai:m in a sling.
He advises, however, that in some way direct pressure should be made
upon the projecting point of bone.

Velpeau objects to any plan which will draw the shoulders back ;
but, on the contrary, he thinks that the shoulders should be kept
slightly forwards, so as to diminish the tendency of the sternal end of
the clavicle to escape in this direction.

Until further observations have determined the relative value of
these and of many other processes, it will be well to adopt no fixed

» Desault on Fractures and Dislocations, by Xav. Bichat, Philada. ed., 1805, p. 62.
< Malgaigne, op. cit., torn. ii. p. 417.



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528 DISLOCATIONS OF THE CLAVICLE.

rule of action ; but, having reduced the bone by either placing the
knee upon the spine and drawing the shoulders back, or by making
use of the humerus as a lever, we recommend that the surgeon shall
seek to maintain it in place by such means as the experiment shall
prove are most successful. Among these means, direct pressure upon
the sternal end of the clavicle, the sling, and perfect quietude of the
muscles of the arm through the aid of bandages, are no doubt of the
greatest importance, and can seldom be omitted. If then we find that
a position of the shoulders more or less forwards or backwards best
maintains the apposition, this position, whatever it is, ought to be
continued.

In order to be successful, sufficient time must elapse for the torn
ligaments to become fil:*mly reunited, during which the reduction mast
be constant; since every time the bone escapes, the whole work of
repair has to be recommenced as from the beginning. To this end at
least four or six weeks are necessary, and sometimes the period most
be lengthened far beyond these limits ; so that it may often become a
grave point of inquiry whether the long confinement of the limb will
not entail more serious consequences than have ever been known to
arise from leaving the bone displaced. In no case seen by me has
the function of the arm been seriously impaired by the displacement.

§ 2. Dislocation of the Sternal End of the Clavicle Upwards.

Malgaigne has collected four undoubted examples of this dislocation,
and I have been unable to find a report of any other except the very
extraordinary case described by Dr. Rochester, at the September
meeting of the BufiFalo Medical Association, and which case, through
the courtesy of Dr. Rochester, I was permitted to see several times.'

Jerry McAulifiFe, set. 44, on the 28th of August, 1858, while seated
upon a load of wood, was caught under the bar of a gateway and
violently crushed, the right shoulder being forced downwards and a
little backward]^. Dr. Rochester saw him very soon after the accident
On examination, it was found that the sternal extremity of the right
clavicle was thrown upwards so far as to rest upon the front of the
thyroid cartilage, occasioning considerable pain, difficulty of respira-
tion, and loss of speech. Reduction was easily effected, and a retentive
apparatus was immediately applied, consisting of a gutta-percha splint,
moulded to the clavicle and ribs, and retained in place with adhesive
plaster. Suitable bandages, a sling, &c., were also employed to main-
tain complete rest.

Notwithstanding all the care employed, the bone again became
displaced, and when, near four months after the accident, this man
came before the class of medical students at the Hospital of the Sisters
of Charity, we found the sternal end of the clavicle carried upwards
half an inch, and across toward the opposite side also about half an
inch, and projecting somewhat in front. It was fixed in this position
by ligaments which allowed it to move much more freely than natural,

* Rochester, Buffalo Med. Joum., vol. xiv. p. 262.



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OP THE STERNAL END OP CLAVICLE UPWARDS. 529

but which would not permit any great displacement. Tlie correspond-
ing shoulder was slightly depressed. McAuliffe said that he felt no
inconvenience or abatement of strength in the arm except when he
attempted to lift weights above his head.

In April, 1870, 1 met with a similar case in a woman fifty years of
age, which had been caused by a fall upon the shoulders nine weeks
before, and which had been overlooked by her surgeon in the first
instance. When seen by me it was immovably fixed in its new
position.

The accident seems to have been produced in all the cases, so far

as can be ascertained, by a force operating upon the end and top of

the shoulder ; in consequence of which the head of the clavicle is

pushed and at the same time lifted, as it were, from its socket, tearing

not only its capsule with the ligaments which immediately invest the

capsule, but also in some instances the costo-clavicular ligament with

some fibres of the subclavian muscle. The sternal end of the clavicle

is found riding upon the top of the sternum, its head being placed

between the sternal fasciculus of the sterno-cleido- mastoid muscle

on the one hand, and the sterno-hyoid muscle on the other. In

one of the cases seen by Malgaigne the head had traversed in this

direction completely the intra-clavicular space, and lay behind the

sternal portion of the opposite sterno-cleido-mastoid muscle.

The symptoms are, a depression of the shoulder, with an elevation
of the sternal end of the clavicle so as to increase sensibly the space
between it and the first rib. The clavicle also encroaches more or
less upon the supra-sternal fossa, occasioning a corresponding dimi-
nution of the space between the end of the shoulder and the centre of
the sternum. The sternal portion of one or both of the sterno-cleido-
mastoid muscles may also be seen raised and rendered tense by the
pressure of the head of the bone from behind.

Fig. 233.



Diilocatioa of the sternal end of the claTicle upwards.

Reduction has been found easy, but Malgaigne thinks a perfect
retention impossible, at least it does not seem to have been accom-
plished in any of the cases reported. In no case did the displace-
ment seriously impair the functions of the arm.



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530 DISLOCATIONS OF THE CLAVICLE.

The same apparatus to which we shall give the preference in cases
of dislocation upwards of the acromial end of the clavicle, at least with
only such slight modifications as the peculiarities of the case will
naturally suggest, will be suitable for this accident. The sfaoalder
must be lifted by a sling, while the sternal end of the clavicle is
pressed downwards by a pad and bandages ; and all the muscles of tbe
arm and chest, so far as is consistent with respiration and comfort,
must be maintained in a state of perfect rest until the ligaments have
become reunited.

§ 3. Dislocations of the Sternal End of the Clavicle Backwards.

The first case upon record of this kind of accident, caused by
violence, was published by Pellieux in 1834, in the Revue MMioaJe;
until which time its existence had been generally denied. In the
London and Edinburgh Journal of Medical Science for October, 1841,
several cases are mentioned.

Two forms of the accident have been described, one in which the
head of the clavicle is driven backwards and a little downwards ; and
another in which it is displaced directly backwards, or backwards and
a little upwards. In both of these classes, the end of the b6ne falls
inwards toward the opposite clavicle, and occupies a space in the
cellular tissue back of the sterno-hyoid and sterno-thyroid mascles,
and in front of the oesophagus ; the trachea, if reached at all, being
probably thrust to the opposite side.

The examples in which it has been found below the top of the
sternum are much the most numerous; indeed, it is probable that the
other form is onlv a secondary displacement, occasioned by the action
of the fibres of the sterno-cleido-mastoid muscle.

Causes. — Of the eleven examples mentioned by Malgaigne, four
were occasioned by direct blows, and most of the remainder bycrush-
ing accidents, as by powerful lateral compression of the shoulders.

One of the cases produced by a direct blow was accompanied with
an external wound, and is the only instance of a compound dislocation
of this kind upon record. The man was admitted into St. Thomases
Hospital in Sept. 1835, and, according to his own account, the sharp
end of a pickaxe had been driven through the flesh against the bone.
The sternal end of the clavicle was found to be displaced backward,
and with the finger thrust into the wound on the front of the chest» it
could be distinctly felt resting upon the side and front of the trachea,
where it interfered somewhat with respiration and deglutition. He
had a great desire to cough, with a sensation of pressure on his wind-
pipe, which was greatly increased when his head was thrown back.
There was also a slight emphysema'in the region below the collar-bone
and over the top of the sternum. The shoulder having been brought
back with straps attached to a back-board, the bone readily resumed
its place. The elbow was then brought forwards and bound to the
side, and the wound being closed with adhesive plaster, he was put to
bed with the shoulders much raised. No unfavorable symptoms fol-
lowed, and in three weeks he left his bed. Three weeks later he left



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OF THE STERNAL END OF CLAVICLE BACKWARDS. 631

tlie liospital with the sternal end of the bone still falling a little back-
'virards, and rather more movable than natural.*

The following example, related by Morel-Lavallfe, will illustrate
tlisit class in which the dislocation results from an indirect blow, or
from a crushing accident.

Xiemoine, seventeen years old, had his right shoulder violently
px^essed against a wall by a carriage. He experienced at the moment
some pain at the bottom of his neck, and a great sensation of suffocation,
lArliich lasted for more than a quarter of an hour. The dyspnoea gradu-
ally subsided, but the motion of the right arm not returning, he, on
tlie eighth day after the accident, entered La Gharitd. On examination^
l^lie two shoulders were found to be on the same level, but the right
one was nearer the median line. The internal extremity of the clavicle
ivas half concealed behind the sternum. On depressing the shoulder,
the inner end of the clavicle arose and disengaged itself from behind
the sternum ; but reduction was effected by elevating the shoulder,
^while at the same time it was carried outwards and backwards. De-
sault's bandage was then applied, but as it became loosened, Yelpeau's
ivas substituted, which kept the bone completely in position until the
eighteenth day, when the patient was lost sight of.*

Symptoms. — The most constant symptoms are, the absence of the
head of the bone from its socket, and its complete or partial disap-
pearance behind the sternum, an approach of the corresponding shoul-
der to the median line, an inclination of the head to the opposite side,
elevation of the shoulder, pain at the bottom of the neck, impairment
of the motions of the arm, sometimes difficulty in respiration and in
deglutition, partial arrest in the circulation of the arm from pressure
upon the subclavian artery, and a slight projection of the acromial end
of the clavicle, noticed twice by Morel-Lavallfe.

It has not generally been found difficult to reduce this dislocation,
nor, when reduced, is it so liable to again become displaced as are the.
dislocations forwards ; yet in only a few instances has the restoration
been so complete as not to leave some deformity.

In order to the reduction, the shoulder must be carried generally
upwards, outwards, and backwards, and it may then be best main-
tained in position by laying the patient on his back upon an elevated
cushion, as practised by Tyrrell in the case related by South. To this
may be added such other measures, differing but little from those em-
ployed in other dislocations of the clavicle, as are necessary to insure
complete rest to the muscles. Of course, no pads or bands across the
clavicle can be of any service in this case.

As in the other cases of dislocation at this point, the patients have
generally recovered nearly the full use of their arms, even in one or
two instances in which the reduction has never been accomplished.

> Soath, note to Chelius's Surgery, Amer. ed., vol. ii. p. 318.

> Morel-Lavall6e, Amer. Joum. Med. Sci., vol. xxix. p. 229, 1842; ttom Gaz. M^d.



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532 DISLOCATIONS OF THE CLAVICLE.

§ 4. Dislocation of the Acromial End of the Clavicle Upwards.

Of all the dislocations of the clavicle; this form is most freqaent.
I have met with it either as a partial or complete luxation thirty-sevea
times. The youngest subject was seven years of age, and the oldest
sixty-three. All but one were males.

Oafises, — It is produced generally by a fall upon the extremity of
the shoulder. Twice the blow has been received rather upon the
back than upon the extremity, and once it was occasioned by the fall
of a board directly upon the top of the shoulder, and once by a bolt
thrust directly up from under the clavicle.

Symptoms. — When the dislocation is complete, the clavicle not only
is lifted from its articular facet to the extent of the breadth of the
bone, but it is pushed more or less outwards over the top of the acro-
mion process ; generally less than half an inch, but I have once seen it
riding the process to the extent of three-quarters of an inch. In this
last example, the case of James Moran, a strong, healthy laboring roan,
the clavicle was easily reduced, and it always went into place with a
sensible click ; but although every possible care was taken to retain



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 61 of 100)