Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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it in place by bandages, compresses, an axillary pad, and a sling, yet
it was not accomplished, and on the third day he removed all the
dressings, and refused to have them reapplied.

I have usually found the shoulder slightly depressed ; and in one
instance where it is probable the deltoid muscle had suffered some in-
jury, the elbow hung away from the body, and any attempts to lay it
against the side produced an acute pain in the shoulder.^ It has been
noticed also, in most cases, that the clavicular portion of the trapezius
muscle appeared lifted and tense, especially when the neck was straight

Inability to raise the arm to a right angle with the body is a general
but not constant symptom. In two instances, where the displacement
was only moderate, the patients were at first and for some time after-
wards unable to lift the arm in any degree from the side. In one
example, a lady sixty years of age had fallen upon her shoulder and
produced a dislocation upwards, but she had not consulted a surgeon
until she called upon me, five months after the accident. The clavicle
was then raised from its socket about half an inch, but it could be
easily pressed back to its place, the reduction being attended with a
grating sensation, a circumstance which I have not noticed in any other
instance. She was not even then able to raise her arm to her head,
nor had she been able to do so since the accident occurred.

In all the motions of the arm and shoulder, the clavicle is seen to
move more freely than natural immediately under the skin, and these
motions are usually attended with some pain at the point of dislocation.

This accident has been sometimes mistaken for a dislocation of the
humerus, but unless the shoulder is already greatly swollen, the error
is not likely to happen. If the point of the acromion process can be
made out, it will be easy to determine, by sliding the finger along its
spine, whether the clavicle is displaced or not, and by these means to

1 Report on Dislocations, by the author. Transac. of New York State Med. See.,
1855, p. 19.



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OP THE ACROMIAL END OF CLAVICLE UPWARDS. 533

Settle the question of its complicity in the accident. The question as
t.o whether the shoulder is dislocated of not may be more difficult of
solution, as we shall hereafter have occasion again to observe.

Pathology, — Generally there exists simply a rupture of the liga-
TTients immediately investing the joint, so that the clavicle rises from
its socket only about half an inch, more or less, according to its dia-
meter, and is carried outwards just
suflSciently far to allow it to rest upon Fig. 238.

the upper margin of the acromial ar-
ticulation. In at least twenty-eight
of the cases seen by me this has been
the position of the acromial end of
the clavicle, and for its complete re-
daction nothing more has been re- .
quired than to press with moderate
force upon the upper and outer end
of the bone.

In five cases I have found the
bone not only thus lifted in its socket,
but also driven over upon the acro-
mion process from half to three-
quarters of an inch; and in one in- n. , *. r*u . i ^ #*». i i

*■ , „ ' , -k r -Tk Dislocation of the acromial end of theo lari-

stance, that of a gentleman, Mr. B., de apwarus.
who was injured in a railroad acci-
dent, the acromial end of the clavicle was displaced outwards half an
inch and backwards three-quarters of an inch, while the sternal end
also was considerably lifted in its socket and slightly sent inwards.
The shoulder fell forwards and the coracoid process was one inch
nearer the sternum than the same process upon the opposite side.
In such cases more or less of the fibres of the coraco-clavicular liga-
ment must have sufiered a disruption ; indeed, without a rupture of
its external fasciculus, which anatomists
have called the trapezoid ligament, such Fig. 284.

a dislocation cannot take place.

prognosis. — It is impossible for me to
say what has been the precise result in all
the cases which I have seen, but my notes
furnish only two cases of perfect retention
after a complete dislocation at this point.
One of these, David Thomas, aged about
twenty-five years, fell sideways upon the
ground, striking upon the extremity, and,
as he thinks, a little upon the top of the
shoulder. I found the clavicle dislocated
upwards and outwards, so that it over-
lapped the acromion process half an inch.
It was easily replaced, and having applied
my own apparatus for broken collar-bones,
with the addition of a band across the ^. , . , , . , , ,

, , , i 1 ^1 11 .1 Dislocation of the acromial end of

shoulder and under the elbow to keep th. oUtici. upwrd. «j «oiw.rd..



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534 DISLOCATIONS OP THE CLAVICLE.

the clavicle down, I found that I had succeeded in retaining the bone
in place. This dressing was* continued until the forty-second day,
when, on being removed, the clavicle was seen to be closely ooofined
upon its articulation ; and after a lapse of two years it still retains its
position so completely that no difference can be detected between the
opposite articulations.

In the case* of Moran, already mentioned, whose clavicle overlapped
the acromion process three-quarters of an inch, and who threw off the
dressings at the end of three dajs, the same degree of displacement
existed at the end of two years ; the scapular end of the clavicle
moving freely in every direction under the skin according as the arm
was moved. In lifting, he says, the strength of his arm is undimin-
ished until he raises the weight nearly to a level with his shoolders,
and from this point upwards he can lift but little. For a ' laboring
man it amounts to a serious maiming. I have seen the same loss of
power in the arm to raise bodies above the head in at least two or
three of the examples of less complete luxation, continuing after the
lapse of several years ; but in the majority of cases, although the
bone does not remain reduced, the patients have recovered eventually
the complete use of the arm in whatever position it may be placed.

The case to which I have already referred as having been caused by
a bolt thrust upwards under the clavicle, will furnish the best illustra-
tion of this general principle. James O'Brien, 1st U. S. Artillery,
was injured in September, 1862, by being run over by a horse-car.
A bolt, three-quarters of an inch in diameter, was driven through
the skin on the anterior margin of the left axilla, breaking the first
rib, severing the coraco-clavicular ligaments, and forcing the clavicle
upwards from its socket. No attempt at reduction was ever made.
When seen by me one year after the accident^ the outer end of the
clavicle was lifted directly up two inches from the acromion process^
to which it was united only by a long and slender ligament. He was
not conscious of any loss of power or limitation of motion in the
injured arm. At my request, my son, then in the U. S. service, insti-
tuted a series of experiments to test the relative strength of the two
arms, and with the following result : First with the right arm, ^nd
then with the left, he lifted from the ground fifty-six pounds and three
ounces, and sustained this weight above his head thirty seconds, with his
arms fully extended. With his right arm extended at full length, at
right angles with his body, he sustained twenty-five pounds for fifteen
seconds. With the left arm he sustained the same weight, in the saoie
position, seventeen seconds.^

Treatment. — When the bone simply rises upon its socket, the re-
duction is always easily accomplished by pressing firmly upon its
extremity with the fingers ; but if, at the same time, it has been car-
ried outwards, or outwards and backwards, the reduction is only
accomplished by pulling the shoulders backwards, or by placing a
pad in the axilla, using the arm as a lever, or by lifting the arm by
the elbow and at the same time pressing the clavicle down ; and it

1 Am. Med. Times, Oct. 24, 1868.



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OF THE ACROMIAL END OF CLAVICLE UPWARDS. 585

-wrill sometimes require the application of all or several of these pro-
cedures at the same moment. In some cases the complete redaction
tas only been eflFected when the patient has been brought under the
inflaence of an anaesthetic.

As to the maintenance of the bone in its socket for a length of time
sufficient to insure a firm union of the broken tissues, this will be
found always more difficult, and, in a great majority of cases, abso-
lutely impossible. Nearly all surgeons who have written upon this
subject have made the same observation ; and if occasionally a new
apparatus in the hands of a clever surgeon has seemed to promise
better results, the same apparatus in the hands of other equally clever
surgeons, and under circumstances equally favorable, has been found
almost constantly to fail ; and we have been compelled again to exer-
cise anew our ingenuity, and to seek for new resources, or to abandon
the effort in despair.

Dr. Folts, of Boston, believed that he had found in Bartlett's appa-
ratus for broken clavicles, modified by the application of a shoulder-
strap, the infallible remedy for this one of the many sad defects in
our art. The most important part of this dressing, according to Dr.
Folts, is the compress placed upon the upper and outer end of the
clavicle, and the bandage or strap passed over the compress and under
the point of the elbow to maintain it in position.^

Dr. Folts is no doubt correct in regarding this strap as an impor-
tant if not the essential part of the apparatus ; and it is surprising
that by Sir Astley Cooper, as well as by many other experienced sur-
geons, its value should have been overlooked. The chief obstacle to
the retention of the bone in place is the powerful action of the tra-
pezius, which constantly tends to elevate the outer end of the bone.
In some measure this may be resisted by elevating very forcibly
the shoulder, or by inclining the head, but both of these positions are
extremely fatiguing, and will not be long endured. The bandage or
strap, adjusted in the manner which Dr. Folts has recommended, is the
only means of counteracting the action of the trapezius, upon which
any substantial reliance can be placed ; but the principle has long been
understood and practised upon. Bradsor^s tourniquet, or Petit's, secured
by astrap brought underthe point of theelbow, Beyer's double shoulder-
straps, and Desault's, third bandage all aimed at the accomplishment
of the same purpose ; yet Boyer and Desault found all these con-
trivances fail in a majority of cases. Mayor employed a dressing
constructed with a strap to buckle over the dislocated clavicle, but
N^laton has seen this apparatus fail also, when applied in his own
wards.

The experience of Dr. Folts at the time of his report did not ex-
tend beyond three cases, and the apparatus had been completely
successful in only two of the three. Our own experience is sufficient
to show that it will be found occasionally, but by no means constantly,
successful. We have already mentioned two cases in which we

1 Folts, Host. Med. and Burg. Joum., vol. liii. p. 259.



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636 DISLOCATIONS OF THE CLAVICLE.

succeeded perfectly by this mode, but in several others which seemed
equally favorable we have met with partial or complete failures.

The practical difficulties are, the sensibility and consequent inability
sometimes of the point of the elbow to bear the requisite pressure,

and the even greater sensibility
^ig- 285. of the skin over the top of the

clavicle; the tendency of the
bandage to slide off from the
shoulder and also to become
displaced from the end of the
elbow; the gradual relaxation
of the bandages, which, when
existing even in the most incon-
siderable degree, is sufficient
sometimes to allow the bone to
slip out from its shallow socket;
the impossibility of fixing the
scapula, upon whose immobility
as well as upon the immobility
of the clavicle the retention
depends ; and, finally, the great
length of time requisite to unite
firmly the ligaments, if indeed
they ever again become actually

Mayor's apparatui for dislocated clavicle. ("Tri- ^l^^^d.

angle cnbito-bis-seapuuire.'*) The band cau be prevented in

some measure from sliding off
from the clavicle by a counter-band attached to a collar upon the
opposite shoulder, but not without causing some pain and giving rise
to excoriations generally in the opposite axilla ; and, in a degree, all
the other difficulties may be met by patience and ingenuity, but un-
fortunately the smallest failure in any one of these numerous indica-
tions insures a defeat.

The axillary pad employed as a fulcrum upon which extension may
be made is equally as dangerous here as in fractures, and I do not
think it ought ever to be used for this purpose, but only as a means
of moderate support and retention ; indeed it would be well, perhaps,
if it were discarded altogether.

The case of Mr. B., already quoted, with a dislocation outwards and
backwards, affords not only an illustration of the inefficiency of either
the shoulder-strap or the axillary pad in certain cases, but also, it seems
to me, of the mischief which may result from their too diligent appli-
cation ; for I cannot persuade myself but that most of the maiming in
this case was due to the apparatus rather than to the original accident

This gentleman was injured on the 10th of November, 1855. A
sling with an axillary pad and bandages was immediately applied. I
saw him on the seventeenth day. The displacement was then such as
I have described, but I did not observe any paralysis or emaciation of
the limb. Having noticed that the clavicle fell into its socket when
he lay upon his back in bed, at my suggestion all the dressings ex-



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OF THE ACBOMIAL END OP CLAVICLE DOWNWARDS. 537

oept the sling were removed, and the patient was laid upon bis back
in bed, witb instructions to continue in this position, if possible, until
the cure was completed ; but after a few days I received a communi-
cation from his physician, stating that, owing to a troublesome cough,
he had found it impossible to maintain this position. His residence
was forty or fifty miles from town, and I sent him one of my dressings
for broken collar-bones with instructions as to its use ; directing espe-
cially that a shoulder-strap should be used to keep the clavicle down.
The dressing was applied and continued six weeks, and on being
removed, the elbow, wrist, and finger joints were found to be stiff'.
The whole arm was emaciated and almost powerless. One year later
there was no improvement* in the condition of the arm ; every joint
from the shoulder down was almost completely anchylosed, the mus-
cles were greatly wasted, and the hand trembled constantly.

These results, it seems to me, were due to too long and too tight
bandaging of the arm, and especially to the pressure of the axillary
pad. I do not state this positively, but this is my belief.

Is it worth while, then, to incur the dangers of too long confinement
and of excessive bandaging for the purpose of attaining the always
uncertain result of maintaining the bone in its socket? We certainly
may be permitted to make the attempt within certain reasonable
limits ; and especially if the patient is a female and the avoidance of
deformity is a point of serious consideration; but never without keep-
ing constantly in mind the possibility of a permanent anchylosis and
paralysis of the limb.

§ 5. Dislocation op the Acromial End op the Clavicle Downwards.

This form of dislocation is exceedingly rare, only three well-authen-
ticated cases having been placed upon record, one of which was seen
and dissected by Melle in 1765, the second was met with by Fleury
in 1816, and the third is described by Tournel.

Cause. — So far as we can asciertain, it has been produced only by a
force which has acted directly upon the top of the clavicle. In the
case mentioned by Tournel, a horse had trod upon the shoulder; and
in the example recorded by Melle, the accident occurred in a child
six years old, from an attempt to support a great weight upon the top
of the collar-bone. In this last example the humerus was dislocated
also, and both dislocations had remained unreduced many years when
the patient was seen by Melle.

This force acting directly upon the top of the clavicle would fail
to dislocate the bone, except by first breaking down the coracoid
process, if it did not happen sometimes that at the same moment the
lower angle of the scapula was thrown outwards, in such a manner
as to depress slightly the coracoid process, and thus to permit the
outer end of the clavicle to fall below the level of the acromion
process.

Symptoms and Pathology. — This dislocation, whether it has been
produced artificially upon the dead subject or accidentally upon the
living, has always been found to be accompanied with a complete
85



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\

538 DISLOCATIONS OP THE CliAVICLE.

rupture of the acromio-clavicular ligamenta itpt only, but also of the
coraco-acromial and coraco-clavicular ligaments; the outer extrenitr
of the bone resting between the acromion process and the capsule of
the shoulder-joint, and a little posterior to the articulating facet which
originally received the clavicle.

The superior angle of the scapula approaches the body slightly,
and its inferior angle is thrown outwards. A marked depression
exists at the point of dislocation, accompanied with a sharp pain,
increased especially when an attempt is made to move the arm. The
patient is unable to lift the arm voluntarily, but it can be moved
pretty freely in the direction forwards and backwards by the hands
of the surgeon : abduction is much more difficult.

Treatment, — Reduction is easily accomplished. At leasts in the only
two examples upon the living subject in which the attempt has been
made, it was effected promptly by drawing the shoulders gently out-
wards and backwards ; nor has it been found any more difficult to
maintain it in position when once replaced. When the scapula is
restored to its natural position, and its lower angle approach^ again
the side of the body, a reluxation becomes impossible; since the
coracoid process now effectually prevents that descent of the clavicle
upon which its displacement always depends. It is only necessary,
therefore, to secure the scapula at its base and lower angle snugly to
the body, by a broad bana and compress, and all the indications of
treatment are completely fulfilled.

§ 6. Dislocation of the Acromial End of the Clavicle under the
Coracoid Process.

Pinjou met with one example of this singular dislocation/ and
Godemer, of Mayenne, has recorded five more,* and these constitute
the whole number which are at this day known to science.

Cause, — Age and a consequent relaxation of the ligaments seem to
constitute a predisposing cause, since of the six recorded examples
four were between the ages of sixty-seven and seventy -one, and the
other two were adults. In all the cases, also, the dislocation was the
result of a fall upon the shoulder.

The symptoms which have been said to characterize this accident
are pain and a very marked depression at the point of displacement,
with a corresponding projection of the acromion and coracoid pro-
cesses; a rapid inclination outwards and downwards of the line of the
clavicle, its outer extremity being felt in the axilla ; the corresponding
shoulder depressed and inclined forwards; freedom of motion in all
directions except inwards and upwards ; the lower angle of the scapula
thrown outwards and backwards ; to which MorelLavall^ has added
an actual increase of space between the acromion process and the
sternum.

TreatmenL — Godemer reduced all the examples which came under
his notice easily, by directing an assistant to pull the arm backwards

1 Pinjou, Jonrn. de. M^. de Lyon, Juillet, 1842, from Yidal (de Cassis).
* Godemer, Recueil des trayaux de la Soc. Med. d^Indre et Loire, 1S43, from
Yidal.



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DISLOCATION AND ROTATION FORWARDS. 539

and outwards while he himself seized upon the olavicle with his fin-
gers, and disengaged it from under the process; but Fiujoa, after
many efforts by the same method, failed completely, and the patient
having left him, the clavicle was reduced the next day by an empiric.
Vidal (de Cassis) recommends that instead of pulling the arm out-
wards, by which procedure the pectoralis major is made to antagonize
the surgeon, the elbow shall be brought down to the side, and kept
there by the left hand, while the right hand, placed in the axilla, shall
pall the upper end of the humerus outwards, converting the arm into
a lever of the third kind. This process, I confess, seems to be much
the most rational.

Finally, having given the history of these cases as they have been
reported, we shall scarcely have performed our duty as a faithful
writer, if we do not state frankly that we entertain a suspicion that
both the gentlemen who have reported these curious examples have
entertained us with fabulous or imaginary stories ; and especially do
these suspicions rest upon the cases reported by Godemer, who in five
years saw five cases, each presenting throughout the same class of
symptoms, the same facility of reduction, accomplished by the same
means, and always with the same perfect result.

If to these singular coincidences we add the fact that only one other
surgeon has ever claimed to have met with the accident, and if we
notice the actual anatomical difficulties which stand in the way of its
occurrence, such especially as the complete occlusion of the subcora-
coidean space by the tendons and muscles which pass from its extre-
mity toward the chest and arm, we shall find a fair apology for some
degree of scepticism.

§ 7. Dislocation and Rotation Forwards of the Clavicle at both
Ends, Simultaneously.

The following example is the only one of this kind of which I have
any knowledge : —

On the 26th of January, 1868, Dr. North, of Brooklyn, N. Y., was
called to see a lad fourteen years of age, who had been thrown with
violence backwards from a stool upon which he was sitting, striking
the back of his left shoulder against the fioor. Dr. North found him
suffering severely from pain, and with some difficulty of breathing.
The shoulder was depressed and thrown forwards. The sternal end
of the clavicle, turned forwards, formed an abrupt, rounded promi-
nence ; the acromial end, turned forwards also, presented its longest
diameter toward the surface, and rested above the acromion process ;
while the central portion seemed depressed or thrown back, an ap<
pearance which was caused by the rotation of the clavicle upon its axis.

Reduction was accomplisned by throwing the shoulders forcibly
backwards, and at the same time pressing with the thumbs upon the
two extremities in such a manner as to reverse the rotation, as follows:
pressing at the acromial end backwards and downwards, and at the
sternal end backwards and upwards. The restoration was complete,
and the bones were retained in place by compresses and adhesive



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540 DISLOCATIONS OF THE SHOULDER.

plasters, with the aid of Day's " neck yoke." At the end of three
weeks the dressings were removed ; and when last seen by his sur-
geon " there was but little, if any, trace of the accident remaining.''
It is the opinion of Dr. North that the rotation was caused by the
action of the pectoralis major and deltoid after the dislocation took
place.*



CHAPTERVI.

DISLOCATIONS OP THE SHOULDER (HUMERUS AT ITS UPPER

EXTREMITY).

. Owing to the great exposure, and the peculiar anatomical structure
of the shoulder-joint, its structure having reference mainly to freedom
of motion rather than to firmness and security in the articulation,
dislocations of the humerus are very common.

Writers have not been agreed as to the precise anatomical relations
of these dislocations, nor as to the nomenclature. Velpeau, Malgaigne,
Vidal (de (Jassis), Skey, and Sir Astley Cooper have each adopted
explanations and classifications peculiar to themselves. With the
arrangement established by this latter surgeon, English and American
students are the most familiar; and believing that it is more simple,
and quite as appropriate as either of the others, I shall adopt it as the
basis of my own descriptions.

I shall have occasion, however, to dissent from the opinions and



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 62 of 100)