— Displacement having been corrected, the bone is immobilized by strapping the chest with adhesive plaster. During expiration a strip of plaster two inches broad is applied, be ginning over the sternum and following the curve of the ribs over the point of fracture, and around to the opposite axilla. If several ribs are broken they are covered from above downward by similar strips overlapping.
Fracture of the Costal Cartilages.— See DISLOCATIONS.
Fractures of the Clavicle.—They are very frequent in children, being caused by a fall upon the arm which in an adult would be more likely to dislocate the shoulder. They occur usually in the middle third of the bone, are not infre quently incomplete, but very rarely com pound.
Fractures of the middle third are transverse or oblique, from above down ward and inward. The shoulder, losing its anterior support, drops downward, inward, and forward, the posterior border of the scapula is raised outward and its lower angle rotated slightly upward and backward. If the fracture is oblique the outer fragment slips below and behind the inner one, whose edge is prominent under the skin. Transverse fracture may give rise to angular deformity, the angle pointing upward and backward. If the fracture is comminuted the small fragments are markedly displaced; if it is bilateral the weight of the two shoul ders on the chest may cause urgent dyspnoca (relieved by dorsal decubitus). Injuries to the great vessels, nerves, and lungs are rare complications. The arm can be moved forward or backward, but cannot be abducted on account of the pain rather than the musclar disability.
In fractures of the outer third the line of fracture is usually transverse and the displacement angular, with the apex backward. Disability and deformity are not great.
In fracture of the inner third the outer fragment passes below the inner one or is accompanied by it, producing angular deformity.
PROGNOSIS.—Union is almost certain to take place at the end of four weeks whether the fracture is immobilized or not. Some persistent displacement is the rule, especially in adults.
—Reduction is effected by pushing the shoulder upward, out ward, and backward. Manipulation of the arm or simple dorsal decubitus will effect this. To maintain perfect reduc tion dorsal decubitus with the head slightly raised and the forearm resting across the chest is usually essential. In the green-stick fractures of children a simple sling may be sufficient, and the same dressing may be applied to all pa tients who are impatient of restraint in the more complicated dressings and are willing to accept the subsequent de formity.
In other cases Sayre's or Velpeau's dressings will produce an cesthetically satisfactory result.
Sayre's dressing (Figs. 3 and 4) re quires two strips of adhesive plaster, each three inches broad and long enough• to reach one and a half times around the body. The end of one strip is fixed loosely about the arm on the injured side just below the axilla. It is then carried around the back and across the chest in such a way as to hold the elbow a little behind the axillary line. The other strap is then carried from the un injured shoulder across the back and the point of the elbow and back to the point of starting, carrying the elbow forward, fortable, and unless carefully padded is likely to interfere with the circulation of the arms.
Fracture of the outer third is best immobilized by Stimson's dressing for dislocation of the outer end of the clavicle (q. v.).
To avoid deformity displaced corn minuted fragments may be removed through a small incision.
Fractures of the scapula are divided into fractures of the body, of the lower angle, of the spine, of the acromion, of the coracoid process, of the surgical neck, and of the glenoid fossa.