CLAVICLE, Fractures of.
The deformity or displacement in fractures of the shaft is mainly if not entirely clue to the depression of the shoulder which causes the outer fragment to be drawn downwards, forwards and inwards by the weight of the arm, whilst the inner fragment is held in its position by the rhomboid ligament or at the most hut slightly if at all elevated by the action of the sterno-mastoid muscle.
By placing the patient upon his hack on a firm hair mattress with a small cushion between the shoulders and the arm supported upon a pillow by the side with the elbow elevated the fragments are at once brought into apposition. if this position be maintained continuously for about 18 days no other treatment is required, but even when sand-bags are employed some occasional movement of the body will produce slight over-riding of the fragments with consequent pain and uneasiness. Hence further support is necessary, especially in patients who refuse to consign themselves for so long a period to the recumbent posture.
To shorten the sojourn in bed in the horizontal position various devices are resorted to. flood's plan of strapping is the simplest, but no method of treatment which allows the patient to move about will give a result free from some deformity save the application of Gordon's original clavicular apparatus, which proved, however, so cumbrous as to be now almost discarded.
Hood's Method.—Three pieces of stout adhesive rubber plaster each about one and a half to two inches wide are vertically applied to the chest at a level below' the angle of the scapula behind and brought over the clavicle in front to be attached as low down as the level of the nipple; the middle strip should be applied first and should cover the site of the fracture, being strengthened on each side by the overlapping edges of the lateral strips. After the application of these the patient should be placed in bed in the position above described and daily gentle friction or massage applied to the muscles. Passive movements at the joints of the fingers, wrist, elbow and shoulder should be commenced, and after a few days active gentle movements at all these joints, the shoulder-joint being cauti ously exercised by a slight swinging motion.
In a week or eight days the patient may be permitted to get up and move about with his arm supported in a sling.
Savre's Method.--This method is devised with the view of permitting the patient to move about from the start, but a pad must be placed in the axilla. Two long strips of stout rubber plaster each measuring 31 inches in width are required. One is stitched with the adhesive surface outwards so as to form a loop for the arm at the insertion of the deltoid; when this strap is in position traction is forcibly made on it to draw the arm back wards and the strapping, heated or moistened with turpentine, is applied to the back of the chest and brought round the side beneath the opposite axilla and over the front of the chest till its free extremity reaches the spine. A second long strip is taken and a slit made in its centre for the reception of the olecranon; this is attached at one extremity over the point of the sound shoulder and applied behind obliquely downwards, securing the elbow on the injured side as in a sling, and its free end is turned upwards on the back of the flexed forearm and hand to join its upper extremity to which it becomes adherent above the sound shoulder. Whilst this second piece of plaster is being made to envelop the elbow the latter should be drawn or pushed forward so as to force the shoulder backwards and upwards upon the fulcrum supplied by the loop of the first strip. A three-inch bandage is applied over the strapping to prevent the plaster adhering to the clothes, and to keep the arm from slipping down under the plaster.
Duncan's modification of Sayre's plaster method consists in applying the principles of Sayre, but using a broad domette bandage instead of the adhesive strapping, the bandage being applied in one piece, and at the overlapping places fastened with safety pins or stitches. It has the advantage of being more easily reapplied should the support become slackened and the over-riding of the fragments return.
Fractures at the acromial end of the bone beyond and between the liga ments may be treated upon the same lines; when fracture occurs in the latter situation, there is no deformity and the patient may be permitted to move about with his arm in a sling.