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Fractures of the Bones of the Upper Extremity

shoulder, fracture, bone, displacement, arm and outer

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Fracture of the Collar-bone (Clavicle). This is a very common fracture, the most common, indeed, with one exception—that of the radius, and is most frequently due to indirect violence, such as a fall on the shoulder. It may be caused by direct violence. It is extremely common in children, in whom, how ever, it does not always break completely through, but takes the form of green-stick frac ture. The break is usually near the middle of the bone, but sometimes it occurs nearer its outer end, when it may not be so readily recognized because of certain ligaments which piss from the outer end to the acromion and corticoid pro cesses of the scapula (see p. 62) and prevent the usual displacement.

Signs.—When the fracture is complete the weight of the arm carries the shoulder down wards and inwards towards the middle line because of the loss of its main stay, and because of the action of the muscles passing from the chest to the shoulder. As the result of this the skin and tissues over the seat of fracture are stretched, and the outer end of the inner frag ment is found projecting. This is not because of its displacement, but because of the falling down o the shoulder. To the outside of this projec tion is a hollow. The outer fragment is carried below the level of the inner one, the two ends often riding. The patient is unable to lift the affected arm, and supports it close to the side. Comparison with the sound side will prove the deformity. In children there may be little or no displacement, either because the fracture is not complete or because the bone has been broken straight across and the outer lining is strong enough to support it. By running the finger along the bone the fracture will be found, irregularity being perceived over the spot where the break is, and pain being experienced by the child at that place.

Treatment.—The displacing forces act down wards, forwards, and inwards; the retaining apparatus must therefore act in the opposite directions—upwards, backwards, and outwards.

To replace the bone, place the patient in bed on a firm mattress, with a pillow lying lengthways down between the shoulders. Standing behind the person pull the shoulder upwards and back wards and reduction will be effected. As soon as the reducing force is removed the displace ment returns. The simplest retaining arrange ment is as follows:—a pad of considerable thick ness, made of cotton-wool rolled up in a hand kerchief, is placed well up into the arm-pit and the arm folded down over it, the had being retained by a strap over the opposite shoulder ; this forces the shoulder outwards; the elbow being kept close to the side, the forearm and hand should be laid across the chest, the fingers pointing to the opposite shoulder and reaching well up towards it; a few turns of a roller ban dage right round the body keep the elbow at the side and the shoulder well back; the elbow should be supported, and the shoulder pushed and kept upwards, by a sling tied over the opposite shoulder. (Fig. 35.) If the pad, sling, and band age are properly adjusted and the arm placed pro perly across the chest the displacement should disappear, and this tests the accuracy of the adjustments. Union takes place in three weeks or four, in young people even earlier. The bandages should occasion ally be examined to see that they do not become loose. Union does not usually occur without some shortening.

Fractures of the (Scap ula).—The shoulder-blade is so well padded by muscles that little displacement is, as a rule, pro duced by fracture. The break is usually due to direct violence, such as the passing of a cart wheel over the back. Movement and grating are best detected by grasping the shoulder and upper part of the bone with one hand and the lower corner of the shoulder-blade with the other and trying to move them on one another, or by placing one hand flat over the bone and moving the arm in various directions.

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