44. We are in possession of but few observations particularly relative
to the different complications, that may accompany fractures of
the clavicle. The treatment, in such cases, varied according to
circumstances, must be accommodated to the indications common to all
fractures of this kind.
When splinters, displaced in different directions, whether adhering to
the bone or not, irritate the soft parts, and, having passed through
the integuments, appear without, most practitioners advise to remove
them and cut off such parts as project beyond the fractured end of the
bone, previously to reduction. This direction is founded on the severe
pains which, in such cases, accompany the common treatment of the
injury, and which the figure of 8 bandage always augments, by drawing
the shoulder inward, and consequently pressing the soft parts against
the projecting parts of the fragment, or the points of the splinters.
But if the splinters, adhering as yet to each other and to the bone, by
means of the periosteum, have not assumed the nature of foreign bodies,
(that is, if they be not actually dead) it is always proper to replace
them. It is here only that we meet with an occasion for that part of
the process, of reduction denominated conformation,[4] which is never
requisite in other cases.
[4] That process or operation in which the surgeon uses his hands
to effect the reduction and apposition of parts, which cannot
be accomplished by extension and counter-extension alone. If
a bone be broken into two or three pieces, mere extension and
counter-extension will not bring all the fragments into their
proper places, so as to restore the natural form of the part.
In such cases, the surgeon uses his hands to aid the action of
the extended muscles, and this is the process which our author
denominates _conformation_. The term occurs in many places in the
course of the work. TRANS.
A fragment which has penetrated the soft parts, but has not been long
exposed to the air, disappears, and is replaced by extension, provided
it be properly directed. Being retained afterwards in a state of
constant extension, it can neither be displaced, nor cause pain by
irritating the parts, which is the inevitable result of the figure of 8
bandage.
In cases of this kind, it is useful to protect the shoulder with a
small splint, which may support the turns of the bandage, and prevent
their pressure on the splinters, or the broken ends, which they might
otherwise disturb. These precautions are alike indispensable when the
fracture is double.
CASE IV. Francis Ricord, twenty-five years of age, was received in the
month of July, 1790, into the Hotel-Dieu of Paris. On the preceding
day, a piece of timber having fallen from a considerable height on
his right shoulder, had broken the clavicle of that side into several
pieces. Severe pains, which occurred at the moment of the accident,
had continued throughout the night, and were still sensibly felt. The
slightest motion of the part augmented them to such a degree, as to
extort from the patient piercing cries.
The point of the shoulder being very much depressed, was also drawn
perceptibly forward and inward; and a large echymosis, without any
external wound, occupied its whole extent.
Desault being satisfied that the several fragments were all connected
together, and that none of them was separated from the periosteum,
placed, as in ordinary cases, the bolster under the arm, completed the
reduction, and applied a splint along the course of the clavicle, after
having, with his hands, brought the fractured pieces into contact.
Confident, then, that the form of the part was perfectly restored, he
applied the bandage, which was moistened with vegeto-mineral water,
twice or thrice a day.
At the moment of reduction the pains ceased, and were felt no more till
the fifth day, when the bandage being a little relaxed, admitted of a
slight displacement of the fragments. This displacement was removed,
and the pains along with it, by the reapplication of the apparatus.
During the six first days a very strict diet was enjoined. This,
however, was dispensed with by degrees, till, on the thirteenth day,
the patient returned to his usual regimen. On the seventeenth day,
there remained nothing of the echymosis, but a yellow tinge, the
customary consequence, of such an accident. The precautions inculcated
in the preceding case, were employed also in this, and the patient
was discharged perfectly cured, on the forty-second day from the time
of his admission. Nor had he experienced, during his treatment, those
severe and long continued pains, which, under a different management,
so frequently accompany this kind of fracture.