15. Few luxations are so speedily reduced, but few are more easily
displaced again, than that of the clavicle. This disposition is the
reverse of that of most other luxations, which are reduced indeed
with difficulty, but seldom afterwards suffer a displacement. The
cause of this we find, 1st, in the extreme mobility of the clavicle,
to which all the motions of the arm are communicated; 2dly, in this
further consideration, that most of the muscles, which have their
insertion towards the shoulder, tend to draw this bone inward, when
the ligaments, in consequence of being either broken or distended, as
happens in this accident, do not offer a sufficient resistance.
16. From this two-fold cause of displacement, arises a two-fold
indication in the arrangement and application of the apparatus. These
are, 1st, to render the clavicle immoveable, by restraining every kind
of motion in the shoulder and arm; 2dly, to retain the extremity of
the clavicle outward, a direction opposed to that in which it has a
tendency to be displaced. But if to those indications we compare the
forms of apparatus hitherto used, we will readily perceive that they
are insufficient to fulfil them.
17. The figure of 8 bandage, so generally in use, and all the various
modifications, under which it has been revived, without being
improved, fix the clavicle in the very direction most favourable to a
displacement, and even do it in the very manner in which that accident
is sometimes brought about; as maybe seen in the history of the case of
the porter (6). This bandage does not, under any of its modifications,
prevent the motions of the shoulder, because it does not restrain those
of the arm, which remains free and unencumbered. Far from constituting
an antagonist power to, it even co-operates with, that which has
produced the displacement. (For further light on this subject, see what
has been already said on the fracture of the clavicle, pages 22 and 25.)
Bell, in condemning the figure of 8 bandage, not so much because of its
action being insufficient, as because of its obstructing respiration,
proposes, as a substitute for it, a kind of machine analogous to the
iron cross of Heister, which, being fixed by straps passing under
the arm-pit, and round the neck and body, is intended to retain the
parts firm and immoveable. But the motions of the arm not being
restrained, nor the action of the muscles of the shoulder opposed by an
antagonizing power, places this piece of apparatus in the same class
with those, which, from not being devised and constructed on a proper
view and conception of the causes of displacement, have no affinity to
rational practice.
18. The apparatus for a continued extension, invented by Desault, for
fractures of the clavicle, fulfil here all those indications in which
the others fail.
By this, 1st. The aim, being firmly fixed against the side, by means
of the roller (_c c_ Fig. 3), can communicate no motion either to the
shoulder, or the clavicle. 2dly. The shoulder itself, being forcibly
drawn outward, with the upper extremity of the humerus, by the action
of the kind of lever into which this bone is converted, and to which
the bolster (_a b_ Fig. 1) serves as a fulcrum, cannot, by its
movements, derange the luxated bone. 3dly. The sternal extremity, being
drawn both by the muscles which tend to displace it inwardly, and by
the bandage which acts on it in an opposite direction, remains fixed
between those two antagonizing forces, which thus destroy each other.
Hence the apparatus of Desault, when accurately applied, offers to both
of these powers of displacement, a resistance perfectly calculated to
combat them.
20. We must, however, admit that this apparatus partakes of one
inconvenience, common indeed to all bandages, but which is perhaps more
particularly applicable to this in consequence of the numerous casts
of the rollers that form it, namely, the great facility with which it
becomes relaxed. Hence one cause of displacement, which the most exact
and scrupulous attention cannot at all times prevent.
CASE. Desault had, for a long time, the care of a patient, whose
luxation, having been neglected for four days, was reduced on the
fifth, by a surgeon, who, for the purpose of retaining it, employed
a bandage of a particular kind. An hour afterwards, a motion of the
shoulder backward, displaced the luxated extremity: a new reduction was
the consequence; on the day following, another displacement, and so on
in succession, for ten days, at the expiration of which, Desault being
consulted, applied to the part the bandage formerly described.
On being examined the next day, the apparatus was found in a favourable
state. On the day following, a slight displacement rendered necessary a
new application of the bandage, which, this time, continued longer than
before. But, about the expiration of the third day, the projection of
the bone was again considerable. Finally, the patient recovered, with a
very perceptible protuberance in front of the sternum, and a difficulty
of motion, great at first, but less afterwards, and which exercise
succeeded ultimately in removing.
21. The application of the apparatus differs from that intended for a
fracture of the clavicle, only in this, that it is of service to place
on the luxated extremity, graduated compresses,[7] calculated to make
pressure backward and outward, and which are to be secured by the turns
of the roller (b Fig. 4).
[7] Compresses laid one upon another, of which the upper one is
still the smallest, not in relation to thickness, but as far as
regards length and breadth. TRANS.
A second precaution, not less essential, is, to push the humeral
extremity of the clavicle, a little forward, and fix it in that
direction, in order that the sternal being directed backward, may be
removed from the place[8] through which it has a tendency to escape.
[8] The rupture in the capsule that surrounds the joint. T.
22. Desault almost always obtained complete success by this process,
and by the most accurate attention to prevent the relaxation of the
bandage. In the mean time, a stiffness, more or less considerable,
always remains in the joint for a long time after the reduction, and it
is not unfrequently a month or two before the part recovers its usual
facility of motion.
The following cases, collected by Brochier, confirm the doctrine for
which I have been contending.
CASE II. A man luxated the clavicle by falling on the point of his
shoulder, and forcing it backward. He was immediately brought to the
Hotel-Dieu, where Desault demonstrated to his pupils, that the head of
the bone, carried in front of the sternum, was removed nearly an inch
from its natural cavity, the ligaments of which were no doubt lacerated.
Here, as in the fracture of the clavicle, the application of the
bandage answered the purpose of reduction, and removed the protuberance
formed by the extremity of the bone.
The patient, being strong and vigorous, and having received besides a
violent contusion, was bled twice, and confined to a low diet. On the
following day, no derangement; on the fourth day, a slight displacement
of the bone, the rollers a little relaxed, bandage applied anew. Eighth
day, no sensible displacement. Eleventh day, some swelling around
the joint; compresses, wet with vegeto-mineral water, ordered to be
frequently renewed. Twentieth day, the swelling almost gone, and no
disposition to a displacement; the apparatus was removed; motions at
first difficult, and contracted. Twenty-ninth day, more free and easy.
Thirty-fourth day, returned to their natural state.
CASE III. Mary Rivert luxated her clavicle, on the seventh day of
January 1789. Being brought some time afterwards, to the Hotel-Dieu,
she was treated in the same manner as the foregoing patient, and with
the same result, except that a very slight protuberance remained at the
extremity of the bone, and the confined state of the motions continued
a little longer. Desault related, in his lectures, other instances of
cures being performed without the least remaining deformity.
After all, even supposing the method just proposed, to possess no other
advantage, than that of diminishing the protuberance of the bone,
which, under other modes of treatment, is almost inevitable, and by
that means preventing the motions of the part from being confined, it
would still, without doubt, be a great step towards the perfection of
the art.
23. Should a luxation backwards occur, the same process of reduction
should be adopted, with this difference, that the extension ought to
be made forward and outward; and the same apparatus should be applied
for retaining the parts, except that the humeral extremity ought to be
directed a little backward, in order that the sternal extremity, being
carried forward, may be removed from the place of laceration in the
capsule.
In like manner, should the bone be luxated upwards, it would be
necessary to draw the arm outwards, and elevate slightly the point of
the shoulder, for the purpose of depressing the sternal extremity.