8. As the displacement is most likely to occur downwards, particularly
in motions of the arm, it is necessary that a continued resistance
be opposed to this tendency. But this resistance should be made by
the head of the humerus, which, if properly directed, will represent,
during the treatment, a kind of splint, which art ought to render fixt
and immoveable lest, being contiguous to the divided surfaces, it might
derange, by its motions, the work of nature in effecting their reunion.
Hence it follows, that the precise and immediate intention of the whole
apparatus destined to support fractures of the acromion apophysis, is,
1st, to keep the head of the humerus constantly elevated or pushed
upwards: 2dly, carefully to prevent all motions of the arm and shoulder.
9. If the means, heretofore employed in this fracture, be examined, it
will be perceived that they by no means fulfil this twofold indication.
A compress placed immediately over the fracture; a roller passed round
this to secure it; a ball or bolster[9] put into the hand; the fore-arm
supported in a sling; such is the apparatus recommended by Petit.
In addition to this, Duverney judiciously advises to keep the sling
elevated, for the purpose of keeping the head of the humerus applied
under the fractured pieces. He employed also the spica-bandage which
has been equally recommended by Heister.
[9] Une pelotte.
10. But, in the employment of these means, the arm, not being confined
against the trunk, can move with ease, and derange the fragments, and,
therefore, the second indication is not fulfilled. Will even the first
be fulfilled? By no means. The sling, being soon deranged, by the
movements of the arm, which are oftentimes involuntary, suffers it to
sink down again, and then the fragments, being no longer supported, are
displaced. Hence the difficulties attending the treatment, difficulties
which have not escaped the notice of authors, and which Heister thus
expresses: “_Nemo ita curari solet_, _ut brachium postea, liberi sursum
attollere queat_,” an observation, which the celebrated Cheselden made
before him, in describing the scapula.
11. These inconveniences will be avoided, by fixing the arm, as
recommended by Desault, firmly against the trunk, by converting, so
to speak, the arm and the trunk into one single and solid piece, in
such a manner, that the humerus having no other motions but those in
common to it and the thorax, may not be able to communicate any others
to the fragments, which are supported by its head. This advantage can
be easily obtained, by means of the bandage, already described, for
fractures of the clavicle, modified agreeably to the circumstances of
the case, in which it is to act.
12. A bolster or pad of an equal thickness in all its parts, is placed
under the arm. The arm is then to be pressed down on this, in like
manner as in the bandage for the clavicle. The fractured apophysis is
now to be covered by two compresses; one extending from the clavicle
to the spinous processes of the vertebræ, while the other, lying over
this, and running in a contrary direction, crosses it at the place
of the fracture. The whole is then to be secured by a roller, which,
starting from the arm-pit of the sound side, pursues nearly the same
course with that destined, in fractures of the clavicle, to retain
the shoulder upwards. (See what has been said on this subject, when
treating of the structure of the bandage.)
13. By this mean, the two-fold indication of keeping the humerus
immoveable, and directed upwards (8), is evidently fulfilled, as I
have already proven at full length, when treating of fractures of the
clavicle; and a reunion, without deformity, may be looked for, of which
we have an instance in the following case, recorded by Derrecagaix.
CASE I. Nicholas Gay, aged twenty-nine, was struck, in passing under
a decayed building, by a stone, which, having become loosened, fell
on the point of his shoulder. In an instant he experienced severe
pain, and a difficulty of moving his arm, particularly upwards. Soon
afterwards there occurred a swelling of the shoulder, and a large
echymosis at the place where the blow was received. The pain, not so
acute during a state of rest, was increased by the motions of the arm,
and even by leaning the head towards the opposite side, which latter
circumstance was, no doubt, owing to the contraction of the trapezius
muscle.
A surgeon being called, judged it sufficient to make use of discutient
applications, to which the swelling and the echymosis appeared to
yield in the course of a few days. On a more accurate examination, a
fracture was discovered, supposed to be in the external part of the
clavicle, and for which the patient was sent to the Hotel-Dieu.
The fracture was discovered to be in the middle of the acromion,
which it divided transversely. The bandage already mentioned (12)
was applied, and, from the first day, the patient was left to his
usual regimen. Fifth day, a renewal of the apparatus which had become
relaxed: seventh day, a fresh displacement, in consequence of an
unguarded motion: a fresh application of the bandage, which continued
in its place till the sixteenth day, when it was replaced anew:
thirty-second day, reunion complete; a stiffness in the motions of the
part, which exercise removed by degrees, and of which the patient felt
no remains after the forty-eighth day.