Part 5

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.

LUXATION OF THE HUMERAL EXTREMITY.

§ V.

OF THE KINDS OF LUXATION.

24. Luxations of the humeral extremity of the clavicle, take place, according to Petit, in two ways, 1st, under, and 2dly, over the acromion. If we attend to the disposition of the articulating surfaces, the superior of which rests obliquely on the inferior; if we examine, in particular, the relative position of the corocoid apophysis with respect to the clavicle, it will be difficult to conceive how the first kind of luxation can occur, without being accompanied by a fracture. Yet some facts added by Desault to the doctrine of Petit, on this point, seem to demonstrate the possibility of the clavicle sliding under the acromion. As to luxations forward and backward, the mobility of the shoulder, the facility with which it yields to motions impressed on it in these two directions, and the want of a resisting power, make the two bones that compose it, move together, still preserving their relative position.

The luxation upward, then, is that which ought chiefly to occupy the attention of the practitioner. Yet even this is less frequent than the luxation of the sternal extremity, on account of the very great strength of the retaining ligaments, which, when this luxation occurs, must be, if not lacerated, at least very much distended.

§ VI.

OF THE MECHANISM AND THE APPEARANCES.

25. A fall on the point of the shoulder is the most frequent cause of this luxation. The two articulating surfaces, representing an inclined plain, slide along each other, in such a manner, that that which belongs to the acromion is pushed inward, while that of the clavicle is directed outward. The capsule being stretched, gives way, and then the displacement is manifested by a preternatural protuberance over the acromion; by a stiffness in the motion of the shoulder; by the direction of this part, which is evidently drawn inward and downward; by the inclination of the head of the patient to the side affected; by a bending of the body; and by severe pains in the luxated part. These characters are essentially distinct, and ought to have prevented the error of Galen, who mistook a case of this kind for a luxation of the os humeri downward. Hippocrates and Ambrose Pare have foreseen the possibility of this mistake and even warned young practitioners to be on their guard against it. But, as citizen Sabattier judiciously observes, the position of the head of the humerus, under the arm, in a luxation of that bone, will remove all uncertainty respecting the nature of the injury.

§ VII.

OF THE REDUCTION AND THE MEANS OF RETAINING IT.

26. The reduction, in this case, is generally attended with but little difficulty. The acromion being drawn outward, by the upper end of the os humeri, which, by means of a fulcrum placed under the armpit, is made to act as a lever of the first kind, is restored, without much trouble, to its natural contact with the corresponding surface of the clavicle. But, it soon becomes deranged again, unless it be retained in its place by a proper apparatus. Now, on what principle ought this apparatus to be constructed? To prevent the displacement, which generally occurs from without inwards, it ought evidently to act from within outwards. Whence it follows, that the rollers in the figure of 8 bandage, recommended in this case by all writers, instead of preventing, actually favour the displacement (17), because they act in the same direction with, and therefore assist, the powers that produce it.

27. Here, in like manner as in the preceding case, the bandage of Desault fulfils with precision the indications of cure, because, by it, the point of the shoulder is, particularly, drawn outward; and if, in certain cases, a slight projection of the humeral extremity still remains, it is to be attributed to the inefficacy of the means of execution, and not to the principles on which they are founded.

MEMOIR IV.

ON FRACTURES OF THE ACROMION, AND OF THE LOWER ANGLE OF THE SCAPULA.

§ I.

FRACTURE OF THE ACROMION.

1. There is no part of the scapula more liable to fractures than the acromion. Being but slightly covered by the soft parts, this insulated kind of appendix has not, in all positions of the humerus, a solid point of support. A strong muscular force oftentimes acts on it with great energy. Being large in front, it presents in that direction a considerable surface to receive the action of external bodies. Whence it follows, that if it is not oftentimes broken, this is to be attributed, not so much to its natural disposition, as to the position which it generally assumes in falls.

2. The fracture, which is almost always transverse, is sometimes at the summit, and sometimes at the base of this apophysis, and is usually produced by a violent shock from a body falling on the shoulder, by a blow received on that part, &c.

3. But in whatever place it occurs, it greatly resembles a fracture of the humeral extremity of the clavicle, of which the acromion appears like a continuation. There is accordingly a strong analogy between the phenomena, the consequences, and the modes of treating these two kinds of fractures.

4. This accident is characterized, 1st, By a severe pain experienced by the patient, at the place of the fracture. This pain is increased by the elevation of the arm, which, generally hangs motionless down along the side. 2dly, If the humerus be removed from the trunk, the hand being at the same time placed on the acromion, the extremity of this apophysis is felt sinking downward, creating thereby an evident depression in the part. 3dly, Generally, the two fragments lose, of their own accord, their relative position; and unless the precaution about to be mentioned be used, their displacement becomes manifest, being produced by the weight of the arm, and the contractions of the deltoid muscle. 4thly, The head is inclined to the affected side.

§ II.

OF THE REDUCTION.

5. Two different processes have been long in use for the reduction of fractures of the acromion. One consists in elevating the arm almost to a right angle with the body, in order, as Heister remarks, to throw the deltoid muscle into a state of relaxation, and then to be able, with the fingers, to place the fragments in their natural situation. In the other mode, the humerus is suffered to retain the position it has assumed, that is, to hang down the side; the surgeon then taking hold of the elbow, pushes it vertically from below upwards, in such a manner, that the head of the bone, pressing against the acromion, elevates and replaces it.

6. Petit seems to have adopted indiscriminately these two methods, one of which, however, is greatly superior to the other. Indeed, it is evident, that if the humerus be removed from the trunk, its head will necessarily sink down in the glenoid cavity. Being thus separated from the fractured apophysis, it leaves beneath it a hollow or vacancy, into which the fragment will be pushed, should it be in any measure, compressed by the casts of the roller, during the application of the bandage.

7. On the other hand, if the arm still fixed against the side, be pushed upwards, it will afford to the acromion a solid point of support, which, during the application of the apparatus, will prevent its displacement downwards. This consideration is unquestionably of moment, during the process of reduction; but ought more particularly, to command the attention of the practitioner, in the choice of means destined to maintain the reduction.

§ III.

OF THE MEANS FOR MAINTAINING THE REDUCTION.

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.

FRACTURE OF THE LOWER ANGLE OF THE SCAPULA.

§ IV.

OF THE SIGNS OR APPEARANCES AND DISPLACEMENT.

14. Next to the acromion, the lower angle of the scapula is that portion of the bone most liable to be fractured. The usual causes of it are, falls on the side, or blows received on the part. It is characterized by a displacement which is always perceptible. On the one hand, the fleshy portion of the serratus-major, which is attached to the inferior fragment, draws it directly forward, while it is drawn upward by the teres-major, and some of the fibres of the latissimus dorsi. On the other hand, the body of the bone itself remains behind, being held by the rhomboid muscles. Hence arises a separation, which renders it difficult to mistake the fracture. Should any doubts still remain, let the shoulder be drawn backwards and the scapula along with it: let the fingers be, at the same time, placed on the lower angle, to ascertain whether or not it follows the motions of the bone; if it does, there is no division: but if, on the contrary, it remains stationary, the existence of the fracture is evident.

§ V.

OF THE REDUCTION, AND THE MEANS OF RETAINING IT.

15. Here, as in all other fractures, the means of reduction must be founded on the causes of displacement. To effect the replacement, therefore, it is necessary, either to push backward and downward, the angle which is displaced in a contrary direction, in order that it may be brought into contact with the body of the bone, or else to draw the body of the bone forward and upward, that it may meet the displaced angle. It is thus, that in a fracture of the condyle, the body of the jaw, is drawn into contact with the fragment.

16. But the first mode of reduction is difficult, and the means of maintaining it impracticable. It is necessary, therefore to have recourse to the second, which is the more easily executed, as the scapula follows the movements of the arm, and as, by drawing this limb forward, and the elbow of it outward, that bone is removed from the spinous processes of the vertebræ, and directed in such a manner, as to be brought into contact with its inferior fragment. This situation possesses another advantage, as it throws into a state of relaxation the muscles which tend to displace the lower fragment.

Hence it follows, 1st, That here, in like manner as in fractures of the clavicle, it is not on the fractured bone, that the force must act, but on the humerus. 2dly, That the humerus ought to be, during the whole treatment, immoveably fixed, because its motions, being communicated to the scapula, must soon derange the contact necessary to a reunion.

18. On these principles were founded the apparatus of Desault, and his process of reduction, which consisted, 1st, in drawing the arm forward, and separating the elbow a little from the thorax; 2dly, in fixing the fore-arm at an angle sufficiently acute, to direct the hand to the point of the opposite shoulder; and 3dly, to bring afterwards into proper apposition and form, the fragments already approximated to each other by the first movements.

19. To retain this reduction, the arm and fore-arm must be permanently fixed in the above position. This object is attained in the following manner, 1st, A bolster in form of a wedge, being placed between the arm and the side, its apex situated in the arm-pit, affords the double advantage of keeping the elbow at a distance from the thorax, and of rendering the position of the arm less fatiguing by serving as a point of support to it. 2dly, Compresses wet with some discutient liquid, are applied on the part corresponding to the fracture. 3dly, The whole is now to be secured by a roller, seven or eight yards long. The first turns of this roller, must secure the hand of the affected side on the sound shoulder to which it had been applied, during the reduction, and running afterwards from before backwards, pass over the place of the fracture, for the purpose of retaining the compresses on it. The wedge-formed bolster is to be secured on the thorax, by circular turns around it. Then, passing under the sound arm-pit, after having made these circular turns, the roller must be brought behind again, conducted obliquely over the shoulder of the diseased side, along the anterior part of the arm, under the elbow, and behind the thorax, where it is carried obliquely, in order to pass again under the sound arm-pit. From this place it ascends again anteriorly over the affected shoulder, redescends along the posterior part of the arm, repasses under the elbow, returns under the arm-pit, and terminates finally in circular turns round the trunk, and arm together. Hence it may be observed, that, in the first turns of the roller, this bandage greatly resembles the third roller applied in the fracture of the clavicle, to retain the point of the shoulder upward and backward (Fig. 4. plate I.)

20. By this, 1st, The movements of the arm being entirely impeded, they cannot have any influence on those of the shoulder; hence, in this respect, the fragments are suffered to remain in contact. 2dly, The serratus-major and teres-major muscles, being kept in a state of habitual relaxation, can no longer draw the inferior fragment forward, which cannot, therefore, be separated from the body of the bone. 3dly, Nor can the body of the bone, being permanently held in this situation, be removed from the fragment; whence, in both respects, a displacement will be effectually prevented. This threefold advantage is not possessed by any of the different kinds of apparatus hitherto proposed, such as the sling and cross-bandage, employed by Petit, which have the fault of suffering the arm to move backward, of allowing the scapula to be easily separated from its insulated angle, of retarding by that means the cure, and even of preventing it entirely, while, by the process just described, it is usually completed by the thirtieth day.

MEMOIR V.

ON THE FRACTURES OF THE UPPER END OR NECK OF THE HUMERUS.[10]

[10] For a very important improvement made by Dr. Physic in the treatment of an old fracture of the os humeri, and which may be applied also to similar fractures of other bones, see Article I. of the Appendix. TRANS.

1. The language of the surgeon differs, in this case, from that of the anatomist, and by the expression, “fracture of the neck of the humerus,” is here meant not that of the slight circular depression, which separates the head from the tuberosities of the bone, but rather that of the contracted or diminished portion of the bone, which commences at the tuberosities above, and being continued down the body of the bone, receives at its lower end the insertion of the tendons of the pectoralis major, the latissimus dorsi, and the teres major. Many practitioners consider this neck or contracted portion as extending even to the insertion of the deltoid muscle.

2. Several facts, the truth of which it is difficult to call in question, attest the possibility of a fracture of the neck of the bone, so called in anatomical language. I have myself seen, in the humerus of a young man, aged seventeen years, the head of the bone exactly separated from its body, by a division which had but slightly affected the upper extremity of the tuberosities. But the examples of this nature which occur in the annals of surgery are too few, to enable us to lay down any general principles for the treatment of such fractures.

§ II.

OF THE VARIETIES AND THE CAUSES.

3. The operation of external bodies, active, when they are thrown against the shoulder, passive, when the shoulder, or the arm, is forcibly driven against them, is always the cause of a fracture of the neck of the humerus. From the mechanism of the part, the division is sometimes direct, and sometimes the effect of a counter-stroke.

The first of these arises very generally from a fall on the point of the shoulder, and as in such a case, the commotion or shock must be very great, to extend with sufficient force through the thick mass which forms the deltoid muscle, that muscle sometimes suffers both contusion and an echymosis. Blood may even escape from a rupture of some of the arteries or veins of the joint, and form, as Desault has observed, a collection or tumour which it would be imprudent to open.

The other is the effect of a fall on the elbow, separated, at the time, some distance from the trunk, or on the hand, which, by a natural instinct, is thrown out, together with the arm and fore-arm, in order to break the violence of the fall.

4. The varieties of this kind of fracture originate, 1st, from the spot which it occupies, being either the middle or the lower part, rarely the upper part, of the neck of the humerus: 2dly, from the state of the surrounding soft parts, which sometimes remain quite natural, and at other times become distended and tumefied. This circumstance always involves the diagnosis in more or less uncertainty; 3dly, from the direction of the fracture, which is sometimes transverse, but usually oblique, particularly when produced in the second mode, that is, by a counter-stroke (3); 4thly, from the relative situation of the fragments, which may remain in contact, an occurrence however but very rare, or may separate from one another in a direction inwardly or upward; and, 5thly, from different complications, with which it may be attended.

§ III.

OF THE SIGNS AND THE DISPLACEMENT.

The whole of the signs of a fracture of the neck of the humerus, taken together, characterize its existence in a manner sufficiently evident. But it is not always an easy matter to take a view of them all at once, and in such a case, there are more difficulties attending the diagnosis here, than in any other fracture of the humerus.

An acute pain is felt at the instant of the fall; and sometimes a crack or report is plainly heard. There is always a sudden inability to move the limb, which, being left to itself, hangs motionless. But if any external force act on it, it yields to it without resistance, and may be moved by it with great ease in every direction.

These motions are accompanied with severe pain, and, if carried too far, may give rise to very troublesome affections, as has been observed in patients, where the fracture was mistaken for a luxation.