SECT. XCIII.—ON FRACTURE OF THE CLAVICLE.
The clavicle in its natural position is united to the sternum at its inner extremity, and at its outer it is articulated with the acromion; and, therefore, as it supports the shoulder and the arm itself, if it undergo a fracture in any part whatever, the portion of it united to the shoulder sinks down, being dragged along with the arm. It is better, then, that the fracture be transverse, and not longitudinal, or partly straight with a lunated extremity, according to the opinion of most surgeons. For that which is fractured transversely, can, by extension and compression with the fingers, be readily restored to its proper position; but the other kinds of fracture have prominences not easily arranged. If, therefore, it be broken in any way through its whole thickness, let one assistant take hold of the arm connected with the fractured clavicle, pulling it at the same time outwards and upwards; and let another pull the opposite shoulder, or at least the neck, and let them make counter-extension. The surgeon then, with his fingers, is to set the fracture, pushing down what is prominent, and drawing outwards what is situated too deep. If more counter-extension be required, a ball of rags, wool, or something such, may be applied below the armpit, and the elbow brought to the rib adjoining to it; and the other things may be done as described already. But if it is found impossible to raise up the end of the clavicle connected with the shoulder that is lodged down below, having laid the man on his back, and placed a moderate cushion under his back, let an assistant push the shoulders downwards, so that the bone of the clavicle which is lodged below may be bent upwards, and then set the fracture with the fingers. But if part of the clavicle be broken off and unconnected, and if we find it irritating the parts, we must make a straight incision with a scalpel and remove the broken portion, and smooth the remainder with chisels, taking care that the instrument called meningophylax, or another chisel be put under the clavicle to make it steady; and if no inflammation is present, we may use sutures, but otherwise, pledgets. And having prepared various splenia (compresses), we must apply the larger and thicker to the projecting part of the bone; and these, when inflammation is present, are to be dipped in oil, but otherwise they are to be applied dry. And having put a moderate ball of wool under the nearer armpit, we apply a suitable bandage round by the armpits, the fractured clavicle and the scapula, bringing the folds in a proper direction; and if the part of the clavicle connected with the shoulder fall downwards, the middle of a broad thong is to be put under the elbow of the same side, and the whole arm suspended by the neck, and the hand is to be slung in another bandage as in cases of bleeding at the elbow. But if, which rarely happens, the outer part be uppermost, we must not have recourse to this arrangement of the arm. The patient must lie in a supine position, and live upon a spare diet, and if necessary, embrocations and other suitable applications are to be made until the callus is formed. The callus of the clavicle is formed in about twenty days at most.
Commentary. Hippocrates gives such an account of this accident as clearly bespeaks his intimate acquaintance with the subject. Transverse fractures, he says, are easily healed, whereas such as are oblique prove more difficult to manage. He justly remarks, that the deformity occasioned by this injury appears at first very great, and annoys both the patient and his physician, but that it gradually becomes less, and the patient, feeling little inconvenience from it, grows careless, and the physician, seeing no evil consequences result from this neglect, acquiesces in it, and presently it is found that proper callus is formed. Hippocrates further exposes the mistake of those who endeavour to push down the projecting bone, which, he justly remarks, cannot be effected. The part which projects, as he states, is almost universally the extremity attached to the sternum, the other portion being dragged down by the weight of the arm; and hence the mistake is obvious of those who attempt to push down the upper extremity. He recommends the patient to lie in bed until adhesion takes place, which generally occurs between the fourteenth and twentieth day. (De Articulis, 16.)
Galen directs us to apply four splenia or oblong compresses intersecting one another like the letter Χ. (Comment, et Fragment, apud Nicetæ Collect.) When the fracture is near the shoulder, Galen recommends the spica bandage (De Fasciis), for a drawing and description of which, see Heister’s ‘Surgery,’ (p. iii, c. 4, §1, c. 3.)
Celsus agrees entirely with the account of the matter given by Hippocrates. When the bone is broken transversely, he says, it will sometimes unite readily without the application of a bandage. In general, as he explains, the upper end of the fractured portions is the part attached to the sternum, the other being attached to the shoulder and dragged down along with the arm. He mentions that this is so generally the state of the parts, that some great masters of the art had declared that they had never seen a case in which the end attached to the shoulder projected, but that Hippocrates, who is rich in information upon these subjects, had affirmed upon his own authority that such an occurrence is to be met with. In setting the fracture he properly directs us to raise the shoulder; and his mode of bandaging would seem to have been little different from that now generally followed. He directs us to fill the armpit with wool, and to apply over the fractured portions of the bone a compress three times folded, and moistened in wine and oil; or, if the bone is broken into many fragments, a splint formed of cane (ferula). If the bones incline to the common position, the arm is to be fixed to the side, but if the outer end has a tendency upwards, the arm is to be tied to the neck. The man is to be laid on his back. All spiculæ of bones are to be cut out, if it is found that they are wounding the flesh.
Albucasis follows our author closely. He particularly enjoins the surgeon when there are any projecting spiculæ, to make an incision and cut them out; after which, a suture may be used to heal the integuments, provided the wound is large. A compress, soaked in rose-oil, vinegar, and wine, is to be applied to allay inflammation. He directs the patient to sleep on his back with a pillow under his armpit.
Rhases, Avicenna, and Haly Abbas give exactly the same account of the accident as Albucasis and our author.