A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

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.

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.

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