Fig. 15.—Adhesive Plaster applied for Fracture of Clavicle.
Treatment.—The displacement in complete fractures of the clavicle is readily reduced by supporting the elbow, bracing back the shoulders, and levering out the tip of the affected shoulder. In a few cases the interposition of some fibres of the subclavius muscle between the fragments has prevented perfect reduction.
In the greenstick variety the bone may be bent back into its normal position, but no great force should be employed, as, in spite of imperfect reduction, the clavicle usually straightens as it grows, and although some deformity may persist, the function of the limb is not interfered with.
Recumbent Position.—There is little doubt that the most perfect æsthetic results are obtained by treating the patient in the recumbent position. In girls, therefore, in whom it is desired that the shoulders should be perfectly symmetrical, the best results are obtained from placing the patient on a firm mattress, with a narrow, firm cushion between the shoulder-blades, so that the weight of the shoulder may carry the acromial fragment laterally and backwards. A pad is inserted in the axilla, the elbow raised, and the arm placed by the side on a pillow and steadied with sand-bags. Massage is applied daily. As this position must be maintained uninterruptedly for two or three weeks, it proves too irksome for most patients. When both clavicles are fractured, however, it is, short of operation, the only available method of treatment.
In ordinary cases the arm should be placed in that position which gives the best alignment of the fragments and least deformity. A thin layer of wool is placed in the axilla to separate the skin surfaces. A sling, supporting the elbow, is now applied, maintaining the arm in position, and a body bandage fixes the arm to the side. Massage and movement should be commenced at once.
A simple method, which yields satisfactory results, is that suggested by Wharton Hood. The fracture having been reduced, three strips of adhesive plaster, each an inch and a half wide, are applied from a point immediately above the nipple to a point 2 inches below the angle of the scapula ([Fig. 15]). The middle strap covers the seat of fracture, and is applied first: the others, slightly overlapping it, extend about half an inch on either side. The elbow is supported in a sling. This plan has the advantage that it permits of movement of the shoulder being carried out from the first, but the plaster rather interferes with massage.
The Handkerchief Method.—In cases of emergency, one of the best methods applicable to all fractures of the clavicle is to brace back the shoulders by means of two padded handkerchiefs, folded en cravate, placed well over the tips of the shoulders and tied, or interlaced, between the scapulæ. The forearm is then supported by a third handkerchief applied as a sling, the base of which is placed under the elbow, the ends passing over the sound shoulder.
Operative treatment may be called for in compound or comminuted fractures when the fragments have injured, or are likely to injure, the subclavian vessels or the cords of the brachial plexus, or when it is otherwise impossible to reduce the fracture or to retain the fragments in apposition. It is also indicated in some cases of fracture of both clavicles.
These various methods of treatment are not equally applicable to all cases. In our experience, in the circumstances indicated, the following methods have proved the most satisfactory: (1) As a temporary means of retention in emergency cases,—for example, accidents occurring on the football field,—the handkerchief method. (2) In uncomplicated fractures of average severity in any part of the bone, the method of sling and body bandage. (3) In cases where, for æsthetic reasons, the chief consideration is the avoidance of deformity and the maintenance of the symmetry of the shoulders, as in girls, the treatment by recumbency. (4) When retentive apparatus fails, or when the fragments are exerting injurious pressure, operative treatment.