When splinters, displaced in different directions, whether adhering to the bone or not, irritate the soft parts, and, having passed through the integuments, appear without, most practitioners advise to remove them and cut off such parts as project beyond the fractured end of the bone, previously to reduction. This direction is founded on the severe pains which, in such cases, accompany the common treatment of the injury, and which the figure of 8 bandage always augments, by drawing the shoulder inward, and consequently pressing the soft parts against the projecting parts of the fragment, or the points of the splinters. But if the splinters, adhering as yet to each other and to the bone, by means of the periosteum, have not assumed the nature of foreign bodies, (that is, if they be not actually dead) it is always proper to replace them. It is here only that we meet with an occasion for that part of the process, of reduction denominated conformation,[4] which is never requisite in other cases.
A fragment which has penetrated the soft parts, but has not been long exposed to the air, disappears, and is replaced by extension, provided it be properly directed. Being retained afterwards in a state of constant extension, it can neither be displaced, nor cause pain by irritating the parts, which is the inevitable result of the figure of 8 bandage.
In cases of this kind, it is useful to protect the shoulder with a small splint, which may support the turns of the bandage, and prevent their pressure on the splinters, or the broken ends, which they might otherwise disturb. These precautions are alike indispensable when the fracture is double.
Case IV. Francis Ricord, twenty-five years of age, was received in the month of July, 1790, into the Hotel-Dieu of Paris. On the preceding day, a piece of timber having fallen from a considerable height on his right shoulder, had broken the clavicle of that side into several pieces. Severe pains, which occurred at the moment of the accident, had continued throughout the night, and were still sensibly felt. The slightest motion of the part augmented them to such a degree, as to extort from the patient piercing cries.
The point of the shoulder being very much depressed, was also drawn perceptibly forward and inward; and a large echymosis, without any external wound, occupied its whole extent.
Desault being satisfied that the several fragments were all connected together, and that none of them was separated from the periosteum, placed, as in ordinary cases, the bolster under the arm, completed the reduction, and applied a splint along the course of the clavicle, after having, with his hands, brought the fractured pieces into contact. Confident, then, that the form of the part was perfectly restored, he applied the bandage, which was moistened with vegeto-mineral water, twice or thrice a day.
At the moment of reduction the pains ceased, and were felt no more till the fifth day, when the bandage being a little relaxed, admitted of a slight displacement of the fragments. This displacement was removed, and the pains along with it, by the reapplication of the apparatus.
During the six first days a very strict diet was enjoined. This, however, was dispensed with by degrees, till, on the thirteenth day, the patient returned to his usual regimen. On the seventeenth day, there remained nothing of the echymosis, but a yellow tinge, the customary consequence, of such an accident. The precautions inculcated in the preceding case, were employed also in this, and the patient was discharged perfectly cured, on the forty-second day from the time of his admission. Nor had he experienced, during his treatment, those severe and long continued pains, which, under a different management, so frequently accompany this kind of fracture.