The principles and practice of modern surgery

by Roswell Park

Symptoms.

—These are often vague, when but a single rib has been cracked through and not displaced, and comprise pain on pressure, as well as that provoked by deep breathing, coughing, and certain other movements. Should this pain be limited, or constant and made worse by pressure, fracture of the rib may be suspected. If auscultation crepitus can be heard, diagnosis is at once made. When abnormal mobility is unmistakable, or when by any means crepitus is elicited, the signs are positive. Sometimes the patient himself will recognize crepitus. This may be learned either by auscultation or by pressure with the flat hand over the affected area. Emphysema is an unmistakable evidence of fracture with perforation, while the signs of the presence of fluid in the chest cavity will also indicate fracture.

Treatment.

—Fracture of one or two ribs with displacement is ordinarily a matter of trivial import, the adjoining ribs acting as splints. It necessitates practically nothing but physiological rest, which may be best afforded by keeping the patient in bed, with firm compression around the chest, made either with a binder of strong cloth or a broad piece of adhesive plaster carried nearly around the body, or in more aggravated cases by a plaster-of-Paris jacket. In thin individuals the formation of callus can be recognized by the sense of touch. So soon as this is fairly formed displacement is less likely to occur and uncomfortable compression may be relaxed. Should there be external angular displacement this may be corrected by pressure. A projecting fragment which threatens to perforate should be cut away with bone forceps through a small incision, taking pains to permit as little air as possible to enter. If there be a traumatic pneumothorax the air should be removed with an aspirating needle. When it is evident that there is serious injury to the chest wall and that air has already separated the lung from it (traumatic atelectasis) the parts should be freely exposed, to permit the rounding off of bone ends, the seizure of intercostal vessels, the cleansing out of the pleural cavity, with perhaps later wiring of fragments or else their complete removal and closure of the external wound with or without drainage, as may be required. If blood or air has already escaped into the pleural cavity the blood should be speedily removed. The same plan is advisable in fractures of the cartilages. Sedatives to check cough, e. g., heroine, are also indicated.

FRACTURES OF THE CLAVICLE.

The clavicle and the radius are the two bones most frequently broken, the former more often in the young, the latter in the elderly; the clavicle yields both to direct violence, as by blows on the shoulder, and that which is transmitted through the arm from the elbow or hand. For convenience of description the bone is divided into thirds, the most common location for fracture being near the junction of the middle and outer third. Save for epiphyseal separations the extremities of the bone are seldom broken. In spite of its subcutaneous position and its proximity to large vessels, compound injuries or other complications are quite uncommon.

The clavicle is the brace which keeps the shoulder proper from falling upon and around the thorax. Consequently when it is broken the shoulder tends to drop downward, forward, and inward, except in a green-stick fracture, while even then there may be some displacement in these directions. Deformity is usually easily recognized, one or other fragment projecting beneath the skin in such a way as to be easily palpated. There is enough spasm of cervical muscles to draw the head over toward the affected side, while there is loss of function in the affected arm. Pain is made worse by pressing the shoulder inward as well as by moving it in any direction.

In young children the bone is often broken with a minimum of displacement. Fracture of both clavicles is not so very rare. Trouble may occur later in the course of the case from pressure of exuberant callus upon nerves and even vessels. This is to be prevented by foresight and by careful attention to maintenance of parts in proper position.

Treatment.

—The multiplicity of dressings which have been suggested for fractures of the clavicle attest the fact that so long as primary indications are observed the treatment can be made very simple. These indications are to keep the shoulder upward, outward, and backward, as it tends to drop in the opposite way. The action of three muscles is of great importance in considering the proper treatment of these cases, i. e., the sternomastoid and the trapezius, because they tend to pull fragments upward, and the pectoralis major because advantage can be taken of its arrangement to overcome upward displacement. It was Moore, of Rochester, who taught many years in Buffalo, who showed how this could be done. The fibers of the great pectoral which arise highest, i. e., from the clavicle, are those which are inserted lowest along the bicipital groove of the humerus, because of the semi-revolution made by the tendon of this muscle as it passes to its insertion. By putting the arm in such a position that these fibers are pulled upon the operator may counteract the upward pull of the other muscles just mentioned. This is the underlying feature of Moore’s suggestion; to force the elbow far backward, into a position which is for the time being uncomfortable, in order thus to pull down fragments which jut up beneath the skin. Any dressing which permits this position to be maintained will be equally serviceable. Moore suggests for this purpose what he calls a double figure-of-eight, which is shown in [Figs. 284] and [285]. It is put on as follows: A strip of cloth, sheeting, or anything of the kind, about two yards in length and folded sufficiently to make a strong strip eight inches wide, is held near its middle over the surgeon’s hand. This hand is placed beneath the elbow of the injured side, so that the strip crosses the under surface of the flexed forearm at the elbow. One end, which should be the longer, lying to the inner side, is passed upward and in front of the arm, carried over the shoulder across the back and under the opposite axilla, then over in front of the sound shoulder, meeting on the back the other end, which is carried up first over the outside of the forearm, then behind the shoulder and across the spine. This bandage should be pulled tightly, while an assistant holds the elbow as far backward and upward as the patient can tolerate it, as the more the position is exaggerated the more are the clavicular fibers of the muscle pulled upon and the better are the fragments held in place. This dressing not only meets the three primary indications laid down, but gives the added advantage just described. By it the shoulders are drawn backward and fixed to each other. The elbow should be lifted as the dressing is applied, so as to lift the shoulder. Most of the cloth materials used for such a dressing are more or less elastic, and it may need to be tightened once or twice a day during the time that it is worn. After a few days, when consolidation should have occurred, it may be changed for some other less irksome form of dressing. The hand should be supported in a sling. This dressing is useful in dislocations of the clavicle, especially of its outer end, and in every kind of injury in which the indication is to hold the shoulder upward and backward. In simple cases without much displacement the primary indications may be more simply met by a dressing of adhesive plaster, known in the East as Sayre’s and in the West as Freer’s. It consists of two strips of plaster of about the width of the arm itself. One of them is wound around the upper end of the arm, close to the shoulder, in such a way that, as it is passed around the back and brought over the chest, the arm and shoulder are pulled backward. The other strip passes from beneath the elbow of the injured side obliquely up and over the opposite shoulder. When it is applied the elbow should be firmly lifted. After the completion of either of these dressings the injured shoulder should appear at least one inch higher than the well one. Should the patient’s arm and chest be hairy they should be shaved before the application of the plaster strips. Like other material, plaster will stretch and slip, and these, like other dressings, should be readjusted every day or two, for the shoulder should be kept elevated for at least a week.