FRACTURES OF THE UPPER EXTREMITY. 



399 



Fig. 247. Fracture of the Middle of the 

 Clavicle. 



Fracture of the clavicle is an exceedingly common accident, and is usually caused by indirect 

 violence, as a fall upon the shoulder ; it occasionally, however, occurs from direct force. Its 

 most usual situation is just external to the centre of the bone, but it may occur at the sternal 

 or acromial end. 



Fracture of the middle of the clavicle (Fig. 247) is always attended with considerable displace- 

 ment, the outer fragment being drawn downwards, forwards, and inwards ; the inner fragment 

 slightly upwards. The outer fragment is drawn down 

 by the weight of the arm, and the action of the Del- 

 toid, and forwards and inwards by the Pectoralis 

 Minor and Subclavius muscles : the inner fragment is 

 slightly raised by the Sterno-cleido-mastoid, but only 

 to a very limited extent, as the attachment of the 

 costo-clavicular ligament and Pectoralis Major below 

 and in front would prevent any very great displace- 

 ment upwards. The causes of displacement having 

 been ascertained, it is easy to apply the appropriate 

 treatment. The outer fragment is to be drawn out- 

 wards, and, together with the scapula, raised upwards 

 to a level with the inner fragment, and retained in that 

 position. 



In fracture of the acromial end of the clavicle, 

 between the conoid and trapezoid ligaments, only 

 slight displacement occurs, as these ligaments, from 

 their oblique insertion, serve to hold both portions of 

 the bone in apposition. Fracture, also, of the sternal 

 end, internal to the costo-clavicular ligament, is at- 

 tended with only slight displacement, this ligament 

 serving to retain the fragments in close apposition. 



Fracture of the acromion process usually arises 

 from violence applied to the upper and outer part of 

 the shoulder ; it is generally known by the rotundity 

 of the shoulder being lost, from the Deltoid drawing 

 the fractured portion downwards and forwards ; and 

 the displacement may easily be discovered by tracing 

 the margin of the clavicle outwards, when the frag- 

 ment will be found resting on the front and upper 

 part of the head of the humerus. In order to relax 

 the anterior and outer fibres of the Deltoid (the opposing muscle), the arm should be drawn 

 forwards across the chest, and the elbow well raised, so that the head of the bone may press the 

 acromion process upwards, and retain it in its position. 



Fracture of the coracoid process is an extremely rare accident, and is usually caused by a 

 sharp blow on the point of the shoulder. Displacement is here produced by the combined 

 actions of the Pectoralis Minor, short head of the Biceps, and Coraco-brachialis, the former 

 muscle drawing the fragment inwards, and the latter di- 

 rectly downwards, the amount of displacement being limited 

 by the connection of this process to the acromion by means 

 of the coraco-acromial ligament. In order to relax these 

 muscles and replace the fragments in close apposition, the 

 forearm should be flexed so as to relax the Biceps, and the 

 arm drawn forwards and inwards across the chest so as to 

 relax the Coraco-brachialis ; the humerus should then be 

 pushed upwards against the coraco-acromial ligament, and 

 the arm retained in that position. 



Fracture of the anatomical neck of the humerus within 

 the capsular ligament is a rare accident, attended-with very 

 slight displacement, an impaired condition of the motions 

 of the joint, and crepitus. 



Fracture of the surgical neck (Fig. 248) is very common, 

 is attended with considerable displacement, and its appear- 

 ances correspond somewhat with those of dislocation of the 

 head of the humerus into the axilla. The upper fragment is 

 slightly elevated under the coraco-acromial ligament by the 

 muscles attached to the greater and lesser tuberosities ; the 

 lower fragment is drawn inwards by the Pectoralis Major, 

 Latissimus Dorsi, and Teres Major; and the humerus is thrown 

 obliquely outwards from the side by the Deltoid, and occa- 

 sionally elevated so as to project beneath and in front of the 

 coracoid process. The deformity is reduced by fixing the shoulder, and drawing the arm put- 

 wards and downwards. To counteract the opposing muscles, and to keep the fragments in position, 

 the arm should be drawn from the side, and pasteboard splints applied on its four sides, a 

 large conical-shaped pad should be placed in the axilla with the base turned upwards, and tho 



248. Fracture of the Surgical 

 Neck of the Humerus. 



