SURGERY. 
shoulder is lowered, and drawn towards the median line of 
the body; the head is inclined towards the injured shoulder; 
the patient supports the weight of his arm with the hand of 
the sound side; the internal fragment projects upwards and 
backwards; the external is situated below it, directed down¬ 
wards and forwards; the natural position of the shoulder 
may be restored by taking hold of the upper part of the 
humerus, and carrying.it upwards, backwards, and outwards, 
which manoeuvre also puts the ends of the fracture in due 
contact, and sometimes produces a crepitus; lastly,the dis¬ 
placement returns immediately the arm is left unsupported. 
Fractures of the middle or inner part of the clavicle are 
rarely united, without some degree of deformity being left; 
but those which happen towards the acromion are both more 
easily and more perfectly cured. 
For this purpose, let a large pad be placed in the arm and 
well secured in its situation; let a bandage so broad, as 
effectually to enclose the elbow, be placed round the lower 
part of the humerus of the affected side, and over the oppo¬ 
site shoulder. When it is properly tightened, it will raise 
the shoulder, and, at the same time, it will employ the pad 
as a lever so as to pull the clavicle outwards. A few turns of 
the roller round the breast, may be used to steady the whole. 
Fractures of the clavicle are much more common than dis¬ 
locations. A dislocation can more readily happen at the 
sternal, than the scapular, extremity of the clavicle, on ac¬ 
count of the greater degree of motion, which takes place in 
the former situation, and the weaker structure of the liga¬ 
ments. When a dislocation happens at the sternum, the 
clavicle is usually thrown forward; sometimes, however, 
backward; in which event, the symptoms may be severe 
and even dangerous, on account of the pressure produced by 
the bone on the parts in the neck. 
The dislocation of the sternal end of the clavicle forwards 
may arise from the sudden application of considerable force 
with a view of drawing back the shoulder, in which state 
the ligaments, and perhaps even a part of the lower tendon 
of the sterno-cleido-mastoideus muscle, are ruptured, and 
the inner head of the clavicle propelled forwards. 
The luxation of the inner end of the clavicle forwards may 
also arise from a fall, in which the shoulder is forcibly driven 
backward. 
The luxation of the inner end of the clavicle forwards is 
reduced in the following way.—the surgeon is to apply one 
hand to the inner and upper part of the arm, and the other 
to the external lower side of it above the elbow. The latter 
part is now to be inclined towards the trunk, while the 
ppper end of the humerus is propelled outwards, by which 
means this hone is made to answer the purpose of a lever, 
the action of which immediately operates upon the clavicle. 
By these combined efforts of both hands, the shoulder is to 
be carried backwards and upwards, and the elbow forwards, 
so that the extension may be made in the oblique direction 
of the clavicle'; that is to say, outwards, backwards, and a 
little upwards. The wedge-like cushion, used for fractures 
of this bone, is to be put under the axilla, as a point d’appui, 
which will tend to do permanently what the surgeon does 
with both his hands. However, if this extension should fail 
to bring the inner end of the clavicle into the articular cavity 
on the sternum, the reduction must be promoted by pressing 
the displaced part backwards. As soon as this is in its place 
again, the shoulder is to be inclined forwards, and the elbow 
backwards, in order to lessen the risk of the head of the bone 
slipping forwards again. Lastly, the arm is to be confined 
in the eligible posture over the cushion by means of a roller 
applied round the member and the trunk, and the elbow and 
forearm are to be well supported in a sling. 
The dislocation of the scapular end of the clavicle is always 
upwards; for, the root of the coracoid process will not allow 
the bone to descend below the acromion. The accident is 
generally the consequence of a fall upon the shoulder, the 
scapula being then suddenly and violently depressed, and 
fixed, as it were, against the ground, while the powerful 
action of the trapezius muscle pulls the clavicle upwards. 
The displacement, however, cannot happen, unless the }iga- 
Ypl. XXIII. No. 1605. ' 
757 
ments tying the bones together be torn, and even some of 
those ligamentous bands, which connect the clavicle to the 
coracoid process. 
The reduction of a luxation of the outer end of the cla¬ 
vicle upwards is easily accomplished: for this purpose, the 
trapezius is to be relaxed, and the shoulder is to be inclined 
outwards, and raised, by making the humerus act in the 
desirable direction. At the same time, pressure is to be 
made upon the outer end of the clavicle, in order to adapt it 
to the inner and upper part of the acromion. 
But, easy as the reduction is, the maintenance of it is ex¬ 
tremely difficult. The apparatus advised for the fractured 
clavicle is the best when used with a slight modification, 
which consists in alternately carrying the roller that goes 
under the elbow, both to the shoulder of the injured, and 
that of the uninjured side. 
The body of the scapula is rarely fractured; and when 
this occurs, it is easily discovered by the crepitus and defor¬ 
mity it causes, and requires nothing but keeping the bone 
quiet to effect its union. 
The acromion is the part which is most exposed, and 
most frequently broken; but the coracoid process, neck and 
glenoid cavity, may be similarly injured. 
When the acromion is broken, the solution of continuity 
mostly happens across its base. The external fragment is 
drawn downwards by the weight of the arm, through the 
medium of the deltoid muscle. The displacement, however, 
is not very considerable, amounting merely to a simple in¬ 
clination of the point of the bone downwards; a change, 
which may be rectified either by raising the arm from the 
trunk, or elevating it in a parallel line to its axis. These 
circumstances, together with the crepitus, suffice for de¬ 
noting the nature of the accident. 
Fractures of the acromion may generally be cured, without 
any deformity, either by keeping the humerus close to the 
side, raised in a line parallel to its axis, or by placing and 
maintaining it at nearly a right angle to the trunk. In the 
first case, it is necessary to interpose between the arm and 
the side a cushion, which is thicker below than above, be¬ 
cause a very close approximation of the elbow to the body 
has a tendency to bring on a displacement of the outer 
fragment of the bone, by rendering the deltoid muscle tense. 
The head of the humerus should also be kept well up against 
the acromion, an object, which may be fulfilled by means 
of a good sling, and a bandage extending from the elbow 
qn the injured side over the opposite shoulder. The diffi¬ 
culty, however, of maintaining the arm constantly in the 
right position, unless the patient be confined in bed, is gene¬ 
rally acknowledged. 
In fractures of the coracoid process, the arm should be 
put in such a position as will relax the coraco-brachialis 
muscle, a tense state of which must produce displacement 
of the detached point of that process. The humerus should 
therefore be inclined towards the sternum, and confined in 
this situation by means of a sling and a roller. When the 
neck of the scapula is broken, the glenoid cavity, and os 
brachii, fall downwards, and a crepitus is usually felt on 
raising the limb, which descends again immediately it is 
left unsupported. The evident indications are, to keep 
the elbow and whole arm properly elevated in a sling, and 
to forbid all exercise of the limb. The shoulder may be 
dislocated in various directions. 
The most common dislocation of the head of the humerus 
is that, in which it is thrown downwards into the axilla. 
This is what might be expected from a review of the struc¬ 
ture of the joint, the capsular ligament being in this direction 
very loose and thin, and unsupported by any muscle. A 
displacement downwards would even be a more frequent 
accident than it is, were it not that the elevation of the arm, 
by which the head of the bone is inclined downwards, is 
not the most common movement of the limb; and that a 
sufficiently oblique position of the bone on the glenoid 
cavity for a dislocation to happen, is usually prevented by 
the scapula following apd adapting itself to all the move¬ 
ments of the humerus. 
9G 
In 
