FRACTURE OF THE CLAVICLE N. T. KIRK, M.D., P.A.C.S.

SAN FRANCISCO, CALIFORNIA

ANATOMICAL

T HE cIavicIe is a semi-fiat S-shaped bone, articuIating mesiaIIy with the sternum, IateraIIy with the acromia1

process of the scapuIa and acting as a strut between these two bones forming the bony support of the shouIder girdIe. The mesia1 end is secured to the sternum by a capsuIar Iigament and an interarticuIar fibro-car- tiIage, and to the first rib by rhomboid Iigament. (Fig. IA.) The IateraI, or acromia1 end, is secureIy tied to the scapuIa by the coracoid-cIavicuIar and the acromiaI-cIa- vicuIar Iigaments. (Fig. IB.) The upper surface of the bone is subcutaneous and paIpabIe for its whoIe Iength. The sterno- cIeido-mastoid is inserted into the upper edge of the inner third and pectoraIis major to the Iower anterior surface. The trapezius, posterior, and the deItoid, anterior, find attachment to the outer third. Underneath Iies the subcIavian muscIe which intervenes between it in its middIe third, the sub- cIavian vesseIs, and the brachia1 pIexis.

CAUSATION AND TYPE

The usua1 site of fracture is the outer haIf of the middIe third, where the Iong anterior and short posterior curves meet- where it is structuraIIy weakest, and is not fixed or supported by muscIes or Iigaments.

Fracture of the cIavicIe is one of the most common of a11 fractures, particuIarIy in chiIdren. It is usuaIIy incompIete or of the greenstick variety. In aduIts, the frac- ture is nearIy aIways compIete and may be cornminuted, but is rareIy compound ex- cept in gunshot or direct crushing injuries.

Indirect vioIence is the usua1 cause; i.e., from a faI1 on the extended hand, eIbow, or shouIder with the arm in abduction. The shouIder is vioIentIy eIevated by the transmission of the force. The sterna1 end

of the cIavicIe being fixed by the strong rhomboid Iigament fractures occur at the weakest point of the bone.

Direct vioIence may cause fracture by compression, being usuaIIy received on the most prominent part of the bone; at its convexity forward in the inner third, or on its acromia1 end.

Muscular action is at times a cause, al- though rarely.

Deformity, of course, must come under this heading, and site of fracture be considered.

In infants and children, the fracture may be easiIy missed. The patient does not use the arm, compIains of pain and tenderness, and paIpation may revea1 a sIight anguIar deformity directed forward and upward in the middle third of the bone.

In aduIts, when the fracture has occurred in the mid-portion of the bone, the patient presents himseIf supporting the ffexed fore- arm of the injured side in his we11 hand. The strut of the shouIder girdIe having coIIapsed, the shouIder drops downward, forward and inward from the effect of gravity and the action of the pectora1 and Iatissimus dorsi muscIes.

The dista1 fragment, being fixed to the scapuIa by the coraco-cIavicuIar and acro- mio cIavicuIar Iigaments, moves down- ward, forward and inward. The proxima1 fragment is dispIaced sIightIy upward by the Sterno-cIeido-mastoid muscIe. The frag- ments override, and the width of the shouIders is Iessened.

Acromial end: Fractures here are usuaIIy the resuIt of direct force, or indirect thrust upward with the arm in abduction. If the fracture occurs between the coracoid and trapezoid Iigaments there is IittIe or no dispIacement, as both fragments retain their Iigamentous fixation. If the Iine of fracture is dista1 to the coracoid-cIavicuIar

486 American Journal of Surgery Kirk-Fracture of CIavicIe

Iigament, and the resuIt of direct vioIence, subcutaneous, if the deformity may be anguIar-the scapuIa minutes by the rotating forward-or the fragment may brought upward,

the operator waits ten watch. The shouIder is backward and outward,

A

FIG. I. The clavicle is secured to the sternum by the ligaments of the sternocIa:icuIar joint and fixed to the first rib by the strong rhomboid Iigament. The outer third is stil1 more securely anchored to the scapula by the coracocIavicuIar Iigament and the Iigaments supporting the acromiocIavicuIar joint.

be driven downward, particuIarIy if the acromio-cIavicuIar Iigament is torn.

DIAGNOSIS

There is pain, tenderness, and usuaIIy deformity at the site of fracture, with Ioss of the use of the arm if the fracture is com- pIete. The attitude is characteristic, as cited above, the shouIder having dropped downward, forward and inward, causing a definite narrowing of the shouIder breadth: the head is heId toward the injured side. X-ray confirms the diagnosis of fracture, its Iocation and type.

TREATMENT

Reduction of the usua1 fracture is not dificuIt, but the maintenance of reduction becomes the probIem, as the weight of the shouIder girdIe must be borne by the soft parts of the axiIIary foId when ambuIatory treatment is empIoyed.

Reduction is rendered painIess if IO to

20 cc. of a 2 per cent novocaine soIution is injected into the fracture Iine, which is

correcting the deformity and the overrid- ing. The bone ends are manipuIated into aIignment by direct digita pressure.

In chiIdren the fracture is usuaIIy incom- pIete, the deformity being anterior and upward. Here direct pressure exerted down- ward and backward over the deformity, whiIe the shouIder is forced forward and upward, wiI1 be necessary to correct the deformity.

Open reduction is rareIy, if ever, indi- cated unIess the fracture be compound, when a thorough dkbridement shouId be done. Fractures of the outer third, with marked dispIacement, may at times neces- sitate open reduction.

Various methods have been used in the past to maintain the reduction: we have the Sayre, VaIpeau and other types of dressings which secure the arm and forearm to the chest waI1. They rareIy accompIish their purpose, and cause increased atrophy and stiffness in the extremity and discomfort to the patient. These have been discarded as unsatisfactory.

NEW SERIES VOL. XXXVIII, No. 3 Kirk-Fracture of CIavicIe American Journal of Surgery 487

The “T” splint (Fig. 3) meets the re- quirements of ambuIatory treatment better than any other apphance, aHowing free motion of both arms. The spIint is easiIy appIied and adjusted. Its appIication to a patient with a round back is diffIcuIt.

The “T” spIint is formed by mortising and fixing with rivets or screws the end of one piece of mapIe or hickory wood 3 inches X 36 inch X 18 inches with the middIe of the other simiIar piece. Straps of 145 inch non-eIastic webbing and I $5 inch steel buckIes are secured to the spIint by carpet tacks, as indicated in Figure 3.

The wooden spIint is we11 padded with saddIe felt or cotton gauze pads held in pIace with adhesive, and the straps which cause pressure over the abdomen and axiIIa are Iikewise padded with saddIe feIt covered with stockinette, secured in pIace by sewing.

It is we11 to have made up and avaiIabIe for use spIints measuring 20 inches in Iength for the broad-shouIdered, Iong-back individua1, and 16 inch Iengths for the smaIIer patient.

For infants and young chiIdren, the “T” spIints are made of bass-wood spIint board, cut the size indicated, tacked together and padded. The shouIders are fixed to the spIint and the spIint t6 the patient with Canton fIanne1 bandages and adhesive.

Application of splint: The fracture hav- ing been reduced, with the patient sitting on a stoo1, the splint, after proper padding, is appIied to the back with the transverse arm above the shouIder IeveI. The ab- dominaI strap is secured to the Iower buckIes on the vertica1 arm and made secure. The inner straps attached to the transverse arm of the spIint are brought up under the spIint, over the shouIders at the base of the neck, crossed on the anterior chest waI1, and secured to the upper buckIes on the Iower end of the vertica1 arm of the spIint. These straps, %ith the abdomina1 strap, fix the spIint to the patient’s back and form a “hitching post” to which the shouIders are “tied.” The shouIders are now secured to the outer end of the spIint

by the outer padded strap which passes under the axiIIa, hoIding both shouIders upward, backward and outward.

FIG. 2. UsuaI site of fracture of the cIavicIe at its weak- est point, showing the characteristic deformity.

The straps are adjusted as indicated, and may be Ioosened whiIe the fractured ex- tremity is supported and the underIying skin cared for daiIy. Pressure downward and backward may be exerted on the proxima1 fragment by pIacing a pad under the retaining strap of the spIint which crosses it. The arms are Ieft free and stiffen- ing of joints, therefore, does not occur. If sweIIing occurs due to pressure of the shouIder supporting straps over the axiIIa, it is quickIy reIieved if the patient Iies down and eIevates the arm.

Recumbent method: ProbabIy the best way to maintain reduction with a minimum of deformity is by recumbency. The patient is pIaced on a hard bed with a smaI1 sand

488 American Journal of Surgery Kirk-Fracture of CIavicIe DECEMBER, 193,

bag between the shouIders; the eIbow is PROGNOSIS

raised, and supported on a sand bag; the ConsoIidation usuaIIy occurs in three to wrist is fixed to the neck by bandaging, and four weeks when the retention apparatus

I------ -_-_-----_- I~“~-----___---______ I--7- < 7

0 0 T S PLINT in WITH STRAPsFOR i-- FRAWRED UAVKLE

P . ,:.

w

k” steel buckle

f#

f I%” non-ehstic

FIG. 3. The T-splint, showing construction and appIication to patient.

the arm steadied by sand bags. This rCgime or bed care may be discontinued and the becomes rather irksome to the patient, forearm supported in a sIinp;. Non-union however, as it must be continue2 for a is rare. So6d deformity at thi site of frac- minimum of three weeks. Nursing care is ture is not unusua1 but this in no way inter- therefore diffIcuIt. feres with function of the extremity.