ON

DISLOCATION OF THE STERNAL END OF THE

CLAVICLE,

WITH A

NEW APPARATUS FOR MAINTAINING ITS REDUCTION

BY

H. D. HOLTON, M. D.,

OF PUTNEY, VERMONT.

VOL. XVI.-27

ON DISLOCATION OF THE STERNAL END OF THE CLAVICLE, WITH A NEW APPARATUS FOR MAINTAINING ITS REDUCTION.

On the 19th of November, 1863, I was called upon to attend an American boy, seven years of age, who had been thrown from a wagon upon a rough bank covered with stones, the last wheel of the vehicle passing over the body. He was healthy and well developed for a child of his age.

On reaching the house of the patient whither he had been conveyed, distant about a quarter of a mile from the place of accident, I found him insensible-not having recovered from the concussion. There were two severe scalp wounds from which the blood was freely oozing.

The fifth and sixth ribs were fractured obliquely directly over the heart, and the sternal end of the left clavicle dislocated forwards.

This dislocation was undoubtedly produced by his striking the point of the shoulder against the bank with so much force as to drive the sternal end through the anterior sterno-clavicular ligament, and leave it almost in front of the right sterno-clavicular articulation. In order to do this, the force must have been sufficient to rupture not only the anterior, but also the posterior sternoclavicular ligament, the inter-clavicular, and the rhomboid..

The shoulder appeared lower, and the acromion process correspondingly approached the sternum. The attachment of the clavicular portion of the sterno cleido-mastoid muscle remaining intact drew the head to the left side and turned the face to the right. The wounds of the scalp were cleansed and dressed in the usual manner, and a broad bandage was firmly applied around the chest. I then directed my attention to the dislocated bone. It was easily reduced by raising and carrying back the shoulder, at the same time that pressure was made upon the dislocated end; but on removing the pressure, the dislocation returned, and I was forcibly reminded of an anecdote related to me by my venerable preceptor,

the late Prof. Mott, of New York. When Mott was a pupil of Sir Astley Cooper, a man one day presented himself with a dislocation of the clavicle at the sternal extremity. Sir Astley requested Mott to reduce it. He did so, but on removing his finger, the dislocation returned. He then requested him to keep it reduced; Mott replied "that he could not." "Neither can I," was the rejoinder of Sir Astley; and this has been the history of these cases, both with ancient and modern surgeons, for Chelius and Malgaigne both speak of the deformity that remains after a cure has been effected. Prof. Hamilton, in his work on Fractures and Dislocations, says: "Not one of the four forward dislocations of the clavicle seen by me has been completely reduced, or, if reduced, they have not been retained in place."

The dislocation returning whenever the pressure was removed, it became evident that it was only to be retained by continued pressure. For that purpose, I devised the apparatus, to which it is the object of this communication to call your attention.

It consists of a piece of spring steel, curved so that the extremities may be brought together like the blades of a pair of forceps. To the anterior one is attached a pad which is applied over the joint after the dislocation is reduced; the posterior blade is longer, and curved to fit the scapula.

The apparatus now being in place, pressure is made by means of a screw which passes through, about an inch and a half from the curved extremity, and which may be turned at pleasure. It is retained in place by means of tapes passed through perforations in the free extremities, and which are attached to a perineal band. This keeps it from slipping up. It is retained in its perpendicular

position by means of a brace which passes and is attached to a band. going round the shoulder. This band serves the double purpose of an attachment for the brace, and, with the strap passing posteriorly to the other shoulder, a means of drawing the shoulder back. The arm should then be placed in a sling and confined to the side by means of a bandage.

This apparatus was thus applied, and the patient continued to wear it for four weeks, when it was removed. The arm was, however, retained in a sling for a couple of weeks longer.

This treatment was perfectly successful. There is no deformity, and the shoulder is not weakened.

It is, therefore, claimed for this apparatus, that it supplies what has long been wanted for the successful treatment of these cases, to wit, a firm, steady, and continuous pressure over the sternal end of the clavicle, for the reduction must be continuous for four or five weeks, in order to give the lacerated ligaments an opportunity to become thoroughly repaired; since every time the bone escapes, the process of reparation must begin anew.