or the fall upon him of a stone, or the passage across his chest of the wheel of a wagon, and in one case the point of a pickaxe was driven through the skin over the cartilage of the second rib by the caving-in of a bank of earth, and then, passing upward, forced the clavicle out of place. In the dislocations by indirect violence the patient has commonly been caught between two bodies, as the pole of a wagon and a wall, or the side of a railway car and a wall, or between two boats, in such a way that the shoulder has been pressed forward and inward. A case mentioned by Sir Astley Cooper' is frequently quoted as one in which the dislocation was caused by progressive distortion (scoliosis) of the spine. It appears, however, that the dislocation was due to an accident, and that the subsequent change in the shape of the spine only increased the unreduced displacement until it seriously interfered with deglutition. The end of the clavicle was then removed by operation. The dislocation may be complete or incomplete. Pathology.-Until quite recently the only recorded case in which a direct examination of the parts had been made was the one of compound dislocation mentioned above in which the injury was caused by the point of a pickaxe. It was reported by Tyrrell. The pectoralis major was freely torn from its attachment to the clavicle, but in all probability this was mainly, if not entirely, the result of a direct action upon it of the point of the pickaxe, and is not a common feature of the dislocation. The meniscus remained attached to the sternum, and the end of the clavicle could be easily felt by the finger in the wound. A second case was reported by Bennett in 1881; the patient was caught between a wall and a railway car and rolled along for some distance. The sternal end of the right clavicle, accompanied by the meniscus, was dislocated backward, and the cartilages of the first, second, third, and fourth ribs of the same side were broken. The end of the bone is displaced inward or inward and downward, and it is generally stated that it lies between the trachea and the sternohyoid and sterno-thyroid muscles, but, in the absence of direct proof of this, I am disposed to believe that it may rather lie between the latter muscle and the sternum, and below the former, for, it will be remembered, the sterno-hyoid arises in part from the posterior ligament of the joint and frequently from the clavicle itself, and the sterno-thyroid lies behind the other and has its origin as low even as the cartilage of the second rib. Possibly the difference noted in the direction of the displacement, inward in some, inward and downward in others, may depend upon varying relations between the bone and these muscles. Whatever the relations between these parts may be, the end of the bone frequently presses upon the trachea and thereby causes more or less dyspnoea, or upon the oesophagus and causes dysphagia. Of sixteen cases analyzed by Polaillon dyspnoea was present in six, and dysphagia in three. The venous congestion of the face and neck coexisting with the dyspnoea has been sometimes attributed to pressure upon the brachio 1 Cooper: Disloc. and Fractures, Am. ed., 1844, p. 309 2 Tyrrell St. Thomas Hosp. Reports, 1836, vol. i. : 3 Bennett: Dublin Journ. Med. Sci., 1881, vol. 71, p. 444. cephalic vein, but although the region into which the end of the bone is displaced is occupied by most important vessels and nerves, the recorded histories do not show that they have ever been seriously pressed upon. Some authors, quoting other accounts of Cooper's case, say that pulsation was arrested in the radial artery on the corresponding side; if this was so, it was probably due to compression of the subclavian artery between the clavicle and the first rib. Beside the complication of fracture of the cartilages of the first four ribs in Bennett's case mentioned above, fracture of the first rib has been noted in a case reported by Dr. N. C. Morse: the patient was a girl eight years old who had been run over by a wagon and had received a dislocation backward of the sternal end of the left clavicle, with fracture of the first rib, and a dislocation "outward" (forward?) of the sternal end of the right clavicle. Apparently the wheel had crossed the left clavicle and chest. There was great dyspnoea and marked venous congestion of the face and neck which disappeared on reduction of the dislocation. The child recovered. Symptoms.-The absence of the end of the clavicle from its articulation, and its position behind the sternum are recognizable by inspection and palpation, the course of the bone can be seen and felt to pass inward behind its normal position, and the cavity and border of the articular surface of the sternum can be traced with the finger. Morel-Lavallée called attention to the marked projection forward of the acromial end of the clavicle and claimed that this was a characteristic sign. Its value, which at the best is so much less than that of the recognition of the position of the sternal end, is still further diminished by the normal differences in the prominence of the acromial end. The shoulder hangs a little forward and nearer the chest; sharp pain, increased by movements of the arm or head, is felt at the seat of injury, but usually is prompt to disappear. These voluntary movements are restricted or abolished by the pain. Disturbance of respiration by compression of the trachea has been noted in only about one-third of the cases, and may be slight or so severe as to threaten suffocation. Ordinarily it lasts for only a short time, even if the dislocation remains unreduced. Difficulty in swallowing has been less frequently noted than dyspnoea (three times in sixteen cases). The prognosis is favorable as regards the reëstablishment of function. even if the dislocation is not reduced, and reduction is, as a rule, easy, and retention more complete than after dislocation forward. Treatment. Reduction can commonly be effected by drawing the shoulder outward and backward, and this seldom requires more force than the surgeon himself can exert without assistance. In one case Lenoir was obliged to provide counter-extension by a bandage carried around. the chest and made fast to the wall, and extension by another bandage passed around the upper part of the arm and drawn upon by two assistants while a third held the elbow near the side. In another of his cases one assistant placed his knee against the patient's back and drew his 1 Morse: Cincinnati Med. News, 1877, vol. 6, p. 819. shoulder backward while a second assistant held up the chin, and Lenoir passed his fingers down behind the end of the clavicle and pressed it forward. Reduction took place promptly and with a distinct snap. Recurrence of the displacement should be opposed by dressings that hold the shoulder back and down. Arnaud aided this by keeping the forearm behind the back, an efficient measure but one that might prove very irksome. The necessity exists as in dislocation forward to examine the joint frequently with the object of promptly detecting and correcting any faulty position, and to wear the dressings for several weeks. DISLOCATION UPWARD. (LUXATIO CLAVICULE SUPRASTERNALIS.) The first recorded case of this form of dislocation was published by Duverney' in 1751, the next was observed by Sédillot in 1835, and Malgaigne in 1855 could collect only five cases. The number is now increased to about twenty,3 with two autopsies, Duverney's and R. W. Smith's. Morel-Lavallée thought the displacement was always secondary to a dislocation backward, an opinion which has not been accepted by others. For reasons given above I am inclined to believe that the essential difference between the two forms is to be found in the relations of the displaced end of the bone to the sterno-hyoid muscle, that in the backward dislocation it lies below or possibly behind it, and in the upward dislocation in front of it. In like manner it differs from the forward dislocation in that the bone lies behind the sternal portion of the sternocleido-mastoid muscle instead of in front of and below it. The cause in the sudden, traumatic cases, is the forcible depression of the shoulder and the acromial end of the clavicle, by which the upper portion of the capsule is torn and the end of the bone lifted out of the joint; then, the force continuing to act and pressing the shoulder inward toward the chest, the bone is forced inward to or beyond the median line and sometimes upward so far even as to rest upon the anterior surface of the larynx. A unique mode of production was reported by Dr. A. N. Blodgett. The patient was carrying one end of a piano when the two men who were carrying the other end allowed it to fall. The patient. felt sharp pain at the root of the neck and front of the chest, and it was found that the sternal end of the right clavicle had been dislocated upward and inward and that the first and second costal cartilages of the same side had been dislocated from the sternum forward and outward. In Duverney's case all the ligaments were torn and the periosteum was stripped from the end of the clavicle; doubtless, therefore, the meniscus remained attached to the sternum. In R. W. Smith's case (Fig. 34), the end of the left clavicle rested on the upper border of the sternum in contact with the right sterno-cleido-mastoid, having passed behind the sternal portion of the left sterno-cleido-mastoid and in front 1 Duverney: Traité des Maladies des Os, vol. i. p. 201. 2 Sédillot: Contributions à la Chirurgie, 1868, vol. i. p. 261. For the bibliography see Malgaigne, Hamilton, and Polaillon, and cases here mentioned passim. R. W. Smith: Dublin Journ. Med. Sci., 1872, ii. p. 450. of the sterno-hyoids. The clavicular portion of the left sterno-cleidomastoid was relaxed, its sternal portion tense. The anterior and pos terior sterno-clavicular ligaments and the costo-clavicular were torn; the meniscus accompanied the clavicle. The subclavius muscle was relaxed but not torn. There was dyspnoea and dysphagia; death was the result of associated injuries. FIG. 34. Dislocation upward of the sternal end of the clavicle. (R. W. SMITH.) In a case reported by Stokes', and mentioned above, the dislocation is described as forward and upward, and the joints as being so loose that the sternal end of each clavicle could be easily moved in any direction; this condition had been produced by the "powerful action of the sternocleido-mastoid muscles "in forced inspiratory efforts provoked by great dyspnoea due to ascites. At the autopsy the ligaments were found to be greatly stretched, the sterno-clavicular being half as long again as natural and the rhomboids (costo-clavicular) also elongated. The relations of the end of the clavicle to the sternal portion of the sterno-cleido-mastoid are not stated, and it remains uncertain, therefore, whether the case properly belongs in the class of dislocations upward. Symptoms. If the dislocation is incomplete the only symptoms are the projection of the end of the clavicle above its normal position, and the local pain increased by movements of the head and arms. The symptoms of the complete form are the recognizable displacement of the end of the bone inward and upward to a variable distance, its position behind the sternal portion of the sterno-cleido-mastoid of the same side, the tension of this portion of the muscle, the depression of the shoulder, and its approximation to the chest; local pain, sometimes dyspnoea and dysphagia, inhibition of voluntary movements of the shoulder and head because of pain, and sometimes the impossibility of passively raising the shoulder. The supra- and infraclavicular fossæ are altered, 1 Stokes: Dublin Med. Journal, 1852, vol. 13, p. 459. and the emptiness of the clavicular notch of the sternum may perhaps be recognized by palpation. Treatment. Reduction is effected by drawing the shoulder outward and making direct pressure downward and outward upon the sternal end of the clavicle, but here again the chief difficulty is to prevent recurrence. Fixation of the shoulder by various dressings, and the recumbent position to avoid the depression of the shoulder by the action of gravity, have been employed with a fair measure of success, the resulting deformity being slight, and the reestablishment of the usefulness of the arm complete. Bardenheuer1 found by experiments upon the cadaver that the dislocated bone could be kept in place so perfectly by Malgaigne's hooks that the most extensive movements communicated to the arm and shoulder would not displace it. One of the hooks was engaged in the clavicle, the other in the sternum. The plan employed by Holden in his case of dislocation forward (p. 176), might be equally efficient in this form. B. DISLOCATIONS OF THE ACROMIAL END OF THE CLAVICLE. Anatomy.-The outer portion of the clavicle is attached to the scapula at two points, namely: at its extreme end to the inner margin of the acromion by the acromio-clavicular joint, and further inward to the cora Ligaments uniting the clavicle to the scapula. (HENLE) coid process by the coraco-clavicular ligaments. The articular surfaces forming the acromio-clavicular joint are flat and oval in shape, the long axis being antero-posterior, and the upper edge of the end of the clavicle rises to a variable distance above the upper surface of the acromion. The articular surfaces are separated in part, sometimes completely, by an interposed meniscus of fibrous tissue, wedge-shaped, with its base directed upward and attached to the broad, strong superior ligament; the inferior ligament, usually much thinner than the superior, closes the joint below. The coraco-clavicular ligament is composed of two portions, the posterointernal, or conoid, and the antero-external, or trapezoid. The conoid ligament, broad above and narrow below, arises from the inner part of 1 Loc. cit., p. 63. |