CHAPTER VI. DISLOCATIONS OF THE SHOULDER. (Part 2)

that the head of the bone is lower and the dislocation assumes slightly the characteristics of the subglenoid type. 56 FRACTURES AND DISLOCATIONS pig_ 7i_ — An anterior dislocation of the shoulder about half-way between the sub- coracoid and subglenoid types. Compare this case Avith those shown in Figs. 63, 64, 67. 75 and 77. Fig. 73. Figs. 72 and 73. — Anterior dislocation of the right shoulder with the head occu- pying a slightly lower position than that seen in the preceding case (Fig. 71). This case might properly be termed a high subglenoid luxation. The empty glenoid is well indicated by the straight lines of the deltoid muscle and the prominence of the cora- coid process with its attached muscles. The thumb pressed into the shoulder lies di- rectly above the displaced head. Note how closely this case resembles the t}i)ical sub- glenoid luxation shown in Fig. 77. DISLOCATIONS OF THE SHOUT^DER 57 taueoiisly, which is impossible in the normal shoulder. The head of the bone maj' be palpated in its new position in the axilla. Slight abduction of the arm facilitates this portion of the exam- ination. The head may also be palpated through the deltoid and pectoralis major as shown in P^'ig. 68. The patient's attitude is characteristic. In standing the body is inclined slightly forward and toward the injured side. This position is assumed so the displaced humeral axis may be brought more nearly to the vertical. There is very seldom any attempt made to support the injured member but instead it hangs limp from Fig. 74. Fig. 75. Fig. 74. — Subglenoid dislocation of right shoulder. The head of the humerus lies below the palpating finger. While plowing the share struck a rock and the handles of the implement v.-ere thrown violently upward and the right shoulder dislocated. Fig. 75. — Same case. The head of the humerus lies between the two index fingers. The brachial plexus and pulsating axillary artery can be felt stretched across the head by the fingers palpating in the axilla. the shoulder. In the sitting position the arm is rested on some convenient object such as a table, or the arm of a chair. In the typical subcoracoid luxation the elbow is close to, but not in contact with, the side. "When the head occupies a lower position on the anterior rim of the glenoid abduction of the arm will be more pro- nounced. In the suh clavicular or intracoracoid type the shoulder is flatter and the prominence below the clavicle, caused by the head, is nearer the median line. After the head clears the coracoid in its inward course it rises to a higher level, and thus the whole humerus occupies a higher position than that seen in the subcoracoid type. 58 FRACTURES AND DISLOCATIONS The level of the anterior axillary fold is variable. The deformity depends somewhat on the completeness of rupture of the coraco- humeral ligament. If this ligament is completelj^ ruptured the arm is usually closely applied to the chest wall. If it is only partially ruptured abduction of the arm may be pronounced even to the extent of being held in a nearly horizontal position. It may be possible to palpate the empty glenoid cavity. The arm usually shows more or less shortening which is accentuated by abduction. When the coraco-humeral ligament is completely ruptured the head may occupy an unusually low position beneath the clavicle. Fig-. 76. — Same ease after luxation had been reduced. Arm bandaged and fixed to side by strip of adhesive encircling the chest. In the subglenoid variety the humeral head rests on the long head of the triceps below the glenoid cavity, though this position is occupied only in the most pronounced cases. All the symptoms noted in the subcoracoid type are present in exaggerated form in the subglenoid variety. The arm is lengthened, the axillary fold much lowered, the axis of the humerus pronouncedly altered and abduction of the arm is a prominent symptom. The. lowering of the humerus is greater in this form than in any other type of luxa- tion occurring at the shoulder joint. The outer side of the arm forms an angle (''deltoid angle") with the insertion of the deltoid as the apex. This angle is the result of abduction and indicates the low position of the head. DISLOCATIONS OF THE SHOULDER 59 Fig. 77. — A typical subglenoid dislocation of the left shoulder. Flattening of the shoulder, lowering of the axillary fold and change in the humeral axis are much more pronounced than in the snhcoracoid type. In the subcoracoid type the outer surface of the arm is approximately a straight line but in this case it will be noted that a distinct angle is formed which for convenience has been termed the "deltoid angle." The apex of the angle is indicated by the arrow. The upper arm of the angle extends to the acromion while the lower arm extends to the external epicondyle. The lower the posi- tion occupied by the luxated head the more pronounced will this angle be. Fig. 78. Fig. 78. — Typical subglenoid dislocation of left shoulder. Fig. 79. — Attitude assumed by patient since it is accompanied by less pain than an;, other position. .This attitude is not especially uncommon in subglenoid luxations. 60 FRACTURES AND DISLOCATIONS Compare the clinical appearance of the cases shown in the accom- panying illustrations. Fig. 11 shows a typical subglenoid luxa- tion. Fig. 72 shows a higher form while Fig. 69 shows what might be termed a low subcoracoid. Fig. 80. — Subglenoid luxation Fig. 79. one seen in Fig. 81. — Another view of patient shown in Fig. 80. In the erect type of subglenoid luxation (luxatio erecta) the shoulder is dislocated while the arm is in extreme abduction and the DISLOCATIONS OF THE SHOULDER 61 head comes to rest at the lowest possible point, being in some cases even caught under the long head of the triceps. The attitude is characteristic; the arm is raised and the hand usually rests on the Fig. 82. — Luxatio erecta. Patient was hit by a train and sustained numerous in- juries, among; them the one shown here. Extension in the altered axis of the arm. and direct pressure on the head accomplished reduction without difficulty. Two days later the patient died as a result of associated injuries and immediately following death the dislocation was reproduced, the upper extremity placed in the same position as when first seen and the photograph taken. It was not feasible to take a picture when the patient was first seen but the position and appearance of the extremity as shown here are the same as existed immediately following the accident. Fig. 83. — Another view of patient shown in Fi 82. top of the head. The patient is unable to adduct the arm and the head may be seen as well as felt in the axilla. The condition is really a subglenoid luxation but the appearance of the patient is quite different from the usual subglenoid. 62 FRACTURES AND DISLOCATIONS In the siibacroynial hjpe the head lies behind the glenoid, having been driven across its posterior lip. The anterior portion of the anatomical neck rests on the posterior edge of the glenoid and the articular surface looks into the infraspinous fossa. A prominence will be noted on the posterior aspect of the shoulder while anteriorly the shoulder will be flattened and the acromion prominent. The arm is usually shortened and more or less fixed with the elbow forward. (See Figs. 84 and 85.) Fig. 84. — Posterior dislocation of right shoulder. The humeral head projecting on the posterior aspect of the shoulder is plainly visible. Note shortening of arm and change in axis. Fig. 85. — Palpation of displaced head. Its position is outlined by the two index fingers and thumbs. The sutspinous type is simply an exaggeration of the preceding. The head is driven further backward on the posterior surface of the scapula till it comes to rest under the spine of the bone. This form is very rare and is usually the result of great violence. The symptoms of the subspinous type are those of the subacromial in pronounced form. The arm is shortened, moderately abducted, rotated inward and the elbow on a plane anterior to the chest. The trauma of the head plowing through the tissues causes more or less extravasation of blood and it is usually only a short time following the accident until the skin covering the head of the bone becomes ecchymotic. The further the head passes backward under the DISLOCATIONS OF THE SHOULDER 63 Fig. 86. — Another view of the case shown in Figs. 84 and 8c Fig. 87. — Case of complete avulsion of the vipper extremity. Case reported b? cause it indicates to some extent the weakest points in the various structures which hold the shoulder together. Capsule torn cleanly from the anatomical neck except over the greater tuberosity where a triangular piece with a base equal to the breadth of the tuberosity and about thi-ee-quarters of an inch to the apex. Supra- and infra-spinatous muscles have been torn from the tuberosity and scales of bone corresponding to the insertions of the tendons have been detached. Tendon of teres minor torn across about two inches from its insertion. Stibscapularis torn cleanly from lesser tuberosity. Small shreds of the pectoralis major remain attached to the external bicipital ridge, large shred of lower portion of this muscle (about three inches long) remains attached to humerus. Teres major and latissimus dorsi torn cleanly from hvimerus. Long head of biceps torn near origin. Short head torn a little below the point at which the tendon joins the belly. About two inches of the coraco-brachialis remains attached to the humerus (transverse tear through muscular tissue). Long or middle head of triceps torn transversely below tendon, at about level of the surgical neck. Median and ulnar nerves torn at level of surgical neck. Deltoid torn loose from clavicular and scapular origins with the exception of the portion arising from the acromion. The acromion is fractured transversely about three-quarters of an inch from the tip, the fragment re- maining attached to the deltoid. Insertion of deltoid torn cleanly from humerus leav- ing deltoid eminence free from shreds. Compound comminuted fracture of radius and ulna, and backward dislocation of wrist. (The wrist was reduced before the picture was taken.) Injury sustained in centrifugal wringer in laundry. The patient recovered. 64 FRACTURES AND DISLOCATIONS spine of the scapula the more liable the arm is to be fixed in its new axis. In the extremely rare upward luxation the arm is shortened, the acromion fractured and the anterior axillary fold raised. The head of the bone may be felt as a prominence at the point of the shoulder and crepitus is present if the fragment of the acromion is manipulated. ir^-"-^ Fig. 88. — Example of a subcoracoid dislocation in a fleshy woman. The symptoms in obese persons are somewhat obscured by the adipose tissue and the condition has not infrequently been overlooked under these circumstances. If the case is carefully in- spected, however, there should be no reason for failure in diagnosis. Diagnosis. — There is a good deal of difference in the deformities of the different types of luxation occurring at the shoulder yet each is characteristic in its way, and if the surgeon is acquainted with the appearance of these deformities there should seldom be any difficulty in recognizing the condition. There is a nice pro- portion existing between the various symptoms in an ordinary sub- coracoid or subglenoid luxation and it is of value for the surgeon to recognize this fact. A given amount of flattening of the shoulder usually goes with a certain degree of change in the humeral axis and lowering of the axillary fold. This relation between the different objective symptoms can best be appreciated DISLOCATIONS OF THE SHOULDER 65 by comparing' the accompanying illnstrations. (Figs. 63 to 77.) These symptoms bear an almost constant relation to each other in simple luxations, but this relation is frequently disturbed when fracture is present. In Fig. 96 flattening of the shoulder is shown without any change in the axis of the humerus. The condition is one of fracture of the anatomical neck with dislocation of the head Fig. 89. — Another example of the same condition as shown in preceding illustra- tiou. The patient is excessively heavy yet the flattening of the shoulder, change in hnmeral axis and lowering of the axillary fold are sufficiently pronounced to recognize the condition by inspection alone. of the bone. In Figs. 117 and 118 the change in the axis of the humerus is apparent but there is no flattening of the shoulder. The condition is one of fracture of the surgical neck. Nearly all the objective symptoms are less pronounced, in fleshy persons, yet this fact should be no excuse for failure to diagnose the condition when present. (See Figs. 88 and 89.) In luxa- tions of the shoulder the patient seldom makes any attempt to support the injured member with the opposite hand but allows the upper extremity to hang limp at the side with a slight inclination of the trunk forward and to the same side. In the exceptional cases in which he does support the arm the act is casual and he will usually release it if requested. This is quite different from the attitude assumed by the patient in the presence of fracture of the humerus. He will then grasp and support the injured member 66 FRACTURES AND DISLOCATIONS with the greatest care and anxiety, and can seldom be induced to release it when in the standing or sitting position. The diagnosis must be made on the symptoms, and relief afforded the patient at once. The X-ray is therefore seldom of value except in verifying reduction and in the exclusion of complicating frac- tures, after the head has been returned to the glenoid cavity. Treatment. — In all forms of luxation the indications are to return the head to the glenoid cavity at the earliest possible moment and to maintain the parts at rest until the torn ligaments are healed. The methods of reduction vary with the type of luxation. The suhcoracoid luxation is best reduced by what is known as Kocher's method, which consists of three steps and is as follows: "With the patient seated in a straight, armless chair the surgeon grasps the elbow with his opposite hand. The elbow is then held firmly against the side while the free hand secures the wrist, brings the forearm to a right angle and then carries it outward away from the median plane. This produces outward rotation of the humerus and opens the rent in the capsule. (See Fig. 91.) The second step in the manipulation consists in gently forcing the elbow forward and inward across the chest Avhile the patient's hand is maintained in a relatively stationary position. (See Fig. 92.) Resistance is here often encountered and should be met by an insistent springing motion in the direction indicated by the arrow in Fig. 94. It is during this second step that the head of the humerus usually slips back into the socket with a distinct snap. When Kocher's method fails it is usually due to the fact that the surgeon is not maintaining outward rotation of the arm during the time the elbow is being brought forward across the chest. In other words the common fault is in allowing the hand to come forward and inward at the same time that the elbow is being carried across the chest. If reduction is not accomplished during the second step the head is almost sure to remain displaced during the third, and the whole manipulation will have to be repeated. The third step consists in carrying the hand to the opposite shoulder but is not an essential part of the manipulation. Figs. 91, 92 and 93 not only demonstrate the proper steps and positions of the upper extremity in performing Kocher's method but actually show the reduction of a subcoracoid luxation done before the camera. A study of these plates will give the reader a better DISLOCATIONS OF THE SHOULDER 67 Fi-. 91. Fig. 92. Demoustration of Koclier's method on a case of subcoracoid dislocation of the right shoulder. Case presented for treatment immediately following the accident with the usual characteristic symptoms. Fig. 90. — Appearance of case after being stripped to waist to facilitate examination and reduction. Fig. 91. — First step in Kocher's method. Head is still displaced as evidenced by the contour of the shoulder. Fig. 92. — Second step in Kocher's method. (See text.) Note the rounded contour of the shoulder : the head has just been returned to the glenoid. Fig. 93. — Third step of Kocher's method. Hand is carried to opposite side of chest. 68 FRACTURES AND DISLOCATIONS idea of the manipulation than could be conveyed by pages of text. Many surgeons prefer the recumbent position in performing Kocher's method and in some respects it is more convenient. Not infrequently the patient hinders the surgeon by a sort of squirming motion in which he arches the body toward the injured shoulder and may even slide off the table away from the operator. This may be avoided by passing a large towel or sheet about the chest and under the dislocated shoulder. The ends lie in front Fig. 94. — This plate shows the essential action in Kocher's method. The patient's elbow should be carried in the direction indicated by arrow CD. while the point A. re- mains stationary or is carried slightly away from the median plane. Resistance is usually encountered and should be met by an insistent, springing motion in the direction indicated by the arrow. If the head of the humerus does not return to the socket dur- ing this stage