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President...

Officers of the N. A. R. S., 1896-7.

First Vice-President...

71

71

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.F. J. LUTZ, St. Louis, Mo. W. R. HAMILTON, Pittsburgh, Pa. Second Vice President....J. H. LETCHER, Henderson, Ky. Third Vice-President......JOHN L. EDDY, Olean, N. Y. Fourth Vice-President....J. A. HUTCHINSON, Montreal, Canada Fifth Vice-President...... A. C. WEDGE, Albert Lea, Minn. Sixth Vice-President......RHETT GOODE, Mobile, Ala. Seventh Vice-President...E. W. LEE, Omaha, Neb. Secretary... .C. D. WESCOTT, Chicago, Ill. Treasurer.. ..E. R. LEWIS, Kansas City, Mo. Executive Committee:-A. I. BOUFFLEUR, Chicago, Ill., Chair

man:

J. N. JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo, O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa.

No. 3.

SHOULDER INJURIES, WITH SPECIAL REFERENCE TO THEIR MORBID ANATOMY AND DIFFERENTIAL DIAGNOSIS.*

BY THOMAS H. MANLEY, M. D., NEW YORK.

The shoulder, because of its situation, its wide range of motion and, frequently a site exposed to considerable concussive force, often sustains various degrees of violence. An impression generally prevails, that the accurate detection of the various types of trauma borne by this region of the body, is ordinarily a simple matter. Applying this statement to the more ordinary injuries, it is probably correct; but, if it be intended to include all, it certainly is an error. My own fifteen years' experience in active hospital service, wherein, traumatism of every description constituted the larger number of cases, has convinced me, that, if perhaps we exclude the elbow, there is no joint in the body, in which the diagnosis of injuries of structures entering into, or contiguous with it, is more difficult to recognize. It may sound strange, but there can be little doubt, that there are not a few practitioners who, in the whole course of their career, have never detected some of them. Paradoxical as it may seem, but it is probably true, that some may have treated lesions, the actual existence of which they have been in ignorance of. On general principles, the case was dealt with; "palmed" off as a sprain or contusion, recovery of function returning in various degrees, not so much in consequence of treatment, but in spite of it.

Through an oversight of this kind, serious consequences may accrue to the patient; and its ultimate detection, by a more cautious, unskilled diagnostician, can only result in seri

*Read by title at the ninth annual convention of the National Association of Railway Surgeons.

ous damage to one's professional reputation, if not involve him in expensive litigation.

With a view especially, of endeavoring to throw some light on this feature of diagnosis, this brief review of the subject is undertaken; more so, inasmuch, as no text-book or other surgical work that the writer is familiar with, deals with it in detail, at this joint. The average work on bone and joint distraints, considers the subject in a manner too technical and artificial to be of much practical value, to those whose practice is exclusively surgical, or, even, the general practitioner, who frequently unaided, must promptly act and give relief to the injured.

CONFIGURATION AND FUNCTIONS.

The shoulders give lateral width, squareness and fullness to the upper segment of the trunk. Regularity in growth and development in this situation, impart that symmetry and perfection of outline, so essential to ideality of

stature.

Some authors imply an analogy between the shoulder and the hip, but, on close inspection, with an analysis of structure and function, this seems very remote, if it exist at all.

The shoulder is made up of a bony framework, with two joints, and a large muscular development, resting on the lateral wall of the thorax, and swung by muscles upon the spine, and only steadied in position, by the clavicle. With their appendages, the arms, forearms and hands, their purposes being solely for prehension, and the performance of the mechanical needs of the body. The shoulders, because of their position and mobility, afford shelter and protection to the contents of the chest or thorax, and in the application of great violence, to the lateral surfaces of the body, receive the primary impact, and so diffuse or moderate it, as to often guard the skull, the spine or thorax, from serious damage. A young lady lately came under my observation, who sustained at fracture in the upper dorsal segment of the spine, from a fall of less than three feet, from a hammock, striking squarely on her back. The consequences to the spinal functions have been most disastrous. The same degree of force, sustained by the shoulder, would probably have resulted in nothing more, than a severe contusion, or, at most, a clavicular fracture or dislocation.

The shoulders, suddenly thrown inward on the body, afford great protection to the upper segment of the thorax. This provision of the economy will largely explain, why, after contusive injuries, we so seldom meet with costal fracture, above the nipple line, or the most vital region of the thorax.

Of all the articulations or joints, in the human body, the shoulder is not only the most complex, but the most perfect and powerful compound articulation, as well, considering its structural composition.

Shoulder motion or movement, involves something more than one articulation, as one might infer, by a superficial examination of the anatomy of this region.

To speak of the shoulder-joint, especially, when function is referred to, is inaccurate, and has so often led to such mistaken inferences, as to betray the unwary into erroneous conclusions, both in the recognition and treatment of injuries, over this area of the body. Full exercise of shoulder motion, always involves two articulations, at least. It is therefore highly proper and equally necessary, that we should speak rather of shoulder-joints, than a shoulder-joint; and let us hope, that in the near future, some rising anatomist, with a greater regard for a full and truthful description of structure and function, than a puerile submission to the tyranny of tradition, will come out, with such an account of this important structure, as will give to the subject such interest and practical value, as never yet has been bestowed on it.

The upper extremity is brought into immediate relation with the body or trunk, through that limited, flat articular surface, connecting above, the shoulder-blade with the collar-bone; the power, being linked with the brachial lever, through the medium of another articulation, which imparts to the arm, a great diversity of motion. Several large nerve cords pass down through the osseo-muscular structure of the shoulder, anteriorly and internally, to reach the axillary pit. Following along the same path are the two great vascular trunks of the arm. These important structures, though well fortified against exposure or injury, by a provision of the economy, yet, in the event of serious disorganization or displacement, of the osseous framework of the shoulder, can scarcely escape damage.

OUTLINE OF THE ANATOMY OF THE SHOUlder.

The shoulder is pressed backward, from the median plane of the body, braced from within, and permitted to move within a limited arc, by the clavicle.

As

One of the shoulder joints-the acromioclavicular articulation-is very superficially located, being immediately under the integument. It is remarkable, because of its exclusive ligamentous composition, and its great resistance, to the application of violence. On the integrity of this joint, the equilibrium of shoulder action depends. It is a true arthrodia. In motion of the shoulder girdle, the scapula moves upon the outer end of the clavicle. Morris puts it, "the entire scapula moves in the arc of a circle, whose center is the sterno-clavicular point, and whose radius is the clavicle" (Morris Human Anatomy, the Articulations, p. 232). Through this joint, the scapula moves on the thoracic walls, backward and forward, and without it, the constantly forward obliquity of the articular surface of the glenoid cavity, would be impossible. By its means, the shoulder can be forcibly advanced forward, on the thorax, and the combined action of the muscles of the scapula and thorax, can be brought into play, in the application of force.

Around the end of the clavicle, the shoulder moves to and fro, as a hinge, on the horizontal axis of a joint.

If the acromio-clavicular junction is signalized, by the absence of muscles, the scapulo humeral depends almost alone on them, for support and retention. The former is the passive articulation of the shoulder, and the latter the active, the one serving as the true joint, to connect the shoulder to the trunk, maintaining a steady unremitting functional action; the other, only called into play periodically, to fulfill special demands. If the scapula be suspended from the end of the clavicle, from a point devoid of any special bone support, except from underneath, the humeral head is quite equally devoid, of any direct osseous collateral support, within its investing capsule. Its chief supports are but accessory, or extra articular, as not more than one-fourth of the head of the humerus, is in contact, at one time, with the narrow, nearly flat surface of glenoid cavity. The head of this bone, then rests rather against an articular surface, than is enclosed by one. It is held up against the scapula, by

muscular action, partly assisted by the long head of the biceps, immoderate forward, or upward movement, being restrained by the coracoid and acromion processes.

The capsular ligament of the scapulo-humeral joint, equal to more than twice the capacity of humeral head, is sometimes continuous with long fibers of the biceps, and by a diverticulum, with the large subacromial bursa. It may be well to note that although this ligamentous support of this joint is unimportant, with the exception of the deltoid, all the muscles inserted into, or near the tuberosities of the humerus, end in broad tendinous expansions, those coming from the dorsum of the scapula, having a dense resisting fasciæ, before they converge at the point of insertion. The shelving arch of the acromion process, affords the greatest protection, to the head of the humerus, which, indirectly, through the medium of the deltoid muscle, is intimately united with it. In sudden muscular strain, or the relaxation consequent on paralysis, the head of the humerus is prone to slide out of its cavity. After certain dislocations, following violent strains or twists, such extensive laceration of muscle, or possible detachment of tendinous fibres follows, that the reduced humeral head persistently falls away from its scapular receptacle.

The head and the greater tuberosity of the humerus contribute an important part of the shoulder. In fact, the whole architecture of this region is primarily formed, and ultimately intended to act on, support and protect this disc of bone, with the shaft and forearm below.

The articular surface of the head, and epiphyseal junction of the humerus are within the capsule, and are so well protected, as to be entirely beyond surface examination, except through the axilla, when the arm is at right angles with the body laterally, or, is forcibly raised to a plane, in the same line of axis with the body.

The great muscular leverage of the upper end of the humerus, has its principal insertion, in the apophyses or the tuberosities, which are primarily possessed of independent centers. This group of muscles serves a dual function, of imparting motion to parts beyond the joint, besides, in a large measure, acting as ligamentous stays.

The whole osseo-muscular structure of the

shoulder is a study of great interest, if we regard it from its mechanical standpoint, alone. Here we have the entire structure of support and motion of the arm and forearm, slung loosely on the walls of the thorax, without any apparent definite fixed center of support, with nothing of greater strength, than the costal bows and inflated pulmonary tissue, underneath to oppose violence, and yet, in the event of danger, or, when necessity demands it, the elastic lung is suddenly expanded, and the pendant scapular wings become fixed, as though set in steel braces. The pneumatic chamber, by some provision of the economy, not easily explained by physics, is suddenly transformed into a pedestal or base, which may receive a tremendous force of impact, through the humerus, with comparative impunity.

When the muscles are in a relaxed state, and are taken, as it were, by surprise, as in many falls, blows, etc., force applied over the latteral aspect of the shoulder, is transmitted through, the clavicle, but, when great force is applied obliquely, from before or behind, or, when notice of its approach is possible, quick muscular adjustment serves to transmit it directly to the chest walls, as well as, to the clavicle.

THE BLOOD VESSELS AND NERVES.

The nerve and blood trunks, on their course to the upper-extremity, are forced to make their way, through a narrow, movable gap, at the point, where they dip under the distal curve of the clavicle, and pass down over the first rib, to reach the armpit, where they are very superficial, and yet, well protected from their sheltered position under the arm.

Except for a few recurrent branches in the axillary space, the parts immediately above the scapulo humeral articulation, derive their arterial supply, from the thyroid axis of the subclavian.

In the axilla, the great blood trunks lie in a loose bed of myxomatous tissue, imbedded in which, are numerous lymph ganglia, arranged in two layers. Besides performing the functions appertaining to these bodies, they no doubt, serve to modify pressure on the vessels, in the event of concussion, or compression from mechanical causes.

NERVES.

The close proximity of the brachial plexus of nerves with the humeral head-being

separated only, by the tendon of the subscapularis and capsule of the joint-would seem to expose it, to serious damage, in the event. of dislocation, or any sudden strain on the humerus. But the inherent property of nerve tissue, to resist injury, with their free, unfettered position, enables this leash of cords to generally escape serious damage. The peripheral nerves of the shoulder, which come down from the upper conical roots, being more exposed, are most frequently affected, by an injury.

It is only in fractures, occupying the upper division of the surgical neck of the humerus, that the deep branches of the brachial plexus, as, the circumflex, muscul and spiral are severely lacerated, or contused.

CHARACTER OF LESIONS MOST COMMONLY BORNE BY THE SHOULDER, AND STRUCTURES IMMEDIATELY CONTIGUOUS

WITH IT.

By some singular provision of the economy, the osteo-arthritic elements of the shoulder, are by far, less susceptible to pathological changes, subsequent to, or simultaneous with, constitutional diseases, than those in other situations. The same may be said of the neurovascular structures. Thus, tubercular synovitis or osteo-arthritis, at the humero-scapular joint, is a rare condition. Why this should be so, in an articulation, the center of such activity, and so near the center of circulation, while the more distant hip and knee are implicated, is not easy of explanation. We will observe, also, that, when rheumatic inflammation falls, with its greatest force on the joints, those of the shoulder more often escape, than the hip, knee or ankle. It is certainly unusual to find the shoulder locked in permanent anchylosis, by an organized plastic exudation of rheumatism, into the tendo-vaginal spaces, or, between the articular surfaces.

When one finds an acute monarticular, paninflammation of a rheumatoid character, at the shoulder, fixing the ends of the bones, and rendering all motion difficult or painful, in an adult previously healthy, we have good reason to suspect, the metastalic transference of gonorrhoeal infection.

In quite a few, after a moderate injury at the shoulder, we may find a marked element of hysteria, with the most intense hyperæsthesia,

along the terminals of the supra-clavicular defensive bulwark of the body, powerfully con

nerve.

The movements of the shoulder, are intimately connected, with the integrity and action of the lungs. This is conspicuous in the trophic wasting of muscle, and falling forward of the shoulder, in phthisis; and, the fixed position of the shoulder blade, when the pleura is distended, or, the parenchyma of the lung is the seat of extensive inflammatory invasion.

Phlegmasia of the arm, with varices or early cutaneous atrophy of the upper limb, as a consequence, of traumatic or infectious phlebitis of the axillary vein, is almost never witnessed, except, in the malignant infiltration of cancer, or, after the enucleation of the absorbents of the armpit, by the resulting scar-tissue.

Certain cardio-pathies may produce such a train of phenomena at the shoulder, as will lead the inexperienced to believe, that the axillaryartery is the seat of aneurism. Such a case once led me to suggest, a consultation with a view of deciding, on the most appropriate mode of treatment. This was ten days after the case first came to me. Now, when the patient was stripped, all the symptoms of aneurism had vanished; but, a most remarkable form of violent and painful muscular spasm remained, involving the entire shoulder and arm. Treves speaks of axillary aneurism as a very common variety (Applied Anatomy, F. Treves, p. 217). It certainly is not in this country. Not a single case has ever come to my notice. This is most extraordinary, when we consider the exposed state of the axillary artery, to various kinds of trauma.

We have no pathological state of the brachial plexus, which gives rise to any phenomenon similar to sciatica, although it would appear, from “crutch palsy," that it bears the effects of pressure, with less impunity than its neighboring blood trunks.

There is a type of neuralgia, however, which involves the brachial nerves, of a spasmodic character, producing spells of the most agonizing, exhaustive, distress, recurring after varying intervals, sudden in its onset and subsidence. It almost invariably involves the right shoulder, and not uncommonly shatters the constitution of the afflicted.

LESIONS OF A TRAUMATIC ORIGIN.

The shoulder girdle being an offensive and

structed, and yet, the center of a double diarthrodial movement, is directly and indirectly exposed, to various degrees of violence.

Blows and falls on the shoulder, are of no great moment, unless the intensity of impact is considerable. When one is about to fall, or receive a violent blow, the scapular defense is immediately set up, the hand and arm are thrown out, or the shoulder is suddenly raised. or pressed forward.

Sprains, contusions and wrenches of the shoulder are common, and, as a rule, are quickly recovered from. But difficulty and trouble may come from mistaken diagnosis, or a superficial examination.

Not a few cases of fracture of the outer third of the clavicle, of the acromial or coracoid process, or dislocations of the acromial end of the clavicle, or head of the humerus, have been mistaken and treated for "sprains." And as will be shown later, the diagnosis of severe types of shoulder injuries, is by no means as simple a procedure, as is generally supposed.

Shoulder dislocations are not rarely so difficult to successfully treat, or so unsatisfactory in final results, that many highly capable, but cautious practitioners, are loath to take them in hand, under any circumstances, if it be possible to avoid it.

Clavicular fracture, so commonly the result of indirect force, acting through the shoulder, when it occurs at the interspace, between the insertions of the deltoid and pectoralis-major muscles, or, the outer third, though uniting with greater rapidity, than any other bone in the body, if we except the inferior maxilla, can seldom be so treated, so as, to entirely avoid overriding of the fragments. Epiphyseal separation within the capsule, or fracture just outside of it, in the femoral shaft, is unsatisfactory to treat, and tedious in its effect, on the functions of the joints.

About one in a hundred dislocations, of the head of the humerus, cannot be reduced, or, if they can be, will not remain.

I have witnessed two surgeons of eminence, utterly fail, by pushing the head into the glenoid cavity. One not only failed, but fractured the shaft, through the surgical, neck in the attempt.

Ten cases of unreduced humero-scapular dislocation, have been under my own notice, and

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