Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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teachings of this distinguished surgeon, as to the exact seat and rela-
tions of the head of the humerus in some of these dislocations.

According to Sir Astley Cooper, there are three complete luxations
of the shoulder, namely, downwards, forwards, and backwards.

§ 1. Dislocation op the Shoulder Downwards (Subglenoid).

This is usually called a dislocation into the axilla ; the head of the
bone resting rather upon the inner side of the inferior border of the
scapula, near the base of that triangular surface which is found below
the glenoid fossa.

Since in both the other complete dislocations of the shoulder, the
head of the humerus, in order to escape from its socket, must be made
to descend more or less downwards, we shall regard this dislocation
as the type of all the others, and shall make it the subject of especial
consideration as well as of reference when speaking of the other forms
of dislocation.

Games. — The most frequent cause of this accident is a blow received
directly upon the upper end and outer surface of the humerus. I bave
found the arm dislocated into the axilla by this cause eleven times;

» N. L. North, M.D., New York Med. Record, April 16Ui, 1S66.

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four times by a fall upon the extended hand; once by a fall upon the
elbow, and in this latter case the arm was probably carried away from
the body at the moment of the receipt of the injury.

In all the above examples the shoulder has been dislocated by the
simple force of the blow, or with only slight aid from muscular action ;
but in a considerable number of cases the bone is displaced almost
wholly by the action of the muscles, the arm having been previously
violently abducted ; and perhaps in some cases the capsule being torn
before the resistance of the overstrained muscles has accomplished the
displacement. Thus, in three instances I have known the dislocation
to result from holding on to the reins after being thrown from a car-
riage; in two cases the patients have fallen through a hatchway and
been caught and suspended by the arms ; once a woman met with
this accident by holding on to a pump-handle when she had slipped
and fallen upon the ice. A few years since I examined the arm of a
Swiss woman, Maria Norregan, who was then sixty-five years old, and
whose humerus had been dislocated into the axilla seventeen years
before, where it still remained. Her own account of the accident was,
that she was returning from the Jura Mountains, near Neufchatel, with
a load of hay upon her head. She had carried it a long way with her
hands held upwards, without once stopping to rest, and when at length
she threw down the load at her door, the right shoulder was dislocated.
The arm soon became very painful, and swollen to the fingers' ends ;
but she was too remote from, and too poor to employ, a surgeon. A
tailpr, who used to do the minor surgery of the neighborhood, bled
her three or four times, but the dislocation was not recognized until
many months after.

A Mrs. Hunn informed me that when she was twenty-two years old
she had a convulsion, and that her attendants in trying to hold her
upon her bed, actually pulled the shoulder out of joint. After the
first accident the dislocation was not repeated for four years, but since
then it had occurred from very slight causes many times. She was
in the habit of reducing it herself by placing a ball in the axilla and
using the arm as a lever.

Dr. Lehman reports the case of a sailor on board an American brig,
who was subject to a dislocation into the axilla from very slight
causes, and especially if he bent his body far over to raise anything.
He could also, by pulling horizontally, remove the head of the bone
from its socket. It was reduced easily, and he experienced no pain
either in the reduction or dislocation, nor, indeed, during the displace-

Pathology, — In this accident the head of the bone is made to press
against the capsule below and immediately in front of the long head
of the triceps, until the capsule gives way, and continuing to descend
in the same direction it is finally arrested by the triangular surface
of the inferior edge of the scapula immediately below the glenoid
fossa. Owing, to. the pressure of the tendon of the triceps behind, it
occupies a position also a little in advance of the centre of this triangle,

1 Lehman, Amer. Joum. Med. Sci., vol. i. p. 242, 1828.

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or rather upon ita anterior edge, so that it rests more or less upon the

belly of the subscapularis muscle.

The capsule is generally torn quite extensively, especially below

and in front; and the tendon of the long head of the biceps may he

broken asunder, or detached
Fig. 286. completely from its insertion;

the supraspinatus muscle is
stretched or lacerated; the
infra-spinatus, subscapularis,
and coraco-brachialis are put
upon the stretch ; the subscapu-
laris being also sometimes com-
pletely torn from its attachment
to the head of the humerus, and
in either case, whether torn
or merely compressed and
stretched, the circumflex nerve,
which runs along its lower
margin, is subject to severe in-
jury ; the deltoid muscle is also
placed in a condition of ex-
treme tension ; while the teres
major and minor in this r^pect
Tv« , . *.v V ,. ^ ^ . . .V arc subjected to but little

Dislocftlion of the shoulder downwards Into the ax- ^ ''

ilia. (Subglenoid.) Change.

In some cases a portion or
the whole of the greater tuberosity is completely detached, and the
fragment displaced by the action of the muscles inserted into it.

Symploms, — A palpable depression immediately under the extrem-
ity of the acromion process, more distinct in children, in very old
and in thin people, than in adults of middle life or than in fat or
muscular people, but never absent completely, unless the shoulder is
very much swollen ; the elbow carried out from the body three or
four inches, sometimes a little backwards, and the line of its axis
directed toward the axilla; the outer surface of the arm presenting
two planes inclined toward each other, and meeting at the point of
insertion of the deltoid muscle; the head of the humerus felt in the
axilla, particularly when the elbow is carried away from the body;
numbness of the arm, accompanied generally with pain, especially
when any attempt is made to press the elbow against the side;
rigidity with inability to move the arm freely in any direction, but
especially inwards; allowing, however, of pretty free passive motion,
but not permitting the elbow to touch the body without great pain,
which pain is occasioned mostly by the pressure of the humerus upon
the axillary plexus.; under no circumstance can the hand be placed
upon the opposite shoulder while at the same moment the elbow
touches the thorax ; the head of the patient, and sometimes the whole
body, inclined toward the injured arm; the arm lengthened from half
an inch to an inch ; a chafing or friction sound is not unfrequently
present, especially if the bone has been some days dislocated; but

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Mr. Lawrence mentions a case in which there was a distinct crepitus,
yet there was no fracture; Dr. Hays saw a similar case in Wills
Hospital, Philadelphia, in a woman sixty years old, whose arm had
been dislocated forwards eight weeks.^ Other surgeons have related

Fig. 287.

DUloeatlon of the ihoalder doxrnwards Into th« axilla. (Sabglenold.)

like examples, but it is probable that in all these cases there has been
an exposure of the bone at or near the edge of the glenoid fossa, by
the partial detachment of its ligamentous margin, or some portion of
the head has become divested of its cartilaginous covering. (For a
more complete differential diagnosis, see chapter on fractures of the

Decisive as these signs usually are of the true nature of the accident,
cases will every now and then occur in which the diagnosis will be
attended with great difficulty, and especially if a few hours have been
permitted to elapse since the occurrence of the injury, so that consid-
erable effusions of blood and of lymph may have taken place; while
at a still later period, when the swelling, has subsided, the diagnosis
again becomes easy. " At this latter period," says Sir Astley Cooper,
" it is that surgeons of the metropolis are usually consulted ; and if we
detect a dislocation which has been overlooked, it is our duty in can-
dor to state to the patient that the difficulty of detecting the nature of
the accident is exceedingly diminished by the cessation of inflamma-
tion, and the absence of tumefaction."

It has never happened to me to have seen a case of dislocation into
the axilla which I have not easily recognized, but in my report to the

' Lawrence, Hajs, Amer. Joum. Med. Sci., vol. xxiv. p. 236, May, 1839.

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New York State Medical Society, already referred to, I have related
two cases which were not recognized by the patients themselves, and
no surgeon was called until after several days or weeks, and three
cases in which empirics having been employed they failed to detect
the dislocation, and since the date of the report, I have met with many
similar examples which had not been recognized by intelligent sur-
geons. Although, therefore, I anri prepared to admit the justness of the
observations made by Sir Astley Cooper, I think that if the case is
seen within an hour or two after the accident, its nature may be ^ne-
rally determined promptly by the surgeon of experience; but upon
this subject I have already spoken very fully in the chapter on frac-
tures of the humerus; and from the examples and opinions which I
have there presented it will be inferred that it is n?uch more common
to mistake a fracture for a dislocation, than a dislocation for a fracture,
an observation which is equally as applicable to dislocations forwards
as to the form of dislocation now under consideration.

Prognosis, — If the force which displaced the bone was not great, or
if the shoulder-joint has not suffered any injury from the accident
itself beyond the mere rupture of the capsule and a moderate straining
of the muscles, and if the dislocation has been early and easily reduced,
the patient is immediately after the reduction able to move the arm
freely in all directions ; very little swelling follows, and in a short
time a perfect restbration of all the functions of the limb is accom-

It cannot, however, always be inferred from the degree of violence
employed in the production of the dislocation, nor from the absence
or presence of swelling, how much injury the tendons, muscles, and
nerves have suffered, since the same causes produce greater lesions in
one person than in another, and the amount of swelling may depend
upon the accidental rupture of an unimportant bloodvessel, or upon
some peculiarity in the constitution of the patient predisposing to
serous, fibrous, or sanguineous effusions.

To whatever cause we may find occasion to attribute the result, it
will nevertheless be observed that, in a great majority of cases, the
limb is not restored to all its original strength and freedom of motion
until after the lapse of some months ; and the shoulder does not re-
sume its perfect form and symmetry until a much later period ; occa-
sional pains, especially after exercise of the muscles, and in certain
conditions of the weather, are present also at irregular intervals and
for indefinite periods of time. Opposite and more favorable termina-
tions must be regarded as exceptions to the rule.

Where the reduction has been made within a few hours, I have
found the shoulder affected with muscular anchylosis with more or
less weakness of the arm after a lapse of from a few days to one or
two years.

A laborer, 89t. 41, had dislocated his right shoulder into the axilla.
Dr. H., an intelligent young surgeon, reduced the bone easily with his
hands alone, while the patient was still unconscious from the shock of
the injury. After six weeks he called upon me, accompanied by his
surgeon, thinking that it was not properly reduced because the arm

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was still painful, and he could not move it freely. The bone was,
however, well in its socket. One year later I examined this man, and
found some anchylosis remaining in the shoulder-joint.

James Rogers, »t. 89, fell while running and struck upon his right
shoulder. Dr. Eastman, Prof, of Anatomy in the BuflFalo Medical
CJollege, reduced the dislocation four hours after the occurrence, in
the following manner: The patient being seated in a chair. Dr. East-
man placed his knee in the axilla and manipulated, while one assistant
supported the acromion process, and another pulled downwards upon
the forearm. The tiqrie occupied in the reduction was about two
minntes, and the bone finally resumed its position with a snap audible
to all the persons in the room. For some months after, and at the
period when I was invited to see him, the muscles about the shoulder
were rigid, and the motions of the joint embarrassed ; but at the end
of two years, Dr. Eastman informed me that the joint had become free
and the arm as useful as before, except that he could not throw a

In another case, a gentleman residing in an adjoining county, sat.
42, was thrown from his carriage, falling forwards upon his hands.
The dislocation was reduced promptly, by placing the heel in the
axilla, and within fifteen niinutes after it had occurred. Three months
after this the patient consulted me on account of the immobility of
the shoulder-joint, and because several surgeons had expressed a
doubt whether it was properly reduced. The anchylosis was then so
complete that the humerus could not be moved separately from the
scapula, but there was no displacement. This gentleman again called
upon me at the end of four years, and I then found the arm nearly
restored to its original condition, but it was not quite so strong as
before. He experienced also " curious" sensations in his arm and
hand occasionally. The anchylosis had continued with very little
improvement about two years, after which it had been gradually dis-

I need scarcely say that in those examples in which the reduction
of the bone has been delayed beyond a few hours, or for several days
or weeks, the continuance of the anchylosis has been more persistent ;
but in no case which has come under my observation, unless the bone
still remained unreduced, has the anchylosis been permanent. For
this reason I am disposed to think that muscular, rather than fibrous
or ligamentous anchylosis, is the cause, generally, of the immobility
of the joint. I have certainly never in any instance met with a true
bony anchylosis as a consequence of a shoulder dislocation. The* an-
chylosis in question seems to be a result simply of laceration or more
generally of a severe strain of the muscular fibres, resulting in in-
flammation and a contraction of these fibres ; and its occurrence in
any particular case may therefore be justly attributable either to the
position of the bone when it is dislocated, to the force of the blow
which has produced the dislocation, or to the violence applied in the
attempts at reduction.

Paralysis and wasting of the muscles of the arm, either with or
without muscular contraction and rigidity, are also observed in a cer-

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tain number of cases. Especially has it been noticed that tbe deltoid
muscle is liable to atrophy ; and in their attempts to explain the fre-
quency of its occurrence in this latter muscle, surgeons have generally
referred to a probable rupture of the circumflex nerve, a circamstaQce
which the autopsies show does occasionally take place ; or to a mere
stretching of this nerve ; yet it is quite as fair to presume that in
many cases it is due solely to the greater injury which the deltoid
muscle has sustained by the unnatural position of the head of the
bone during the continuance of the dislocation, for, with the exception
of the supra-spinatus, it i^ placed more upon the stretch than any other.
Nor is it improbable that in some cases it is due to the mere force of
the blow which, having been received directly upon the top of the
shoulder, has contused the muscle. In short, any of the causes which
may determine in the deltoid inflammation and consequent rigidity,
must finally result in desuetude and consequent atrophy.

In quite a number of cases ^y attention has been called to a re*
markable fulness just in front of the head of the bone, which has
continued sometimes for many months and even years after the re-
duction has been effected, the patients having in several cases applied
to me to know whether this did not indicate that the bone was act in
its socket, es{!)ecially« as it his been usually attended with some stiff-
ness in the joint. Not unfrequently I have been told that auigeoiu
who had noticed this fulness, thought the bone was not reduoed; and
in one instanpe I am informed that a jury returned a verdict against
the surgeon, where there was no other evidence of malpractice than
this* fulness with some anchylosis, but which; in the opdnion of these
gentlemen, was conclusive evidence that the bode was not properly
set. The deception is also often the more complete from the fact that
there may exist a corresponding depression *^underneath the acromion
process, behind.

It may be present where but little force has been used, either in the
production of the dislocation, or in its reduction. I have seen it in a
girl, only fourteen years of age, who had dislocated her left shoulder
into the axilla, by a fall upon a slippery side-walk. I reduced the
bone, assisted by Dr. George Burwell, within half an hour after the
accident. Dr. Burwell held upon the acromion process while I lifted
the arm to a right angle with the body, and pulled gently, and the
reduction was at once accomplished ; but we immediately noticed that
the head of the bone seemed to press forwards in the socket so as to
resemble what Sir Astley Cooper has described as a partial forward
luxation. There was also a corresponding depression behind. Carry-
ing the elbow back rendered the projection more decided, but bringing
it forwards would not make it entirely disappear.

In other instances much more difficulty has been experienced, and
more force has been employed in the reduction. A man weighing
two hundred pounds, and forty-one years of age, residing at Bath, in
Steuben Co., fell from a load of hay in May, 1853, striking upon the
top and front of the left shoulder. It was immediately ascertained
that he had dislocated bis arm into the axilla, and broken his leg. A
young surgeon attempted within a few minutes to reduce the disloca-

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tion, but failed ; and about two hours later it was reduced by another
surgeon, with the aid of chloroform and Jarvis's adjuster. Four years
after the accident had occurred, this gentleman came to me accom-
panied by the surgeon who had made the reduction, in consequence
of its having been intimated by some medical men that it was not
properly reduced. The arm was not as strong as the other ; some
anchylosis existed at the shoulder-joint; but especially it was noticed
that there still remained a remarkable fulness in front, as if the head
of the bone was pressed forwards. By no manipulation or position
could this fulness be made to disappear, yet the bone was plainly
enough in its socket.

This phenomenon is probably due in some cases to a rupture of the
Bupra-spinatus muscle, and the consequent preponderating action of
the antagonizing muscles, or to the laceration of the capsule, buV most
oflen, I imagine, to a rupture or to a displacement of the long head of '
the biceps, a circumstance to which I shall more particularly allude
under the subject of " partial dislocations."

Among the results of this dislocation must' be platied a tendency to
reluxation, which, although it may not often be made manifest by its
actual occurrence, owing perhaps to the prudence of the surgeon, yet
it does take place in a sufficient number of cases to establish its
peculiar liability. Indeed, we need only consider bow imperfect is
the protection against this accidenty when once the capsule has been
torn, to appreciate this observation. Examples of spontaneous luxa-
tion, or of luxation of the shoulder from very trivial dauses, after it
has once been luxated, may be fpund in the experience of almo^
every surgeon. I have myself met with several persona who. have
had repeated luxations from a slight cause, and in some instances,
where the patients were subject to epilepsy, the luxations have oc-
curred whenever the convulsions returned.

A gentleman residing at Toronto, Canada West, had a dislocation
of the right shoulder into the axilla when he was quite a child, and
the accident was renewed when twenty-nine years old by falling from
a carriage head foremost, with his right arm extended and uplifted.
Since then, until he called upon me, a period of about six years, he
has been constantly subject to the same dislocation ; and he cannot
raise his arm high above his shoulders without producing a subluxa-
tion, the head of the humerus resting upon the outer margin of the
lower and anterior edge of the glenoid fossa, but by rotating the arm
outwards it immediately resumes its place. I found the whole limb
as fully developed, and he said it was quite as strong, as the opposite

I have already mentioned the case of Mrs. Hunn, whose arm had
been dislocated more than twenty times in the last five years; and I
remember a lad, Pat. Dolan, aged nineteen years, whose left arm was
dislocated by falling from the mast-head of a vessel, and hanging by
his hand. No attempt was made to reduce it until fourteen hours
afler the accident, at which time it was set by two German doctors,
but not until they had pulled upon it three hours. Four months after
it was again dislocated by the slipping of an oar while he was rowing

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a boat. A surgeon having failed this time to bring it into place, I
succeeded readily and without the aid of an anaesthetic, by raising
the arm directly upwards in the line of the body, while my foot was
pressed upon the top of the scapula. Many other similar examples
nave come under my notice.

We have referred more than once to the occasional diflRculty of
diagnosis in this as well as in many other shoulder accidents; and I
have alluded to five cases in which the dislocation was not recognized,
but none of them had been seen by a surgeon. Other writers have,
however, mentioned many examples of unreduced dislocations of the
shoulder, for which surgeons of skill and experience were responsible.
I have myself met with these cases quite often. For example, I have
seen two dislocations of the humerus into the axilla, both of which
had been seen and examined by New York hospital surgeons within
a few hours after the receipt of the injury, but the nature of the ac-
cident had not been recognized. One of these I reduced at Bellevue
Hospital on the seventh day, and one on the tenth. There was also
presented to me, at the Charity Hospital (Blackwell's Island), in my
service, an axillary dislocation of twenty years' standing, which a
surgeon saw immediately after the receipt of the injury and failed to
recognize. In other cases the dislocation has been clearly made out,
but the surgeon has been unable to reduce the bone. It has been my
fortune to succeed in several instances where others have made a fair
trial and have failed, but the following case leaves me no opportunity
to boast the superiority of my own skill above that of my con/rirts.

Mary Kanally, set. 49, a large, fat, laboring woman, was admitted
into the Buffalo Hospital of the Sisters of Charity, with a dislocation
of the right humerus into the axilla, which had occurred twelve hours
before. This is the same woman of whom I have before spoken as
having produced the dislocation by a fall while holding upon the
handle of a pump.

Drs. Lockwood and Baker, of BuflFalo, were first called, and at-
tempted reduction. They made extension and counter-extension in
every possible direction, and for a long time, but to no purpose. She

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 63 of 100)