Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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' Norris, Amer. Joum. Med. Sci., xxxi. p. 24.

« Boston Med. and Surg. Joum., No. i., 1828; also, Amer. Joum. Med. Sci.,
vol. ii. p. 233.

J Hichet, Amer. Joum. Med. Sci., vol. xii., new ser., p. 293, from Bulletin de-
Tiierap.



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566 DISLOCATIONS OF THE SHOULDER.

>vith the fingers was made in the axilla, forcing the head toward the
socket, and the bone slipped into its position.*

In the TranscLciions of the American Medical Association, I have re-
ported a case of supposed dislocation accompanied with a fracture,
which I succeeded in reducing on the eighth day.'

I have, however, twice failed in attempts to reduce similar disloca-
tions. The first patient, John Riley, set. 49, was admitted to BellcTue
Hospital, March 29th, 1864, having received the injury two days
before. The dislocation was subcoracoid, and the bumeros was
broken at its surgical neck. Having placed him under the infiueooe
of ether, assisted by Dr. Stephen Smith and several other surgeons of
the hospital, I attempted to reduce the dislocated bone» but after a
trial prolonged through one hour or more, the effort was abandoned.

The second case was in a man aged about 40 years, who was ad-
mitted to Bellevue Hospital in July, 1864, with a dislocation of the
head of the humerus forwards, and a fracture of the surgical neck, of
four weeks' standing. A surgeon had attempted reduction immedi-
ately after the receipt of the injury, but had failed. We found the
fracture still ununited, and placing him under the influence of ether,
we tried faithfully, by pushing and pulling and by various other ma-
noeuvres, to reduce the dislocation, but without success.

The fractures united in both cases promptly, and attempts were
subsequently made to reduce the dislocation, but to no purpose.

Other examples have been recorded by surgeons in which the re-
duction has been accomplished immediately, and without much diffi-
culty, by simple pressure upon the head of the bone, while the patient
was under the influence of an anaesthetic, and without the aid of ex-
tension ; indeed, it is quite doubtful whether extension in these cases
is of any service. If, however, the surgeon were to fail by pressure
alone, it would be proper to employ extension and manipulation ;' in
the event of a failure by these means, the case ought to be treated aa
a fracture, and the earliest period after the union of the fragments
should be seized upon to accomplish the reduction of the dislocatioo.
The frequent success of the older surgeons by this method is sufficient
to warrant the attempt

The treatment of compound dislocations of this joint will be dis-
cussed in a separate chapter devoted to the general consideration of
compound dislocations of all the joints connected with the long bones.

§ 2. Dislocation of thb Humerus Foewards. (Subcoracoid and
Subclavicular,)

Causes. — The causes of this dislocation are the same with those
which produce dislocation downwards into the axilla, except that it
is more likely to occur in a fall upon the elbow or upon the hand
when the line of the axis of the arm and forearm is thrown behind

* Watson, Amer. Joum.'Med. Sci., vol. xvi., new eer., p. 883.
« Op. cit., vol. ix. p. 93.

' Hartshome, Case reduced by Manipulation, Amer. Joum. Med. Sci., Jan. 18-^
pp. 273-4, from Med. Examiner.



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DISLOCATION OF THE HUMERUS FORWARDS. 567

the body. If it is the result of a direct blow, the impulse has usually
been received rather upon the back than upon the outer side of the
head of the humerus; or the upper end of the bone having been
originally thrown directly downwards upon the inferior edge of the
scapula, may have been made to assume the position forwards, be-
neath the pectoral muscle, in consequence of the peculiar action of
the muscles, or of the position of the arm in an attempt to rise. By
this latter mode of explanation the dislocation forwards is consecu-
tive only upon a dislocation downwards.

In several instances which have come under my notice the disloca-
tion has been due to muscular action alone. In one example the
dislocation occurred frequently in consequence of epileptic convul-
sions. This was in the person of a lad, set. 18, of a slender frame and
feeble muscles. When the dislocation had taken place, he was fre-
quently able to reduce it himself; sometimes he was obliged to call
upon a surgeon, and at other times he lefl it out a day or two, or
until it became reduced spontaneously. This spontaneous reduction
generally took place at night, during sleep. At the time he called
upon me the bone had been out two days, and he could not reduce it.
I administered chloroform, and then made repeated and prolonged
efforts at reduction, adopting all the usual modes of manipulation, but
without resorting to mechanical appliances. The father now refused
to allow me to proceed, and he was taken home with the bone unre-
duced. The following day he called at my oflBce, to say that during
the night, while asleep, and, he thinks, while turning over in bed, the
bone suddenly resumed its place.

Pathology. — Omitting for the present to speak of partial luxations,
the existence of which, as a form of traumatic dislocation, we are pre-
pared to question, we shall proceed at once to describe the anatomical
relations and the various lesions
which generally accompany a com- Fig. 246.

plete luxation forwards.

Of these we shall observe two
principal varieties, diflfering mainly
in the degree or extent of the dis-
placement.

Thus we may find the head of the
humerus resting beneath the coracoid
process, having the conjoined tendon
of the short head of the biceps and
of the coraco-brachialis lying upon
its anterior surface, while its poste-
rior and outer surface rests upon the
venter of the scapula in front of the
glenoid fossa; in which position it
has usually thrust up, to a greater

or less extent, the belly of the sub- sabcorMoiddisioeuion.

scapular muscle.

Sir Astley Cooper, Fergusson, and others, when mentioning this
form of dislocation, call it a "dislocation into the axilla;" by Boyer



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568 DISLOCATIONS OF THE SHOULDER.

it is called a " primary luxation forwards." Dr. Wood, of New York,
has reported an example, accompanied with a fracture of the neck of
the humerus, which he has named ''dislocation under the subscapularis
muscle." The drawing which accompanied the report, made from the
autopsy, sufficiently shows that it was a dislocation of the same char-
acter as that which we are now describing.* Dr. Parker has called
attention to a similar case, an account of which was first given in
Beese's edition of Cooper's Surgical Dictionary, The head of the
humerus reposed in the " subscapular fossa.'^ By Malgaigne, Vidal
(de Cassis), and others, this is called a subcoracoid dislocation, a term
which, as being more distinctive and appropriate than either of the
others, I shall choose to adopt.

In the second variety, the head, having escaped from underneath the
coracoid process, is made to approach nearer to the sternum, so as to
apply itself more or less closely to the inferior edge of the clavicle.
In which case the head and neck will be placed behind the pectoralis
minor, and also behind the short head of the biceps and coraco-bra-

chialis ; or between these several mus-
Fig. 247. cles on the one hand, and the serratus

magnus, covering the second and third
ribs, on the other hand.

Upon the appearances which accom-

f)any this more advanced form of dis-
ocation writers have generally based
their descriptions, diagnosis, treatment,
&c., of forward luxations.

In either form of the accident, the
deltoid, with the supra- and infra-spina-
tus, is greatly stretched, and the two
latter sometimes torn ; the subscapu-
laris is displaced upwards and back-
wards, while its tendon is in some in-
stances completely wrenched from the
head of the humerus. Mr. Erichsen
sabciavicQiar dislocation. has sccu the Icsscr tubcrclc itsclf Com-

pletely broken oflf in two examples of
this accident which he has been permitted to examine after death.^
Occasionally the axillary nerves are carried forwards with the head
of the bone ; and in this case the pain produced by their being thus
pressed upon is even greater than in dislocations into the axilla.

In this accident, as in dislocation downwards, the long head of the
biceps is sometimes broken ; the circumflex nerve may be contused or
ruptured, and the capsule is generally torn very extensively.

Symptoms, — If the dislocation is subclavicular (Fig. 247), a depression
exists under the outer end of the acromion process, extending also un-
derneath its posterior margin ; the elbow hangs away from the body,
and a little backwards; the axis of the limb is much changed, being

* Wood, New York Joum. of Med., May, 1850, p. 282.
« Parker, New York Journ. of Med., March, 1852, p. 187.
■ Erichsen, Science and Art of Surgery, 2d Amer. ed., p. 250.



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DISLOCATION OF THE HUMERUS FORWARDS. 569

thrown inwards in the direction of the middle of the clavicle, the
whole body inclining moderately to the same side ; there is also more
or less inability to move the arm, especially in a direction forwards or
outwards; a fulness is seen underneath the clavicle, and to the sternal
side of the coracoid process, occasioned by the head of the humerus;
the bead moving with the shaft. To these we may add the common
sign of all dislocations of the humerus, mentioned by Dugas, viz., the
impossibility of placing the hand upon the opposite shoulder while at
the same moment the elbow is made to touch the front of the chest.

If the dislocation is forwards, but subcoracoid, the head of the bone
will be found below this process and deep in the anterior margin of
the axillary fossa. It cannot, therefore, be so distinctly felt ; but the
other signs are the same as in the dislocation forwards under the
clavicle.

Prognosis. — While on the one hand experience has shown that the
axillary nerves and artery are less liable to sufifer serious and permanent
injury than in dislocation downwards, and that the capsule, with the
tendinous and muscular tissues about the joint, are no more liable to
laceration, on the other hand, the difficulty of reduction has been often
increased, and consequently a large number of examples, in propor-
tion to the actual number which occur, have been left unreduced.

Fig. 248.



Sobcoraooid luxation.



Dr. Norris relates a case which the surgeon who was first called

supposed to be a mere contusion, but which, on being admitted to the

Pennsylvania Hospital, three months after the accident, was found to

he a dislocation forwards under the clavicle. The arm was almost

87



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570 DISLOCATIONS OF THE SHOULDER.

useless. Dr.Norris made extension and compound counter-extension
with pulleys nearly an hour, but to no purpose ; and finally, at the
request of the patient, the attempt was given over.'

Treatment, — The same rules of treatment which we have established
in relation to dislocations into the axilla will be found to be applicable
to this dislocation, with the exception that the extension will have to
be made generally at first somewhat in a line backwards from the
body, and that our efforts will frequently have to be continued with
more perseverance, although with less fear of injury, in conseqaence
of supposed adhesions between the artery and the adjacent tissues.
The extension also must always be made downwards and outwards^
if the dislocation is subclavicular, until the head of the bone has es-
caped from beneath the coracoid process; we may then pull directly
outwards or even upwards, while at the same moment pressure is
made with the hand upon the head of the bone in the direction of the
socket, and the arm is rotated inwards.

If the dislocation is subcoracoid, our modes of procedure need
scarcely vary in any respect from those which we have recommended
for dislocations into the axilla.

The plan adopted in the following case has been found sufficient in
several examples of subcoracoid dislocation.

Mr. McA., of Bufialo, set. 78, moderately muscular, fell through a
trap-door, striking upon his right elbow, and dislocating the humeras
forwards. Within two hours after the accident, I found the head of
the bone resting under the coracoid process, where it could be dis-
tinctly felt and seen. There was a marked depression under the
acromion process, and the arm was carried out from the body and
slightly back. He had not sulBFered much pain. The patient was
seated in a chair, and while Dr. Lemon, who was at that time my
pupil, supported the acromion process, I pushed the head of the hu-
merus outwards toward the socket with my left hand, while with my
right I pulled gently upon the arm in the direction of the axis of the
body. After about twenty seconds it slid suddenly into its place
with an audible snap.

Simple manipulation alone will also be found sufficient in many
cases of subclavicular dislocation.

A German, Simeon Grennas, sdt -21, fell upon an icy side-walk, and
dislocated his right humerus under the clavicle. We found him about
an hour after the accident sitting with his head inclined to his right
side, and supporting his elbow with his left hand. A marked depres-
sion existed under the outer end of the acromion process, and instead
of the usual fulness there was a flatness under the process behind.
The elbow was carried out from the body, and very slightly backwards.
While Dr. Boardman supported the acromion process I lifted the
elbow from the side, carrying it first upwards and backwards, and
then forwards, making thus a short detour with the arm, and when
the manoeuvre was nearly completed the bone slid into its socket
with a slight snap. No extension was used, and no more force was

» Norris, Amer. Joam. Med. Sci., vol. xxv. p. 279.



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DISLOCATION OF THE HUMERUS FORWARDS. 671

employed than was sufficient to lift and rotate the arm. He was not
at the time of the reduction faint, nor were his muscles relaxed from
any other cause.

More than once I have accomplished tne reduction by extension
made directly upwards, as in the following example.

A gentleman, forty-five years of age, had his left shoulder dislocated
forwards under the clavicle in a railroad collision, on the 8th of Octo-
ber, 1858. A young surgeon had been making extension in various
ways for half an hour, when, by placing my foot upon the top of the
scapula and drawing the arm directly upwards, I accomplished the
reduction immediately and without much effort. Six months after
the accident, I found the deltoid muscle considerably wasted, and he
was still unable to raise his arm to a right angle with the body.

I have in this way also reduced a dislocation which had existed
seventeen days, the nature of the accident having been misunderstood
by the attending surgeon. The man was twenty-three years old, and
quite muscular. The dislocation had been produced by a severe blow
received directly upon the shoulder, and the arm was still considerably
swollen and very tender. The reduction was accomplished in a few
seconds while the patient was under the influence of chloroform, but
by my hands alone, aided only by the pressure of the foot upon the
top of the scapula.

In December, 1857, Dr. White, of Buflfalo, and myself, reduced a
subclavicular dislocation of the right shoulder, which had existed sixty
days, in a man sixty -eight years of age. The surgeon who first saw
the man thought it was only a sprain or a severe bruise. When he
came to Bufialo, the whole limb was enormously swollen, and neither
Dr. White nor myself had much expectation of accomplishing a re-
duction without a resort to pulleys and ansBsthetics. He was, however,
J laced upon the floor, and after extension made for about half an
our, during which time we had pulled the arm in various directions,
upwards, outwards, and downwards, I at last succeeded while my heel
was placed in the axilla, and while the limb was undergoing a slight
rotation. No anaesthetic was employed.

Dr. M. 0. Cuykendall, of Bucyrus, Ohio, informs me that he has
recently reduced a subclavicular dislocation on the sixty-fourth day,
in a man 62 years old, by the following method : "As a last resort I
secured the pulleys to the arm above the elbow, making the counter-
extension with Skey's knob in the axilla, flexed the arm and made
extension downwards and forwards ; and when well extended I moved
his body under the pulley ropes, so as to bring the arm forcibly
across the breast, and then, keeping up the extension, I had Dr.
Bichey place his knee upon the top of the scapula, and lock his fingers
around the elbow, while I placed my knee against the elbow and
locked my fingers around the top of the scapula, and directing the
extension removed, we forced the bone upwards and outwards to its
socket;" adhesions were felt to give waj, and the restoration of the
bone was found to be complete.

It will be understood that this method did not succeed until after
repeated and long-continued efforts had been made by other methods^



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672 DISLOCATIONS OF THE SHOULDER.

such as pulling down, pulling out, and pulling directly up. Dr. Cay-
kendall informs me that this is the second time he has succeeded in
" completing" the reduction of old dislocations of the shoulder by this
manoeuvre. *

These several cases are mentioned that the surgeon may understand
how impossible it is always to establish absolute and invariable rul^
of procedure which shall be applicable to every accident of this cha-
racter. The method which will succeed readily in one case may fail
completely in another, although belonging to the same class, and oot
apparently differing in its anatomical relations. Before relinquishing
the attempt, we ought to have put into requisition all the expedients
which the experience of other surgeons has shown to be worthy of a
trial.

During the year of 1865, two ancient subcoracoid dislocations came
under my observation at Bellevue Hospital. One of these cases^ in the
person of James Thompson, »t. 49, bad existed two years or more-
Be was employed about the hospital as a carpenter, and has a tolera-
bly useful arm. The second, in the person of Rosanna Casey, set. 32,
had existed six weeks when she was admitted. Various attempts had
been made to reduce the dislocation before admission. During the
week following her admission an attempt was made at reduction by
Dr. Verona, an intelligent house surgeon, subsequently by Dr. Jarn^
B. Wood, and at the end of three months the attempt was made by
myself, before the class of medical students, the patient being each
time under the influence of an ansdsthetic. She was finally discharged
with the bone still unreduced.

Mary Coffee, sdt. 46, was admitted also to the Charity Hospital, in
Feb. 1864, with the same dislocation, which had existed six months,
having been mistaken at first for a fracture. I found her arm free
from swelling or paralysis, and moving quite freely in its new socket,
and declined to make any attempt at reduction.

§ 3. Dislocation of the Humerus Backwards. (Sub^nous.)

This form of dislocation has been seldom met with. Only two
cases, according to Sir Astley Cooper, occurred in Guy's Ho^ital in
thirty-eight years ; but in the last edition of Sir Astley Cooper's
treatise on Fractures and Dislocations^ edited by Bransby Cooper, nine
cases are mentioned.* Sedillot,* Malgaigne, Desclaux,' Van Buren,*
W. Parker,* Lepelletier,* Trowbridge,^ Physick, Snyder,^ and myself,
have each seen one example. Examples have also been seen by Du-
puytren, Arnolt, Best, Levacher, Berard, Fizeau, Velpeau, Fergusson,
Kirkbride,* and by Rogers.'*

» A. Cooper, op. cit., p. 852.

« Bedillot, Amer. Joum. of Med. Sci., vol. xiii. p. 551, Feb. 1884.

» Desclaux, New York Joum. of Med., Nov. 1851, p. 109, from Revue M^dicale.

* Van Buren, ibid., Nov. 1851, p. 110.
» Parker, ibid., March, 1852, p. 186.

« Lepelletier, Amer. Joum. Med. Sci., vol. xvi. p. 526, from Arch. Gdn., Nov. 1834.
' Trowbridge, Bost. Med and Surg. Joum., vol. xxvii. p. 99.

• Gibson's Surgjery. • New York Joum. Med., March, 1852.
'0 Amer. Med. Times, November, 9.



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DISLOCATION OP THE HUMERUS BACKWARDS, 573

Causes. — One of the patients mentioned in Mr. Cooper's book had
liis shoulder dislocated backwards in an epileptic convulsion ; one had
fiallen upon his shoulder ; another met with the accident while push-
ing a person violently with the arm elevated ; and a fourth, seen by
Coley, was " pulled down by a calf which he was driving, a cord hav-
ing been tied to one of the calf's legs, and being held fast by the
man's hand." My own patient, Frederick Kretner, had his arm caught
in machinery on the 14th of January, 1860. The dislocation was dis-
covered when I was preparing to amputate the arm soon after the
accident occurred. Of the manner in which the other cases were pro-
duced no precise account is given. Desclaux's patient fell from a
height with his arm in front' of him. In the case seen by Dr. Parker,
of New York, a woman, set. 60, had fallen forwards and struck upon
the outside of her elbow, arm, and shoulder. No attempt was made
to reduce it until the fourteenth day, she not having for some time
called the attention of any surgeon to its condition. Trowbridge's
patient was thrown from a horse, striking on the palm of his hand.

Pathology, — Mr. Cooper has given us a careful account of the dis-
section in the case of Mr. Complin, already alluded to, whose arm had
been dislocated by muscular spasm. This gentleman was fifty-two
years of age, and had been subject to epileptic fits, in one of which the
shoulder was dislocated. Many attempts were made to reduce it, but
although it seemed to be easily drawn into its socket by extension
merely, yet, as soon as the force ceased, the head of the bone slipped
again upon the dorsum scapulae, and in this situation it was finally
permitted to remain until his death, which did not take place until
five years after. In the meantime he was able to move the limb but
very slightly, so that his arm was almost ufeeless.

Mr. Cooper, to whom the arm was s^nt after death, found the head
of the bone resting under the spine of the scapula, and against the
posterior edge of the glenoid fossa, where it had formed a slight de-
pression, and the head itself had become somewhat changed in form
by absorption. The tendon of the subscapularis muscle and the
internal portion of the capsular ligament were torn at the point where
the muscle was inserted, but the greater portion of the capsule re-
mained, having been pressed back by the head of the bone. The
supra-spinatus was stretched, while the infra-spinatus and teres minor
were relaxed. Thelottg head of the biceps was elongated, but not
ruptured. The glenoid fossa was rough and irregular upon its sur-
face, the cartilage being absorbed.

The fact that the bone would not remain in place when reduced,
was explained by the rupture of the subscapularis, and the consequent
loss of antagonism to the action of the infra-spinatus and teres minor.^

The accompanying drawing is a copy of that furnished by Mr.
Cooper, to illustrate the position occupied by the bone.

I ought to mention that this case has been regarded by Vidal (de
Cassis), Malgaigne, and others, as only subacromial, and as a variety
of the dislocation backwards, differing from that in which the head

* Sir Astley Cooper, op. clt., p. 854.



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574 DISLOCATIONS OF THE SHOULDER.

^S- 249. of the bone occupies a position under-

neath the spine. But as I can see no
diflerence except in the degree or ex-
tent of the displacement^ I prefer not
to regard the distinction made by these
surgeons.

Symptoms, — The signs of this accident
are, a projection under the spine of the
scapula, produced by the head of the
bone, the head being obedient to the
motions of the arm; a corresponding
depression in front and under the outer
extremity of the acromion process; a
wide space between the head of the bone
and the coracoid process, into which the
Subspinous dislocation. fiugcrs may be pushed deeply; the axis

of the shaft of the humerus directed up-
wards and outwards toward a point posterior to the glenoid fossa;
the forearm carried forwards across the chest ; the humerus rotated
inwards, unless the subscapularis muscle is torn ; immobility, but the



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 66 of 100)