Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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The motions permitt^ in the lower jaw were more extensive than
those which it enjoys in its normal condition, that is, upon the right
side the ramus could be moved very freely forwards and backwarcls,
while upon the left, the condyle underwent a species of rotation upon
its axis. During life the patient was observed to be constantly per-
forming this motion, and the right side of the face was continually
affected with spasmodic twitches. When the mouth was closed, the
front teeth of the upper jaw projected beyond those of the lower, and
when opened the deformity was in all respects greatly increased.^

1 Robert Smith, op. cit., p. 288.

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CONGENITAL DISLOCATIONS OP INFERIOR MAXILLA. 763

Mr. Smith takes this occasion also to express his dissent from the
iriews i^iaintained bj Ribes, namely, that the formation of the glenoid
cavity is consequent upon the growth of the condyle, and that, were
tbis process not formed, there would not exist either a glenoid cavity
or an articular eminence. It is true that neither the glenoid cavity
nor the articular eminence is found in the foetus. Until the seventh
month of intra-uterine life there exists at this point of the temporal
Tx>ne only a plane surface, and the glenoid cavity with its correspond-
ing eminence is developed in proportion to the growth and develop-
ment of the condyle. But Mr. Smith justly observes that although
the development of the condyle does precede that of the glenoid
cavity, "it by no means follows that the formation of the latter is due
to the pressure of the former." The cavity, or rather the transverse
eminence in front of the plane surface, does not exist in foetal life,
because, owing to the peculiar form of the inferior maxilla at this
period, its existence is not necessary. The vertical portion of the jaw
(vertical only in the adult) is in the foetus nearly in the same line with
the axis of the shaft, and consequently when the mouth is opened by
the action of the muscles, the condyles are pressed upwards and back-
wards instead of upwards and forwards, as iti the actult. A displace-
ment forwards cannot therefore very well occur ; and the protection
of the articular eminences is not required. As age advances the
angles of the jaw increase, the portions upon which the condyles rest
become more vertical, and finally a displacement forwards would occur
whenever the mouth was well opened if the articular eminences were
not present to afford a sufficient protection in front.

In the case of Lacy the foetal condition of the bones upon one side
remained during life, there being neither cavity nor eminence, and
the condyle itself being only imperfectly developed ; but the an^le of
the jaw had assumed the form which belongs to the adult, and the
ascending ramus was vertical, consequently the condyle became some-
what displaced forwards.

Chronic rheumatic arthritis is occasionally found in the temporo-
maxillary articulation of old persons; and it may be important to
distinguish it from congenital luxation, with which, owing to the ab-
sorption of the articular eminence, and the consequent displacement
of the condyle, it might possibly be confounded.

Says Mr. Smith: "In a majority of instances, this remarkable dis-
ease attacks those of advanced age, and is symmetrical ; but occasion-
ally it occurs during the period of adult life. In the latter case it is
generally more rapid in its progress, is accompanied by greater pain,
and is more liable to implicate the neck of the condyle, and the ramus
of the jaw."

When the condyle is implicated it becomes enlarged, and can be
felt beneath the zygoma, in front of the meatus externus. The lym-
phatic glands of this region are sometimes enlarged, and the progress
of the malady is attended with a constant but not generally severe
pain.

The deformity of the face varies according as one or both articula-
tions are afiected. When the malady is confined to one joint, the chin



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764 CONGENITAL DISLOCATIONS.

is thrown slightly forwards, but chiefly to the opposite side; and when
both are implicated, the chin is simply advanc^ so that the tee)h pro-
ject beyond those of the upper jaw.

As the disease progresses, the glenoid cavity enlarges by absorp-
tion, and at length a considerable portion or the whole of the articular
eminence disappears and the jaw becomes gradually displaced through
the action of the external pterygoids. The disease does not ezteod
in the temporal bone beyond the articulating surface of the glenoid
cavity. The condyle assumes a variety of forms, sometimes being
greatly enlarged in all its diameters, wnile its upper surface may be
flattened, or conical. The inter-articular cartilage disappears; but
Mr. Smith has never yet found any foreign bodies in the joint, and in
only one instance have the surfaces been polished or ebumated as we
often see in examples of chronic rheumatic arthritis occurring in the
hip, knee, and other joints.

The following is an excellent summary of the diagnostic marks
between congenital, accidental, and rheumatic dislocations, given by
this writer : —

"1. In the congenital luxation, the mouth can be freely opened and
closed ; in chronic rheumatism these motions can be performed, bat
not without uneasiness to the patient, an uneasiness which sometimes
amounts to severe pain ; in luxations from accident, the mouth cannot
be closed.

'' 2. An involuntary flow of saliva accompanies the accidental luxa-
tion alone, although m some cases of chronic rheumatism there is an
increased secretion of that fluid.

" 8. In congenital luxation, the teeth of the upper jaw project be-
yond those of the lower ; the reverse is observed in accidental luxa-
tion and in chronic rheumatism.

" 4. In congenital luxation there is no fulness in the cheek, such as
the coronoid process produces in cases of accidental luxation, and the
condyle is not enlarged, as in some instances of chronic rheumatic
arthritis."*

§ 4. CoNGKNrrAL Dislocations of the Spins.

Says Gu^rin,«of the subluxation occipito-atloidean there are two
varieties : " First. Backwards, consisting in an exaggerated flexion of
^ the head upon the front of the neck and chest, with a commencement
of sliding backwards of the occipital condyles upon the articular
facets of the atlas. Here are two examples in foetal enenc^phaloos
monsters. Second. Forwards Those who follow my consultations
can recollect having seen last year an infant, about two or three
months old, who offered a remarkable example. The head was ex-
actly applied against the posterior part of the neck, and upper part
of the back. There was probably a sliding of the condyles forwards,
with elongation of the anterior ligaments.'"
The existence of the first of these varieties has since been denied

> B. Smith, op. cit., p. 392. < Gu^rin, op. dt., 1S41, p. 80.

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CONGENITAli DISLOCATIONS. OP THE STEBNUM, 765

"by Gu^rin himself;^ and it will be noticed that he only speaks of the
second as & probable sabluxation forwards. Neither of them can there-
fore be regarded as established.

Gu^rin further remarks that he has observed subluxations in the
other regions of the spinal column many times : and he showed to the
-Academy a foetus in which the spine presented, besides the occipito-
atloidean displacement, a series of angular flexions in the antero-pos-
terior direction, with sliding of the articular surfaces.

In attempting to appreciate the value of Gu^rin's observations upon
tbis point, it must be remembered that he regards all cases of congeni-
tal torticollis, and other deviations of the spine, as examples of sub-
luxation ; and, in some sense, we think the theory of this distinguished
surgeon may be regarded as correct. The amount of articular dis-
placement between each of the adjacent vertebrae may be very incon-
siderable in any such case, yet^ however trivial, if it exceeds the limits
of natural motion, it may properly enough be regarded as the com-
mencement of a luxation.

§ 6. Congenital Dislocations of the Pelvic Bones.

Bassius speaks of a diastasis or separation of the sacro-iliac sym-
physis, observed by him in newly-born children, and in infants ; but,
according to Malgaigne, his account of these cases is not such as to
warrant any conclusions as to the true nature of the displacements.

Congenital exstrophy of the bladder is accompanied always with a
deficiency of the central and upper portions of the pubic bones, the
result manifestly of an arrest of development; but these cases, of
which I have seen several examples, are not properly examples, of
congenital dislocations, but only of diastases, the separated portions re-
maining in their normal position with reference to each other, except
that they are not prolonged sufficiently to meet in the median line.

Gu^rin declares, however, that he has seen congenital displacement,
or overriding of the iliac bone upon the sacrum, accompanied with
coxo-femoral dislocation and curvature of the spine. The same writer
mentions an example, in a foetal monster, of diastasis of the pubic
bones, and of the sacro-iliac symphysis, accompanied with a turning
out of the pubes upon the external face of the ischium.'

§ 6. Congenital Dislocations or the Sternum.

Seger alone has reported one example of luxation of the xiphoid
cartilage from the sternum.

A woman in her fifth month of pregnancy fell and dislocated her
shoulder. Just four months after this she was brought to bed with
an infant, well formed, except that^ soon after it was born, the ensiform
cartilage was observed to be remarkably movable, especially when the
child hiccoughed, to which it was very subject. The cartilage was
separated from the sternum by the breadth of the little finger. No

» Ibid., op. cit., p. 82. « Ibid., Gaz. Med., 1851, p. 227.



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766 CONGENITAL DISLOCATIONS.

treatment was employed ; the cartilage gradually became restored to
its place, and in aoout one year it was firmly united to the steraom.^

f *l. OONOKIflTAL DiSLOOATIOHS 09 THX ClAVICLK.

Malgaigne says that a congenital dislocation at the stemo-claYiool&r
articulation has never been observed; but Ou^rin declares that he has
established the existence of three varieties, namely : —

1. A luxation of the sternal end of the clavicle inwards and for-
wards; this extremity of the clavicle lying in front of the stenud
fourchette. In illustration of which he presented to the Academy a
plaster cast of a girl eight years old, in whom the displacement existed
upon both sides.

2. Inwards and upwards. Observed by him in a girl eight years
old; but which displacement took place only when the arm was
moved, and through the contraction of the stemo-cleido-mastoideas
muscle.

8. Backwards. Of which he presented two examples in the cor-
responding sides of a foetal monster.

I believe I have already referred to Fer^usson's case of dislocatioQ
of the sternal end of the clavicle forwards^ which occurred daring
birth. The end rested in front of the sternum, and could be poshed
into its place with ffreat ease; but when left alone it immediately
slipped out again. Nothing was done, a new joint formed, aod the
child afterwards possessed as much power in the one arm as in the
other."

Gu^rin says that he has seen a dislocation upwards and outwards at
the acromial end of the clavicle in a foetus of three months.

In regard to the treatment of either of these displacements of the
clavicle, we need only remark that a reduction ought to be attempted;
and, if practicable, without much confinement of the little patient, it
should be maintained until the bones have become fixed in their
natural positions. It is quite probable that this can never be accom-
plished, at least perfectly ; but it will nevertheless be proper always
to make the attempt.

§ 8. CoNGiNiTAL Dislocations of thb Shouldib. (Upper End of the

Humerus.)

Gu^rin affirms that he has established the existence of three varie-
ties of scapulo-humeral dislocations, namely : —

1. Dislocations of the head of the humerus downwards; of which
variety he presented to the Academy a plaster cast taken from a boy
ten years old. The displacement existed in both arms, but much
more pronounced in the qght than in the left arm. It was due wholly
to paralysis of the muscles about the joint, and to elongation of the
capsule.

> Seger, Ephem. Nat. Gnrios., 1677, from Malg., op. cit., p. 410.
' Fergnsson, System of Sorg., 4tli Amer. ed., 1858, p. 208.



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CONGENITAL DISLOCATIONS .OF THE SHOULDEB. 767

2. Downwards and inwards ; complete upon one side and incom-
plete npon the other, in the same person. The head of each humerus
vras applied against the ribs, and the arms maintained in an abduc-
tion almost horizontal, under the influence of the retraction of the
deltoid muscles. " The same case," Gu^rin remarks, " has been con-
firmed by Roux."

8. Subluxation upwards and outwards: seen on both sides in a
foetal monster, which was offered to the Academy for examination ;
and in one arm of a young man fifteen years old, of which Gru^rin
presented a plaster cast. " It is characterized by a sliding of the head
of the humerus in the direction indicated ; this sliding being favored
by a corresponding displacement of the coracoid and acromion pro-



Malgaigne, who regards " all luxations in consequence of paralysis
as essentially posterior to birth," will not admit the first example
mentioned by Gu^rin ; but» as we stated before, the objections made
by Malgaigne have failed to convince us of the propriety of rejecting
all of this class of reported examples. Of the second case, mentioned
by Gudrin as having been confirmed by Boux, Malgaigne declares
that he has consulted Boux upon this matter, and that he affirms that
" he has never seen a congenital luxation of the shoulder."

Robert Smith has met with but two of the forms of congenital
luxation of the humerus described by Gti^rin, namely, that in which
the head of the humerus is displaced forwards, and that in "which it
is displaced backwards. Of the first variety he has seen several ex-
amples.

The first was in the person of Alexander Steele, »t. 29, who pre-
sented both a dislocation of the head of the humerus under the cora-
coid process of the left scapula, and pes equinus in the foot of the left
leg. The muscles of the arm and shoulder upon that side were feeble
and greatly atrophied. The humerus was shortened ; its head being
of the natural size and form, but when the arm hung by the side it
dropped so far from its socket as to permit the thumb to be placed
between the head and the acromion process. By pressing the hume-
rus forwards the finger could be placed in the outer part of the glenoid
cavity ; and, although the head could be moved about thus freely, it
seemed naturally to occupy only the anterior half of the glenoid
fossa.

Bobert Smith's second example of subcoraooid congenital luxation
was presented in the person of Mr. H., set. 20, the condition of whose
left shoulder resembled almost precisely that of Mr. Steele. " The
deformity had existed from his birth, but became much more obvious
and striking as he increased in age and stature."

In the third example the child bad attained nearly the age of one
year before the condition of the limb attracted attention, which was
then excited, not by the deformity of the shoulder, but by the atro-
phied condition of the muscles of the arm. The child had never
complained of pain about the joints nor had he ever met with any ac-



Gu6rin, op. clt., p. SO.



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768 CONGENITAL DISLOCATIONS.

oident. No doubt this also was an example of paralysis, and it is not
improbable that it was congenital, but the evidence upon this point is
not very conclusive. When seen by Mr. Smith, he was nine years
old, the shoulder and arm presenting the same appearance as in the
other cases mentioned.

The fourth was also subcoracoid and symmetrical, the same defor-
mity existing in both shoulders. This was in the person of a female,
»t. 21, who had been for many years a patient in a lunatic asylum,
and who died of chronic inflammation of the meninges of the brain.

Mr. Smith, who himself made the autopsy, first noticed the condi-
tion of the left shoulder. The muscles were atrophied; the head of
the humerus could be felt lying under the coraooid process ; the elbow
projected from the side, but could be readily brought into contact
with it. The right shoulder presented the same appearance, but the
deformity was somewhat less, and the head of the humerus was not
so directly underneath the coracoid process.

From the external appearances presented by the two shoulders, Mr.
Smith did not doubt that these deviations from the natural state of
the parts were not the result of violence.

Proceeding to remove the soft parts upon the lefl side, scarcely any
trace was found of a glenoid cavity in its natural situation, but im-
mediately underneath the coracoid process, upon the costal sur&ce of
the scapula, was formed an oblong socket completely surroanded by
a capsular ligament, which ligament included also that small portion
of the original socket which remained. The head of the humerus
was changed in form, being oval, and fitted, in some measure, to both
the old and new sockets, upon which it seemed to rest alternately.

Upon the right side, although the condition of the bones was some-
what difierenty the characteristic features of the deformity were similar.

Malgaigne, who quotes Mr. Smith as saying that these dislocations
must have been congenital, and for no other reason than because they
were symmetrical, has scarcely done this author justice. Says Mr.
Smith : '' The position of the glenoid cavity, the remarkable n>rm of
the head of the humerus, the presence of a perfect glenoid ligament,
the absence of any trace of disease, and the existence of the defor-
mity upon each side, all indicate the original nature of the malforma-
tion."

The only example of backward luxation seen by Mr. Smith was
also symmetrical, and seems to be equally well authenticated. This
was in the person of a woman named Doyle, nt. 42, a lunatic also,
who died Feb. 8, 1889, in Dublin. She had been a patient in the
lunatic asylum fifteen years, and was subject to severe epileptic con-
vulsions, which ultimately proved fatal.

Mr. Smith made the autopsy on the day following her death. The
convolutions of the brain were small and atrophica, as is frequently
observed in idiots.

The two shoulders resembled each other so perfectly, both in ex-
ternal appearance and in their anatomy, that Mr. Smith has only
found it necessary to describe particularly the condition of one.

The coracoid process was remarkably prominent^ but the acromion



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CONGENITAL DISLOCATIONS OP THE SHOULDEB. 769

"w^is not ao prominent as in accidental dislocations of the shoulder.

The head of the humerus could be seen and felt distinctly moviug

inrith the shafts upon the dorsal surface of the scapula. On removing

the integuments, muscles, &c., no trace of a glenoid cavity was found

in its natural situation ; but upon the external surface of the neck of

the scapula was a well-formed socket, which received the head of the

humerus. This socket was covered with a cartilage of incrustation,

and surrounded by a perfect capsule. The tendon of the biceps arose

from the top and internal margin of the socket. The form of the

acromion process was changed ; the capsule smaller than natural ; the

head of the humerus irregularly oval, its anterior half alone being

in contact with the glenoid cavity ; the great tubercle natural, but the

lesser was elongated and curved, forming a process of an inch in

length, around the base of which the tendon of the biceps muscles

played.^

Gaillard relates the case of a female child, upon whom the left arm
was discovered to be deformed a few days after birth, and the elbow
separated from the side. Later, the arm was found to be nearly im-
movable, and only at the end of four years was the dislocation recog-
nized ; but no attempt at reduction was then made. When sixteen
years old, she was seen by Graillard, who found the head of the hume-
rus in the infra-spinous fossa. The scapula, clavicle, and arm were
preternaturally small ; the forearm, although well developed, could
not be completely extended nor supinated.

Despite these unfavorable circumstances, Gaillard determined to
make an attempt to accomplish the reduction. Four times in the space
of eight days he submittea the arms to extension made at right angles
with the body, by means of sixteen-pound weights, the extension being
continued from twenty to twenty-five minutes, and occasionally his
own exertions being added to the weights. On the fourth attempt,
the head of the bone was drawn gradually forwards, and by a rotatory
motion it was finally made to slip into its socket ; but it became im-
mediately displaced. The next day Gaillard reduced it anew, and
retained it in place one hour. Six days later it was again reduced,
and, by the aid of bandages, permanently retained in place. The
slight |ain and swelling which followed soon disappeared ; and by the
aid of careful exercise, at the end of two years the arm had increased
in leng||bh, and the patient could use the arm and hand so much better
than before, as to encourage a hope that the recovery would be com-
plete.*

Aristide Rodrigue, of Hollidaysburg, Penn^ in a letter to the editor
of the American Journal of Medical Sciences, gives the following brief
account of a case of intra-uterine dislocation of the shoulder, compli-
cated with a fracture of the forearm.

"The woman, when about four months gone with child, fell on her
left side, striking a board, and felt herself much hurt at the time : at
the full period she was delivered of a full-grown large boy with the

1 Robert Smith, op. cit.
11. a<



< Gaillard, M6m. de TAcad. de. M6d., 1841, from Malg.,^. 569.



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770 CONGENITAL DISLOCATIONS,

folio wing deformity : dislocation of the hameros into the axilla ; frac-
ture of both bones of the forearm of left side, lower third. Dislocation
could not be reduced; union of the bqnes of the ibrearm by oasific
matter complete ; bones passing each other, and hand at an angle of
about 40°; the child did well otherwise; now, four years old, strong
and healthy ; humerus has grown nearly apace with the other; forearm
has not, and remains short and deformed as in birth ; the hand is of
the same size with that of the sound side."^

§ 9. CONQXNITAL DiSLOOATIOKS OF THE RADIUS AND UlNA BACKWARDS.

It is not uncommon to meet with examples of a slight subloxation
backwards of these bones in feeble and newly -bom infants; which
condition is probably due to a relaxation and elongation of the cap-
sule. It is characterized by a preternatural mobility of the joints and
especially by the circumstance that the limb is capable of abnormal
extension, or flexion backwards, as it is sometimes called. Gu^rin has
seen this condition more advanced, the bones of the forearm having
actually overlapped somewhat upon the lower end of the humems, so
that the articular surface of this latter presented itself in the fold of
the elbow. This was especially observed in a girl of fourteen and a
boy of thirteen years, and also in the two sixms of a foetal monster.'

Chaussier relates that a young woman, at the commencement of the
ninth month of pregnancy, perceived suddenly movements of the foetus
so violent that she almost lost her consciousness. These movements
were repeated three times in the space of six minutes, after which
everything returned to its natural order, and the accouchement took
place naturally and at the usual term. The infant was pale and feeble,
and presented a complete backward luxation of the radios and ulna.'

§ 10. CONGSNITAL DISLOCATIONS OF THB HeAD OF THE IUDnJ&

Examples of this luxation have been reported by Dupuytren, Cru-
veilhier, Sandiforte, Adams, Dubois, Verneuil, Deville, Robert Smith,
and Gu^rin, most of which were in the direction backwards, some
outwards, but only one of them forwards; some were double, the same
deformity being presented in both arms, and others were single. In
a few examples the dislocations were complicated with a consolidation
of the radius to the ulna, and in others with a deficiency of the nlna
or with some deformity indicating its congenital origin. .

Of the symmetrical or double dislocation backwards Dupuytren



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 89 of 100)