upon it. But I doubt the correctness of this, as the skin wound was not more than two inches long, and beneath it my little finger would just enter, and no room to spare. He complains of a little pain opposite the middle of the second piece of the breast-bone; but he has not any other pain in his chest, and no fracture can be discovered. He seems to breathe easily, although he complains of difficulty of breathing, accompanied with great desire to cough, and a sensation of pressure on the windpipe, which is much increased on raising the skin of the neck when he throws his head back. The shoulder having been brought back with straps attached to a back-board, the bone readily resumed its place. The elbow was brought forward and bound to the side. The wound was dressed with sticking plaster, and he was put to bed with the shoulders much raised. He went on without the least unfavourable symptom; in three weeks left his bed, and three weeks after went out of the house. The sternal end of the collar-bone still fell a little backwards, and was a little more movable than natural. He was warned not to use his arm violently. In September, 1839, VELPEAU (a) had under his care a case of simple dislocation of the sternal end of the collar-bone inwards and backwards. The man had been violently squeezed between the wall and a cart, "in such a manner as to thrust the left shoulder forcibly inwards, and break up the ligaments which connected the clavicle of the same side to the first bone of the sternum; in this way the sternal end of the left clavicle lay upon the superior edge of the sternum, behind the sternal attachment of the sternomastoid muscle. The articulating surface of the bone lay close to the junction of the sternum with the clavicle of the opposite side. VELPEAU considered that in the first instance the force producing the dislocation had operated, so as to displace the sternal extremity of the clavicle upwards and backwards, inasmuch as the bone lay behind the sternal portion of the sterno-mastoid muscle, and that it was after this had been effected, that the displacement inwards and across the upper part of the sternum occurred. He considered this was the first instance of this kind of displacement of the sternal extremity of the clavicle which had been observed; in which opinion, however, he was wrong, as the case just mentioned proves.-J. F. S.] 1024. The reduction of the dislocated sternal end of the collar-bone is easy; with one hand the elbow is fixed, and with the other placed on the upper part of the humerus, the shoulder is drawn outwards and backwards, as in treating fracture of the collar-bone (par. 639.) In dislocation forwards, the shoulder should be pressed forwards, in that backwards, backwards, and in the upward dislocation upwards, so as to prevent the slipping out again of the end of the bone; and the arm is to be kept in proper position with the apparatus already mentioned for fractured collarbone. According as this apparatus is more or less relaxed, there commonly remains greater or less deformity at the sternal end of the bone, which, however, has no effect upon the motions of the arm. MELIER'S apparatus, in dislocation of the collar-bone forwards, in which a compress similar to a truss, and pressing on the projecting end of the bone, is connected with DESAULT'S apparatus (b). [It will not be out of place to mention here, the operation performed by DAVIE, of Bungay, on the case of backwardly dislocated sternal end of the collar-bone referred to by ASTLEY COOPER, in which the bone pressed so upon the esophagus as to occasion extreme difficulty in swallowing. "An incision was made of from two to three inches in extent on the sternal extremity of the clavicle, in a line with the axis of that bone; and its surrounding ligamentous connexions, as far as he could reach them, were divided with the saw of SCULTETUS (often called HEY'S); he then sawed through the end of the bone, one inch from its articular surface from the sternum, and fearful of doing unnecessary injury with the saw, he introduced a piece of well-beaten sole-leather under the bone whilst he divided it. When the sawing was completed he tried to detach the bone, but it still remained connected by its interclavicular ligament, and he was obliged to tear through that ligament by using the handle of the knife as an elevator, and after some time succeeded in removing the portion of bone which he had separated." The case did well (c).] ccxxvii. Lancet, 1839-40, vol. i. p. 422. 1025. The scapular end of the collar-bone can only be dislocated upwards, (extremely seldom downwards beneath the acromion,) and the separation of the two articular surfaces is not great. The cause is generally a severe fall upon the shoulder, by which it is violently turned backwards. The signs of this dislocation are pain on the top of the shoulder, depression of the shoulder, a great space between the acromion and scapular end of the collar-bone, or a projection of the latter; unaccustomed motion of these two parts, impeded motion of the arm, especially in elevation, diminished distance of the shoulder from the chest, disappearance of the prominence when the shoulders are drawn backwards, but which reappears when it is let go; and if the finger be carried forward upon the spine of the blade-bone it is stopped by the projecting end of the collarbone. It has been hitherto assumed that the acromial end of the collar-bone can only be dislocated upwards; at least, experience knew no other kind. TOURNEL (a), however, saw a case in which the weight of a horse, in a sudden fall, caused separation and driving back of the blade-bone, the collar-bone still remaining fixed at its sternal end, but its outer end, from which the inferior and coraco-clavicular ligaments were torn, was separated from both articular surfaces, and slipped beneath the acromion. The pivot motions of the arm could be made in the usual directions; the left arm was somewhat longer than the right, the elbow and upper part of the arm lay against the side of the trunk; the voluntary motions, especially those upwards, were impossible, the patient could not bring his hand to his head; the communicated motions were free and painless; the shoulder had lost its rounded form, and below the acromion externally was a deep hollow. The shoulder had also two prominences, an internal and upper, formed by the acromion, and an external under by the lower end of the collar-bone. Neither numbness of the fingers nor pain were present; the point of the left shoulder was much nearer the breast-bone than the right; when the finger was carried along the spine of the blade-bone from behind forwards to the acromion it was stopped by the projection of the collar bone. This was perfectly discernible, and disappeared, as well also as the hollow beneath the acromion, when the shoulders were drawn back, the knee being placed between them; but so soon as this was left off, the projection formed by the end of the collar-bones and the depression beneath the acromion reappeared. With DESAULT'S apparatus, and subsequently with that of FLAMMANT, a cure was effected without deformity, and without restriction of the motions of the arm. MElle (b) examined after death, and described such a dislocation of the outer end of the collarbone downwards. 1026. This dislocation is always easily reduced; the arm is to be raised up against the collar-bone, the scapular end of which is to be depressed. DESAULT'S apparatus for fractured collar-bone is applicable, with the alteration of putting a thick compress upon the scapular end of the collar-bone, and the turns of the bandage which are carried over the injured shoulder and the elbow, to be sufficiently tightened, and further, the arm to be also fixed to the breast with a bandage. The first days the injured parts are to be moistened with cold dispersing applications. As often as the bandage becomes loose it must be tightened. In from four to six weeks it may be removed; most commonly there remains greater or less displacement, which, however, does not interfere with the motions of the shoulder. [The dislocation of the collar-bone upon the spine of the blade-bone is one of the most tiresome accidents we have to do with; at least in all the cases I have had to deal with, and the injury is not unfrequent, I have never been able by any contrivance to keep it in place, and have therefore given up attempting to keep it reduced, and only endeavour to keep it at rest, so that it may form new connexions on the scapular spine.-J. F. S.] (a) Archives générales de Médecine, 1837, De cember. (b) Nova Acta physico-medica, 1773, vol. v. P. 1. VI.-OF DISLOCATION OF THE UPPER-ARM. (Luxatio Humeri, Lat. ; Verrenkung des Oberarmes, Germ.; Luxation du Bras, Fr.) BONN, Abhandlung von Verrenkungen des Oberarmes. Leipzig, 1783. DESAULT, above cited. WARNECKE, Abhandlung über die Verrenkung des Oberarmes aus dem Schultergelenke und deren Heilart. Nurenberg, 1810; with plates. BOYER, above cited, p. 174. MOTHE, Mélanges de Chirurgie et de Médecine. Paris, 1812. BUSCH, Dissert. de Luxatione Humeri. Berlin. 1817. DUPUYTREN, De la différence dans le Diagnostic des Luxations et des Fractures de l'extrémité supérieure de l'Humerus; in Répertoire Général d'Anatomie et de Physiologie Pathologique, vol. vi. part iii. p. 165. MALGAIGNE, Luxations de l'Articulation Scapulo-humérale; in Journal des Progrès des Sciences et des Institutions Médicales, vol. iii. Paris, 1830. COOPER, ASTLEY, above cited, p. 415. CRAMPTON, PHILIP, M.D., On the Pathology of Dislocation of the Shoulder-Joint; in Dublin Journal of Medical and Chemical Science, vol. iii. p. 42. 1833. 1027. The free motions of the shoulder, the great misproportion between the size of the head of the upper-arm-bone and the flattened hollow of the joint-surface of the blade-bone, the slight strength of the capsule of the joint, and the frequent operation of external violence upon the shoulder-joint, render the dislocation of the upper-arm more frequent than that of any other bone. 1028. The head of the upper-arm-bone may be displaced in three different directions: 1, Upwards (and inwards); the head of the bone rests on the front edge of the blade-bone, between the insides of the long heads of the m. triceps and the m. subscapularis. 2, Inwards; the head of the bone recedes between the subscapular pit and the muscle of the same name, beneath the m. pectoralis major. 3, Outwards; between the infra-spinate pit and muscle. [This is the dislocation backwards of English Surgeons.-J. F. S.] The dislocation downwards is the most common, that inwards more rare, and that outwards the rarest. The dislocation upwards is impossible, partly on account of the acromial process, and the firmness of the joints especially, partly because the upper-arm cannot, on account of the trunk, be driven inwards as much as necessary in order to dislocate it upwards. ASTLEY COOPER (a) speaks of a fourth partial dislocation, when the front of the capsular ligament is torn, frequently only stretched, and the head rests against and on the outer side of the coracoid process of the blade-bone (b). 1029. If the head of the upper-arm-bone be dislocated downwards, it may be drawn inwards by the contraction of the muscles, (but the m. triceps extensor prevents it being pulled outwards,) and thence gradually upwards towards the collar-bone. In the dislocation outwards such consecutive displacement towards the spine of the blade-bone is not possible. In dislocation of the upper-arm-bone, there may be therefore a fourfold varying position of the head of the bone: 1, downwards; 2, outwards, always primitive; 3, inwards, frequently primitive, usually consecutive, and, 4, inwards and upwards, constantly as consecutive dislocation. A. COOPER, (a) Above cited, p. 446. (b) DUPUYTREN, Leçons Orales, vol iii. p. 105. -HARGRAVE, W.; in Edinburgh Medical and however, does not think that the head is dislocated consecutively, when the muscles have once contracted and no great violence operates. Less change of position may originate in the absorption arising from pressure. Opinions vary in reference to the primitive direction of dislocation of the upper arm. Many (HIPPOCRATES, DUVERNEY, FABRICIUS AB AQUAPENDENTE, DESAULT, MURSINNA, RICHERAND, MOTHE, and others) admit only the dislocation downwards as primitive, and that inwards and outwards as secondary. Others (VELPEAU, MALGAIGNE) determine only two primitive dislocations, namely forwards and inwards, and backwards and outwards. 1030. The several kinds of dislocation of the upper-arm are charactererized by the following symptoms: In dislocation downwards, the arm is rather longer, can be moved only a little outwards, and motion in any other direction causes severe pain; in old persons, however, the laxity of the muscles often permits more extensive motion; the elbow stands out from the trunk; the patient inclines himself towards the side of the dislocation, holds the arm half-bent, and supports his elbow on his hip. Beneath the acromion, which seems more prominent, a hollow is observed, the joint has lost its roundness, the middle line of the arm is directed towards the arm-pit in which is felt a globular protuberance, formed by the displaced head of the bone, only however when the arm is separated from the trunk. A kind of crackling is frequently noticed on motion, depending on the exuded matter, or on the effusion of synovia, which disappears on continuance of motion, and is never so great as in fracture. The pressure of the head of the bone upon the axillary plexus often causes loss of sensation, and the sensation of being asleep in the fingers. In dislocation inwards, the elbow stands out from the trunk, and is inclined a little backwards; the direction of the arm corresponds to the middle of the collar-bone, the movement of the arm backwards is not very painful, but forwards extremely so. Beneath the great pectoral muscle is felt the protuberance of the head; the arm has either its natural length or is rather shorter; the flattening of the shoulder is observed especially at its hinder part; the fore-arm is not half bent. In dislocation outwards, the arm is inclined inwards and forwards, the flattening of the shoulder is most distinct in front; the head of the bone forms a prominence in the infra-spinate pit; the arm may be moved forwards with the least pain, but every other movement is in the highest degree painful. In imperfect dislocation, where the head is inclined forwards against the coracoid process, a hollow is observed opposite the back of the shoulder-joint and the hinder half of the glenoid cavity is perceptible; the axis of the arm is inwards and forwards; the under motions of the limb may be completely performed, but the arm cannot be raised, because the upper-arm is thrust against the coracoid process of the blade-bone; the head forms a distinct protuberance, and if the arm be rotated, the rolling motion of the head is felt. It is very difficult, and generally impossible, in dislocation of the upper arm, to determine whether the dislocation of the head of the bone inwards, be primary or consecu tive; but inquiry as to how the symptoms have followed each other, and even the treatment in setting, may perhaps afford some clue. 1031. Dislocations of the upper-arm are produced by violence, which strikes the arm, and happens only on that particular direction of the arm, at the moment when the violence acts, according to which side the head of the bone is driven against the capsule and dislocated. In the occurrence of dislocation downwards, the contraction of the m. pectoralis major, latissimus dorsi and teres major especially participate. It, however, particularly depends on the m. deltoides, as shown by examples when this dislocation has happened in raising a heavy load. The destruction of the soft parts in dislocation of the upper-arm, is for the most part restricted to the tearing of the capsular ligament to a tolerable extent and the bruising of the neighbouring parts. In dislocation inwards, however, a tearing of the m. subscapularis has been observed; as also oftentimes palsy of the arm, oedematous swelling of it; or a palsy of the deltoid muscle is connected with, or subsequently ensues on dislocation. Fracture of the neck of the upper-arm-bone has also been noticed simultaneously with this dislocation. 1032. The inflammatory symptoms which occur in dislocation of the upper-arm, are usually of little consequence, if reduction be soon effected; but if the dislocation be left alone, considerable interference with the movements of the arm occurs; the dislocated head is kept fixed in its position, the motions of the arm depend only upon the mobility of the blade-bone, and often after from four to eight weeks, reduction is no longer possible, even with the greatest efforts. 1033. In reducing dislocation of the upper-arm, the shoulder must be well fixed, the arm extended to a proper degree, and its head brought back in the same way in which it was dislocated. The patient should sit on a common seat, (in difficult cases it is advantageous to lay him horizontally on a couch,) a folded cloth is to be applied above the wrist, its two ends tied and given to an assistant. An oblong, tolerably thick bolster should be put into the arm-pit, projecting beyond the edges of the great muscles of the breast and back, and over it a folded cloth, the ends of which are to be carried over the front and back of the chest, to the sound shoulder, there tied, and given to an assistant. For the more complete fixing of the shoulder-blade, a second cloth is applied, with its middle on the acromion, its ends carried obliquely forwards and backwards, towards the other side of the chest, and given to an assistant, who draws them properly in this direction towards him. Or the shoulder is fixed by a proper bandage, (retractor,) through the opening of which the arm is passed (a). The Surgeon stands on the outside of the limb, and directs the assistants as to the direction and commencement of the extension. In the dislocation downwards, extension must be made directly outwards, and when carried to a proper extent, the arm must be pulled downwards, and somewhat forwards till it be applied to the side of the body, when the Surgeon rests his body against the elbow, and with both his hands applied, the one on the upper, and the other on the under surface of the upper arm, carries the head back into the socket. In dislocation inwards the extension must be made outwards and backwards, the arm brought forwards and downwards, till it lie obliquely across the front of the breast, and the Surgeon then assists the return of the head of the bone, by placing one hand upon the elbow and the other on the inside of the arm, and pressing the head outwards. The dislocation outwards requires extension in the opposite direction to the preceding (a). (a) Proper retractors are described by PITSCHEL (Anatom. und chirurg. Anmerkungen. Dresden, 1784, p. 66); by MENNEL (LODER'S Journal, vol. iii. p. 300); by ECKOLDT (KÖRLER'S Anleitung zum Verbande. Leipz, 1796, p. 299. Pl. viii. fig. 8, 9); by SCHNEIDER (LODER's Journal, vol. ii. p. 466); and by ASTLEY COOPER. |