The Treatment of Old Dislocations of the Shoulder

1897 Boston Medical and Surgical Journal  
Tine number of old dislocations of the shoulder which present themselves for treatment at surgical clinics is fortunately becoming Bmaller from year to year. Thanks to the wide publication of the work of Kocher and others on receut dislocatious and their reduction, by far the greater number of dislocations are reduced as soon as seeu by the surgeon or general practitioner. Notwithstanding this fact, however, a certain number of patients with old dislocations present themselves at the clinics,
more » ... s at the clinics, some of whom have never previously consulted a surgeon, aud a few who have been unfortunate in their choice of a surgical adviser. By the personal observation of a few of those, which 1 have been kindly allowed to examine by members of the visiting staff at the Bostou City Hospital, and by personal experience of some of the difficulties of their reduction, I was led to look up the question of their treatmeut, and see what light, if any, could be thrown upon it by an examination of the literature of the subject and of the hospital records. The result, though not entirely satisfactory, owing perhaps to the small experience iu these cases which comes to any one man, and the resulting meagreness of the literature of the subject, has nevertheless been that certain interesting and important points with reference to the treatment of these injuries have beeu brought out. In the first place, as is well known, the diliiculty of reducing dislocations of the shoulder after the lapse of a very short period, say two weeks, increases directly in proportion to the interval of time. Dislocations of less than two weeks' duration are almost as easy to reduce as fresh dislocations ; and since Kocher has shown that all fresh, uncomplicated dislocations are reducible by manipulative methods, all dislocations two weeks or less old are capable of reduction by methods of manipulation. The same anatomical characteristics which render the shoulder-joint the moat liable to dislocation of any joint in tin-body iu themselves facilitate reduction. It is comparatively easy for the large globular head of the humérus to slip out of the shallow cup of the glenoid cavity, if the necessary rupture of the capsule is present, and the rupture of the capsule made by the head of the humérus is always big enough to let the head slip back, if it is properly opened by Kocher's, or other methods of manipulation. The free play of the head of the bone under the arch of the acromiou, the comparative looseness of the capsule, all reuder dislocation and reduction comparatively easy. The tendons of most of the muscles about the joiut are short, aud so intimately blended with the capsule as not to afford obstacles to reduction by .slipping iu between the head of the boue and the socket. Even the long tendon of the biceps, which at first thought oue would suppose most likely to fall in between the head and the socket, so as to prevent reduction, is held up out of the way by its special fibrous channel in the capsule of the joint, from which, in the ordinary subcoracoid dislocation, it is never displaced. The manipulative methods for reduction of the shoulder-joint, especially the simple, beautiful and efficient method devised by Kocher, of Berne, are too well known to ueed discussion here. Suffice it to say that Kocher'8 method is to be preferred iu all fresh dislocations, as being the simplest, and easiest, as requiring no direct pressure on the axillary vessels and nerves, and as being successful in a large proportion of cases without auestheBia. Dislocations of tho shoulder a week or less old, then, should be reduced in all cases, preferably by Kocher's method. After the head of -the humérus has been out under the coracoid process for two weeks or more, however, difficulties in the way of reduction begin to present themselves. The uiiruptured posterior portion of the capsule, which has been tightly stretched across the glenoid cavity, has become in old cases rather firmly adherent to that cavity. Tho head of the humérus has become adherent as it lies nipped between the biceps and coraco-brachialis muscles and the neck of the scapula. The posterior rotators of the humérus, the supra-spiiiatua, infra-spinatus and teres minor muscles, have become so paralyzed by continued stretching as to no longer afford efficient aid to the surgeon in ¡lulling the head of the bone back into place. In order to successfully reduce the dislocation, the head of the humérus must be freed from the adhesions which bind it into its new position, the adherent capsule must be peeled off from the surface of the glenoid cavity, aud the head of the humérus forced back under the acromion, lifting the adherent capsule and the tendons of the posterior rotators out of the way. After a still longer time, say two or three months, has elapsed, the neck of the humérus has become fixed under the coracoid by firm fibrous adhesions, the capsule haB become so firmly bound down to the glenoid cup as to actually form a part of it, and the atrophy of the deltoid and posterior scapular muscles bear witness to the fact that even if the dislocation should be reduced, these muscles would require a long course of training in order to recover strength enough to hold the head of the humérus up in place in its socket. The important part, played by these muscles in holding the head of the bone in place is shown by the subluxation of the head of the bone which takes place when they have become paralyzed. In paralysis of the deltoid and scapular group without dislocation we have seen the head of the humérus fall downward and forward out of its socket, within the loose capsule of course, to such an extent that the head got over the anterior edge of the glenoid, the arm was lengthened nearly an inch, and this, together with the flattened deltoid, gave a typical picture of a dislocation. By grasping the humérus, however, the head of the bone could be easily lifted into position, but the paralyzed muscle could not hold it. Now with regard to this adhesion of the posterior portion of the capsule to the glenoid cup. The capsule, of course, is more or less thickened by the inflammatory processes, aud fills up the cavity, adhering over its broad surface, bo that it cannot be stripped off. It is in this class of cases that we read in the records, that the head was almost reduced, but could uot quite be made to get into perfect position, that it remained just ou the edge of the glenoid; that although something had beeu gained, reduction could not be considered quite satisfactory. What has hap-
doi:10.1056/nejm189704291361701 fatcat:w3n6jsa7uve5leoupvuqlr6trm