Manual of Surgery Volume II Part 5

CHAPTER III

INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM

Surgical Anatomy--FRACTURES OF CLAVICLE: _Varieties_--DISLOCATION OF CLAVICLE: _Varieties_--DISLOCATION OF SHOULDER: _Varieties_--Sprains and contusions of shoulder--FRACTURE OF SCAPULA: Sites--FRACTURE OF UPPER END OF HUMERUS: _Surgical neck_; _Separation of epiphysis_; _Fracture of head, anatomical neck, or tuberosities_--FRACTURES OF SHAFT OF HUMERUS.

The injuries met with in the region of the shoulder include fractures and dislocations of the clavicle, fractures of the scapula, dislocations and sprains of the shoulder-joint, and fractures of the upper end of the humerus.

#Surgical Anatomy.#--For the examination of an injury in the region of the shoulder the patient should be seated on a low stool or chair.

After inspecting the parts from the front, the surgeon stands behind the patient and systematically examines by palpation the shoulder girdle and upper end of the humerus. The uninjured side should be examined along with the other for purposes of comparison.

Immediately lateral to the supra-sternal notch, the sterno-clavicular articulation may be felt, the large end of the clavicle projecting to a varying degree beyond the margins of the small and shallow articular surface on the sternum. Any dislocation of this joint is at once recognised. The clavicle being subcutaneous throughout its whole length, any irregularity in its outline can be easily detected. A small tubercle (deltoid tubercle) which frequently exists near the acromial end is liable to suggest the presence of a fracture. The lateral end forms with the acromion the acromio-clavicular joint, which, however, is not always readily identified. The fingers are now carried over the acromion, which often exhibits in the situation of its epiphysial cartilage a prominent ridge, which must not be mistaken for a fracture. The tip of the acromion is usually employed as a fixed point in measuring the length of the upper arm.

The outline of the spine of the scapula can be traced back to the vertebral border; and the body of the bone may be manipulated, and its movements tested by moving the arm.

The coracoid process can be recognised in the upper and lateral angle of the triangular depression bounded by the pectoralis major, the deltoid, and the clavicle.

The head and surgical neck of the humerus may now be felt from the axilla, if the axillary fascia is relaxed by bringing the arm to the side. The great tuberosity can be indistinctly felt on the lateral aspect of the shoulder through the fibres of the deltoid. It lies vertically above the lateral epicondyle, and may be felt to rotate with the shaft. The inter-tubercular (bicipital) groove looks forward, and lies in a line drawn vertically through the biceps muscle.

The subclavian artery, with its vein to the median side and the cords of the brachial plexus to the lateral side, pa.s.ses under the middle of the clavicle, and may be compressed against the first rib immediately above this bone.

FRACTURE OF THE CLAVICLE

Fracture of the clavicle is one of the commonest injuries met with in practice. As about one-third of the cases occur in children, the fracture is often of the greenstick variety. The fractures are seldom compound or complicated, unless as a result of gun-shot injuries; but occasionally one of the fragments pierces the skin, or comes to press upon the subclavian vessels or the cords of the brachial plexus, arresting the pulsation in the vessels of the limb, and causing severe pain in the arm.

[Ill.u.s.tration: FIG. 13.--Oblique Fracture of Right Clavicle in Middle Third, united.]

The most common site of fracture is in the _middle third_ (Fig. 13), and this usually results from indirect violence, such as a fall on the outstretched hand, the elbow, or the outer aspect of the shoulder, the force being transmitted through the glenoid cavity to the scapula, and thence by the coraco-clavicular ligaments to the clavicle. The violence is therefore of a twisting character, and the bone gives way near the junction of the lateral and middle thirds, just where the two natural curves of the bone meet, and where the supporting muscular and ligamentous attachments are weakest.

The fracture so produced is usually oblique from above, downwards and inwards. The sternal fragment may be slightly drawn upwards by the clavicular fibres of the sterno-mastoid, while the acromial fragment falls by the weight of the arm, and the fragments usually overlap to the extent of about half an inch. The shoulder, having lost the b.u.t.tressing support of the clavicle, falls in towards the chest wall, narrowing the axillary s.p.a.ce, while the weight of the arm pulls it downward, and the muscles inserted in the region of the bicipital groove pull it forward.

Fracture of the middle third may result also from a direct stroke, such as the recoil of a gun, or from violent muscular contraction, the fracture as a rule being transverse, and the displacement less marked than in fracture by indirect violence.

_Clinical Features._--The att.i.tude of the patient is characteristic: the elbow is flexed and is supported by the opposite hand, while the head is inclined towards the affected shoulder to relax the muscles of the neck. Crepitus is elicited on bracing back the shoulders, or on attempting to raise the arm beyond the horizontal, and these movements cause pain. Tenderness is elicited on making pressure over the seat of fracture, and also on distal pressure. The sternal fragment almost invariably overrides the acromial, and can usually be palpated through the skin; on measurement, the clavicle is found to be shortened. When the fracture is incomplete (greenstick) or transverse, the symptoms are less marked.

[Ill.u.s.tration: FIG. 14.--Fracture of Acromial End of Clavicle. Shows forward rotation of lateral fragment, and line of fracture united by bone.]

Fracture of the _lateral_ or _acromial third_ of the clavicle is a common form of accident at football matches, and usually results from direct violence, the bone being driven down against the coracoid process, and broken as one breaks a stick over the knee. The fracture may take place through the attachment of the conoid and trapezoid ligaments, in which case the only symptoms are pain and tenderness at the seat of fracture, with impaired movement of the limb. Displacement and crepitus are prevented by the splinting action of the ligaments.

When the break is lateral to the attachment of the trapezoid ligament, the fracture is usually transverse, and is almost always due to a fall on the back of the shoulder--the angle between the spine and the acromion process striking the ground. The acromial fragment rotates forward (Fig. 14), sometimes even to a right angle, causing the tip of the shoulder to pa.s.s forwards, and so to lie slightly nearer the middle line. The integrity of the coraco-clavicular ligaments prevents any marked drooping of the shoulder. It is noteworthy that the displacement is not always evident at first.

Fractures of the _medial_ or _sternal third_ are rare, are usually oblique, and result either from an indirect force acting in the line of the clavicle, or, less frequently, from direct violence or muscular action. As a rule, the deformity is insignificant, except when the costo-clavicular ligament is torn, in which case the medial end of the distal fragment is tilted up by the weight of the arm. The shoulder pa.s.ses downwards, forwards, and medially. When close to the sternal end, this fracture may simulate a dislocation of the sterno-clavicular joint or a _separation of the clavicular epiphysis_. This last is a rare accident, which may occur between the seventeenth and the twenty-fifth years, and is usually the result of violent muscular action. It differs from the other injuries in this region in being more easily reduced and retained in position, the epiphysis lying entirely within the limits of the articular capsule of the sterno-clavicular joint.

_Simultaneous fracture of both clavicles_ usually results from a severe transverse crush of the upper part of the thorax or from a fall on the outstretched hands--for example, in hunting. The middle third of the bone is implicated, and there is marked displacement and overriding. The patient is rendered helpless, and from the extrinsic muscles of respiration being thrown out of action and the weight of the powerless limbs pressing on the chest, there is considerable difficulty in breathing, and this is often increased by the fracture being complicated by injuries of the lung or pleura.

The _prognosis_ as to union in all these injuries is good. Firm bony union usually occurs within twenty-one days. Non-union, false-joint, or fibrous union is but rarely met with. At the same time it is to be borne in mind that, in spite of all precautions, some deformity and shortening may result, without, however, interfering with the usefulness of the limb.

_Treatment._--The displacement in complete fractures of the clavicle is readily reduced by supporting the elbow, bracing back the shoulders, and levering out the tip of the affected shoulder. In a few cases the interposition of some fibres of the subclavius muscle between the fragments has prevented perfect reduction.

In the greenstick variety the bone may be bent back into its normal position, but no great force should be employed, as, in spite of imperfect reduction, the clavicle usually straightens as it grows, and although some deformity may persist, the function of the limb is not interfered with.

_Rec.u.mbent Position._--There is little doubt that the most perfect aesthetic results are obtained by treating the patient in the rec.u.mbent position. In girls, therefore, in whom it is desired that the shoulders should be perfectly symmetrical, the best results are obtained from placing the patient on a firm mattress, with a narrow, firm cushion between the shoulder-blades, so that the weight of the shoulder may carry the acromial fragment laterally and backwards. A pad is inserted in the axilla, the elbow raised, and the arm placed by the side on a pillow and steadied with sand-bags. Ma.s.sage is applied daily. As this position must be maintained uninterruptedly for two or three weeks, it proves too irksome for most patients. When both clavicles are fractured, however, it is, short of operation, the only available method of treatment.

In ordinary cases the arm should be placed in that position which gives the best alignment of the fragments and least deformity. A thin layer of wool is placed in the axilla to separate the skin surfaces. A sling, supporting the _elbow_, is now applied, maintaining the arm in position, and a body bandage fixes the arm to the side. Ma.s.sage and movement should be commenced at once.

A simple method, which yields satisfactory results, is that suggested by Wharton Hood. The fracture having been reduced, three strips of adhesive plaster, each an inch and a half wide, are applied from a point immediately above the nipple to a point 2 inches below the angle of the scapula (Fig. 15). The middle strap covers the seat of fracture, and is applied first: the others, slightly overlapping it, extend about half an inch on either side. The elbow is supported in a sling. This plan has the advantage that it permits of movement of the shoulder being carried out from the first, but the plaster rather interferes with ma.s.sage.

_The Handkerchief Method._--In cases of emergency, one of the best methods applicable to all fractures of the clavicle is to brace back the shoulders by means of two padded handkerchiefs, folded _en cravate_, placed well over the tips of the shoulders and tied, or interlaced, between the scapulae. The forearm is then supported by a third handkerchief applied as a sling, the base of which is placed under the elbow, the ends pa.s.sing over the sound shoulder.

_Operative treatment_ may be called for in compound or comminuted fractures when the fragments have injured, or are likely to injure, the subclavian vessels or the cords of the brachial plexus, or when it is otherwise impossible to reduce the fracture or to retain the fragments in apposition. It is also indicated in some cases of fracture of both clavicles.

These various methods of treatment are not equally applicable to all cases. In our experience, in the circ.u.mstances indicated, the following methods have proved the most satisfactory: (1) As a temporary means of retention in emergency cases,--for example, accidents occurring on the football field,--the handkerchief method.

(2) In uncomplicated fractures of average severity in any part of the bone, the method of sling and body bandage. (3) In cases where, for aesthetic reasons, the chief consideration is the avoidance of deformity and the maintenance of the symmetry of the shoulders, as in girls, the treatment by rec.u.mbency. (4) When retentive apparatus fails, or when the fragments are exerting injurious pressure, operative treatment.

[Ill.u.s.tration: FIG. 15.--Adhesive Plaster applied for Fracture of Clavicle.]

In quite a number of cases, there is an excessive amount of pain, preventing sleep; where this is due to cramp-like contractions of the muscles and movements of the fragments, it is relieved by more accurate fixation, as by strips of plaster; otherwise a hypodermic injection of heroin or morphin is indicated.

DISLOCATION OF THE CLAVICLE

Dislocation of the #acromial end#--sometimes, and perhaps more correctly, spoken of as dislocation of the scapula--is more frequent than that at the sternal end, and it usually results from a blow from behind, or from a fall on the tip of the shoulder, driving down the scapula, so that the clavicle projects _upwards_ and overrides the acromion process.

_Downward_ displacement of the acromial end of the clavicle is much rarer, and may follow a fall on the elbow or a blow over the clavicle.

The end of the bone lies under the acromion process, in contact with the capsule of the shoulder-joint, and the acromion stands out prominently.

The _clinical features_ are so well marked that the diagnosis is unmistakable. The head inclines towards the affected side, and the tip of the shoulder tends to pa.s.s slightly downward, forward, and medially. The displaced end of the bone can be seen and felt as a prominence under the skin, or the empty socket can be palpated, while the muscles attached to the displaced clavicle stand out in relief.

The movements at the shoulder are restricted, particularly in the direction of abduction above the level of the shoulder. These injuries are sometimes a.s.sociated with fracture of the ribs, a complication which adds materially to the difficulties of treatment.

_Treatment._--Reduction is easily effected by bracing back the shoulders and replacing the bone in its socket by manipulation; but retention is invariably difficult, and in many cases impossible; even when the displacement is permanent, however, the usefulness of the arm is not necessarily impaired.

Treatment is similar to that for fracture of the clavicle by sling and body bandage. Another plan is to place a pad over the acromial end of the clavicle, and fix it in this position by a few turns of elastic bandage carried over the shoulder and under the elbow. The forearm is placed in a sling with the elbow well supported, and the arm is bound to the side by a circular bandage. When the bone cannot be kept in position and the usefulness of the limb is impaired, the joint surfaces may be rawed and the bones wired, with a view to obtaining ankylosis.

#The sternal end# may be dislocated forwards, backwards, or upwards.

_Forward_ dislocation is the most common; the end of the clavicle lies on the front of the sternum, somewhat below the level of the sterno-clavicular joint, and its articular surface can be distinctly palpated (Fig. 16). The inter-articular cartilage sometimes remains attached to one bone, sometimes to the other; the rhomboid ligament is usually intact.

In the _backward_ dislocation the end of the clavicle lies behind the manubrium sterni and the muscles attached to it; there is a marked hollow in the position of the joint, and the facet on the sternum can be felt. In a comparatively small number of cases the bone exerts pressure upon the trachea and sophagus, producing difficulty in breathing and swallowing. It has also been known to press upon the subclavian artery and on other important structures at the root of the neck.

[Ill.u.s.tration: FIG. 16.--Forward Dislocation of Sternal End of Right Clavicle. From a fall on a polished floor, in a man aet. 40.]

In rare cases the rhomboid ligament is torn, and the end of the clavicle pa.s.ses _upwards_, and rests in the episternal notch behind the sterno-mastoid muscle.

The bone may be retained in position by keeping the shoulders braced back by a figure-of-eight bandage, or by padded handkerchiefs, and making pressure over the displaced end of the bone with a pad. The forearm is supported by a sling, and the arm fixed to the side.

Ma.s.sage is employed from the first, and the patient is allowed to move the arm by the end of a week. Imperfect reduction interferes so little with the functions of the limb that operative measures are seldom required except for aesthetic reasons.