Manual of Surgery Volume II Part 31

In the more common type, the scapula seems to be held in its elevated position by shortening of the muscles attached to its body, and it is often rotated so that its lower angle is close to the spine and its axillary border nearly horizontal, or the axillary border may lie in close to the ribs, and the vertebral border project from the chest wall. The shoulder is generally higher and farther forward on the affected side, and there is a moderate degree of scoliosis. There is a want of purchase in the movements of the shoulder and upper arm.

[Ill.u.s.tration: FIG. 164.--Congenital elevation of Left Scapula in a girl: also shows hairy mole over Sacrum.

(Mr. D. M. Greig's case.)]

When the deformity is bilateral, which is rare, the neck is short and thick, the chin lies close to the sternum, and the arms can scarcely be raised to the horizontal.

Gymnastic exercises and the wearing of a brace to hold the shoulders back and down may be followed by some improvement, but, as a rule, it is necessary to mobilise the scapula by operation. An X-ray photograph should first be taken, because, when the scapula is connected with the spine by a bridge of bone, this must be resected. The muscles attached to the vertebral border and spine of the scapula are divided, the bone is drawn down to its proper position, and the parts are fixed by plaster bandages.

_Winged Scapula._--This condition consists in a marked displacement backwards of the lower angle and vertebral border of the scapula, when the patient attempts to raise the arm from the side (Fig. 165). Under normal conditions, in making this movement the serratus and rhomboid muscles pull forward the vertebral border and inferior angle of the scapula, and so fix the bone firmly against the chest wall. When these muscles are paralysed, as a result of anterior poliomyelitis, neuritis, or injury of the long thoracic nerve of Bell, or of the fifth and sixth cervical nerve-roots through which they receive their supply, the patient is unable to abduct the arm, and the deltoid having lost its _point d'appui_, its contraction merely results in tilting the angle of the scapula backward (Fig. 165).

[Ill.u.s.tration: FIG. 165.--Winged Scapula; the patient is holding the arms out in front.]

_Treatment._--In the majority of recent cases the condition yields to the administration of strychnin and other muscle and nerve tonics, and the use of ma.s.sage and the faradic current. The application of a carefully adjusted padded belt is sometimes useful. The method of treatment by st.i.tching the latissimus dorsi over the lower angle of the scapula is based on the erroneous a.s.sumption that the displacement is due to the slipping of that muscle off the bone; at the same time, it must be admitted that the operation sometimes diminishes the deformity and adds to the patient's comfort.

A more efficient method consists in detaching the clavicular portion of the pectoralis major from its insertion, and st.i.tching it to the serratus anterior so as to make it take on the function of this muscle, or st.i.tching it to the axillary border of the scapula. Success has also followed suture of the vertebral border of the scapula to the subjacent ribs (Eiselsberg).

_Displacement of the scapula upwards and laterally_ has been observed as a result of partial paralysis of the trapezius when the nerves supplying it have been divided in removing tuberculous glands from the neck. In these acquired displacements, treatment is directed towards the nerve lesion and towards the improvement of the muscles by electricity, ma.s.sage, and exercises; when the paralysis of the trapezius is permanent, the disability is gradually overcome by the compensatory hypertrophy of the levator muscle.

#Congenital Dislocation of the Shoulder.#--This rare condition is usually bilateral, and is a.s.sociated with other congenital defects.

The glenoid cavity is deformed or absent, and the dislocation may be sub-coracoid, sub-acromial, or sub-spinous. The movements of the arm are restricted, and the development of the extremity as a whole is imperfect. It is sometimes possible to reduce the dislocation by manipulation, or, if this fails, by operation. Unilateral dislocation is sometimes mistaken for dislocation that has occurred during delivery and _vice versa_.

#Habitual Dislocation# is described on p. 65.

#Paralytic Deformities--Paralytic Dislocation of the Shoulder.#--The muscles in the region of the shoulder may have their innervation interfered with as a result of various conditions, of which poliomyelitis and injuries of the brachial plexus at birth are the most important. The capsular ligament of the shoulder-joint, being no longer kept tense by the scapular muscles--especially the deltoid and lateral rotators--becomes relaxed, and is gradually stretched by the weight of the arm. The appearances are characteristic; the muscles of the shoulder are wasted, the acromion is prominent, and between it and the upper end of the humerus there is a marked hollow into which one or more fingers may be inserted. The arm hangs flaccid by the side, rotated medially and p.r.o.nated, and moves in a flail-like fashion in all directions, the patient having little control over it. The best results are obtained by the transplantation of muscles, the trapezius being detached from the clavicle and st.i.tched to the surface of the deltoid, and the upper arm fixed in the position of horizontal abduction with the arm rotated laterally and supinated. Bradford inserts a portion of the trapezius into the humeral insertion of the deltoid. When these methods are impracticable, the upper arm may be fixed to the trunk by some form of apparatus, or arthrodesis is performed so that the movements of the scapula are communicated to the upper arm; the best att.i.tude for ankylosis is one of abduction with medial rotation, so that the hand can be brought to the mouth.

In cases of poliomyelitis, when all the muscles governing the elbow are paralysed while the muscles of the hand have escaped, it may be of great service to fix this joint permanently at rather less than a right angle. This may be effected by arthrodesis, or by removing an extensive diamond-shaped portion of skin from the flexor aspect of the joint and bringing the raw surfaces together, commencing the st.i.tching at the lateral apices of the gap.

[Ill.u.s.tration: FIG. 166.--Arrested Growth and Wasting of Tissues of Right Upper Extremity, the result of Anterior Poliomyelitis in childhood.]

#Congenital Dislocations at the Elbow.#--_The head of the radius_ may be dislocated forwards, backwards, or laterally--usually in a.s.sociation with imperfect development of the radius and of the lateral condyle of the humerus. When the displaced head of the bone interferes with supination, or with extension, it should be removed.

Congenital dislocation of both bones of the forearm is extremely rare.

#Cubitus Valgus# and #Cubitus Varus#.--When the normal arm hangs by the side with the palm of the hand directed forward, the forearm and upper arm form an angle which is open outwards--known as the "carrying angle"; it is usually more marked in women in a.s.sociation with the greater breadth of the pelvis and the relative narrowness of the shoulders. When this angle is increased, the att.i.tude is described as one of _cubitus valgus_. This deformity may be acquired as a result of rickets, but more commonly it is due to fracture of the lateral condyle of the humerus, in which the separated fragment has been displaced upwards.

_Cubitus varus_ is the reverse of cubitus valgus. It is more common, is always pathological, and is nearly always a result of fracture of the lower end of the humerus or separation of the lower humeral epiphysis and subsequent interference with growth. These deformities may be corrected by supra-condylar osteotomy of the humerus.

[Ill.u.s.tration: FIG. 167.--Lower end of Humerus from case of Cubitus Varus.]

#Synostosis of the superior radio-ulnar joint# is a rare congenital condition, in which the hinge movements at the elbow are free, but supination is impossible; an attempt may be made by operation to form a new joint.

#Volkmann's ischaemic contracture# of the muscles of the forearm, resulting in the production of claw-hand, is described in Volume I., p. 415.

#Deformities of the Forearm and Hand.#--The _radius_ may be absent completely or in part, frequently in combination with other malformations. The most evident result is a deviation of the hand to the radial side--one variety of _club-hand_. The forearm is shortened, the ulna thickened and often bent, and the thumb and its metacarpal bone are often absent, so that the usefulness of the hand and arm is greatly impaired (Fig. 171). For this condition Bardenheuer devised an operation which consists in splitting the lower end of the ulna longitudinally and inserting the proximal bones of the carpus into the cleft.

Congenital deficiency of the _ulna_ is extremely rare.

#Intra-uterine amputation# by constriction of amniotic bands sometimes occurs (Figs. 168, 169).

[Ill.u.s.tration: FIG. 168.--Intra-uterine Amputation of Forearm.]

[Ill.u.s.tration: FIG. 169.--Radiogram of Arm of patient shown in Fig.

168.]

#Drop Wrist from Anterior Poliomyelitis.#--In this condition the capacity of extending the fingers is deficient or absent. Recovery can be confidently predicted if, on still further flexing the fingers, they can be voluntarily extended towards the point from which they are flexed (Tubby and Jones). Considerable improvement may result from fixing the hand by means of a splint in the att.i.tude of dorsal flexion. The splint is removed at frequent intervals to allow of ma.s.sage and other treatment being carried out, and it has usually to be worn for a period of one to two years. In some cases recourse should be had to arthrodesis.

[Ill.u.s.tration: FIG. 170.--Congenital absence of Left Radius and Tibia in a child aet. 8.

(Mr. D. M. Greig's case.)]

In _spastic paralysis_ the most p.r.o.nounced deformity is flexion of the forearm and p.r.o.nation and flexion of the hand (Fig. 166). Gradual extension at the wrist may be brought about by the use of a malleable splint, in which the angle is gradually increased, over a period of at least twelve months. Failing success by this method, operation may be had recourse to, and this consists in lengthening of tendons, and tendon transplantation. Tubby has devised an operation for converting the p.r.o.nator radii teres into a supinator, and Robert Jones another in which the flexors of the carpus are made to take the place of the extensors. "These operations, combined if necessary with elongation of the flexors of the fingers, pave the way for diminution of the angle of flexion at the elbow, lessening of the p.r.o.nator spasm, increase of the supinating power, reduction of the carpal flexion, and addition to the extensor power at the wrist" (Tubby and Jones).

#Congenital Club-hand.#--This rare deformity corresponds to congenital club-foot, and probably arises in the same way. The hand and fingers are rigidly flexed to the ulnar or radial side, so that the patient is incapable of moving them. Treatment is carried out on the same lines as for club-foot.

A deformity resembling this, _acquired club-hand_, is brought about when the growth of either of the bones of the forearm has been arrested as a result of disease or of traumatic separation of its lower epiphysis. The hand deviates to the side on which the growth has been arrested--_ma.n.u.s valga_ or _vara_. The treatment consists in resecting a portion of the longer bone.

[Ill.u.s.tration: FIG. 171.--Club-hand, the result of imperfect development of radius. The thumb is absent.

(Photograph lent by Sir George T. Beatson.)]

#Madelung's Deformity of the Wrist.#--In 1878, Madelung called attention to a deformity also called sub-luxation of the hand, in which the lower articular surface of the radius is rotated so that it looks towards the palm; there is palmar displacement of the carpus, and the lower end of the ulna projects on the dorsum. The cause of the condition is obscure, but it is met with chiefly in young women with slack ligaments, whose laborious occupation or athletic pursuits subject the hand and wrist to long-continued or repeated strain. It is as frequently unilateral as bilateral and may recur in successive generations. There is a good deal of pain, the grasping power of the hand is impaired, and dorsiflexion is considerably restricted. The deformity disappears on forcible traction, but at once reappears when the traction is removed. A wristlet of poroplastic or leather extending from the mid-forearm to the knuckles is moulded to the limb in the corrected position, and is taken off at intervals for ma.s.sage and exercises.

When _operative treatment_ is called for, it takes the form of osteotomy of the radius and ulna about an inch or more above their articular surfaces.

#Congenital dislocation of the wrist# is rare.

#Deformities of the Fingers.#--Various forms of _congenital dislocation_ of the fingers are met with, but they are of little clinical importance, as they interfere but slightly with the usefulness of the digit affected.

_Congenital lateral deviation of the phalanges_ is more unsightly than disabling; it is met with chiefly in the thumb, in which the terminal phalanx deviates to the radial or to the ulnar side in extension; the deviation disappears on flexion.

_Congenital contraction of the fingers_ is comparatively common. It is an inherited deformity, and is often met with in several members of the same family. It most frequently affects the little or the ring and little fingers (Fig. 172), and is usually bilateral. The second and third phalanges are flexed towards the palm; the first phalanx is dorsiflexed, this being the reverse of what is observed in Dupuytren's contraction. Duncan Fitzwilliams suggests that it should be called "hook-finger," and that it is probably due to imperfect development of the anterior ligament of the first inter-phalangeal joint. He has observed it in a.s.sociation with laxity of the ligaments of the other joints of the body.

[Ill.u.s.tration: FIG. 172.--Congenital Contraction of Ring and Little Fingers.]

The affection is usually disregarded in infancy and childhood as being of no importance. In young children, the deformity is corrected by wearing a light splint fixed with strips of plaster, or a piece of whalebone or steel inside the finger of a glove. In older children, the finger may be straightened by subcutaneous division of the ligament over the palmar aspect of the base of the middle phalanx, or failing this by lengthening the flexor tendons and resecting a wedge from the dorsal aspect of the first phalanx close to the inter-phalangeal joint.

#Dupuytren's Contraction.#--This is an acquired deformity resulting from contraction of the palmar fascia and its digital prolongations (Fig. 173). It is rare in childhood and youth, but is common after middle life, especially in men. It is often hereditary, and is said to occur in those who are liable to gout and to arthritis deformans.

While it is met with in the working-cla.s.ses and attributed to the pressure of some hard object on the palm of the hand--such as a hammer or shovel or whip--its greater frequency in those who do no manual work, and the fact that it is very often bilateral, indicate that the const.i.tutional factor is the more important in its causation.

[Ill.u.s.tration: FIG. 173.--Dupuytren's Contraction.]

In the initial stage there is a localised induration in the palm opposite the metacarpo-phalangeal joint, and the skin over it is puckered and closely adherent to the underlying fascia. After a variable interval, the finger is gradually and progressively flexed at the metacarpo-phalangeal joint. The ring finger is usually the first to be affected, less often the fifth, although both are commonly involved. It is rarest of all in the index. The flexion may be confined to the metacarpo-phalangeal joint, or the middle and distal phalanges may also be flexed; and as the deformity becomes more p.r.o.nounced, the nail of the affected finger may come into contact with the skin of the palm. Dissections show that the flexion of the finger is the result of a chronic interst.i.tial overgrowth or fibrositis and subsequent contraction of the palmar fascia and of its prolongations on to the sides of the fingers. The digital processes of the fascia are thickened and shortened, and come to stand out like the string of a bow. The adipose tissue in the skin of the palm disappears, and the skin and fascia thus brought into contact become fused. The tendons and their sheaths are not implicated; they are found lying deeply in the concavity of the curve of the flexed digit. There is no pain, but the grasp of the hand is interfered with, the patient is unable to wear an ordinary glove, and he may be incapacitated from following his occupation.

The condition is easily diagnosed from congenital contraction by the fact that in the latter the proximal phalanx is dorsiflexed.

_Treatment._--When seen in the initial stage, contraction may be prevented by pa.s.sive movements of the finger and by ma.s.sage of the indurated fascia; we have observed cases in which these measures have held the malady in check for many years, but when flexion has already occurred, they are useless, and according to the social position, habits, or occupation of the patient, the condition is left alone or the deformity is corrected by operation.

Adam's operation consists in multiple subcutaneous division of the contracted fascia in the palm and of its prolongations on to the finger; in addition to dividing the fascia, the tenotomy knife should be used also to separate the skin from the fascia. The finger is then forcibly extended, and a well-padded splint secured to the hand and forearm. The skin on the palmar aspect opposite the first inter-phalangeal joint may give way when the finger is extended; should this occur, the resulting gap may be covered by a skin graft.