ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



603 



the superior and inferior fragments. As the 

 fracture thus generally exists without any 

 very obvious displacement of the fragments, 

 and as it is usually accompanied by much swell- 

 ing of the shoulder joint, the diagnosis may 

 be very obscure. 



Symptoms. The patient will complain of 

 severe pain in the shoulder, which is much 

 increased by the least pressure, or by commu- 

 nicating any movement whatever to the arm ; 

 and he cannot, by any voluntary effort of the 

 muscles of the injured arm, elevate it ; on 

 making a methodical examination soon after 

 the accident has occurred, crepitus can be 

 elicited- As to the degree of power which 

 the patient possesses of moving his arm in 

 these cases, some variety may be noticed, par- 

 ticularly if some days have elapsed since the 

 receipt of the injury. 



The following case of fracture through the 

 tuberosities of the humerus was very recently 

 under observation at the Richmond Hospital, 

 and may be here adduced, to show the diffi- 

 culty that may occur in making our diagnosis 

 if the case is not seen soon after the occur- 

 rence of the accident. 



Case. Mary Trainor, set. 60, was admitted 

 into one of Mr. Peile's wards in the Richmond 

 Hospital on the 19th of May,' 184-8. She com- 

 plained much of the left shoulder, on which 

 she had fallen fourteen days before. She had 

 never used her arm since the accident, nor 

 left it unsupported. The patient pointed to 

 one part close to the head of the humerus 

 anteriorly, which was particularly painful, and 

 here a small bony projection was detected, 

 whether a spicula of bone or a small exostosis 

 could not be known. She could elevate, or 

 abduct her arm some inches from her side, 

 and could rotate it freely herself, without these 

 movements causing her any pain. Although 

 many examinations had been made since her 

 admission into the hospital, no satisfactory 

 evidence of crepitus could be detected ; there 

 was some tumefaction, and heat showing in- 

 flammation of the shoulder joint. She died 

 suddenly of apoplexy on the fourth day after 

 her admission. 



Post-mortem. Before the shoulder joint 

 was examined, it was ascertained by careful 

 measurement from the posterior angle of 

 the acromion to the outer condyle of the 

 humerus, as well as from the scapular ex- 

 tremity of the clavicle to the same point 

 below, that the left or injured arm was 

 fully one quarter of an inch shorter than 

 the right. On removing the muscles anil their 

 tendons, a fracture was seen to have traversed 

 the superior extremity of the humerus: the line 

 of this fracture was somewhat irregular; pos- 

 teriorly it passed along the basis of the head 

 of the humerus, or nearly as high as the level 

 of the anatomical neck, and anteriorly along 

 the basis of the lesser tuberosity, which was 

 thus left attached to the head, while the greater 

 tuberosity was detached, and broken into frag- 

 ments ; and it appeared as if this last was the 

 mechanical result of the impaction of the head 

 into the cancelli of the shaft of the bom: ; the 



amount of this impaction was to the extent 

 of one quarter of an inch. The synovial mem- 

 brane was perforated or punctured in one or 

 two points by spiculas of the broken humerus, 

 and this membrane showed decided traces of 

 having been the seat of inflammatory action. 

 The cartilaginous covering of the head of 

 the humerus seemed to have been somewhat 

 thinned the result of the inflammation which 

 had engaged the joint more or less ever since 

 the occurrence of the accident. 



The diagnosis in this case was very diffi- 

 cult, for there was some swelling and decided 

 inflammation of the shoulder joint : fourteen 

 days had passed since the accident occurred, 

 and no crepitus, although carefully sought for, 

 could at this period be detected. Apparently 

 self-persuaded that no fracture existed, the 

 woman repeatedly showed to Mr. Robert 

 Macdonnell (the resident pupil, who had im- 

 mediate charge of the case) how freely she 

 could rotate the injured humerus ; she could 

 also abduct the elbow some inches from her 

 side. A fracture through the superior part of 

 the humerus was suspected ; but as there was 

 no obvious displacement of the fragments, the 

 principal indication seemed to be to reduce 

 the inflammation of the shoulder joint, and 

 this line of practice was pursued. The ex- 

 pedient of making a comparative measure- 

 ment as to the relative length of the two 

 arms was not thought necessary as an aid 

 in the diagnosis of this case ; yet the result 

 of this experiment would have shown in 

 the living as it did subsequently in the dead 

 body, a decided shortening of the left arm to 

 the amount of a quarter of an inch, an ob- 

 servation which would no doubt have con- 

 firmed the idea already existing in the minds 

 of the attendants, that a fracture of the hu- 

 merus existed, as well as an inflammation of 

 the shoulder joint. 



3. Fracture of the superior extremity of the 

 humerus through the line of junction of the epi- 

 physis with the shaft of the bone, or close to this 

 line. 



This is a species of fracture which not un- 

 frequently occurs in early life. In the old 

 subject we occasionally witness cases of frac- 

 ture in the same situation. This accident is 

 so far unlike that last adverted to, that while 

 in the former there is no displacement, the 

 latter accident is attended with considerable 

 deformity. We may make this general remark 

 with respect to fractures above the line of 

 junction of the epiphysis, whether the fracture 

 be extra-capsular or intra-capsular. There 

 is little or no deformity, and crepitus (a 

 symptom of fracture, the possibility of eliciting 

 which usually exists), and shortening to a 

 small amount of the length of the humerus, 

 are the only positive signs to which we can 

 refer to establish our diagnosis ; but when a 

 fracture of the humerus, either at the line of 

 junction of the epiphysis with the shaft of the 

 bone, or below this line in the surgical neck, 

 occurs, then much displacement of the frag- 

 ments may generally be observed. 



Sir A. Cooper has described an assemblage 



