THE UPPEE EXTREMITY. 1445 



be pressed. The medial angle of the scapula, covered by the trapezius and the 

 supraspinatus muscles, is, too deeply placed to be palpated distinctly. The inferior 

 angle, and the vertebral border, from the root of the spine downwards, form visible 

 prominences which are readily felt ; the inferior angle overlies the seventh inter- 

 costal space on a level with the seventh thoracic spine, while the vertebral border 

 lies a little medial to the angles of the ribs. 



To elicit crepitus in a transverse fracture of the scapula below the spine, ..the surgeon 

 stands behind the patient and grasps the upper fragment by placing the forefinger upon 

 the coracoid and the thumb upon the spine, while, with the other hand, he grasps the 

 inferior angle ; the two fragments are then moved the one upon the other. 



The tip of the coracoid process may be felt by pressing the finger firmly upon the 

 anterior border of the deltoid at a point one inch below the junction of the middle 

 and lateral thirds of the clavicle. Medial to the coracoid is a triangular depres- 

 sion which corresponds to the superior end of the interval between the clavicular 

 fibres of the pectoralis major and deltoid muscles. Behind this triangular depres- 

 sion are the termination of the cephalic vein, a lymph gland, the first part of 

 the axillary vessels, and the cords of the brachial plexus. By firm pressure in this 

 situation the pulsation of the axillary artery can be felt, and by further pressure 

 the circulation in the vessel can be arrested by compressing the artery against the 

 second rib. The first part of the axillary artery may be cut down upon either by 

 a transverse incision through the clavicular origin of the pectoralis major, or by a 

 longitudinal incision in the interval between that muscular slip and the deltoid. 

 The companion vein lies in front of, as well as to the thoracic side of, the artery, 

 thus adding to the difficulty of exposing the vessel. In fractures of the middle 

 third of the clavicle the subclavian vessels are protected by the soft pad formed by 

 the subclavius muscle. 



The proximal extremity of the humerus, covered by the deltoid, gives rotundity 

 to the shoulder. The greater tubercle projects beyond the acromion, and constitutes 

 the most lateral bony landmark of the shoulder. When the head of the bone is 

 dislocated, the lateral border of the acromion then becomes the most lateral bony 

 landmark, and the shoulder presents a square contour. The lesser tubercle, small 

 but conical, can be felt through the deltoid. Pointing directly forwards, it lies one 

 inch lateral to and a little below the level of the tip of the coracoid process. In 

 examining the proximal extremity of the humerus for fracture, the tubercles 

 should be grasped between the finger and thumb of one hand, while the flexed 

 elbow is rotated with the other hand. The head of the humerus has the same 

 direction as the medial epicondyle ; its distal part can be palpated through the 

 axilla, the arm being meanwhile abducted, to bring the head in contact with the 

 inferior surface of the capsule. It is through this, the weakest part of the capsule, 

 that the head is driven in the common varieties of dislocation of the shoulder, 

 viz., those due to forcible abduction. The proximal epiphysis of the humerus in- 

 cludes the head and the greater part of the tubercles. The capsule is attached 

 mainly to the epiphysis ; hence, in children, we find that separation of the 

 proximal epiphysis takes the place of dislocation. Disease in the proximal end 

 of the diaphysis does not necessarily involve the cavity of the joint. The inter- 

 tubercular sulcus of the humerus, which lies immediately lateral to the lesser 

 tubercle, may be mapped out upon the surface by drawing a line, two inches in 

 length, distally along the axis of the humerus from the tip of the acromion. 

 When there is effusion into the joint, the arm becomes slightly abducted, and 

 there is fulness in front, along the line of the long tendon of the biceps. With 

 the elbow at the side the lower part of the capsule of the shoulder-joint is loose 

 and folded upon itself to form a dependent pocket ; if, after an injury, the arm 

 is retained too long in this position, the patient may be unable to abduct the arm, 

 in consequence of the formation of adhesions in and around the pouch. To 

 evacuate pus from the shoulder - joint, the integuments, deltoid, and capsule 

 should be cut into by an incision passing vertically and distally from the tip of the 

 acromion. 



92 b 



