604 



ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



of symptoms belonging to a class of cases of 

 fracture of the superior extremity of the hu- 

 merus, which we have no doubt he conjectured 

 to belong to the separation of the superior 

 epiphysis from the shaft of the humerus in the 

 young subject. In the adult, a fracture through 

 the original line of junction of the superior 

 epiphysis with the shaft of the humerus would 

 be attended with nearly similar symptoms. In 

 alluding to the injury in question, Sir A. C. 

 observes, that in children it is the result of 

 falls upon the shoulder. The signs of it are 

 as follow : The head of the bone remains in 

 the glenoid cavity of the scapula, so that the 

 shoulder is not sunken as in dislocation; when 

 the shoulder is examined a projection of bone 

 is perceived upon the point of the coracoid 

 process, and when the elbow is raised and 

 brought forward this projection is rendered 

 particularly conspicuous. By drawing down 

 the arm the prominence is removed, but it im- 

 mediately re-appears upon ceasing to make 

 the extension, and the natural contour of the 

 shoulder is lost. 



All the movements of the shoulder joint 

 are painful, and the patient cannot raise the 

 arm unless by the aid of the other hand. The 

 elbow is with difficulty withdrawn from the 

 side, and the arm requires support. Sir A. 

 Cooper adduces a case illustrating the above 

 symptoms in a child aet. 10, who had fallen on 

 the shoulder into a sawpit the depth of which 

 was eight feet. 



The writer has witnessed many examples of 

 fracture of the humerus in the line of junction 

 of the superior epiphysis with the shaft of the 

 bone, or in the immediate vicinity of this line. 



In these cases the youth of the patient, and 

 the situation of the fracture, led him to con- 

 jecture that a separation of the superior epi- 

 physis of the humerus had occurred ; but he 

 had no opportunity of ascertaining anatomi- 

 cally the true nature of the lesion. 



The principal deformity noticed by the 

 writer in these cases is attempted to be de- 

 lineated in (fig. 433.), the representation of 

 one of the plaster casts which he has preserved 

 of one out of many of these cases. The pro- 

 minence here delineated is found to be owing 

 to a very remarkable projection forwards of 

 the upper extremity of the inferior fragment 

 of the humerus. This was best seen by view- 

 ing the shoulder in profile, or sidewise. The 

 antero-posterior measurement of the shoulder 

 was much increased. Sir A. Cooper, in re- 

 ference to the cases he has seen of this kind, 

 observes, that when the shoulder is examined 

 a projection of bone is perceived " at the front 

 of the coracoid process ;" in four cases which 

 the writer has witnessed, the projection of 

 bone formed by the superior extremity of the 

 lower fragment of the humerus was situated 

 exactly in the centre of a line stretching an- 

 teriorly from the acromio-clavicular articula- 

 tion to the lower margin of the anterior fold 

 of the axilla. This remarkable projection of 

 the bone, formed by the lower fragment, was 

 in two cases engaged in the deeper layers of 

 the integuments covering the deltoid muscle 



near to its anterior margin, and hence the 

 deltoid muscle must have been itself per- 

 forated. In these latter cases it was found 

 impossible to disengage the bone from its faulty 

 position, or from the fibres of the deltoid 



Fig. 433. 



Case of C. Austin. Fracture of the humerus in or 

 near the line of junction of the epiphysis. 



muscle, and deeper layer of the internments. 

 The following case of the above description 

 has been recently seen by the writer. 



Case. Fracture through the humerus imme- 

 diately below the tuberosities , or through the 

 original line of junction of the epiphysis and 

 shaft of this bone. Charles Austin, aged 14 

 years, on the morning of the 12th April, 

 1848, fell from a height of seven feet off 

 a ladder, and was thrown on the posterior 

 part of his left shoulder on uneven ground. 

 He was not seen until next morning, 

 when the injured shoulder presented the 

 following appearances * : " There was a 

 great deal of ecchymosis and swelling about 

 the joint ; the acromion process appeared pro- 

 minent, and in viewing the shoulder sidewise 

 the measurement of its antero-posterior diame- 

 ter appeared greatly increased. The patient 

 supported the hand and fore-arm of the injured 

 arm with the opposite hand ; the elbow was 

 slightly abducted, but it could be readily 

 pressed against the side. He could not him- 

 self make the least effort to move the arm, 

 and the attempt to raise it from the side, or 

 to deprive it, even for a moment, of the sup- 

 port of the right hand, was productive of 

 much pain. On placing one hand over the 

 joint, and rotating the humerus with the other, 



* For the notes of this case, the writer is obliged 

 to Mr. W. Court, resident surgeon to Steeven's Hos- 

 pital, with whom he examined it. 



