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Dislocations of the shoulder
DISLOCATIONS
OF THE SHOULDER
LT. COL. LEONARD F. BUSH MEDICAL CORPS, ARMY OF THE UNITED STATES
T
HE frequent occurrence of disIocations of the shoulder makes this subject of interest to the general practitioner and surgeon alike. Acute or initia1 disIocations of the shoulder are common, and require not only early, non-traumatic reduction, but adequate post-reduction treatment to prevent the recurring or chronicaIIy dislocating joint. Patients suffering from recurrent dislocations of the shouIder deveIop a definite fear or anxiety complex, which can be relieved onIy by correction of the condition. With these thoughts in mind, the purpose of this article is to present a simpIe method of reduction of disIocations, and a corrective operation for the chronic diswhich have proved locating shoulder, successfu1. When the shoulder dislocates, there is not onIy a Iaceration of the joint capsule, but a stretching or sprain of the biceps tendon and its surrounding tendon sheath. At operation on recurrent1.y dislocating shoulders, it has been noticed that there is old blood along the tendon sheath, a shallow bicipital groove and a Iooseness of the transverse humeral fascia and tendon sheath at the anatomical neck of the humerus. The oId bIood has been found severa days after recent dislocations, indicating severe trauma at that point. X-ray examinations should be made of all acute disIocations of the shouIder to rule out an accompanying fracture. Thorough x-ray studies shouId aIso be made before operative procedures are undertaken. When the Iower border of the gIenoid fossa has been fractured Ieaving a shaIIow cup for the head of the humerus, contempIated suspension operations, such as that of NicoIa,5 wiI1 be Iess successful. In such instances, the operation devised would seem most efficacious. by Speed6
In recurrent dislocations in which the shouIder slips out of joint without trauma, x-ray examinations are not necessary prior to reduction. In recurrent dislocations of the shoulder folIowing the NicoIa procedure, one shouId suspect a complete atrophy of the tendon or separation of the suture site. The atrophy which has been found may be expIained by the fact that the nutritive suppIy which comes from the muscle beIIy of the biceps has been severed at operation and has not regenerated. In such cases the operation devised by Henderson2 should be considered. Acute di.sZocations, or those occurring for the first time, are reduced and treated by a body bandage and supporting sling for three weeks before motion is started. After this period of immobilization, graduated exercises are started unti1 normal activity is reached in six or eight weeks. We have had no recurrences in patients treated in this manner. This is perhaps a coincidence, but it is betieved that proper immobilization, foIIowed by gradual use, will alIow the torn capsule and tendon sheath to heal. REDUCTION
OF DISLOCATIONS
Acute or recurrent disIocations are easily reduced without trauma in the foIIowing manner. X-rays are taken as indicated. One-fourth gr. of morphine is given, either by the subcutaneous or intravenous route. With the patient lying supine, an assistant firm traction on the opposite applies arm, or the same force may be obtained by placing a sheet around the thorax. Gentle, constant and increasing traction is appIied on the involved arm, with the eIbow flexed at a right angIe, the forearm being held in a vertica1 position. The patient is reassured and asked to breathe
520
Nt-w SFH,ES Var.. LXVII,
Bush-Dislocation
No. 3
deeply and relax the shoulder muscles. While constant traction is maintained, the flexed arm is gently rotated toward the
of Shoulder
American Journal 01’Srrrgr.rv
j21
particular care being taken to preserve the anterior branches of the circumflex humeral nerve. (Fig. 2.) This precaution prevents
I
J
FIG. I. Illustrates the position of the patient and the direction of forces exerted for the reduction of disIocated shoulders.
head as shown in Figure I. The head of the humerus then slides into the joint with ease. This method has been entirely successful in al1 anterior, posterior and inferior or subglenoid dislocations, and is not as traumatizing as some of the methods and maneuvers which have been advocated. This same procedure may be used with a general anesthetic, although anesthesia has not been found necessary in a successive number of either acute or chronic dislocations of the shoulder. MODIFICATION FOR
RECURRENT
OF
THE
NICOLA
DISLOCATING
OPERATION SHOULDERS
The operative technic which is to be described has been suggested by Capt. H. W. Grosselhnger, who was associated with the Orthopedic Department at Strong MemoriaI Hospital prior to his entry into the armed forces. We have used this procedure, with some modihcations, on twenty patients. Roberts’ has described a somewhat simiIar procedure. A four inch incision Operative Technic. is made from a point just anterior to the acromium process, extending distally to the lower end of the dehoid muscle. The deltoid muscle fibers are separated posterior to the path of the cephahc vein,
postoperative atrophy of the anterior portion of the deltoid muscle, although it makes the operation slightly more difficult. By rotating the arm, the bicipital groove is easiIy palpated and the transverse humerus ligament and the synovial sheath surrounding the long head of the biceps (bicipital tendon) are opened. The entire tendon sheath is incised along the course of the tendon, including part of the joint capsule of the shoulder. Considerable bleeding can be eliminated at this point if the circumflex humerus vessels are isolated and ligated. The tendon is then removed from the groove and retracted by a cotton tape. (Fig. 3.) By means of osteotomes and chisels, a new channel is created from a point on the head of the humerus onehalf inch above the anatomical neck to the point of exit of the bicipital tendon from its sheath. (Fig. 4.) By forcing two osteotomes laterally, in opposite directions to each other, along the entire groove, a new channel approximately one-half inch deep is made in the cancellous portion of the humerus. The tape is removed, and the tendon is placed into its new groove, onehalf inch in depth in the upper shaft and head of the humerus. The contraction of the muscIe wiI1 hoId the tendon in place, but a tension suture is placed through the
522
American
Journal
of Surgery
Bush-Dislocation
tendon and fascia at its exit from the channel to keep it taut. The joint capsuIe is usualIy redundant or excessiveIy Ioose
of ShouIder
MARCH.
in two Iayers, the deltoid fascia skin, by means of interrupted sutures.
,945
and the cotton
FIG. 3. FIG.
2.
FIG. 4.
FIG. 2. The type of incision and the structures encountered, showing preservation of the circumflex humeral nerve. FIG. 3. The tendon sheath of the biceps tendon has been incised and the tendon retracted. The joint capsule of the shoulder has been opened for a short distance. FIG. 4. The osteotomes are shown in the new groove at the site of the bicipita1 depression, which shouId extend into the head of the humerus at least onehalf inch. FIG. 5. The transverse humerus fascia and tendon sheath are shown sutured over the new channe1. Insert shows tightening suture.
aIong the anterior portion. Added security is obtained by freezing the joint capsule aIong the anterior border of the neck of the humerus and pIicating it by suturing the anterior cut edge to the IateraI border of the bicipita1 groove. (Insert Fig. 5.) The transverse humerus Iigament, synovial sheath and periosteum are then sutured as one over the top of the tendon in its new channel (Fig. 5.) The wound is then cIosed
POSTOPERATIVE
CARE
The arm is supported by a VeIpeau-type dressing, care being taken to separate opposing skin surfaces by padding. New dressings are aPPIied weekly, and the sutures are removed on the seventh to the ninth day. After three weeks a11 dressings are removed, the arm is pIaced in a sIing, and earIy motion is started. At four weeks,
NF.%SEHIESVOI.. I.XVII, No. 3
BushbDisIocation
the sIing is discarded, increasing motion and physiotherapy are begun. At the end of five weeks, the patient is able to move the arm in all directions, including complete abduction and extension above the head. The only limitation after six weeks is placing the hand in the hip pocket. After adequate exercise, normal use can be expected in eight weeks. Excessive exercises are discouraged unti1 a threemonth period has elapsed. There have been no recurrences in our series. All patients have been followed for several weeks after returning to active duty, where they have done exercises and work which had caused their previous Two patients have been dislocations. examined well over a year foIlowing their operation. Both are doing strenuous army work and their shoulders were functioning normaIly. One of these men was quite neurotic and apprehensive prior to operation, but has improved and deveIoped into a useful soIdier. There have been no complications resulting from the operation. One patient has been detached from the service because of neuropsychiatric reasons. The advantages of this operation are: It is technically simple; it preserves the
of Shoulder
Amcricun Journal
of Surpcry
523
blood and nerve supply to the biceps tendon; it gives earIy and normal function and a new feeIing of support and security to the previously afflicted patient. CONCLUSION
A method for the reduction of uncomplicated dislocated shoulders, and an operation for the correction of recurrent dislocations have been presented. REFERENCES I. BAKER, L. D. NicoIa
2.
3.
4.
5.
operation; simpIified technic. J. Bone IY Joint Surg., 22: 118-r rg, 1940. HENDERSON, M. S. Teno-suspension for habitua1 disIocation of the shouIder. Surg., Gynec. Ed Obst., 43: 18, 1926. HOKWITZ, Ml. T. and DAVIDSON, A. J. Recurrent evaIuation dislocation; of Nicola operation. Surgery, 4: 74-80, 19x8. MORTON, W. I., MORTENSEN, 0. A. and SULLIVAN, W. E. Morphologic changes accompanying fixation of biceps tendon (Nicola operation); experimenta1 study on animaIs. J. Bone GYJoint Surf., 21: 127-132, 1939. NICOLA, T. Recurrent dislocation (description of operation). J. M. Sot. New Jersey, 36: 73-77,
1939. 6. SPEED, K.
Recurrent anterior dislocation at the shoulder. Operative cure by bone graft. .Surg.. Gynec. PY Obst., April, 1927. 7. ROBERTS, P. W. An operation for disIocation of the shoulder. J. Bone Joint Surg., 15: 333, 1933.
OF THE SHOULDER
LT. COL. LEONARD F. BUSH MEDICAL CORPS, ARMY OF THE UNITED STATES
T
HE frequent occurrence of disIocations of the shoulder makes this subject of interest to the general practitioner and surgeon alike. Acute or initia1 disIocations of the shoulder are common, and require not only early, non-traumatic reduction, but adequate post-reduction treatment to prevent the recurring or chronicaIIy dislocating joint. Patients suffering from recurrent dislocations of the shouIder deveIop a definite fear or anxiety complex, which can be relieved onIy by correction of the condition. With these thoughts in mind, the purpose of this article is to present a simpIe method of reduction of disIocations, and a corrective operation for the chronic diswhich have proved locating shoulder, successfu1. When the shoulder dislocates, there is not onIy a Iaceration of the joint capsule, but a stretching or sprain of the biceps tendon and its surrounding tendon sheath. At operation on recurrent1.y dislocating shoulders, it has been noticed that there is old blood along the tendon sheath, a shallow bicipital groove and a Iooseness of the transverse humeral fascia and tendon sheath at the anatomical neck of the humerus. The oId bIood has been found severa days after recent dislocations, indicating severe trauma at that point. X-ray examinations should be made of all acute disIocations of the shouIder to rule out an accompanying fracture. Thorough x-ray studies shouId aIso be made before operative procedures are undertaken. When the Iower border of the gIenoid fossa has been fractured Ieaving a shaIIow cup for the head of the humerus, contempIated suspension operations, such as that of NicoIa,5 wiI1 be Iess successful. In such instances, the operation devised would seem most efficacious. by Speed6
In recurrent dislocations in which the shouIder slips out of joint without trauma, x-ray examinations are not necessary prior to reduction. In recurrent dislocations of the shoulder folIowing the NicoIa procedure, one shouId suspect a complete atrophy of the tendon or separation of the suture site. The atrophy which has been found may be expIained by the fact that the nutritive suppIy which comes from the muscle beIIy of the biceps has been severed at operation and has not regenerated. In such cases the operation devised by Henderson2 should be considered. Acute di.sZocations, or those occurring for the first time, are reduced and treated by a body bandage and supporting sling for three weeks before motion is started. After this period of immobilization, graduated exercises are started unti1 normal activity is reached in six or eight weeks. We have had no recurrences in patients treated in this manner. This is perhaps a coincidence, but it is betieved that proper immobilization, foIIowed by gradual use, will alIow the torn capsule and tendon sheath to heal. REDUCTION
OF DISLOCATIONS
Acute or recurrent disIocations are easily reduced without trauma in the foIIowing manner. X-rays are taken as indicated. One-fourth gr. of morphine is given, either by the subcutaneous or intravenous route. With the patient lying supine, an assistant firm traction on the opposite applies arm, or the same force may be obtained by placing a sheet around the thorax. Gentle, constant and increasing traction is appIied on the involved arm, with the eIbow flexed at a right angIe, the forearm being held in a vertica1 position. The patient is reassured and asked to breathe
520
Nt-w SFH,ES Var.. LXVII,
Bush-Dislocation
No. 3
deeply and relax the shoulder muscles. While constant traction is maintained, the flexed arm is gently rotated toward the
of Shoulder
American Journal 01’Srrrgr.rv
j21
particular care being taken to preserve the anterior branches of the circumflex humeral nerve. (Fig. 2.) This precaution prevents
I
J
FIG. I. Illustrates the position of the patient and the direction of forces exerted for the reduction of disIocated shoulders.
head as shown in Figure I. The head of the humerus then slides into the joint with ease. This method has been entirely successful in al1 anterior, posterior and inferior or subglenoid dislocations, and is not as traumatizing as some of the methods and maneuvers which have been advocated. This same procedure may be used with a general anesthetic, although anesthesia has not been found necessary in a successive number of either acute or chronic dislocations of the shoulder. MODIFICATION FOR
RECURRENT
OF
THE
NICOLA
DISLOCATING
OPERATION SHOULDERS
The operative technic which is to be described has been suggested by Capt. H. W. Grosselhnger, who was associated with the Orthopedic Department at Strong MemoriaI Hospital prior to his entry into the armed forces. We have used this procedure, with some modihcations, on twenty patients. Roberts’ has described a somewhat simiIar procedure. A four inch incision Operative Technic. is made from a point just anterior to the acromium process, extending distally to the lower end of the dehoid muscle. The deltoid muscle fibers are separated posterior to the path of the cephahc vein,
postoperative atrophy of the anterior portion of the deltoid muscle, although it makes the operation slightly more difficult. By rotating the arm, the bicipital groove is easiIy palpated and the transverse humerus ligament and the synovial sheath surrounding the long head of the biceps (bicipital tendon) are opened. The entire tendon sheath is incised along the course of the tendon, including part of the joint capsule of the shoulder. Considerable bleeding can be eliminated at this point if the circumflex humerus vessels are isolated and ligated. The tendon is then removed from the groove and retracted by a cotton tape. (Fig. 3.) By means of osteotomes and chisels, a new channel is created from a point on the head of the humerus onehalf inch above the anatomical neck to the point of exit of the bicipital tendon from its sheath. (Fig. 4.) By forcing two osteotomes laterally, in opposite directions to each other, along the entire groove, a new channel approximately one-half inch deep is made in the cancellous portion of the humerus. The tape is removed, and the tendon is placed into its new groove, onehalf inch in depth in the upper shaft and head of the humerus. The contraction of the muscIe wiI1 hoId the tendon in place, but a tension suture is placed through the
522
American
Journal
of Surgery
Bush-Dislocation
tendon and fascia at its exit from the channel to keep it taut. The joint capsuIe is usualIy redundant or excessiveIy Ioose
of ShouIder
MARCH.
in two Iayers, the deltoid fascia skin, by means of interrupted sutures.
,945
and the cotton
FIG. 3. FIG.
2.
FIG. 4.
FIG. 2. The type of incision and the structures encountered, showing preservation of the circumflex humeral nerve. FIG. 3. The tendon sheath of the biceps tendon has been incised and the tendon retracted. The joint capsule of the shoulder has been opened for a short distance. FIG. 4. The osteotomes are shown in the new groove at the site of the bicipita1 depression, which shouId extend into the head of the humerus at least onehalf inch. FIG. 5. The transverse humerus fascia and tendon sheath are shown sutured over the new channe1. Insert shows tightening suture.
aIong the anterior portion. Added security is obtained by freezing the joint capsule aIong the anterior border of the neck of the humerus and pIicating it by suturing the anterior cut edge to the IateraI border of the bicipita1 groove. (Insert Fig. 5.) The transverse humerus Iigament, synovial sheath and periosteum are then sutured as one over the top of the tendon in its new channel (Fig. 5.) The wound is then cIosed
POSTOPERATIVE
CARE
The arm is supported by a VeIpeau-type dressing, care being taken to separate opposing skin surfaces by padding. New dressings are aPPIied weekly, and the sutures are removed on the seventh to the ninth day. After three weeks a11 dressings are removed, the arm is pIaced in a sIing, and earIy motion is started. At four weeks,
NF.%SEHIESVOI.. I.XVII, No. 3
BushbDisIocation
the sIing is discarded, increasing motion and physiotherapy are begun. At the end of five weeks, the patient is able to move the arm in all directions, including complete abduction and extension above the head. The only limitation after six weeks is placing the hand in the hip pocket. After adequate exercise, normal use can be expected in eight weeks. Excessive exercises are discouraged unti1 a threemonth period has elapsed. There have been no recurrences in our series. All patients have been followed for several weeks after returning to active duty, where they have done exercises and work which had caused their previous Two patients have been dislocations. examined well over a year foIlowing their operation. Both are doing strenuous army work and their shoulders were functioning normaIly. One of these men was quite neurotic and apprehensive prior to operation, but has improved and deveIoped into a useful soIdier. There have been no complications resulting from the operation. One patient has been detached from the service because of neuropsychiatric reasons. The advantages of this operation are: It is technically simple; it preserves the
of Shoulder
Amcricun Journal
of Surpcry
523
blood and nerve supply to the biceps tendon; it gives earIy and normal function and a new feeIing of support and security to the previously afflicted patient. CONCLUSION
A method for the reduction of uncomplicated dislocated shoulders, and an operation for the correction of recurrent dislocations have been presented. REFERENCES I. BAKER, L. D. NicoIa
2.
3.
4.
5.
operation; simpIified technic. J. Bone IY Joint Surg., 22: 118-r rg, 1940. HENDERSON, M. S. Teno-suspension for habitua1 disIocation of the shouIder. Surg., Gynec. Ed Obst., 43: 18, 1926. HOKWITZ, Ml. T. and DAVIDSON, A. J. Recurrent evaIuation dislocation; of Nicola operation. Surgery, 4: 74-80, 19x8. MORTON, W. I., MORTENSEN, 0. A. and SULLIVAN, W. E. Morphologic changes accompanying fixation of biceps tendon (Nicola operation); experimenta1 study on animaIs. J. Bone GYJoint Surf., 21: 127-132, 1939. NICOLA, T. Recurrent dislocation (description of operation). J. M. Sot. New Jersey, 36: 73-77,
1939. 6. SPEED, K.
Recurrent anterior dislocation at the shoulder. Operative cure by bone graft. .Surg.. Gynec. PY Obst., April, 1927. 7. ROBERTS, P. W. An operation for disIocation of the shoulder. J. Bone Joint Surg., 15: 333, 1933.