REPRINTED KROM ANNALS OF SURGERY A MONTHLY REVIEW OP SURGICAL SCIENCE AND PRACTICE EDITED BY ORIGINAL MEMOIRS UL to «*&*' ■■'■< fl» Xiniaid TRANSACTIONS OP THE NEW YORK SURGICAL SOCIETY. TABLE OF CONTENTS. 3= Fc^iatarA EDITORIAL ARTICLE. 1. Tto r^hdi. America* Svfwa. Mi INDEX OF SURGICAL PROGRESS BOOK REVIEWS. ANNOUNCEMENTS UNIVERSITY OF PENNSYLVANIA PRESS. PHILADELPHIA. PA tj.oo a Year in Advance. Great Britain: Cassell and Company. London. Single Copiet, Two Sliilliiyra. JANUARY, 1898 TREATMENT OF ACR0M10-CLAVICULAR DISLOCATION. By THOS. LEIDY RHOADS, M.D., OF PHILADELPHIA, Assistant in the Surgical Clinic, Jefferson Medical College Hospital. TREATMENT OF ACROMIO-CLAVICULAR DISLOCATION. By THOS. LEIDY RHOADS, M.D., OF PHILADELPHIA, ASSISTANT IN THE SURGICAL CLINIC, JEFFERSON MEDICAL COLLEGE HOSPITAL. Dislocation of the acromio-clavicular articulation is usually described as a dislocation of the acromial end of the clavicle, but following the usual nomenclature of dislocations it would more rightly be termed a dislocation of the acromion process of the scapula, the distal bone being the one usually spoken of as the bone dislocated. In the great majority of dislocations of this joint the acromion process is displaced downward and inward beneath the clavicle, the outer end of the latter bone riding on the top of the acromion, and the instances are very few where dislocation of the acromion takes place upward with the clavicle engaged beneath the process. This fact is readily explained when one studies the structure of the joint and the character of the injury usually received. The articular ends of the bones are simply two small plane surfaces that are held in apposition by a capsular ligament which completely sur- rounds the articular margins, but which is so lax in all po- sitions of the joint that the acromion is not tightly braced to the clavicle. This provision of laxity of the capsular liga- ment permits of a fair range of motion of the scapula upon the clavicle as the former glides upon the thorax, not only in the forward and backward and upward and downward move- ments, but also in a rotary direction, which is called for in the complex movements of the upper extremity. As the joint is superficially placed, some protection is given to it by the 2 TH OS. LEIB V RHOABS. aponeurosis of the trapezius and deltoid muscles, the fibres commingling with those of the upper surface of the ligament, while beneath the clavicle is firmly bound down to the cora- coid process by the short conoid and trapezoid ligaments, which have, however, no relation to the joint proper. In all motions in which the shoulder is engaged, the scapula moves upon the outer end of the clavicle, the latter moving in unison upon the sternum, the function of the acromio-clavicular joint being principally to preserve the ob- liquely forward direction of the glenoid cavity. That is, if there was no such joint, when the scapula slid forward on the thorax the glenoid cavity and shoulder-joint would point in- ward, and when the scapula slid backward the shoulder- joint would point outward. The joint, therefore, governs the various movements of the scapula, and keeps the glenoid cavity, at all times, in a forward position. But in accom- plishing this preservation of uniformity of position of the shoulder there is but a small-edge to edge, so to speak- articular surface of each bone on which the function solely depends, and when certain forms of injury are brought to bear upon the joint,-injuries to which the articulation is always exposed from its superficial relations and its position in the body,-a disturbance of these meagre joint relations, or dislocation, is easily brought about. The injury that may produce a luxation of this articular union is a blow of sufficient force on the back or the shoulder, as, for example, a heavy weight falling from above and strik- ing the shoulder when the body is bent forward, or the par- ticipation in an accident in which the body is hurled forcibly, striking the back or the shoulder against some solid object. If the blow lands on the front of the shoulder, a fractured clavicle usually results, whereas if the blow is struck pos- teriorly, over the acromion or spine of the scapula, the dislo- cation under consideration is what generally takes place. A blow over this particular area is, however, somewhat infre- quent, which accounts for the fact that in the vast majority of cases the blows which the shoulder sustains more generally CT? OMIO- CL A VICULAR DISL O CA 77 ON. 3 result in a fracture of the collar-bone. The injury is, how- ever, of sufficient frequency to make it one of the surgical pathological phenomena for which the practitioner must be constantly on the look-out. The recognition of the luxation is not a matter of serious study, and yet it presents, on first sight, a deformity so akin to that of a dislocation of the humerus forward that an un- practised eye may have some difficulty in exactly determining the precise lesion. The rotundity of the shoulder will be destroyed, and the projection of the overriding clavicle may be mistaken for the apparent projection of the acromion in shoulder-joint dislocation. When, however, it is remem- bered that the shoulder-joint is depressed but that its motion is not seriously curtailed,-i.e., it is not rigid; that the shoul- der-joint is carried slightly forward and inward; that the hand of the injured side may easily be carried to the shoulder of the sound side when the elbow is on the chest; that by following the line of the clavicle the normal relations of this bone with the acromion are disturbed, the clavicle being on top; that there is no marked fossa above the head of the humerus; and that the projection of the clavicle is fully one inch within the line of the humerus,-one cannot fail to rec- ognize the actual condition. The treatment of the luxation will necessarily consist in reduction, and retaining the limited articular surfaces in po- sition until union of the torn capsular ligament is established. The former is usually easy, the latter most difficult. Reduc- tion can be effected by pushing upward and outward on the arm, which raises the glenoid cavity and scapula, and by manipulation pressing down the overriding end of the clavicle into its normal position and relation with the acromion. This may be done with or without anaesthesia according to the pain-resisting powers of the patient. The retention of the bones in position now becomes a matter of some difficulty. Desault's dressing is usually rec- ommended, but it proves inadequate for the purpose, the deformity being resumed after the lapse of a few hours, when 4 THOS. LEID Y RHOADS. bandages have stretched and muscles are relaxed. Stimson's adhesive plaster dressing has the disadvantage of causing erosion of the skin in most patients before ligamentous union takes place, which erosion at least is a source of great annoy- ance, and the test of the efficiency of the method as a curative agent is rendered rather dubious by the information which accompanies the description; "Recurrence can be readily detected through the plaster by the finger or the eye." In fact, some text-books even go so far as to say the retention of the bone in place after reduction presents so many diffi- culties that it is not worth while to attempt it; to this, how- ever, we could not rightfully acquiesce; a method of treat- ment which has answered admirably in the writer's hands seems to meet all the requirements for obtaining a satisfac- tory result, and the application may be set forth in the follow- ing case: H. H., aged forty-five years, of strong muscular develop- ment. Sent by Dr. Eugene Reade, of Atlantic City. While the patient was driving in a carriage the horse became unmanage- able and ran away, upsetting the vehicle and hurling its occu- pant out into the road. He struck the earth forcibly with the upper and back part of his right shoulder, and when found was suffering with a marked deformity of the shoulder, bruises at different parts of the body, severe pain, and shock. A temporary dressing was applied to the shoulder and the patient was sent to this city in the writer's care on the following day. On examina- tion there was found considerable swelling, but not sufficient to occlude a marked prominence of the outer end of the clavicle, the acromion could not be felt, and the shoulder was depressed and approximated to the middle line of the body. There was also an apparent lengthening of the right arm. The patient suffered such intense pain that I decided to give him an anaesthetic to effect the reduction, and determine at the same time if there was any fracture associated with the luxa- tion. I called to my assistance Dr. J. C. Brick, and while he anaesthetized the patient the reduction was effected by the aid and advice of Dr. J. Chalmers Da Costa, no other lesion being found. A pad was placed in the axilla, and a Desault bandage Fig. i.-Showing the dressing after reduction. Fig. 2.-Bandage applied, with arm and elbow anchored to side. A CR OMIO- CL A VICULA R DISL OCA TION. 5 applied. The following day it was found that the deformity had reappeared, and, on being reduced by manipulation, the same dressing was reapplied more tightly. This, too, failed to keep the bones in position, and the patient complained of the pain from the tight dressing. Other dressings were then applied ac- cording to prescribed methods, and each day the deformity was found to persist. At the end of a week, in conversation with Dr. Da Costa regarding the case, it was suggested that a strap fastened over the shoulder and drawn as tightly as the patient could stand might prove capable of holding the bones in place, and after again reducing the dislocation and holding the bones in position, the writer applied the dressing as shown in Fig. A. A wedge-shaped pad of absorbent cotton rolled in a towel was placed under the arm, the apex of the pad being pressed firmly into the axilla. A folded towel of heavy texture was placed across the shoulder so as to make it possible to exert pressure over a broad area at the site of injury, and a strap two inches wide (an ordinary trunk-strap was used in this instance) was thrown across the shoulder and under the elbow, and tight- ened. A pad of absorbent cotton prevented too great pressure on the elbow where the strap crossed. The strap was drawn as tightly over the shoulder as the patient could well bear, the point where pressure was exerted being internal to the joint,-i.e., be- tween the articulation and the root of the neck,-so as to control both the scapula and the clavicle, and the trapezius muscle, with- out causing the pain of pressure directly over the site of injury. A single retaining bandage passed under the opposite axilla pre- vented the strap from slipping off the shoulder. As will be readily seen from the illustration, the placing of the wedge- shaped pad under the arm, with the broad base downward, made it possible to exert pressure on the arm in the line which would do the most good,-upward, outward, and backward, raising the glenoid cavity and with it the scapula, while the clavicle was pushed downward by the same force, and thus prevented from again riding up over the acromion. A roller bandage around the chest anchored the arm and elbow to the side, the buckle of the strap not being covered in, so that the strap could be tight- ened, if necessary, without disturbing the rest of the dressing. (Fig. B.) The skin was prevented from being irritated by strips of 6 THOS. LEID Y RHOADS. cotton properly placed. As the patient became accustomed to the pressure, and the shoulder pad felt somewhat loose on the day following the application, the strap was drawn several holes tighter, the bones being found, however, to have remained in good position during the intervening twenty-four hours. This dressing was kept in situ for a week, the parts being examined daily to see that the bones had not slipped. At the end of a week, a hand was inserted under the shoulder pad and the bones firmly held, the arm being held in a fixed position by an assist- ant, while the entire dressing was removed and the skin surface bathed. The dressing was reapplied weekly after this for two weeks longer, at the end of which time it was discarded alto- gether, and a spica of the shoulder substituted for still another week. All dressings were then withheld. Some pain was ex- perienced on the side of the neck after the original dressing was discarded, which was likely due to some injury to the nerves con- stituting the cervical plexus at the time of the accident. This disappeared on massaging the parts daily for several weeks, and the patient is now in excellent condition, having full use of his arm, without any pain or deformity in the shoulder. The good result obtained in this case, and the simplicity of the application, would tend to recommend the method as a suitable one in the treatment of this refractory lesion.