Roentgenological Studies of Traumatic and Recurrent Anterior and Inferior Dislocations of the Shoulder Joint 9780773592995

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IVAN HERMODSSON, M.D. (WOI-) IVAN HERMODSSON w i t s horn in the Pro\.inrc of Skine, Swedcn, on Octoher 2nd. 1901.

He beran his xnediei~l stndies in 1920 a t t h r University o l Lunrl, and obtained his 3I.K. (Medical Cnndidatc) in 1924, and his h1.1. (Jledieal Lieeneistr) in 1928. His post-pmdantr studies were largely in thc field of R;tdiolngy nnd h e obtained his Doctor o l Medicine (M.D.) degrce in 1934 a t tho snrnc University, nrxl this present publication forrnetl t h e thcsis for this dogrce. It was published in German in the Aetn Rndiologica (Stockholm) ns Supplemmtnm XX it, the same year. Hermodsson hns also contributed a number of scientific pnpcrs in Diagnostic Roentgenology and Pnthologienl Anatomy o n subjects denling with t h e musculo-skeletal system. I n 1934, Dr. Hcrntodsson was awarded the King of Swedcn's Trnvelling Fellowship for studies o n t h e European eontincnt. I n 1935 h c was appointed Radiologist-in-Chid a t the County Ccntrol Hospitnl, Karlskrona.

He h a s held t h e post of Rndiolagist-in-Chie n t t h e Hospital in Hiilsinghorg since 1948.

HERMODSSON'S ROENTGENOLOGICATJ STUDIES OF TRAUMATIC AND RECURRENT ANTERIOR AND INFERIOR DISLOCATIONS OF THE SHOULDER JOINT

EDITED 13Y

H. F. MOSELEY LA., D.M., ~I.CII.(OSOK).), F.R.C.S. (EKG. AXD CANADA), F.A.C.S. DIRECTOR, A C C I D E S T SERVICE, A K D SURGEOS, ROYAL VICTORIA IIOSI'ITAL, ASSOCIATE PROFESSOR O F SURGERY, DICGILL UKIVERSITY, DIOKTREAL, HUNTERIAN PROFESSOR, ROYAL COLLEGE O F SURGEOSS O F EXGLAND.

AND

DIERCK, S H A R P A X D DOHDIE RESEARCII FELLOW, ACCIDEXT SERVICE, ROYAL VICTORIA HOSPITAL, BIOXTREAL.

Originally prcblislrecl in German in Acta Rndiologica (Stockholnl) as Srrpplementum X X , 1934.

--.-. ..-,_-MUP iC: 4

MONTREAL McGILL UNIVERSITY PRESS 1963

@ COPYRIGHT, CANADA, 1963 McGill University Press All rights reserved Printed in Great Britain

EDITORS' FOREWORD The purpose of this publication is to make available to readers of the English language the classic thesis by Dr. Hermodsson, which was originally written in German, and now has become unavailable in that form. The radiological and surgical literature on shoulder disorders in English reflects little knowledge of this excellent investigation. It is hoped that this translation will be of value to both radiologists and surgeons interested in advancing their knowledge of this subject. Our original translation was started for the senior editor by Dr. F. H. Lowy and Dr. Peter Meiisel when the monograph "Recurrent Dislocation of the Shoulderw*was being prepared. The presence of the junior editor, from the University of Goteborg, in Montreal for a year of research on shoulder disorders, has made it possible to give this careful translation to the English-speaking reader. Dr. Hermodsson has kindly agreed to this publication, and has supplied all his original illustrations, only one of which required replacement. Montreal, 1961.

* Moseley, H.F.: "Recurrent Dislocation of the Shoulder", Edinburgh, E. & S. Livingstone, and Montreal, McGill University Press, 1961.

AUTHOR'S ACKNOWLEDGEMENTS At the conclusion of my work it is a pleasant duty for me to express my deep gratitude to my chief, Lars Edling, M.D., Radiologist-in-Chief a t the University Hospital in Lund, for the kind interest with which he has always supported my work, as well as for the valuable discussions we have enjoyed together. I wish t o express my sincere gratitude t o Professor Hugo Laurell, M.D., Radiologist-in-Chief a t the Academic Hospital in Upsala, for the part he has played in my investigations as well as for his assistance in placing materials a t my disposal. Through his kindness it became possible for me to undertake part of my investigations in his Department. I am deeply indebted t o Professor Gustaf PetrCn, M.D., Surgeon-in-Chief in Lund, for placing clinical records a t my disposal. I wish t o thank Professor Torsten Hellman, M.D., Lund, most sincerely for the worthwhile discussions concerning the investigations carried out in the Department of Histology in Lund. I am also much indebted t o Dr. Tage Larsson, Ph,Lic., Department of Statistics, University of Lund, for assisting me with the statistical calculations. Finally, I wish t o thank the nurses in the Department of Roentgenology in Lund and in the Academic Hospital, Upsala, for their help in carrying out the roentgen examinations.

TABLE OF CONTENTS Page EDITORS'

v

FOREWORD

AUTHOR'S

ACKNOWLEDGEMENTS

vii

1

INTRODUCTION

PART I : HISTORICAL SURVEY

1880 1880 TO

A. BEFORE B. FROM

THE PRESENT DAY

PART I I : CONTRIBUTION TO T H E OSSIFICATION KNOWLEDGE O F T H E UPPER END OF THE HUMERUS

27

ROENTGEN EXAMINATIONS O F DISLOCATIONS O F T H E SHOULDER JOINT CHARACTER AND EXTENT OF THE MATERIALS TECHNIQUE USED FOR THE ROENTGEN EXAMINATIONS

30 31

RECURRENT DISLOCATIONS

34

TRAUMATIC DISLOCATIONS

45

DISLOCATIONS UNCOMPLICATED B Y FRACTURE O F T H E GREATER TUBEROSITY

47

DISLOCATIONS COMPLICATED BY FRACTURE O F T H E GREATER TUBEROSITY

60

REMARKS REGARDING T H E CONCEPT OF T H E MECHANICS O F ANTERIOR AND INFERIOR DISLOCATIONS O F T H E SHOULDER CAUSES O F RECURRENT DISLOCATIONS ROENTGENOLOGICALLY RECOGNIZABLE CHANGES COMPATIBLE WITH ARTHRITIS DEFORMANS I N T H E SHOULDER JOINTS OF MY CASES GENERAL SUMMARY

PART I I I : CASE RECORDS

REFERENCES INDEX OF NAMES

77 93

LEGENDS FIGURE 1

ILLUSTRATION O F RESECTED H E A D O F HUMERIJS, P U B L I S H E D BY K ~ ~ S T E R1882, , SHOWIXG LARGE POSTERO-LATERAL NOTCH

FIGURE 2

SIMILAR D E F E C T ON RESECTED IIUMERAL H E A D P U R L I S H E D B Y CRARIER, 1882 POPKE'S ILLUSTRATION (1882), SHOWING A POSTERIOR D E F E C T ON A RESECTED H E A D O F HUMERUS

FIGURES 3 & 4

STAFFEL'S (1895) T W O RESECTED SPECIMENS WIT11 LARGE POSTERIOR DEFECTS

FIGURES 5 & 6 FIGURE 7

V E R Y LARGE POSTERO-LATERAL NOTCH ON A RESECTED H E A D OF HUMERUS, PUBLISHED BY WEKDEL, 1903

FIGURE 8

PILZ' (1925) ILLUSTRATION, SIIOWING A "TYPICAL DEFECT ON TIIE HEAD", AS RECORDED BY ANTERO-POSTERIOR ROENTGEN PROJECTION (A-B) INDISTINCT CONTOUR (C ) NARROW, WEDGE-SHAPED SHADOW (MEDIAL BORDER OF THE DEFECT)

FIGURE 9

THE ARRANGEMENT FOR THE AUTHOR'S TANGENTIAL PROJECTION OF THE HUMERAL HEAD ( L C 3"). ~ THE DIA~ GRAM SHOWS DIRECTION OF CENTRAL RAY. (COURTESY MOSELEY, H.F. (1961): "RECURRENT DISLOCATION OF THE SHOULDER", EDINBURGH, LIVINGSTONE)

FIGURE 10

PILZ' (1925) ILLUSTRATION, SHOWING A "TYPICAL DEFECT ON THE HEAD", AS RECORDED BY ANTERO-POSTERIOR ROENTGEN PROJECTION (A-B) INDISTINCT CONTOUR (C ) NARROW, WEDGE-SHAPED SHADOW (MEDIAL BORDER OF THE DEFECT)

FIGURE 11

T H E T W O LEVER-MECHANISMS ON ELEVATION O F T H E ARM WITH FIXED SCAPULA (SCHEMATIC) FROM: SOMMER

FIGURE 12

(1928),

"NEUE DTSCH. CHIR",

41, 1954.

L E F T SHOULDER J O I N T , ANTERIOR VIEW. T H E U P P E R ARM I S P U L L E D DOWNWARDS W I T H FORCE; T H E OBLIQUE LIGAMENT HAS B E E N REMOVED I N ORDER T O OBTAIN A B E T T E R V I E W O F T H E OTHER LIGAMENTS. 1. CORACO-HUMERAL LIGAMENT. 2. S U P E R I O R GLENO-HUMERAL LIGAMENT. 3. MIDDLE GLENOHUMERAL LIGAMENT. 4. I N F E R I O R GLENO-HUMERAL IdGAMENT. 5. TRICEPS MUSCLE (LONG HEAD). 6. SUBSCAPULARIS MUSCLE (REFLECTED). 7. LONG HEAD OF BICEPS BRACLIII MUSCLE.

FROM: DELORME

(1910),

"ARCH.

ICLIN. CHIR."

92, 86.

~

~

~

FIGURE 13

SCHULTZE'S (1914) RADIOGRAM, SHOWING COMPLETE DETACHMENT O F T H E GREATER TUBEROSITY A N D A FRACTURE O F T H E GLENOID I N A CASE O F RECURRENT DISLOCATION. T H E H E A D L I E S LOW AND IMPINGES UPON T H E I N F E R I O R GLENOID RIM B U T HAS OTHERWISE NO CONTACT WITIF T H E GLENOID FOSSA.

FIGURE 14

T H E GRAPH SHOWS T H E RELATIVE NUMBER O F DISLOCATIONS, E X P R E S S E D I N P E R CENT O F T H E TOTAL NUMBER O F CASES, WHICH HAVE TAKEN PLACE PRIOR TO A CERTAIN AGE, (SEE T H E TABLES, COLUMN "c")

FIGURE 15

DOUBLE LAYER O F ARTICULAR CARTILAGE O N T I I E RIGHT FEMORAL CONDYLE. FEMALE, AGE 74. CELLOIDIN SECTION. ARCH." 260, 562 FROM: H E I N E (1926), "VIRCHOW'S

PLATE I

RADIOGRAMS AND ANATOMICAL SECTIONS DEMONSTRATING T H E OSSIFICATION O F T H E U P P E R E N D O F T H E HUMERUS

PLATE

n

RECURRENT DISLOCATIONS

PLATE I11

RECURRENT DISLOCATIONS

PLATE IV

RECURRENT DISLOCATIONS

PLATE V

TRAUMATIC DISLOCATIONS: COMPRESSION FRACTURE

PLATE VI

TRAUMATIC DISLOCATIONS:

PLATE VII

TRAUMATIC DISLOCATIONS : COMPRESSION FRACTURE

PLATE VrII

TRAUMATIC DISLOCATIONS: COMPRESSION FRACTURE.

PLATE IX

TRAUMATIC DISLOCATIONS:

COMPRESSION FRACTURE

COMPRESSION FRACTURE

PLATE X PLATE XI

TRAUMATIC DISLOCATIONS : FRACTURE TUBEROSITY

OF

THE

GREATER

TRAUMATIC DISLOCATIONS : FRACTURE TUBEROSITY

OF

THE

GREATER

OF

THE

GREATER

PLATE XIII TRAUMATIC

DISLOCATIONS : FRACTURE

TUBEROSITY

PLATE XN

ARTHRITIS DEFORMANS I N T H E SHOULDER J O I N T

PLATE X V

ARTHRITIS DEFORMANS I N T H E SHOULDER JOINT: (SEE PAGE 107)

PLATE Xm

ARTHRITIS DEFORMANS I N T H E SHOULDER JOINT

CASE E-F-

INTRODUCTION THE STIMULUS for my investigations of shoulder dislocations came when, during radiological studies of traumatic dislocations several years ago, I found a peculiar change in the head of the humerus to which I was unable to find any reference in the literature on these disorders. On the contrary, similar changes in recurrent dislocations (the "typical defect") have been described; I have therefore made it my task t o study the different types of defects found in the various types of dislocations. First, however, it was necessary to work out a special technique of radiological examination, by means of which one could obtain a satisfactory general concept of the anatomical relations in these disorders.

I have tried to show by means of the results obtained regarding thc origin of these defects that, contrary t o presently accepted theories, the complication which often appears with traumatic dislocation, i.e. fracture of the greater tuberosity, itself originates in the same way as does the defect. After this I have examined the present theories on the mechanism and causes for development of recurrent dislocations. I have, a t the same time, tried to determine to what degree the results of my tests could assist in clarifying obscure points in present teaching. Finally, in my own cases of shoulder dislocations, I have attempted to find whether there are roentgenological changes characteristic of arthritis deformans, and, if present, what these are.

PART 1, HISTORICAL SURVEY*

HISTORICAL SURVEY A. BEFORE 1880 Dislocation of the shoulder is the commonest of all dislocations, and produces serious and significant damage. The subject has, therefore, attracted the interest and attention of the medical profession from the earliest times. HIPPOCRATES gives us detailed descriptions of both the clinical symptoms and methods of reduction. I n fact, one must marvel at the knowledge of the field displayed in his chapter on the problems of joints. With regard to the various types of dislocations, HIPPOCRATES recognizes only one, i.e. that into the axilla. He is uncertain about the possibility of an anterior dislocation, although a t that time it must have been frequently seen. Recurrent dislocations were well known to HIPPOCRATES. I n his opinion the cause of recurrence is, chiefly, the absence of secondary inflammatory changes, which would "bind the joint and hold it together". I n his therapeutic method, HIPPOCRATES produced the inflammatory changes by cauterization of the axilla, thereby securing scar tissue to prevent the dislocation of the humeral head. The teaching on shoulder dislocations, their causes, clinical symptoms and treatment remained generally unchanged for a long period after HIPPOCRATES.

CELSUS mentions two types of shoulder dislocations, namely the anterior and the inferior. He adds nothing new to the teaching of HIPPOCRATES with reference to symptoms or treatment. PAULOF AEGINA(quoted by BARDENHEUER) mentions anterior, inferior, and lateral dislocations. Until the beginning of the 18th century, science made no appreciable progress in the knowledge of pathologico-anatomical changes or of the mechanism of shoulder dislocations. At that time increasing interest was sho~vnin this subject. Primarily, it was the mechanism of the traumatic dislocations which received attention. The French scientist F A B R formed ~ new theories which remained undisputed well into the 19th century. According to FABRE, the mechanism is as follows: "If the arm is struck in the region of the elbow or the hand by a force which propels it into abduction while the muscles of the lower portion of the shoulder joint (pectoralis major and latissimus dorsi) simultaneously contract, the head of the humerus descends from the joint socket into the axilla. Then the type of secondary dislocation downwards which will result from the

primary displacement will depend on the continuation of. the external force or on further muscular contractions."

At the end of the 18th and the beginning of the 19th centuries, a start was made in obtaining greater knowledge of the mechanism of shoulder dislocations and of the anatomical relations by means of experimental investigations on cadavers. Significant names of this era are BONN,MALGAIGNE, ROSER, BIGELOW, Busca, and STREUBEL. On the basis of knowledge gained in cadaver experiments, doubts arose as to whether the muscles in fact have the deciding influence on the dislocated position of the humeral head which FABRE attributed to them. ROSER,in 1842 writes: "The luxation which all modern authors unanimously accept as the most common, i.e. that of the humeral head downwards into the axilla onto the neck of the scapula between the triceps and the subscapularis, must be looked upon as an exceptional rarity; what usually is described under this name is invariably the dislocation between the shoulder blade and the subscapularis." These cadaver experiments, continued by numerous investigators have played an important role in the understanding of the anatomical relations and the mechanism in shoulder dislocations. Their conclusions are still considered correct in most respects. It is, in fact, often impossible to determine whether an author in this field bases his findings on facts he has unearthed during his patient's life time, or on postmortem observations. I shall not express an opinion here regarding the merits of such conclusions based upon cadaver experiments but will only mention what I~RONLEIN said in 1882 in his "Lehre von den Luxationen". "These experiments showed that the typical or regular (BIGELOW) dislocations always present a typical anatomical picture; they also permitted us, for the first time after long-standing erroneous belief, to deduce the characteristic signs of the dislocation from the type of tissue-damage and, furthermore, to prepare a therapeutic plan on a strictly anatomico-physiological basis. The place of the muscles, which heretofore have been considered to play so important a role in the pathology of dislocations is now taken by the joint capsule. The capsule is always torn if the dislocated joint was previously normal. Those parts of' the capsule which are not torn are taut, distorted or displaced, as are the auxiliary ligaments strengthening the capsule. These, because of their sturdy structure, are able to resist the pulling and stretching force and for this reason remain totally or partially untorn. These, the undamaged parts of the capsule and the auxiliary ligaments afford the only basis for stability of the luxated head in its new location and the characteristic position of the dislocated limb. On the contrary, if the capsule, together with the most important auxiliary ligaments, is completely torn, (lesionswhich may occur in exceptional cases if considerable force has been applied), the characteristic fixation is absent as is the typical displacement of the head. This luxation is then atypical, and its signs are not constant." or irregular (BIGELOW),

HISTORICAL SURVEY

In the chapter on mechanisms, I will return to the question of the value of cadaver experiments for the purpose of correlation with the diagnosis of dislocations in vivo. Before this, however, I shall report about new findings regarding in vivo pathologico-anatomical changes. The author will also deal with the complications occurring in the dislocations of the various joints of the extremities, i.e. with fractures a t the articular ends of the component bones; it is agreed that fractures which involve bony projections near joints often arise because of the tearing of the attached muscles or ligaments ("Fractures par arrachement" MAISONNEUVE).The fracture of the greater tuberosity in shoulder dislocations is also generally designated such a sprain-fracture. KRONLEIN (1882) and BARDENHEUER (1886) are of the same opinion. However, DEUERLICH (1874) came to a different conclusion on the basis of his cadaver experiments. I n my chapter on the origin of fractures of the greater tuberosity I shall go into further detail on this subject. At this time DUCHENNE conducted his well known experiments on the function of the muscles and the physiology of movements. I n this connection, his electrical experiments on the function of the deltoid and supraspinatus deserve special mention. DUCHENNE found that, when the deltoid contracts independently, the head of the humerus tends to be subluxated downwards, and it is primarily the supraspinatus which opposes this. have played a certain role in the The results obtained by DUCHENNE discussion on causes of recurrent dislocations.

B. FROM 1880 TO THE PRESENT DAY I. RECURRENT DISLOCATIONS One might say that around 1880 there began a new period in the history of shoulder dislocations characterized by a primary interest in recurrent dislocations. During the long period of time which had elapsed since Hippocrates, science had not made any major progress in this field. I n 1880, JOESSEL, Professor of Anatomy a t Strassburg, published the first precise descriptions of examinations of shoulder joints presenting recurrent dislocations. His most important findings, from dissection of four shoulder joints, were tearing of the supra- and infra-spinati muscles from their insertions on the greater tuberosity and an associated tearing of the joint capsule from the lateral and postero-lateral part of the anatomical neck. Thereby the head of the humerus has made direct contact with the lower surface of the acromion. A new capsular wall has formed which, however, is fastened to the rim of the acromion and t o the greater tuberosity which, thereby, has moved into a partly intra-articular position. As a consequence the joint capsule is enlarged.

conclusions from these experiments were: a. The predisposition for recurrence of shoulder dislocations is produced by the tearing of muscles which have not grown together again with the head of the humerus. b. Recurrence is favoured by the constant enlargement of the capsule. In very rare cases an additional reason for recurrence is a fracture of the glenoid rim or the head of the humerus, and the subsequent decrease of the articular surface. JOESSEL'S investigations have attracted the interest not only of his contemporaries but also of later investigators in the field of dislocations. This is partly because, since the publications of JOESSEL, only isolated precise anatomical investigations of shoulder joints have been made in corpses of patients with recurrent dislocations. This is a great pity because a t operation the surgeon is usually not in a position to conduct an exact examination of changes in the joint as a whole.

JOESSEL'S

Operative Methods Shortly after JOESSEL'S investigations, knowledge of recurrent dislocations was further advanced when surgeons began to operate on these shoulder disorders. The operative technique first used was resection of the head of the humerus. Thanks to the resected operative specimens, our knowledge of the changes in the head of the humerus present in cases of recurrent dislocation has been considerably increased. The first information about resection of the head came in 1882 from KUSTER(Berlin), KRAMER(Wiesbaden) and POPKE(Halle). KUSTER, however, also mentions that shortly before this VOLKMANN operated on three cases in the same manner. Almost simultaneously, attempts were made to avoid recurrences of the dislocations by shrinking the joint capsule. BARDENHEUER, in his great work "Die Verletzungen der Extremitaten" (Injuries to Extremities), 1886, mentions that he had performed such an operation. Around 1888, arthrodesis of the shoulder joint was performed by ALBERTand others, in some cases. FRANCKE pointed out in 1898that W. MULLER had performed advancement of the external rotators. .HILDEBRAND, 1901, reveals that he attempted to prevent recurrence by deepening the joint socket so that an elevated anterior rim was created. There have not been many proponents of this technique. PERTHES, 1906, published reports of operations in which he describes different methods which he himself had employed in various cases. In some he refastened the torn external rotators to the greater tuberosity. I n others he found that the capsule had been torn from the anterior rim of the glenoid fossa; here he refastened the capsule and the glenoid labrum to the anterior rim of the fossa. PERTHES is the one who insisted that, in

HISTORICAL SURVEY

this field, operations should be directed at the cause of the disorders. Although in his own cases he achieved excellent results, he has not had many followers.

CLAIRMONTand EHRLICH introduced a new principle into the operative treatment by performing myoplasties. A part of the deltoid was used to restrict the head of the humerus to the glenoid fossa when excessive range of motion was present. Other operative procedures using muscles were subsequently introduced, for instance that of FINSTERER and ROPKE. I n another group of operative procedures check ligaments were devised for the humeral head which suspended it, for example, from the acromion. I n 1918, EDENreported a new technique, transplantation of a piece of bone to the anterior part of the neck of the scapula in order to strengthen the anterior rim of the socket. The torn capsule was then fastened to the strengthened socket rim. Almost simultaneously with EDEN,HYBBINETTE here in Sweden began similar operations. These seem to me to be the most important dates in the history of operations for this disorder. Many variations of these techniques exist, but I have no reason to delve into them on this occasion. Of some importance, however, is the fact that many of these operative techniques are extraarticular, and for this reason the surgeon obtains only an incomplete insight into the changes which have occurred in the joint in any particular case. During the last few years radical operations involving the joint have been avoided where possible for fear of secondary changes in the joint. Concerning this PERTHES stated (1926) that extra-articular methods were principally preferred. (Congress of the German Society of Surgery, 1920). This tendency to perform as few radical operations as possible has had the unfortunate result that our knowledge of the anatomical changes in recurrent dislocations has not increased of late. Therefore, to give a summary of the lesions found in recurrent dislocations, one must concentrate on the earliest years during which operations were performed. The Typical Defect of the Head of the Humerus

Anatomical Examinations As previously mentioned, the earliest operative technique used in cases of recurrent dislocations was resection of the head of the humerus. On the specimen obtained in this way, a peculiar change was found which had previously been unknown, and which was not obtained when experimental dislocations were produced on cadavers. This change consisted of a defect in the postero-lateral part of the articular surface of the humeral head which was covered by cartilage. The defects which different surgeons found in their cases showed a great similarity and, as earlyas 1887, LOBKER

shelved t h a t his resected specimens correlated well with those described b y others. Because of the characteristic appearance of the defect in the head of the humerus, it has been generally called L'the typical defect", and this term persists.

I should now like t o repeat a few typical descriptions which various surgeons have published concerning their resected specimens. They have been of grmt importance for my investigations since new. specimens of this sort are now unobtainable for examination. Several authors have included with their descriptions good illustrations which I shall reproduce as well.

I i i j s (1882): ~ ~ ~ "There Isas considerable splintering of the hnmeral head which made it appear much smaller" (Fig. 1). CRAMER(1882): L'The closer view of t h e resected head showed an appearance which deviated considerably from the normal. A rather large part of the articular surface was missing from the postero-lateral part of the posterior rim of the greater tuberosity, just where t h e capsule begins t o insert. Also, instead of the convexity, there was a n excavation. When the entire defect was filled with wax, a boat-shaped model was obtained which measured $ cm. a t its deepest point, 4 cm. i n its length from above downwards, and 2 cm. in its width. Thus the boundary of the articnlar surface deviated from its usual circular form i n a FIGURE 1. oc resectcabend hlmcms,C O ~ S ~ ~ C U O manner. US It appeared as if a p8rhlirl~cd1,y Xiislcr, 1882, showing Imge Segment of .?bout one-third length of postrro-ltatcrnl notell its radius was cut off." I n the joint, CRAMER fonnd "a loose body of irregular form, measuring about 1 em. in its greatest dimension; i t had even surfaces and, as shown b y later examination, its core was osseus tissue, while the outer layer was formed of fibrous connective tissue with some cartilage deep t o this. It hung on a very thin fibrous thread about 2 cm. long attached t o the posterior rim of the glcnoid fossa (Fig. 2). LOBICER (1887): T ~ v opreparations, both from individuals suffering from recurrent shoulder dislocations: on its outer half, bordering on the greater tuberosity, the head has lost its convexity. Here there is a defect, spanning the entire height of the head, which measures nearly 1 cm. in depth and 2 cm. in breadth. This defect is set off from the relatively normal part of the head by a sharply protruding ridge, which is absolutely regular throughout. The bone adjacent to the defect is completely covered b y cartilage

HISTORICAL SURVEY

and nowhere is there evidence of previous splintering. The tuberosities and the Defect bicipital groove are intact, but the long tendon of the biceps has been torn from the labrum and has become attached within the groove. Only the smaller, lateral part has remained of the original glenoid fossa, which is sharply demarcated medially by a vertically inclined edge. The larger, inner portion of the scapular alticular surface does not lie in the same plane as the outer part, but meets it a t an angle a t the edge previously mentioned. The FIGURE 2. inner segment is completely regular, is Similar defect on resected humeral head covered by cartilage, and shows no trace publisl'ed by Cram-, 1882 of previous avulsion. The humeral head and the cavity fit together in such a way that the relatively normal inner segment of the head articulates with the inner half of the fossa, and the notch-defect of the head rides on the protruding glenoid rim. There exists, therefore, a subluxation of the head with formation of a neoarthrosis". POPKE(1882): "The head, otherwise covered by normal cartilage, is deformed so that i t presents a defect posteriorly on its cartilaginous surface" (Figs. 3 and 4). SCHULLER (1890): "Here too there is a defect on the head in the same place as in the resected specimens of other surgeons." STAFFEL (1895) "The humeral head showed an extensive defect, the joint relations being otherwise completely normal. Resected specimen: in its postero-lateral segment the humeral head shows a defect occupying nearly one-third of its surface. A wedge-shaped piece is missing, and the defect throughout shows a completely smooth surface of separation, as if the piece had been cut out with a saw. The greater part of the surface of the defect consists of exposed sclerotic bone while the smaller portion is covered with a sturdy, shiny white membrane. Microscopic examination of this membrane reveals that it consists of vascular connective tissue containing, for the most part, few nuclei, which is interspersed with generous clumps of pigment and pigment-containing cells; very small flecks of well developed cartilage, which lie directly on the bone, can be found beneath this membrane, but only in isolated places. The bone itself is absolutely normal" (Case I, Fig. 5). STAFFEL (Case 11): "The head of the humerus again shows a defect on the posterior periphery of exactly the same kind and extension as in the case already described. The formation of the defect here concerns exactly the same segment of the head of the humerus which, in the position of luxation, presses on the anterior edge of the joint socket; it is that portion of the

FIGURES 3 & 4. Popke's Illustration (1895), showing a posterior defect on a resected head of humerus.

head which, first and foremost, was pressed against the anterior rim of the socket and was bruised a t the beginning of the luxation and during subsequent movements of the luxated head. For the most part, the surface of the defect shows sclerotic, mirror-smooth bone; only towards the periphery is it covered by a thin, tough connective tissuk membrane" (Case 11, Fig. 6).

FRANCKE (1898) (Case I, No. 15): "In the postero-lateral part of the head of the humerus there is a sharply demarcated notch about d) cm. deep, 2 cm. long and 1 cm. wide, which is thinly covered with cartilage. Its floor and edges are irregular and slightly bumpy. From the edge, several small cracks reach out into the surrounding area. In the joint there is a loose body which corresponds to the shape of the defect in the head, and has smooth cartilage on one side and a bony fracture surface on the other. On the anterior rim of the socket, there is a narrow defect in the cartilage. The fragment corresponds exactly to the depression in size and shape to the smallest detail; it can be fitted precisely into the defect, and it then restores the normal cartilage-covered convexity of the head."

WENDEL(1903): "The head of the humerus had a large defect on its posterior surface which reduced its normal articular arc to about two-thirds. The head was resected, but the missing bone fragment was not found inside the capsule. There was no tuar in the capsule. The defect lies on the posterior and lateral portion of the circumference of the head and is bordered by two completely smooth surfaces which are at an approximate right angle to each other. With the arm dependent, these surfaces run vertically, so that a horizontal cut, which would bisect the head of the humerus, would

HISTORICAL SURVEY

also bisect the defect. The outer surface is located approximately a t the site of the anatomical neck. Therefore the greater tuberosity is preserved and the portion of the cartilage-covered joint surface which is situated medially and posteriorly to it is missing. The second, or inner surface of the defect forms a right angle with the first one so t h a t about half of the joint surface has disappeared. Both surfaces of the defect are smooth and, as is evident even macroscopically, are for the most part covered with a thin connective tissue layer which appears tendinous in the alcohol preparation. On the medial borders of the defect, the joint cartilage slopes abruptly and without transition towards the defect, so t h a t the thickness of the cartilage may be seen, as it were, cut transversely. One may then observe t h a t the joint cartilage does not adhere t o t h e bone evenly, but t h a t for a length of about 1 cm. it is considerably thinner. This thinning can also be detected on the surface of the preserved joint cartilage, covering

FIGURES 5 & 6. StnfTcl'r (1895) lrvo resected specimens wit11 litrgc l>osleriordefects

a n area about 2 em. in diameter. The cartilage here is so thin t h a t the hone shines through distinctly. At the rim of this thinned area t h e cartilage is separated into fihres. Various transverse sections of the hcad of the humerus were decalcified and examined microscopically after having been fixed in formalin. It was found that in the defect, the cancellous hone lies partly uncovered and is partly covered by a delicate connective tissue layer which joins the open marrow spaces. I n the neighhourhood of the defect, the spongiosa is denser than usual, and the marrow between the bone traheculae is more vascular. The trabeculae bordering immediately on the defect are mostly necrotic, irregular on their free margins, and covered with giant cells. Giant cells are also present whcre fragments of viable bone are lying free in the defect. Some young, newly formed trahcculae can be found beneath the surface of the defect in the neighbouring marrow spaces, and some also on the free edge where they jut into the granulation tissue which, as has heen previously mentioned, mostly covers the hone" (Fig. 7).

I have repeated t h e description of thc resection preparations in such detail because they form, in part, the basis on which I have built n ~ ytechnique of roentgen examinations of shoulder joints in which clislocations have taken place. I n a11 cases of recurrent shoulder dislocations, whcre a resection of the head of the hnmcrns has been performed, a typical defect has been found. Since this operative procedure has been replaced long ago by other more conservative methods i t has now hecomc practically impossible t o obtain asuitablepreparationfor examination. FIGURE 7. I-lowcvcr, in many cases where operation performed for recurrent Very large pastero-lateralnotch on s resected hend of humerus, published by IT'endel, 1903 dislocation, the operator has succeeded in finding, by palpation, a t>-pica1defect on the postero-lateral part of the head of the humerus. Usually, however, i t is necessary t o open the joint capsule t o be able t o evaluate the changes in question. Since a t present extracapsular operations are generally performed, this method of establishing by palpation the presence and extent of a possible typical defect of the humeral head is unavailable. The other possibility for an anatomical examination of recurrently dislocated shoulder joints is a t autopsy or anatomical dissection of persons who have suffered from this disorder. Subsequent t o JOESSEL'S work there are relatively few investigators of this kind reported in the literature.

HISTORICAL SURVEY

BROCA and HARTMANN (quoted by Seidel), in a case in 1890, found a defect on the posterior circumference of the head of the humerus which extended down t o the anatomical neck giving the head the shape of an orange from which a quarter had been removed. The planes bordering the area of tissue loss met a t nearly a right angle, one of the sides of which measured 19 mm. from the top t o the pole of the head of the humerus, the other, from the top to the posterior surface of the humerus, measured 14 mm. SICK (quoted by Seidel), 1891, found a case with "a cartilaginous defect with irregular rims of about 4 em. in length and 1 em. in breadth extending t o the sclerotic bone on the head of the humerus a t the insertion of the infraspinatus mnscle, still intra-capsularly." SEIDEL(1918) reports that a t autopsy of a case of recurrent dislocation he was unable to find any changes whatsoever. Finally, I should like t o add, in this connection, that G R ~ G O I R(1913) E found a typical defect on the humeral head while examining a corpse for whom he was uncertain whether or not there had been a shoulder dislocation during life. Besides the defect, G R ~ ~ G O found I R E a number of abnormalities which correspond closely to those found by other workers in cases of recurrent dislocation of the shoulder, e.g. by JOESSEL. Such changes concerned the external rotators and the relations of the capsule beneath thc acromion and a t the anterior glenoid rim. Oddly enough, GR~GOIRE explains his findings as malformations, although he probably does not really know whether there had been dislocations in these joints or not. Roentgen Exaniinations

I n our departments of anatomy and pathology examinations of recurrently dislocated shoulder joints are rarely made. Practically, therefore, there is only one way in which an idea can be gained of the appearance of the humeral head in recurrent dislocations, and that is by roentgenologic examination.

I have found in the work of FRANCKE (1898)the first information on roentgen examinations in such cases. He did not, however, discover any positive lesions. (At operation only a small defect on the head was found). I n 1906, PERTHES described two cases where roentgen examination yielded positive results with regard t o the defect in the humeral head. PERTHES describes his findings as follows: Case I: "The roentgen picture demonstrates that the humeral head does not have its normal roundness, but shows a broad, shallow defect in the area of the greater tuberosity, in the base of which some roughness can l ~ e discerned." Case 11: "In the region corresponding t o the upper segment of the greater tuberosity, a flattening may be recognized which suggests the presence of a shallow defect on this tuberosity."

HERMODSSON'S

ROENTGENOLOGICAL STUDIES

SCHULTZE (1914) seems to be the first to have concerned himself, in a little more detail, with the roentgenologic picture of the defect. "Of the 24 roentgen pictures (24 shoulder joints) which are at my disposal, only a very small number show changes; most show an absolutely normal outline of both the greater tuberosity and the socket. The contours of the bone trabeculae are so very sharp that with certainty one can also exclude any previous changes in structure. Only in one picture could I see an avulsed and possibly loose body, and then the shadow lies so high that I should almost like to believe that it belongs rather to the subdeltoid bursa than to the joint cavity." "In one Case (Case IV) I wish to describe here only the final appearance. I n this case, there had probably occurred first a severe lesion in the uppermost facet of the greater tuberosity which, in its subsequent progress, led to a softening and finally to the complete resorption of this portion of bone. We now see a very unique picture. Apparently a considerable section is missing from the aiticular surface of the humeral head, ground out directly above the greater tuberosity. The entire image of the head appears to be abnormally elongated and placed considerably higher than normal." "The second case, that of the epileptic L., with bilateral dislocations, brings out a further point. In the roentgen picture of the right side, no fracture can be seen, but there are positive signs of bone softening, that indistinct, washed-out pattern of the trabeculae, which is characteristic for this process. The site of the softening here is the same as that of the large defect in the first case.'' Concerning his Case IV, SCHULTZE says: "Case P. also deserves special mention here. I n the first picture taken of him, I saw a deep defect in the same place; in the second, taken four years later, this defect is very much smaller, filled in by more than two-thirds. Repeated trauma had been arrested and so the process of healing could take place." I cannot but agree with PILZwho says, concerning this process of healing: "Under any circumstance one must reject the roentgenologic proof for this process, as SCHULTZE presents it; a prerequisite for such proof would be an absolutely identical position a t the picture taking. I n his pictures, a different position of the whole shoulder joint can be recognized without difficulty; furthermore, there is a distinctly different position of the humerus regarding rotation and abduction." In 1925, PILZgives the first detailed description of techniques for roentgenologic examination of recurrent shoulder dislocations. The extraordinary importance of projection, especially for the disorder in question, is clear to PILZ.He states: "Here, the usual anteroposterior view is certainly inadequate even with a comparative picture of the contralateral shoulder. We must systematically search the shoulder joint for the known changes and for this purpose we must apply a definite method of examination which is directed towards these specific changes recognized as 'typical'." When examining the defect on the humeral head,

HISTORICAL SURVEY

PILZused the following technique: "Usually there are no difficulties in recognizing the defect by fluoroscopy. The patient is fluoroscoped from behind forwards while standing or sitting. First he stands with his chest parallel to the screen. Then the affected shoulder is turned slightly forwards, the trunk inclined somewhat forwards, the arm stretched slightly backwards and turned outwards slightly. Very soon the defect will be seen on the patient if he is fluoroscoped during the above described movements". Thereupon PILZproceeds to take a roentgenogram using the position found at fluoroscopy to be the most favourable for demonstrating the defect. The aim of PILZ'investigation is "to discover to what extent it is possible to form a trustworthy concept of the anatomical state of the component bones of the shoulder by roentgen examination." Thus, he does not concern himself with the origin or meaning of the changes he has found. PILZdescribes the roentgen picture of the defect as follows: "In quite pronounced cases, the changes on the radiogram cannot be mistaken. The structlval design is washed out in a characteristic manner, while there is a deficiency of the head shadow, large or small, which makes possible a diagnosis a t first glance. I n some cases the radiological diagnosis is not so easily made; in such i t can only be made after thorough consideration, and with knowledge of all the characteristic signs. I n the usual anteroposterior shoulder projection in middle rotation position, attention should first be directed towards any interruption of the sharp contour line of the articular surface. This normally runs as a sharp line from the top of the head to the greater tuberosity, with a notch the size of a lentil just medial to the greater tuberosity, which corresponds to the anatomical neck; if a defect exists, this line is not sharp, beginning at the greater tuberosity and continuing 1 to lh and even 2 cm. towards the top of the head. In this region, the bone structure as well is usually indistinct; the effaced structural pattern only reaches a few millimeters below the surface; it can sometimes be followed downwards for several centimeters, appearing in the form of a wedge. The washed out appearance of the structure usually reaches down more deeply towards the greater tuberosity, which apparently is the reason why such findings hare been interpreted as avulsion-fractures of the greater tuberosity. A particularly characteristic sign for the existence of an extensive 'typical' defect is the shadow which is produced by the medial defect surface by virtue of its sharp separation from the surface of the sphere (Fig. 8). It appears as a sharply outlined narrow wedge which sometimes approaches the shape of a sickle. I t runs from the top of the sphere somewhat parallel to the humeral axis towards the lateral side of the humerus. Its peak points downwards. It measures up to 2 cm. or more in length. We believe this wedge-shaped shadow to be especially important. Its length permits certain conclusions to be drawn regarding the size of the defect. We have been able to observe the narrow wedge as a sign of the typical defect on four occasions. The signs we have described for the roentgen diagnosis of the typical defect-interruption of

contour, washed-out structure, and the wedge-shaped shadow-are more or less easily recognizable on the radiogram. The clarity of their appearance depends on the amount of rotation of the humerus, and on the direction of the rays. I n various positions the defect may appear differently as regards clarity and size. It is certain too, t h a t there may be absolutely no signs of a defect on a radiogram although an extensive one may exist." PILZ'entire material includes 21 .. - . '-P cases. I n 1.2 of these, a defect was , observed in the roentgen examinatlon. Towards the end of his series, PILZwas ableto demonstrateroentgenologically the existence of a .. ' ..; ' (I .., , ,, / defect almost routinely, i.e. in 4 out I, ~. ,..--. of 5 cases. / Many others, in addition t o the i above-mentioned authors, have found clefect in the humera1 ), head onthe roentgenological examina'

'";I 1

''

/

.I

tion of cases with recurrent dislocations. I-Iowever, I have been unal~le t o find anything significantly new heyond the results descrihcd above. The frequency of positive radioFIGURE 8. logical findings varies considemhly Pilz' (1925) illnstrnlian. showing n"1ypiesldcfcel on the reenrc~edI,? anten,-l,osterior with different authors. Some have roentgen projection only been ahle to find any rocnt(a-b) Indistinct contour (C ) N I I ~ ~ U I I . wcdpe-sh.pec~ E I , ~ , I O ~( , n r r ~ i n ~ genologcally changes bardrr of the dcfeer) in exceptional cases, while others have seen the defect on the radiogram in the majority of their cases. However, as a rule, the different reports refer only t o a few isolated cases, and a series comprising a large numher of cases with precise examinations is unavailable. .

All of the above roentgen examinations which have shown a typical defect in the head of the humerus referred t o recurrent dislocations. To complete my survey I should like t o mention here that there is only one report in the literature of such a defect in the humeral head observed in cases of traumatic, non-recurrent dislocation. This contribution is from DIDICE (1930). I n fact, he found a defect in the head of the humerus in t ~ v ocases (see also under traumatic dislocations). Tlieorier: on the A'nt~irennd Origin of the Defect

It has been very difficult t o explain this defect in the postero-lateral part of the humeral head. I n the course of time a number of attempts to interpret i t Iiave been made, but t o this day no unanimity has heen possible.

HISTORICAL SURVEY

I n the beginning it was generally thought that an avulsion from the site in question on the head had taken place. KUSTER,for example, held this opinion, and, as already mentioned, he was one of the first to find and describe the defect in resected specimens. However, neither he nor other surgeons were able to find an avulsed fragment, and so another explanation had to be found for this strange fact. FRANCICE thought of the possibility that the fragment might, in some way, have passed into the soft tissue parts outside the capsule and thus have escaped the attention of surgeons. Concerning this, he states: "what if the fragment is lying outside the capsule, whether extruded immediately a t the first dislocation, or whether it came to lie there a t the time of reduction?" However, this way of explaining the absence of an avulsed fragment did not find general support; on the one hand there was a gradual increase in the number of cases in which no fragment was demonstrated a t operation, and on the other hand the alleged fragment could not have been so very small. The possibility of a complete resorption of a totally avulsed fragment was also discussed, but was opposed by other investigators (e.g. SEIDEL).AS early as ten years before FRANCKE, LOBKERhad advanced another theory, namely, that the defect was due to a grinding phenomenon, or was an erosion due to pressure resulting from the steady rubbing of abnormally positioned articular surfaces against each other. This might possibly be acceptable in those cases where such an abnormal position was allowed to persist for a prolonged period before reduction was secured. However, in many cases this is not true and this explanation cannot be valid, especially since it has been possible to observe the defect even after a few dislocations. Thereafter, the matter was believed to have occurred as follows. At the first dislocation the humeral head is pressed against the glenoid rim with such force that a fracture of the superficial bony trabeculae occurs, with a ~ossiblelesion of the nutrient vessels. The damaged bony trabeculae die after reduction, and are absorbed; a preliminary, quite superficial, defect is now present. Since subsequent dislocations of the joint are usually of the same type as the first one, the injured portion is forced anew against the rim of the socket, and the same process regarding the damage to the bony trabeculae with absorption ensues. STAFFEL,whose very exact examinations of the defect have already been described, believes that it is caused by an osteochondriiis dissecans, and he published his cases under the title "A further contribution to the knowledge of osteochondritis dissecans." WENDELopposed this explanation and his microscopic examinations in this field might well he the most detailed ever published. WENDELexplained it as follows: "For the most part we find necrotic pieces of bone in the defect borders. But these are not 'dissected', not separated or divorced from the living tissue by a sequestrated inflammation. We can only explain the necrosis as having developed as a consequence of a fracture. For the interpretation of the entire process

HERMODSSON'S

ROENTGENOLOGICAL STUDIES

as traumatic, it is immaterial whether the fracture was such that it immediately forced out the missing part, or whether the fracture, or infraction, destroyed firstly only the vascular but not the mechanical connection, and the latter was lost later through a reactive inflammation. The two explanations differ only in that in the one the defect is produced gradually, and in the other, primarily. Essentially, a loose body in the j oint is missing. If it is missing, where is it? It is difficult to believe in its resorption. This is not conceivable without the participation of the blood vessels. The possibility of resorption is more easily understood if the bone fragment in question is not avulsed immediately but has remained connected with the rest of the hone.

PERTHES (1906), who has achieved much recognition on the subject of recurrent dislocations, expressed the following opinion concerning the origin of the defect, one which he still defends in 1926: "The characteristic wedge shape of the defect, which would be difficult to explain by an avulsion-fracture, in my opinion allows only the conclusion that the pressure of the prominent anterior rim of the socket has caused the defect. I leave it for discussion whether, with LOBKER,one should postulate a grinding effect, or whether one should think of a pressure necrosis of the superficial bony layers which are pressed against each other. The defect is caused by the repeated recurrence of the dislocation; it is the consequence of the recurrence and therefore cannot be the basic lesion predisposing to it." This opinion that the defect in recurrent dislocations develops gradually is also defended by SCHULTZE on the basis of his roentgenological findings. He believes that the defect results from "gradual resorption, through traumatic softening." This softening appears on the radiogram as 'that indistinct, washed-out trabecular pattern which is characteristic for this process'. SEIDEL(1918), mentions as important in the development of the defect: "Necrosis, by caused the temporary pressure of the corresponding parts of the head on the anterior glenoid rim." This pressure necrosis is described by SEIDELas follows. "At the first dislocation, a firm compression of the head against the anterior glenoid rim has occurred. The force was so strong that it caused an infraction of the superficial bony trabeculae in that site, and possibly also an interruption of the nutrient vessels. After reduction has been achieved, the bony trabeculae die, and are absorbed. A defect originates which at first is quite shallow. Since the subsequent dislocations are usually of the same type, the injured portion of the head on each occasion is again compressed on the anterior glenoid rim and the same type of injury to the bony trabeculae with their subsequent absorption occurs." I n sharp contradiction t o all authors mentioned stands a Frenchman, GRI~GOIRE. As reported, he found a clear-cut defect on the humeral head in one case where, in his opinion, no dislocation had taken place. On the basis

HISTORICAL SURVEY

of this observation he denied that the defect was secondary to dislocations and believed that he was dealing with a congenital anomaly. His compatriot, DIDI~E,who had seen a defect in radiograms in two cases, where in both only one dislocation had taken place, is of the same opinion. This view of the defect as a congeuital anomaly has won support primarily in France, but has been particularly attacked by the Germans. The primary objection to this opinion has been that if this were so these changes would be found bilaterally much more often than they are. Furthermore, no undisputed records of cases with such a defect have been reported for shoulder joints in which dislocations have not occurred. (e.g. SEIDEL). To date the literature still lacks unanimity concerning the nature of the defect.

Fracture of the Greater Tuberosity I n the literature the opinion is sometimes expressed that fracture of the greater tuberosity is a not unusual complication of recurrent dislocations. I n general, the authors in question do not have any positive observations of their own to support this view. Some exemplify their statements with cases which they have borrowed from the communications of other authors. If one reviews the original reports, one generally finds that the original affirmation rests on a very doubtful basis. The usual reason for the false conclusions is that the typical defect has been assumed to be a fracture of the greater tuberosity. These mistakes are generally connected with the misinterpretation of roentgenological findings. One example of this, among others, is PERTHES' case 2, in his 1906 presentation. Another case where there is strong reason to doubt that a fragment has been avulsed from the greater tuberosity is case 2 of SCHULTZE. The radiogram which the author includes does not prove anything. Probably there are calcifications in the soft parts, or something similar. Case 2 of SEIDELalso seems to me to represent a confusion between a defect and a fracture of the greater tuberosity. The bone shadow which is interpreted by SEIDELas an avulsed fragment, could be the condensed zone which is a common appearance when the defect is present. I n a critical and accurate perusal of the literature, I was able to find only two positive cases of recurrent dislocation with a fracture of the greater Case 19. The other is PERTHES' Case 4, tuberosity. One is SCHULTZE'S in his 1926 paper.

Injuries of the Joint Capsule and of the Glenoid Rim

In line with the prevailing theories about the mechanism of dislocation, it was expected that at operations for recurrent dislocations a tear would

be found in the antero-inferior part of the capsule, through which the humeral head would have passed. I n general, however, it turned out that no such capsular tear was discovered. KOLHASE, however, described a case in which a large tear was observed in the front part of the capsule. The author, however, does not say whether the size of the hole and its position fit the assumption that it served as an exit for the head. I n many cases, surgeons have described a condition of the antero-medial part of the capsule which led them to the conclusion that a capsular tear had existed there which later was bridged by connective tissue. In general, that capsular part is meant which is situated inferior to the subscapularis muscle. (Similar cases have been described by JOESSEL in his autopsy reports). However, there are numerous clear cases where a tear of the capsule from the anterior part of the glenoid labrum, or a tear of the labrum together with the capsule from the anterior glenoid rim have been found. I n a great number of cases there have been simultaneously found: deformation, flattening by pressure of the anterior glenoid rim, and even fracture of the anterior glenoid rim. PERTHES had already pointed out these facts (1906). The experience of all the years since this reference confirms PERTHES' assumption. I n Sweden, HYBBINETTEhas made accurate and similar observations about injuries to the capsule and the glenoid rim in a great number of cases. Tear of the Muscles Inserted on the Greater Tuberosity

It is primarily PERTHES who has reported on such cases, but similar ohservations have been contributed by others. One has the definite impression that it is generally difficult to recognize injuries of this type a t operation, and the surgeon must definitely examine the anatomical structures of the region in question in order to form an exact opinion about the lesions. Similar thoughts are expressed by PERTHES. 11. TRAUMATIC DISLOCATIONS As previously mentioned, interest in shoulder dislocations was chiefly focussed on the recurrent type as these began to be treated operatively. This investigative approach seems t o have remained unchanged to the present time. Uncomplicated traumatic dislocations are usually reduced immediately without any need for a primary open operation. Surgeons and orthopedists rarely have cause or opportunity for a precise examination of the particular injuries in these disorders and only rarely does a patient die a t the time of a dislocation, or shortly thereafter, so that an exact anatomical examination of the shoulder joint might be obtained on the autopsy table. I n those rare cases where this is possible, there are usually major multiple injuries present which make comparison with

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