Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

THE SHOULDER-JOINT

The shoulder is seldom the seat of disease, and most affections of the joint are met with in adults. In young subjects, infective processes result chiefly from extension of disease from the upper epiphysial junction of the humerus, which is partly included within the limits of the synovial cavity. The synovial membrane, in addition to lining the capsular ligament, is prolonged down the inter-tubercular (bicipital) groove around the long tendon of the biceps, and pus may escape from the joint by this diverticulum and gravitate down the arm; we have also observed loose bodies of synovial origin in this diverticulum. There is frequently a communication between the joint and the sub-deltoid bursa. There is no attitude characteristic of disease of the shoulder-joint, but the girdle is usually elevated, the upper arm held close to the side and rotated medially, while the elbow is carried a little backwards. In the later stages, the head of the humerus may be drawn upwards and medially towards the coracoid process. Fixation of the shoulder-joint is largely compensated for by movement of the scapula on the thorax, so that when testing for rigidity the scapula should be fixed with one hand while passive movements of the arm are carried out with the other. The deltoid is usually atrophied, allowing the acromion, coracoid, and great tuberosity of the humerus to stand out prominently beneath the skin. Swelling is rarely a prominent feature, except when there is a collection of synovial fluid or of pus in the bursa beneath the deltoid.

Tuberculous Disease is usually met with in young adults, and is more common in the right shoulder. The prominent features are pain, rigidity, and wasting of the deltoid and scapular muscles. The pain is sometimes severe, shooting down the arm and interfering with sleep, and it may be associated with tenderness on pressure over the upper end of the humerus. In cases with carious destruction of the articular surfaces there are starting pains, and the arm is shortened. If a cold abscess forms in the bursa underneath the deltoid, the pus may burrow and appear at the anterior or posterior boundary of the axilla or in the axillary space. Pus formed in the joint tends to gravitate along the inter-tubercular groove. The axillary glands may be infected.

The primary lesion is either a caseating focus in one of the bones—most often in the upper end of the humerus—or it is of the nature of caries sicca. The greater part of the head may disappear, and the upper end of the shaft be drawn against the socket. In exceptional cases, portions of the glenoid or humerus are found separated as sequestra, or the disease involves parts outside the joint, such as the acromion or coracoid process. Hydrops with melon-seed bodies is rare. In young subjects, destruction of the tissues at the ossifying junction may result in considerable shortening of the arm.

The diagnosis is to be made from (1) arthritis deformans, in which the movements are less restricted, and are attended with grating and cracking; (2) paralysis involving the deltoid and scapular muscles—by the absence of pain, and the flail-like character of the movements; (3) disease in the sub-deltoid bursa—by the absence of rigidity and other evidence of implication of the articular surfaces; and (4) sarcoma of the upper end of the humerus—by the history of the case, the use of the X-rays or an exploratory incision. Injuries in the region of the upper epiphysis resulting in loss of movement, may, in the absence of a reliable history, be mistaken for tuberculous disease.

While the prognosis is favourable on the whole, recovery is usually attended with fibrous ankylosis and incapacity to raise the arm above the level of the shoulder. The disease often progresses slowly, and may last for years.

Treatment.—The limb should be immobilised in the position of abduction with the forearm and hand directed forwards; the most efficient apparatus is a plaster spica embracing the thorax and the upper limb down as far as the wrist. If the articular surfaces are affected and the disease is likely to lead to ankylosis, the arm should be abducted to a right angle. The severe pain of caries sicca may be relieved by blistering or by the application of the cautery. To inject iodoform, the needle is introduced either immediately outside the coracoid process, or just below the junction of the acromion process and spine of the scapula. When the disease does not yield to conservative measures, or the X-rays show a gross lesion in the bone, excision of the joint should be performed; a close fibrous ankylosis usually results, and the arm is quite a useful one provided the abducted position has been maintained throughout.

Pyogenic Diseases.—The shoulder-joint may be infected by extension of suppurative osteomyelitis from the upper end of the humerus, or from suppuration in the axilla, or through the blood stream by ordinary pus organisms, pneumococci, typhoid bacilli, or gonococci. Extension should be applied to the arm abducted at a right angle. When it is necessary to open the joint, the incision should be placed anteriorly in the line of the inter-tubercular groove; if a counter-opening is required it is made on the posterior aspect by cutting on the point of a dressing forceps introduced through the anterior incision.

Arthritis Deformans.—The shoulder is seldom affected alone, except when the arthritis is a sequel to injury, such as a fracture of the neck of the humerus. The common type of lesion is a dry arthritis with fibrillation and eburnation of the articular surfaces. The long tendon of the biceps is usually destroyed, the head of the bone is drawn upwards, and, after wearing through the capsule, rubs on the under surface of the acromion, which also becomes eburnated. The clinical features are pain, stiffness, and cracking on movement, and as these symptoms may also be caused by loose bodies in the joint, an X-ray picture should be taken to differentiate between them.

Neuro-arthropathies of the shoulder are met with chiefly in syringomyelia. In some cases there is a large fluctuating and painless swelling; in others marked and rapid wasting of the deltoid and scapular muscles with flail-like movements of the joint associated with disappearance of the upper end of the humerus ([Fig. 104]).