Harrison L. McLaughlin

Recurrent anterior dislocation of the shoulder: I. Morbid anatomy

Abstract Interest in the morbid anatomy of recurrent dislocation of the shoulder was prompted by the obvious incongruity between the integrity and accuracy of the multiple and variable observations recorded, and the confusing and conflicting theories which they had engendered. As a result of our observations it is believed that there are no real grounds for argument, and that almost all recorded observations and valid theories on etiology can be reconciled with a single denominator which, in one way or another, represents damage to the ligament supports of the shoulder joint, even as is the case in dislocations of all other joints. It has become increasingly clear that altered or absent function of the glenohumeral ligaments is this common etiological denominator, and that given an adequate operative exposure in a dry field, the pathomechanics of dislocation can be reproduced and the crucial lesion or lesions identified and repaired. One cannot refrain from concluding that this knowledge makes possible a more logical therapeutic approach than the current practice of utilizing some predetermined operation for all patients with dislocating shoulders without regard to or documentation of their morbid anatomical status.

Primary anterior dislocation of the shoulder

Abstract The authors were unable to find authoritative or documented evidence that any form of conservative treatment prevented all dislocations of the shoulder from recurring. The trends indicated by this preliminary study suggested, on the contrary, that treatment of the primary episode was of little importance and that the site and nature of the primary pathologic disorder was of utmost importance in determining whether or not recurrences would take place. The incidence of recurrence was 90 per cent in patients under twenty years of age, 60 per cent in patients between twenty and forty and only 10 per cent in patients over forty. This would appear incompatible with theories that recurrence depends upon specific details of treatment or mechanisms of injury. It might be postulated that one explanation of this age incidence depends upon the balance of strength between the anterior and posterior Joint supports at different ages. In the young both the tendon cuff and the humeral head are strong but also supple and elastic as compared to those in older persons in whom both become progressively weaker and more brittle. This fact of attrition may predicate that during youth the glenohumeral ligaments are the weaker components of the joint supports which give way first under stress. In any event recurrence of a traumatic lesion depends essentially upon rupture or avulsion of these ligairents. Comparable damage to the ligamentous supports of most other larger Joints warrants early operative repair since neither in the shoulder nor any other joint do such lesions often heal in a functionally satisfactory manner. It is submitted, therefore, that in the appropriate age groups these avulsed or ruptured glenohumeral ligaments deserve early operative repair as the only reasonably sure method of achieving healing and preventing the great majority of recurrent dislocations. There was definite evidence that the posterior supports of the Joint were the weaker component which gave way to allow dislocation in about 70 per cent of all patients past the age of forty. Was this because the attritional changes of advancing years had made both tendon cuff and tuberosity weaker and more brittle? Such dislocations in theory should not and, in fact, did not recur but were prone to nerve injuries, delay in recovery and permanent disability of some degree resulting from internal derangement of the subacromial mechanism. This syndrome proved more common and disabling than recurrent dislocation but could be anticipated consistently by roentgenographic demonstration of residual tuberosity displacement or clinical evidence of cuff damage. Early identification and operative repair proved by far the best treatment for properly selected lesions of this type with operative revision following the establishment of late symptoms a poor second choice.

Fracture of the carpal navicular (scaphoid) bone; some observations based on treatment by open reduction and internal fixation.

Internal fixation for fracture of the carpal navicular bone is surgically feasible, but requires an exacting technique for the prevention of complications potentially more serious than non-union. The relative merits of nails1 or screws as fixation devices remain to be established. The small experience reported here warrants no conclusions, but suggests the following: 1. With perfection of operative technique, internal fixation may become the treatment of choice for displaced and unstable fractures of the carpal navicular. 2. The prognosis for any fracture of the carpal navicular may depend as much upon the intrinsic stability of the fragments as upon the level of the fracture, or the vascular status of the proximal fragment. 3. The morbidity of fractures of the carpal navicular is reduced greatly by internal fixation. 4. Rapid relief of symptoms and return of function follow stabilization of an ununited navicular fracture by internal fixation, but bone healing is not to be expected following this procedure alone.

Open Reduction And Internal Fixation Of Fractures Of The Long Bones

The use of open reduction and internal fixation, by choice, is vindicated in selected fractures of the shafts of the tibia and femur, and in certain compound fractures of these bones. In this study, good results were found to be much more dependent upon the way the materials for internal fixation were used than upon their composition. Fixation rigid enough to make possible a maintenance of physiological function throughout healing most nearly accomplished the primary aim of all fracture therapy, —to restore the patient to his usual activities as soon as possible and in a condition as nearly normal as possible.

An adjustable internal fixation element for the hip

IGID and accurately fitted internal fixation making possible R a maintenance of IocaI and genera1 physioIcgy during the heaIing period is the therapy of choice for fractures at the hip and for the management of certain reconstructions of the upper femur. The mechanica probIem of such fixation usuaIIy requires that the proxima1 fragment be heId in the desired reIationships to the femora1 shaft rather than vice versa. This is accomplished in intertrochanteric, pertrochanteric and subtrochanteric fractures and in high osteotomies by mechanicaIIy fastening the proxima1 fragment or fragments to the solid cortical bone of the subtrochanteric region. The fixation is carried out by various singIe or doubIe unit devices, the proxima1 component of which is driven through the trochanter into the substance of the femora1 neck and head whiIe the distaI is fixed to the femoral shaft by screws. The avaiIabIe devices a11 are characterized by certain common defects which make the technic of their appIication unnecessariIy difflcuIt and the resuItant fixation potentiaIIy insecure. AI1 have a fixed angIe between their component eIements. BJ use of bending irons it is possibIe to change this angIe prior to insertion into the bone. Estimation of the desired angIe prior to actual appIication of a device to the Iesion requiring fixation cannot be exact and rareIy is accurate. SeIdom has it been found possible to adjust the angle accurateIy enough to make the apparatus fit the femur exactIy. InvariabIy it has been necessary to change the position of the femora1 shaft to conform with that of the pIate in order