the subscapular bursa, pouch tendon ARTHROGRAPHY OF THE

ARTHROGRAPHY
OF
BRIAN
From
REEVES,*
the
Royal
The
differences
between
acute
and
arthrograph-As
of the humerus
and
fills the subscapular
the
biceps
the
humerus
tendon
and
Figure
1-Normal
tendon
sheath
Axial
pouch
outlines
(see
views
the joint
recurrent
anterior
the
with
begins
(C in Fig.
inferior
I) and
the
margin
small
of the
with
the
arm
abducted
To avoid
meniscus
synovial
glenoid
pouch
labrum
overfilling,
between
80 degrees
Leverhulme
ten and
used for
of a mixture
appears
subscapular
to show
bicipital
from
Research
lies
which
the
head
the head and
recess around
between
the
neck
show
pouch
and bicipital
corresponding
to
a small
is increased
of medium
posterior
the medium
(C in Fig. 2)
in recurrent
are usually
used.
Fellow.
THE
JOURNAL
of
1).
trunk
millilitres
be
reduction,
of fifteen
between
bursa, inferior
transradiant
areas
sheath
(see text).
the
can
injected
through
Radiographic
that
overfilling,
(A in Fig. 2). Normally
2) and posterior
edge
millilitres,
fourteen
which
(D in Fig.
the entry to the subscapular
bursa
triangle
at the anterior
(B in Fig.
*
424
general
anaesthetic
local infiltration
shoulder
1); the fluid then flows around
of more fluid fills the synovial
of the glenoid
fossa caused
by the glenoid
labrum.
The normal
joint
capacity
is sixteen
to twenty
dislocation.
of the
of 1 per cent Lignocaine
to the coracoid
process.
the injection
to ensure
antero-posterior
arthrograph
to show
the
text).
Figure
2-Normal
axial
arthrograph
the glenoid
labrum,
subscapular
bursa
and
(D in Fig. 2) and
a transradiant
dislocations
to fill a thin
the glenoid
fossa (A in Fig.
bursa
(B in Fig. 1). Injection
the
of England
DISLOCATIONS
millilitres
of 45 per cent Hypaque
and ten millilitres
a fine lumbar
puncture
needle
inserted
just lateral
screening
with an image
intensifier
was used during
with consequent
lack of definition,
was avoided.
normal
ENGLAND
of Surgeons
demonstrated
by arthrography
and cine-radiography.
Technique-The
initial
arthrograph
is made
under
and those at seven to ten days and at three weeks
The
SHOULDER
LONDON,
College
ANTERIOR
THE
OF
BONE
AND
JOINT
SURGERY
ARTHROGRAPHY
OF
THE
TABLE
CAPSULAR
Case
number
years
Age
in
Humeral
head
defect
Male
34
No
Yes
2
Male
72
Yes
No
Sex
Rotator
cuff
defect
I
TEARS
7 to 10 day
arthrograph
3 week
arthrograph
Healed
anterior
Recurrent
dis1ocation
Spill into
capsule
I
subdeltoid
No
bursae
Operation
Repair
tendinous
Healed
-
Yes
-
3
Male
26
No
No
Healed
-
No
-
4
Male
19
No
No
Healed
-
No
-
5
Female
62
No
Yes
6
Male
18
No
No
Healed
-
No
-
7
Male
52
No
No
Healed
-
No
-
8
Female
76
No
No
Healed
-
No
-
9
Male
48
No
Yes
10
Male
77
No
No
Healed
-
No
-
11
Male
39
No
No
Healed
-
No
-
12
Male
67
No
No
Healed
-
No
--
13
Male
58
No
No
Healed
-
No
-
14
Male
61
No
No
Healed
-
No
-
15
Male
52
No
No
Healed
-
No
-
Healed
Spill
anterior capsule
anterior
TABLE
Case
numler
Sex
Age
in
years
16
Male
22
17
Male
Humeral
head
defect
Rotator
Spill
capsule
CAPSULAR
into
subdeltoid
Healed
subdeltoid
into
bursae
No
Repair
cuff
II
arthrograph
3 week
arthrograph
No
No
Not
Not
36
No
Yes
7 to 10 day
healed
No
subscapularis
spill
Yes
Repairof
Bankart’s
Spill into
subdeltoid
bursa
No
Healed
No
-
Male
36
No
No
Healed
-
No
-
20
Female
39
No
No
Healed
-
No
-
21
Male
62
No
No
Not
healed
Yes
None
22
Female
73
No
No
Not
healed
Healed
No
-
23
Female
67
No
Yes
Spill into
subdeltoid
No
25
26
Male
28
No
No
Male
49
No
No
53
No
No
Female
48 B,
NO.
3,
AUGUST
1966
No
subscapularis
spill
Healed
Not
healed
bursa
No
No
operation.
significant
dIsabilIty
-
No
-
Not healed
Healed
No
-
Healed
-
No
-
Not
healed
Healed
No
lesion
Repair
of
tendinous
cuff
19
No
healed
Operation
No
No
Not
healed
Recurrent
dislocation
No
18
of
tendinous
29
Male
cuff
No operation.
No disability
Female
24
of
DETACHMENTS
cuff
defect
No
bursae
18
27
vo
425
SHOULDER
-
426
B. REEVES
3
FIG.
Figure
3-Antero-posterior
the joint through
from
is also
showing
FIG.
well
seen.
Figure
a free
spill
of
infraspinatus
and
subscapularis
ACUTE
Arthrography
there
demonstrates
is rupture
4
arthrograph
after reduction
of an acute dislocation.
The medium
is flowing freely
a large anterior
hole in the capsule.
The head defect caused at the time of the dislocation
4-Case
9, Table I. Antero-posterior
arthrograph
done three weeks after reduction
medium
into
the subdeltoid
bursa.
At operation
a rupture
of supraspinatus
and part of
of the
two
capsule
axillary
tissues
(Figs.
adjacent
capsule
becomes
tendons
found.
DISLOCATION
distinct
anteriorly
types
of acute
dislocation.
or antero-inferiorly
3 and 4). In the second
detached
from the glenoid
the
was
with
In the
free
first
leakage
type (Table
II) the glenoid
margin
which
allows
fluid
(Table
of fluid
labrum
to flow
I)
into
or the
beneath
the subscapular
bursae
(Figs.
5 and 6). When
the joint
is
leak of fluid from the region
of the glenoid
margin
into the
axilla.
The supraspinatus
tendon
was never
seen to be ruptured
at the initial
examinations
but this was shown
in five patients
in later
arthrographs.
Capsular
rupture-There
were
fifteen
patients
in this group
(Table
I and Fig. 3). In none did
the
subscapularis
full
there
the
leak
in the
region
of fluid
into
however,
showed
free
in Table
I, fluid
flowed
significant
of
a small
is occasionally
disability,
the axilla persist
spill of medium
out
but
through
the other,
this his shoulder
was explored.
supraspinatus
and three-quarters
from
their
neck
insertion.
third
In the
patient
(Fig.
4) and
infraspinatus
and
who
patient.
This
(Case
was
the
repaired
and
I) the fluid
shoulder
subscapularis
sustained
the top
a young
seven
to ten
region
were
a large
humeral
six months
flowed
out
was
explored
found
to
head
defect
be
4).
first
Three
In two,
involving
one and
Cases
patients,
I and
the whole
a quarter
5
no
of
of the
inches
he was working
as a plasterer.
in the region
of the anatomical
the supraspinatus
avulsed
from
their
at the
later.
a woman
of sixty-two.
had
handicapped
and because
cuff
found
later
freely
days
(Fig.
of the joint.
One,
man, was severely
A rupture
of the tendinous
of the subscapularis
was
9. Table
when
at arthrography
into the subdeltoid
and half
insertion.
of both
Only
(Fig.
3), progressed
dislocation
the
one
to recurrence.
Capsular
capsular
detachment-Twelve
outline
when
lesion
were seen (Table
II and
was repeated
seven
to
six
had normal
arthrographs
three weeks
failed
to regain
a normal
capsular
outline,
injury.
One patient,
a man of sixty-two
remaining
patients
significant
the
patients
arthrography
other,
a man
corresponding
of
twenty-two
to
the
defect
(Table
in the
Figs. 5 and 6).
ten days
later
Six had a normal
and four
of the
after the initial
injury.
The two remaining
and in both dislocation
recurred
without
(Table
11, Case 21), refused
operation,
and
II, Case
16) was found
to have
glenoid
labral
outline
in the axial
THE
JOURNAL
OF
BONE
a Bankart
view.
AND
JOINT
(1938)
SURGERY
ARTHROGRAPHY
OF
THE
427
SHOULDER
FIG.5
Figure
beneath
Figure
arthrograph
after reduction
of an acute dislocation
showing
extravasated
medium
There
is a marked
similarity
between
this arthrograph
and that in Figure
7.
6-Antero-posterior
arthrograph
after reduction
of an acute
dislocation showing
spill of medium
below
subscapularis.
This is the initial arthrograph
of Case 16, Table II; a Bankart
lesion was found at operation
later.
One
5-Antero-posterior
the subscapularis.
Two patients
were seen who
was a man ofthirty-six
(Table
a woman
of sixty-seven
(Case
had radiological
evidence
of rupture
of the tendinous
II, Case 17) whose
supraspinatus
was repaired.
The
23),
found
her
disability
RECURRENT
Eight
patients
with
anterior
recurrent
had enlargement
of the subscapular
pouch
(Fig.
7) forming
a continuous
definition
of the transradiant
area
Bankart
entrance
type lesion
was
to an enlarged
and at operation
from the anterior
Voluntary
was
bursa
was
continuous
DISLOCATION
of the
larger
with
girl
The
giving
fourteen
of
increased,
other
the
accepting
than
normal
(Fig.
the inferior
pouch.
three
effect
as
in post-traumatic
were
could
dislocate
28 millilitres
9) and continued
The axial view
recurrent
patients
had
of an anterior
examined.
All
with the inferior
showed
a lack of
8), and in each a
an unusually
capsular
large
hernia.
was found
to be attenuated
and separated
with an enlarged
subscapular
bursa.
her
of
shoulder
medium
at will.
Her
The
subscapular
easily.
joint
in a steady
convex
curve
to become
(Fig.
10) showed
a normal
anterior
and
posterior
glenoid
labral
outline
and a normal
posterior
dislocated
the capsule
became
wrapped
around
the head
it and the glenoid
fossa
but the head
did not appear
bursa
shoulder
bursa
so that its outline
was continuous
smooth
line.
In five the axial view
of the glenoid
labrum
anteriorly
(Fig.
the glenoid
labrum
of each patient
capsule,
which
became
continuous
greatly
no handicap.
dislocation
found
at operation.
subscapular
bursa,
dislocation-One
capacity
cuff.
other,
pouch.
When
the shoulder
was
and apparently
constricted
between
to enter
the enlarged
subscapular
dislocations.
DISCUSSION
Arthrography
contrast
medium.
series
was
125
patients.
of the shoulder
This was soon
reviewed
of
dislocation.
by Samilson,
whom
had
nine
A correlation
between
was first described
followed
by the use
Raphael,
recurrent
by Oberholzer
of radio-opaque
Post, Noonan,
Sins
anterior
dislocation
arthrographic
and
operative
(1933)
materials.
and Raney
and three
findings
using
air as a
The largest
(1961) who studied
recurrent
posterior
was
made
in three
the former
and two of the latter.
The arthrographic
findings
in the present
series were basically
the same in recurrent
dislocation
as those
of previous
authors.
Demonstration
of a Bankart
lesion was not as difficult
as expected
if axial views were taken with the patient
lying obliquely
across
VOL.
the
table,
48 B, NO.
3.
with
AUGUST
the
arm
1966
abducted
80 degrees
from
the
trunk.
of
428
B. REEVES
There
present
are
no
series
was
previously
not
recorded
suitable
for
post-reduction
care:
all patients
bandaged
to the trunk
or in the
arthrographs
attempting
of acute
to use
the
dislocation
arthrograph
were treated
by immobilisation
arm sling described
by Reeves
initial
7-Antero-posterior
severe
which has
arthrograph
Figure
arthrograph
with recurrent
dislocation
the
of deciding
with
likely
the arm
that all
8
of three
years
duration.
An
by frequent
dislocations.
There is much enlargement
of the subscapular
bursa,
become
continuous
with the line of the inferior
pouch (compare
with Figure
1). Figure
8-Axial
of the same patient
as in Figure
7. There
is here lack of definition
of the outline of the glenoid
labrum
anteriorly,
though
this is well shown posteriorly.
injury
was
followed
9-Antero-posterior
There
is a large subscapular
Axial
arthrograph
arthrograph
bursa
with
in a girl of 14
and
of the same patient
here
patients
of a patient
therefore,
for three weeks
(1963).
It seems
.3.
Figure
and,
as a means
capsular
tears
much
as in
though
would
years
with voluntary
anterior dislocation
of the shoulder.
the inferior pouch.
Figure 10of the glenoid labrum is outlined
redundant
capsule associated with
Figure 9. The anterior portion
not
have
as well as the posterior
labrum.
been
by rest
safely
treated
in a sling
for
then beginning
early shoulder
movements.
The patients
with capsular
detachments,
present
a different
problem.
Here
the initial
arthrographic
appearances
were
those
seen in recurrent
dislocation
and half of them
had not healed
after seven
THE
JOURNAL
OF
BONE
AND
a week
and
however,
the same
as
to ten days,
JOINT
SURGERY
ARTHROGRAPHY
though
four
should
be treated
of the
remaining
group
in fixed
medial
OF
of six had
rotation
THE
healed
for
three
429
SHOULDER
after
three
weeks
weeks.
These
(Watson-Jones
undoubtedly
1955)
though
even
not entirely
reliable.
The causes
of failed
healing
of the glenoid
labrum
are
unknown.
In one experiment
in a monkey
(Scougall
1957) the glenoid
labrum
healed
rapidly
after its detachment
posteriorly.
The occurrence
of tendinous
cuff defects
in five patients
following
acute
dislocation
is
not surprising.
Their
diagnosis
was undoubtedly
helped
by the arthrograph-especially
in
this
is probably
one patient
with
in this series
as
that
opinion
finding
a circumflex
there
was
arthrography
palsy as well as a tendinous
initial
arthrograph.
These
is a valuable
of a symptomless
which
no
rupture
was confirmed
aid in the exact
of the
at operation,
cuff
together
in one
with
cuff lesion,
which
findings
support
diagnosis
of the
ofthis
eight
five ruptures
cases
is not reported
Kessel’s
(1950)
lesion.
The
unexpected
of recurrent
in twenty-seven
dislocation,
acute
dislocations,
happens
more often than is suspected.
It seems that when a tear is confined
to the supraspinatus
it causes
only trivial
disability,
and that rupture
of the greater
part of
the cuff is needed
to produce
characteristic
clinical
evidence
of tendinous
cuff tear.
This is
supported
by Van
Linge
and Mulder
(1963)
who
observed
the effects
of paralysing
the
suggests
that
this
supraspinatus
In the
capsule
one
and
nerve.
patient
increased
of generalised
increased
redundancy
capsular
with
voluntary
joint
dislocation
but
volume,
joint
with
laxity
a normal
normal
in other
in the
patient
and
posterior
outline
POSTERIOR
This
is a well
In
dislocations.
with
Injury
Three
dislocation
drawing
is less
more
are
even
important
than
described
though
in anterior
non-traumatic
Weissman
in this
Recurrent
non-traumatic
was
increased
shoulder
was
normal,
triangle
of the
On
the chest
dislocating,
wall, tilting
away
it forms
and
the
labrum
atlas
defect
from
to become
the glenoid
(Fig. 16).
The trapezius
initiates
isolated
anterior
is unknown.
less
first
than
2 per
cent
recorded
case,
in 1855 described
of all shoulder
an epileptic
patient
the pathology
of
to his book on fractures
fitting
into the glenoid
and dislocations
edge.
dislocations,
or
AND
CINE-RADIOGRAPHY
dislocation
more
axial
was
(Table
millilitres
view
showed
ill defined
fluid.
a large
of
or absent
the scapula
moves
initially
in a
the glenoid
either downwards
or
the glenoid
fossa and comes
to lie posteriorly
convexity
balanced
upon the cartilaginous
constricted
over the head and an isthmus
its greatest
and
but
glenoid
23
an
anterior
no evidence
series.
posterior
to
for
lax
was
though
it is still the greatest
factor.
bilateral
dislocation
of the shoulder
have been
Torok
1958; Gitlin,
Schwartz
and WeIner
1959).
ARTHROGRAPHY
capacity
reason
stability
a very
There
DISLOCATION
and in the companion
demonstrating
the head
patients
with recurrent
(M#{246}llerud 1946;
recorded
Two
condition
revealed
respects.
the
and
1839 Sir Astley
Cooper
described
the
dislocation
of the shoulder.
Malgaigne
unilateral
the unreduced
there
is a line
known
arthrography
was
scapular
movement
but
111)-In
these
four
patients
the joint
The antero-posterior
outline
of the
posterior
pouch
and the transradiant
(Figs.
11 to 17).
rotatory
manner
backwards
away
from
upwards.
The humeral
head then moves
to the axis of the glenoid
fossa with
edge of the glenoid.
The capsule
appears
forms
in the capsule
between
the head
the
final
dislocation
appears
to be caused
by the posterior
cuff muscles
and the posterior
fibres of the deltoid;
these can be seen contracting
while
the anterior
fibres
are inactive.
Once
dislocated,
the head
is stable
in its displaced
position
finger
VOL.
but a slight
achieves
48 B,
NO.
contraction
reduction.
3, AUGUST
1966
of the anterior
fibres
of the deltoid
or a push
with
the examining
430
B. REEVES
Case
28, Table
III.
Figure
11-Axial
radiograph
of the right shoulder taken under
the humeral
head dislocated posteriorly but not under the spine of the scapula.
Figure
12-Axial
arthrograph
of right shoulder,
showing
a large
posterior
pouch
glenoid
labral
outline
posteriorly.
anaesthesia, showing
with
Figure
18.
lack of definition
of the
general
Compare
and
FIGS.
13 TO 15
28, Table III. Figure 13-Three
months after
operation
the arthrograph
of the right shoulder
shows a normal posterior
pouch and a normal
outline of the posterior
glenoid labrum.
Figure
14-Antero-posterior
radiograph
showing voluntary dislocation
of the left shoulder.
The upward
and posterior
movement
of the scapulae and the
full view of the glenoid are characteristic
of all
published
radiographs
of this condition.
Figure
Case
15-Axial
humerus
arthrograph
dislocated
THE
JOURNAL
showing
into
the
OF
BONE
the head
large
AND
of the left
posterior
pouch.
JOINT
SURGERY
ARTHROGRAPHY
FIG.
Case
29. Table
III.
Figure
OF
THE
43!
SHOULDER
16
FIG.
16-Antero-posterior
arthrograph
of the right
The capsule is tightly applied to the head of the humerus and constricted
Figure 17-Axial
arthrograph
of the right shoulder
showing a large
glenoid labral shadow.
Traumatic
dislocation
(Table
IV)-This
was
associated
with
shoulder
between
posterior
an
17
on voluntary
dislocation.
the head and the glenoid at A.
pouch and a poorly defined
initial
head
defect
(Fig.
18) in
two of three patients.
In all, arthrography
showed
the presence
of extravasated
fluid beneath
the infraspinatus
muscle
without
any leaking
into the axillary
tissues.
Axillary
views showed
absence
of the glenoid
labral
outline
posteriorly,
with a large pocket
of fluid lying behind
the
line of the glenoid
in the region
of the neck of the scapula.
FIG.
Case
33,
shoulder
Table
1V-Axial
showing
the
18
arthrograph
head
glenoid
defect
of
engaged
the
left
on
the
margin.
DISCUSSION
The
etiology
congenital
joint
been posterior.
VOL.
48 B,
NO.
of
recurrent
laxity
is uncertain,
It was suggested
3, AUGUST
1966
dislocation
of
the
shoulder
not
associated
with
injury
or
and nearly
all of the purely
voluntary
dislocations
have
by M#{246}llerud (1946)
that there
was a congenital
capsular
432
B. REEVES
TABLE
VOLUNTARY
Case
number
Age
in years
Sex
.
Duration
29
30
31
.
.
.
32
21
16
16
.
.
.
Female
Female
Female
Female
.
Right
Right
Right
Left
I 8 months
3 months
1 year
I 1 years
involved
shoulder
logically
involved
.
radio.
.
symptoms
Right
Yes
Yes
Yes
No
Yes
No
Yes
No
.
symptoms
of
SHOULDER
28
Second
Duration
OF THE
.
of symptoms
Producing
III
DIsLocAnoN
.
shoulder
First
PosTrRIoR
4 months
.
Large
pouch.
Large posterior
pouch.
Detached
glenoid
labrum
shoulder
Large
Left
shoulder
Large
-
posterior
pouch
labrum
posterior
pouch.
.
posterior
Superficial
split in
glenoid
Operative
findings*
1 1 months
-
Large
Largeposterior
-
Attenuated
Attenuated
glenoid
glenoid
Right
shoulder
Left
shoulder.
posterior
pouch.
No
recurrence
at 3 years
No
recurrence
at 3 years
No
recurrence
at 2 years
Recurred
1 year
at
Result
*
All patients
were
operated
In each shoulder
buttressing
infraspinatus
the
to
neck
upon
because
dislocation
of its posterior
of
the
aspect
scapula,
started
overlapping
it
to
with
its
TABLE
POSTERIOR
to occur
was done by attaching
infraspinatus
ACUTE
Recurred
at
18 months
-
the
Recurred
involuntarily
as well as voluntarily.
the distal part of the tendon
of the
posterior
capsule
and
reattaching
IV
DISLOCATION
OF THE
SHOULDER
number
.
32
33
34
Age
in years
.
49
49
43
Male
Male
Male
.
Cause
.
.
.
.
Convulsive
.
Second
Head
defect
Initial
arthrograph
episode
Fell off motor
dislocation
First
Large
Treatment
.
Arthrograph
treatment
.
pouch beneath
infraspinatus.
No spill into axilla
.
6 weeks
Larger
after
.
in external
posterior
.
.
Lost
dislocation
Sling
10 days
Head
otherwise
defect,
normal
Large
pouch beneath
infraspinatus.
No spill into axilla
from
THE
in external
Reduced
joint
Restricted
External
injury
JOURNAL
rotation
volume.
Obliterated
inferior
Head defect
Full movement
2 months
on ice
First dislocation
4 weeks
defect
to follow-up
Slipped
than
normal.
Lack of definition
of posterior
glenoid
labrum.
Head
Function
pouch
scooter
Large pouch beneath
infraspinatus.
No spill into axilla
rotation
the
insertion.
Case
Sex
at
9 months
neutral
OF
BONE
AND
pouch.
movement.
rotation
to
only
JOINT
SURGERY
ARTHROGRAPHY
insufficiency,
until
that
and
subluxation
the
could
et al. (1959)
suggested
reasonable
assumption
here,
however,
was
heads
even
entered
these
A second
the
dislocation
and
31 who
moved
of
from
abduction
fibres
posteriorly
margin
without
responsible
cases.
head
that
there
and
is increased
the
and
patients
shoulder
Gitlin
in whom
joint
and
On dislocation
is contraction
of
this
rotated
the
does not
Following
head
a large
the
move
dorsi
is just
In
humeral
into
an
shows
believed
by
before
the
Reischauer
the
be
This
the
(1923)
is
published
tightly
16),
head
glenoid
position.
in all
(Fig.
29
30 degrees
scapula
the
moving
to
glenoid
28,
the scapula
action
of the
cartilaginous
seen
capsule
the
of
infraspinous
the
it and
the
16)
producing
Cases
Initially
by the
contract,
over
1 1, 14 and
position
muscles
to act normally
initial
rotation
or
(Figs.
as
of the
antagonists.
latissimus
between
elasticity
start
the
on
to
dislocated
their
was a complex
action.
upwards
or downwards
and
constricted
joint
movement
(1923)
In the three
in
dislocated.
dislocation
radiographs
in the
humerus
not
is balanced
for
characteristic
arthrograph
of the
had
infraspinatus
convexity
tendency
the
elsewhere.
capacity
contraction
operation,
and was
deltoid,
greatest
any
for
The
the
its
physiological
Reischauer
15).
simultaneous
of the
until
which
according
to Saha (1961),
then
only
sluggishly.
and
constant
notably
mobility
increased
in voluntary
studied
before
the chest wall
which,
posterior
(Fig.
factor
without
were
an
shoulders
pouches
with
Others,
was abnormal
elasticity
of the capsule,
and this would
be a
with hypermobility
in other joints.
The patients
reported
was
in two
433
SHOULDER
stretched
injury.
of increased
there
possible
away
trapezius
no sign
done
pouch,
posterior
slowly
without
that there
in patients
showed
arthrography
capsule
occur
OF THE
applied
which
and
to
suggests
er al.
Gitlin
(1959).
A labral
tear
which
finding
in Case
labrum
was
already
account
for
Asplund’s
completely
was
almost
There
28
was
Valentin
but
was
patella
as noted
Several
authors
1946, Gitlin
et a!.
any
dislocation
dislocation
shoulder.
with
family
It is possible
congenital
history
by Carter
and Sweetnam
(1960).
have not treated
their patients
1959) because
they
thought
the
the
traumatic
repeated
on the boy he operated
and that this was not
association
there
by
other
observation
posteriorly
hereditary
with
caused
in the
(1942)
absent
nor
associated
probably
present
no
(1931),
is usually
was
operatively
disability
or
split
injury
the glenoid
lesion.
hip
(Reischauer
to be too
1923,
slight.
fractures
in Case
of the
32 on
beneath
of
infraspinatus
detachment
of
the
without
any
glenoid
labrum
33 and 34 at
Arthrography
free
spill
and
into
the
the
time
in each
axillary
stripping
of
the
may
labrum
by
dislocation
(1938)
explored
three
painful
shoulders
after
varying
periods
of the shoulder
and found
erosion
of articular
cartilage
in one.
three
patients
with
traumatic
dislocations
(Table
IV) all sustained
humeral
head,
in Cases
the second
dislocation.
in the
as noticed
recurrent
dislocation
The
Tommasini
unexpected
repeated
of the
laxity
an
that
upon that
a congenital
dislocation
ofjoint
was
; a superficial
of
M#{246}llerud
However.
of
recurrent
compression
of the initial
injury,
showed
a spill
of
tissues;
this
periosteum
was
from
and
fluid
suggestive
the
neck
of
the scapula
at the time of the initial
injury
rather
than
the presence
of a capsular
tear,
and this would
be in agreement
with the views
of Moullin
and Keith
(1904).
Rowe
and
Yee (1944)
said
that
they
had
noticed
tears
in the posterior
capsule,
or avulsion
of the
capsule
from
the neck
of the scapula,
in their
patients.
Capsular
tears would
be expected
in about
half the acute
dislocations
if traumatic
posterior
dislocations
are comparable
to
anterior
dislocation.
In the
episode
indeed
the
in lateral
anteriorly;
monkey
VOL.
two
healing
48 B,
one
patients
in whom
appeared
to have
taken
place
in a sling
made
a much
treated
rotation.
It may
the only
and quoted
NO.
3,
AUGUST
be that
experimental
by Scougall
1966
dislocation
labral
was
despite
quicker
detachment
caused
the
by injury
two
recovery
posteriorly
different
than
heals
lesion
produced
on the glenoid
(1957)
showed
rapid
healing.
and
not
in a convulsive
regimes
the
more
labrum
after
patient
readily
reduction;
immobilised
than
posteriorly
those
in
a
434
B. REEVES
SUMMARY
AND
ANTERIOR
1
.
Arthrography
of the
2.
demonstrates
two
types
CONCLUSIONS
DISLOCATIONS
of injury
to the capsule
The
first
shoulder
in ten
is a capsular
unless
days
there
and
rupture
which
is concomitant
it should
be
does
not
humeral
safe
to start
appear
head
to lead
damage.
exercises
arthrographs
show
either
an absence
the subscapular
bursa.
5. Ruptures
of the supraspinatus
of a total
of twenty-seven
acute
common
than
was
previously
of the
equally
only
All
the
patients
with
to contract
the
preceded
8. No
In
two
examined
ability
dislocation
In
all
three
as
occurred
there
in
greater
than
a better
was
thanks
due
are
Hospital,
to
London,
to use the x-ray image
Strange
and
of
Case
Mr
C. Lloyd-Roberts
in his
intensifier
the
labral
for
their
joints
the
to
though
at the
the
in any
the
but
no
one
leakage
patient
shoulder
seen
second
for
was
after
the
dislocation.
into
the
healing
treated
in lateral
were
patients.
was
of the
capacity
and
dislocation
of the
head
time
The
control
Each
humeral
detachment;
with
axilla
appeared
in a sling
had
rotation.
encouragement;
his
to the orthopaedic
staff of St George’s
to Dr E. H. Allen
for his kindness
in allowing me
30 was seen through
the kindness
of Mr F. G. St Clair
patients;
and
Case
department.
the kindness
of
rupture.
treated
muscle
subscapularis
capsular
another
to study
even
separately.
in other
defect
it occurred
with
than
31 through
found
beneath
dislocations
anaesthesia
voluntary
of deltoid
the
with
result
G.
was
patient
fluid
general
a curious
parts
laxity
dislocation
for permission
had
posterior
third
a spill
in anterior
functional
entrance
cuff were seen in five patients
out
that this associated
injury
is more
under
dislocations
in the
anterior
or an enlarged
of the
Axial
one.
dislocation
and
acute
and
outline
enlargement
inferior
pouch.
DISLOCATIONS
radiologically
voluntary
with
of the
is complete
there is marked
elasticity
of the capsule
but the joint
is
examined
under
anaesthesia.
Both
shoulders
appear
to dislocate
anterior
patients
healing
believed.
by scapular
movement.
evidence
of increased
joint
initial
My
when
has
dislocation
group
is constant
with the
labral
portion
of the tendinous
dislocations,
suggesting
dislocation
is voluntary
in one direction
when
affected
patient
9.
dislocations
from
the glenoid
and most
heal with
to recurrent
dislocation.
It is not known
of the lesion
in these
patients
and this
glenoid
POSTERIOR
6. When
the
only
unstable
to recurrent
In this
remains
the subject
of further
investigation.
4. In recurrent
anterior
dislocation
of the shoulder
there
subscapular
bursa,
the outline
of which
becomes
continuous
able
anterior
early.
3. The second
is associated
with labral
detachment
immobilisation
for three weeks.
Failure
to heal leads
whether
immobilisation
had any influence
on healing
7.
in acute
shoulder.
of Mr A. G. Pollen.
REFERENCES
ASPLUND,
G.
(1942):
A.
Acta
Chirurgica
S. B. (1938):
luxation.
BANKART,
British
Journal
C., and
CARTER,
Boize
and
COOPER,
Sir
Near
GITLIN,
Em
(1839):
On
R. (1960):
42-B,
the
G.,
KESSEL,
A.
W.
Journal
L. (1950):
(habituell-willk#{252}rlicher)
hinterer
Schultergelenks-
103.
and
Treatment
of
Dislocation
Recurrent
of the
Shoulder-Joint.
Recurrent
and
of the
Hospital
WELNER,
of Surgery,
Arthrography
Dislocation
of the Patella and
Journal
of the Shoulder.
Os
Reports,
A. (1959):
Humeri
Upon
the
Dorsum
Scapulae
and
Upon
Fractures
4, 265.
Voluntary
Bilateral
Posterior
Dislocation
of the Shoulder
97, 777.
of
the
Shoulder-Joint.
Proceedings
of the Royal
Society
of Medicine,
43, 418.
MALGAIGNE,
J. F. (1855):
of
721.
Guy’s
A.,
SCHWARTZ,
American
willkUrlicher
87,
Dislocation
the Shoulder-Joint.
Joint.
von
26, 23.
SWEETNAM,
Surgery,
Fall
Scandinavica,
The Pathology
of Surgery,
Joint
A.
operierter
Trait#{233}des fractures
et des
luxations.
Tome
THE
2, 433.
JOURNAL
Paris:
OF
J. B. Bailli#{232}re.
BONE
AND
JOINT
SURGERY
ARTHROGRAPHY
A.
MOLLERUD,
Acta
(1946):
Chirurgica
C. W. M.,
MOULLIN,
Humerus
B. (1963):
An
F.
Pendel
Notes
Lancet,
Action.
Luxation
in the
Posterior
Part
of the
Shoulder-Joint.
on a Case
of Backward
Dislocation
of the
Head
of the
i, 496.
Arthropneumoradiographie
Anti-Rotation
(1923):
C. R., and
Surgery,
26,
K.
Charles
of the
A. (1904):
bei habitueller
But#{233}eost#{233}oplastique
Luxationen)
SAMILSON,
Habitual
SHOULDER
94, 181.
KEITH,
Die
Bilateral
435
THE
pour
luxation
Schulterluxation.
cong#{233}nitale
de
R#{246}ntgen-Praxis,
l’#{233}paule en
5, 589.
arri#{233}re. Journal
(Ic
43, 481.
REISCHAUFR,
A.
of
Muscular
L. (1934):
clzirurgie,
ROWE,
by
J. (1933):
OSIBRFDANNE,
REEVES,
Case
and
Caused
OBFRHOLZER,
SAHA.
A
Scandinavica,
OF
Arm
Ober
willkUrliche
und
“schnappende
L. B. K. (1944):
YEE,
Sling
For
Use
in Place
Schulterverrengkungen
Schulter.”
(rein
Archiv
A Posterior
of a Bankart’s
Approach
Bandage.
willk#{252}rliche,
f#{252}rOrthop#{228}dische
to the Shoulder
und
ii, 441.
Lancet,
habituell
willk#{252}rliche
Unfall-Chirurgie,
Joint.
Journal
und
22, 45.
of Boo”
a,zd Joint
580.
Theory
(1961):
of
Shoulder
Mechanism.
R. L., POST,
L., NOONAN,
Descriptive
and
Applied,
p.
20.
Springfield,
Illinois:
C. Thomas.
R. L.,
RAPHAEL,
Shoulder
Joint.
S. (1957):
SOUGALL,
M.
TOIMASINI,
Clinical
Dislocation
Posterior
(1938):
La
Orthopaedics,
lussazione
C.,
20,
of the
posteriore
SIRIS,
E., and
RANEY,
F. L., Jun. (1961):
Arthrography
and Joint
39-B,
21.
Shoulder.
volontaria
Journal
of Bone
della spalla.
Giornale
Surgery,
vento
di scieizze
726.
mediche,
12, 617.
VALENTIN,
VAN
B. (1931):
LINGE,
B.,
Sir
WATSON-JONES,
VOL.
48 B,
R.
(1955):
Schulterluxation.
Zeitschrzftfiir
Orthop#{228}dische
(1963):
Function
of the Supraspinatus
Muscle
Journal of Bone and Joint Surgery,
45-B, 750.
Fractures
and Joint
Injuries.
Vol. 2, p. 482.
Edinburgh
J. D.
(‘hirurgie,
and
and
55,
Its Relation
London:
229.
to the
E. & S.
Ltd.
Livingstone
a Case.
MULDER,
Syndrome.
Supraspinatus
WEISSMAN,
Die kongenitale
and
S. L.,
and
Journal
NO.
T0R0K,
of
Bone
3, AUGUST
G.
and
1966
(1958):
Joint
Bilateral
Surgery,
Recurrent
40-A, 479.
Posterior
Dislocation
of the Shoulder:
Report
of