Case. — Mary Trainor, wt. GO, was admitted into one of Mr. Peile's wards in the Richmond Hospital on the 19th of May, 1848. She com plained much of the left shoulder, on which she had fallen fourteen days before. She had never used her arm since the accident, nor left it unsupported. The patient pointed to one part close to the head of the humerus anteriorly, which was particularly painful, and here a small bony projection was detected, whether a spicnla of bone or a small exostosis could not be known. She could elevate, or abduct her arm some inches from her side, -and could rotate it freely herself, without these movements causing her any pain. Although many examinations had been made since her admission into the hospital, no satisfactory evidence of' crepitus could be detected ; there was sonic tumefaction, and heat showing in flammation of the shoulder joint. She died -suddenly of apoplexy on the fourth day after her admission.
Post-mortenz. —Before the shoulder joint was examined, it was ascertained by careful measurement from the posterior angle of -the acromion to the outer condyle of the humerus, as well as from the scapular ex tremity of the clavicle to the same point below, that the left or injured arm was fully one quarter of an inch shorter than the right. On removing the muscles and their tendons, a fracture was seen to have traversed the superior extremity of the humerus: the line of this fracture was somewhat irregular ; pos teriorly it passed along the basis of the head of the humerus, or nearly as high as the level of the anatomical neck, and anteriorly along the basis of the lesser tuberosity', which was thus left attached to the head, while the greater tuberosity was detached, and broken into frag ments ; and it appeared as if this last was the mechanical result of the impaction of the head into the eancelli of the shaft of the bone; the amount of this impaction was to the extent of one quarter of an inch. The synovial mem brane was perforated or punctured in one or two points by spiculge of the broken humerus, and this membrane showed decided traces of' having been the seat of inflammatory action. The cartilaginous covering of the head of the humerus seemed to have been somewhat thinned — the result of the inflammation which had engaged the joint more or less ever since the occurrence of the accident.
The diagnosis in this case was very diffi cult, for there was some swelling and decided inflatnmation of the shoulder joint: fourteen days had passed since the accident occurred, and no crepittis, although carefully sought for, could at this period be detected. Apparently self-persuaded that no fracture existed, the woman repeatedly showed to Mr. Robert Macdonnell (the resident pupil, who had im mediate charge of the case) how freely she could rotate the injured humerus ; she could also abduct the elbow some inches from her side. A fracture through the superior part of the humerus was suspected ; but as there was no obvious displacement of the fragments, the principal indication seemed to be to reduce the inflammation of the shoulder joint, and this line of practice was pursued. The ex
pedient of making a comparative measure ment as to the relative length of the two arms was not thought necessary as an aid in the diagnosis of this case ; yet the result of this experiment would have shown in the living as it did subsequently in the dead body, a decided shortening of the left arm to the amount of a quarter of an inch, an ob servation which would no doubt have con firmed the idea already existing in the minds of the attendants, that a fracture of the hu merus existed, as well as an inflammation of the shoulder joint.
3. Fracture of the superior extremity of the hunzerus through the line of junction of the epi physis with the shaft of the bone, or close to this line.
This is a species of fracture which not un frequently occurs in early life. In the old subject we occasionally witness cases of frac ture in the same situation. This accident is so far unlike that last adverted to, that while •in the former there is no displacement, the latter accident is attended with considerable deformity. We may make this general remark with respect to fractures above the line of junction of the epiphysis, whether the fracture be extra-capsular or intra-capsular.— There is little or no deformity, and crepitus (a symptom of fracture, the possibility of eliciting which usually exists), and shortening to a small amount of' the length of the humerus, are the only positive signs to which we can refer to estabiish our diagnosis ; but when a fracture of the humerus, either at the line of junction of the epiphysis with the shaft of the bone, or below this line in the surgical neck, occurs, then much displacement of the frag ments may- generally be observed.
Sir A. Cooper has described an assemblage of symptoms belonging to a class of cases of fracture of the superior extremity of the hu merus, which we have no doubt he conjectured to belong to the separation of the superior epiphysis from the shaft of the humerus in the young subject. In the adult, a fracture through the original line of junction of the superior epiphysis with the shaft of the humerus would be attended with nearly similar symptoms. In alluding to the injury in question, Sir A. C. observes, that in children it is the result of falls upon the shoulder. The signs of it are as follow ; — The head of the bone remains in the glenoid cavity of the scapula, so that the shoulder is not sunken as in dislocation; when the shoulder is examined a projection of bone is perceived upon the point of the coracoid process, and when the elbow is raised and brought forward this projection is rendered particularly conspicuous. By drawing down the arm the prominence is removed, but it im mediately re-appears upon ceasing to make the extension, and the natural contour of the shoulder is lost.