All the moveinents of the shoulder joint are painful, and the patient cannot raise the arm unless by the aid or the other hand. The elbow is with difficulty withdrawn from the side, and the arm requires support. Sir A. Cooper adduces a case illustrating the above symptoms in a child 10, who had fallen on the shoulder into a sawpit the depth of which was eight feet.
The writer has witnessed many examples of fracture of the humerus in the line of junction of the superior epiphysis with the shaft of the bone, or in the immediate vicinity of this line.
In these cases the youth of the patient, and the situation of the fracture, led him to con jecture that a separation of the superior epi physis of the humerus had occurred ; but he had no opportunity of ascertaining anatomi cally the true nature of the lesion.
The principal deformity noticed by the writer in these cases is attempted to be de lineated in (fig. 433.), the representation of one of the plaster casts which he has preserved of one out of many of these cases. The pro minence here delineated is found to be owing to a very remarkable projection forwards of the upper extremity of the inferior fragment of the humerus. This was best seen by view ing the shoulder in profile, or sidewise. The antero-posterior measurement of the shoulder was tnuch increased. Sir A. Cooper, in re ference to the cases he has seen of this kind, observes, that when the shoulder is examined a projection of bone is perceived " at the front of' the coracoid process ;" in four cases which the writer has witnessed, the projection of bone formed by the superior extremity of the lower fragment of the humerus was situated exactly in the centre of a line stretching an teriorly from the acromio-clavicular articula tion to the lower margin of the anterior fold of the axilla. This remarkable projection of the bone, formed by the lower fragment, was in two cases engaged in the deeper layers of the integuments covering the deltoid_ muscle near to its anterior margin, and hence the deltoid muscle must have been itself per forated. In these latter cases it was found impossible to disengage the bone from its faulty position, or from the fibres of the deltoid muscle, and deeper layer of the integuments. The following case of the above description has been recently seen by the writer.
Case.—Fracture through the humerus imnze diately below the tuberosities, or through the original line of junction of the epiphysis and shaft of this bone.— Charles Austin, aged 14 years, on the morning of the 12th April, 1848, fell from a height of seven feet off a ladder, and was thrown on the posterior part of his left shoulder on uneven ground. He was not seen until next morning, when the injured shoulder presented the following appearances * " There was a great deal of ecchymosis and swelling about the joint ; the acromion process appeared pro minent, and in viewing the shoulder sidewise the measurement of its antero-posterior diame ter appeared greatly increased. The patient supported the hand and fore-arm of the injured arm with the opposite hand ; the elbow was slightly abducted, but it could be readily pressed against the side. He could not him self make the least effort to move the arm, and the attempt to raise it from the side, or to deprive it, even for a moment, of the sup port of the right hand, was productive of much pain. On placing one hand over the joint, and rotating the humerus with the other, a distinct crepitus could be perceived. The head of the bone could be felt in the glenoid cavity, and when the shaft of the humerus was rotated no motion was communicated to the head. On the seventh day after the accident all swelling had subsided, and the appearances noted were as follows On viewing the shoulder in front, a very remarkable angular projection of bone forwards is observed. This prominence is very near the anterior margin of the deltoid muscle, and near the centre of a line drawn from the srapular end of the clavicle to the margin of the anterior wall of the axilla. This projection is evidently the abrupt termination of the upper extremity of the lower fragment of the humerus ; every movement communicated to the shaft of the bone also moves this projecting point, a little below, and to the outside of which, an indent ation or slight puckering of the skin is observ able. This last we can readily suppose has been produced by the lower frag,ment having perforated the deltoid muscle, and engaged itself in the deeper layer of the integument.