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Lesions of the brachial plexus complicated by...

CHAPTER XII

LESIONS OF THE BRACHIAL PLEXUS COMPLICATED BY RUPTURE OF THE SUPRASPINATUS TENDON

INSTANCES will arise in industrial clinics where it will be difficult to differentiate between a direct injury to the supraspinatus tendon and a circumflex paralysis. The most important point I have in mind to accent in this chapter is that one should never be misled by the fact that the patient's deltoid is paralyzed, into thinking that the supraspinatus is undamaged. As a matter of fact, the combination of these two injuries is not infrequent, and the supraspinatus injury remains undetected because the deltoid paralysis seems to be accountable for the fact that the patient cannot raise his arm. I want to present arguments for my conviction that in case a patient has deltoid paralysis and is unable to elevate his arm, we should make an exploratory incision in the bursa to determine whether the supraspinatus tendon is ruptured. This dictum is supported by my observation that if the supraspinatus is intact, i.e., neither ruptured nor paralyzed, the patient can feebly raise his arm in spite of paralysis of the deltoid. I believe that the industrial surgeon who bears this in mind may be able to save his company some trouble and expense.
In the previous chapter, Dr. Stevens has made it very clear that most of the postdislocation paralyses are due to local, peripheral injuries of the axillary and musculocutaneous nerves, caused by actual stretching of these nerves by the head of the humerus in the course of its process of dislocation. He has also shown that the suprascapular nerve is subj ect to a considerable amount of variation in its association with the 5th root, so that many times it may escape paralysis, even in cases otherwise of Erb-Duchenne type.
Although I have never studied the plexus in regard to the mechanical stresses caused by different forms of injury, as Dr. Stevens has done, I had come to somewhat the same conclusions from clinical study, for I had observed cases in which it was very clear that the site of the lesion was below the nerve supply of the supraspinatus and above that of the deltoid. My observations had brought me to the conclusion that one should always be suspicious that the supraspinatus may be ruptured, rather than paralyzed, in all cases of postdislocation palsies.
For the purposes of our particular study concerning the diagnosis of paralysis of the supraspinatus versus rupture of its tendon, either of which combined with deltoid paralysis would cause inability to perform elevation, observation of the conditions of the rhomboids and pectorals is important, as the nerves for the rhomboids and those for the clavicular part of the pectoralis maj or leave the plexus above the circumflex, and also above the suprascapular nerve which supplies the spinati.
One can, by observation alone, determine the question of whether the pectorals or rhomboids are paralyzed, but the spinati under cover of the acromion are not readily palpable, although in a perfectly normal shoulder it is easy to feel (through the trapezius) the contraction of the supraspinatus when appropriate effort is made by the patient. When the patient folds his arms across his chest, and then shrugs the shoulders, the contours of the rhomboids appear. However, in cases of injury where the whole shoulder is tender, it is difficult to make sure that the patient is really making an effort to contract his supraspinatus. Thus the positive is pretty positive, but it is difficult to say that you are sure that the supraspinatus is out of commission. Later atrophy of these muscles does not signify paralyses, for it occurs after almost all shoulder injuries.
Nevertheless, if the rhomboids are paralyzed and the pectoralis major is partly paralyzed (the clavicular portion), we may assume that the supraspinatus is, also. Since the nerves to the pectorals have an additional supply from the lower cords of the plexus, paralysis of the pectorals need not necessarily be found. It is especially important to observe the clavicular portion of the pectoralis major, for this is probably always supplied by the 5th and 6th roots and perhaps by these roots only. Of course, proof of paralysis of the supraspinatus does not necessarily mean that there has been no rupture, for this might have occurred simultaneously with the same injury which dislocated the humerus and injured the plexus. If the rhomboids are paralyzed it makes it more probable that the supraspinatus is merely paralyzed and is not ruptured, but it does not absolutely exclude rupture.
As a matter of fact, in injuries to the plexus from dislocation or near-dislocation, we commonly find only the axillary nerve involved and consequently only the deltoid and teres minor paralyzed. The teres minor is naturally overlooked. Often the biceps and coraco-brachialis and brachialis anticus are simultaneously involved, and not infrequently the supinator longus. Yet all these may be involved without the spinati, for the suprascapular nerve may be almost independent of the 5th root. 
Of course, testing the activity of these muscles implies cooperation on the part of the patient, who must exert his will to raise the arm in spite of the soreness from the recent injury. Fortunately, in cases of paralysis the sensation of the joint is usually absent owing to the sensory paralysis of the axillary. In a recent severe case in which all the tendons had also been evulsed and the axillary paralyzed, I could move the joint about in any direction, without causing the least pain.
Taking all these considerations into account, I should lay it down as a dictum that if, following such injuries, one finds the deltoid paralyzed and the patient is unable to slowly raise his arm with the supraspinatus alone, the probability of a diagnosis of a ruptured supraspinatus tendon is so likely that exploration of the bursa should he done, unless there is a coincident paralysis of the rhomboids or the clavicular portion of the pectoralis major.
The following cases are illustrative of some of the points considered :

CASE 30
On Sept. 3rd, 1912, I operated on a man of 47, who had a circumflex paralysis which followed a dislocation two months previously. I was in doubt as to whether the supraspinatus was torn. The bursa, on exploration, proved to be normal, and the supraspinatus tendon was intact. It occurred to me that as the patient must wait for his incision to heal, he might as well wait in abduction and external rotation and give his deltoid a rest, on the general principle that all paralyzed muscles recover their tone better if they are maintained in a relaxed position. After a few days this man began to be very complimentary about the success of my wonderful operation, and said he could move his arm better than he had since the accident. In two weeks the power of the deltoid had almost entirely returned and the patient was greatly pleased.

Of course, my operation being simply a small incision through the deltoid fibers and the roof of the bursa had nothing to do with the matter. His improvement was due to rest in elevation. Since this experience I have treated deltoid paralysis in the same way, sometimes without exploratory incision, with invariably gratifying results. Most of the "improvement takes place in the first two weeks, so that the patient is usually very cooperative, for he realizes his progress. Part of the rapid progress in the first two weeks is due to readjustment of the swelling and edema in the joint and bursa. If the patient has been up and about for several months and the shoulder has "dropped," the space between the acromion and the head of the bone must become filled with fluid or with edema of the joint and bursal tissue.   The elevated position gives this edema an opportunity to be absorbed, the circulation becomes more active and the muscle fibers, not being stretched, soon respond. It may be months, however, before the muscle becomes fully developed again. The principle of relaxing paralyzed muscles is well accepted, but so far as traumatic circumflex lesions are concerned, it has certainly not become an appreciated routine practice, in this community at least. Previous to the above experience I had never seen it applied to a case of circumflex paralysis, and even since the above experience, my own cases have been the only ones I have observed, although I have no doubt the principle is constantly gaining in the extent of its recognition and perhaps practice. (See p, 482 on relaxed capsule.) It is well recognized now in the treatment of infantile paralysis. I feel sure that there are many industrial cases of axillary and other paralyses, for which our insurance companies might well pay for the use of a hospital bed for the sate of the time which the patient would gain in returning to work, As a rule, the exploration of the bursa should be done with local anaesthesia at the same time, for it is a trivial operation and causes no delay. The wound is healed long before the use of the arm returns. If a rupture of the supraspinatus is found and repaired, permanent disability may be prevented.

CASE 49.
On Dec. 13th, 1913, I operated on a man of 64, who had an axillary paralysis following a dislocation three weeks previously. On this case I made a preoperative diagnosis of a rupture of the supraspinatus as well as of deltoid paralysis. .Exploration showed that not only the supraspinatus but the infraspinatus, teres minor and long head of the biceps were evulsed. The destruction was too great to make any suture possible, so the wound was closed and the arm put up in abduction. Within two weeks there was a fair return of the power of the deltoid and months later the deltoid even became hypertrophied, but the full power of abduction never returned. I was called to see this patient ten years later, on April 23rd, 1923, because he had an ununited .fracture of the neck of the femur. The deltoid of the injured arm was very large and powerful, but he still could not abduct the arm when standing.,

Undoubtedly if this patient had been operated on immediately after the accident, the capsule and short rotators could have been sutured in place. Increased experience in these cases makes me feel confident that at the present time I could suture the tendons in a similar case even after three weeks, but the longer the period of time that elapses between the injury and the operation, the more retracted the tissues and the greater the difficulty. Quite recently I had to abandon suture in a case of seven months' duration in which both spinati and the teres minor had been evulsed.

A more encouraging instance was Case 107, a strong woman of 58, who had been employed as a cook. On July 18th, 1927, she fell on the floor of her kitchen and dislocated her left shoulder. She was taken to an emergency hospital, and the dislocation was reduced. The shoulder remained sore, almost useless, and did not progress. After seven months she was referred to the office of the insurer and an X-ray was taken showing that the dislocation had been reduced. Next day, Feb. 16th, 1928, she was referred to me. I reported as follows:
"Examination of the left shoulder reveals that there is a sensory and muscular paralysis of the circumflex and little power in the biceps. The head of the humerus falls away from the glenoid, as is usual in these cases of circumflex paralysis.
"I would recommend that the patient enter a hospital and have the arm retained comfortably in abduction. I have had a number of cases which responded promptly to this treatment, probably because the nerve trunks are put at rest and their circulation therefore made better for repair. Also the drag of the weight of the arm is taken from the deltoid and its fibers have a chance to recover their tone.
"With this treatment the prognosis is good.   Two weeks in this position with occasional appropriate exercises produces marked improvement. If it does not, the prognosis is poor, but I have never yet failed to see demonstrable improvement recognized by the patient in this time."
 *        *        *        *
"In my report of Feb.  16th concerning this patient, I stated that Dr.   reported to me by telephone that the films showed normal bones. I have since called at his office and inspected the films. They are not wholly negative for they show, faintly, crumbs of bone in a position suggesting that they were torn off the greater tuberosity by the supra-spinatus tendon. The films were not clear, for the patient moved, but the suggestion is strong that the damage is not only to the brachial plexus but that a certain amount of evulsion of the superficial part of the tuberosity occurred at the accident.
"At your suggestion, the patient entered the Trumbull Hospital on Feb. 19th to be under my care, and I put her to bed with the arm held loosely in abduction, so far as it was possible. I have seen her yesterday and today. She is not very cooperative and I find her a hard patient to handle, as she is rather stupid about getting the idea of keeping her arm up and when the nurse's back is turned, gets it down again.
"There is spasm of the groups of muscles on each side of the axilla and this tends to make her arm return to her side, as there is no opposition in the deltoid. It appears to abduct fairly well up to about half the normal distance and then there is a block, as if the above-mentioned fragments impeded further progress. It may be that there is some callous formation about them. However, I shall try for a few days longer to cope with her and endeavor to carry out the treatment. Unless she becomes more cooperative I fear that I may have to discharge her, for I do not think she would be willing to have an exploration of the bursa to see if the tendon is evulsed with a bit of tuberosity attached." 

 *       *        *       *
"I reported on this patient last on Feb. 21st. Since then she has remained in bed at the Trumbull Hospital with the arm in abduction. I finally succeeded in getting it into her head that she should help, and after the first week she, herself, could notice the daily improvement and has been more enthusiastic with her cooperation. It took about five days to overcome the spasm of the latissimus and pectorals, etc., but when they once yielded the arm could be comfortably retained in a semi-abducted and externally rotated position without other apparatus than a bandage, about her wrist tied to the head of the bed, to remind her.
"Her progress has been good, and there is distinct improvement in sensation and muscular activity in the deltoid region. I give her exercises in the stooping posture and she can do them quite freely, the arcs of motion being normal and the pendulum movement taking the place of the muscular power of the deltoid. There is still no real power in the latter, but I am confident I can feel a beginning contraction of the fibers, especially when a counter effort is being made.
"In my opinion it is well worth while to keep this patient in the hospital as long as she is clearly improving and she is willing to stay. The result of the two weeks makes me confident that progress will continue and the result will be good. I wish I could also explore the bursa to see whether the tendon is torn or whether the atrophy and loss of power in the supraspinatus is wholly from the nerve paralysis. I suspect the tendon is torn, but as it is masked by the paralysis, I am not certain.
"Would Dr. - - approve of my trying to persuade the patient to
have this done? The bursa and tendon could be inspected through a very small incision, not over a half-inch long. It would save the patient much time to have this done now rather than to wait until the paralysis would disappear. Then, too, if the tendon is torn, it would be easier and less painful to mend it while the paralysis is present than after the power of the deltoid has returned. If I were in her place I would beg to have this done, but I can see that she is not a patient to be easily persuaded."

Consent being obtained, the operation was done.

"Operation on Mrs. B.j March 13, 1928—ether anaesthesia. An incision was made (not over .one-half inch long) over the bursa and the new instrument I have had made was introduced. It is a modified nasal speculum and worked perfectly. On incising the bursa, free fluid escaped. The diagnosis of rupture of the supraspinatus and infraspinatus could be made and the extent of the rupture determined. The incision was then enlarged into the routine bursal incision, about two inches in length.
"Considerable difficulty was encountered in pulling forward the retracted ends of the tendons. The biceps tendon was intact and covered by the edge of the capsule and the tendon of the subscapularis. I eventually succeeded in drawing the tendons together, and, as no stub was left on part of the tuberosity, I drilled a hole and passed a braided silk ligature through it and the heaviest portion of the supraspinatus tendon. I also curetted lightly the raw bone on the tuberosity to stimulate attachment of the tendon. Some crumbs of bone were found in the retracted portion.   One bit was removed and another sewed to the tuberosity with 
the tendon still attached.   The muscle was closed with catgut, but the bursa was not sutured. A folded pillow was placed in the axilla.
"N. B. In this case an unusually accurate closure was made, perhaps because the retracted muscles were paralyzed and yielded more when pulled forward. A good result should be obtained if the wound heals normally, and, as I fully expect, the muscles regain their power."

The wound healed well and the muscles redeveloped. The patient has now a good strong arm with considerable power in abduction. I saw her last on Nov. 10th, 1930. She still complains of soreness and pain and weakness after using it, although it is a year and a half since the operation. She still receives compensation and feels unable to go to work. The X-ray shows a defect in the tuberosity where the small fragments were removed. The patient admits great improvement, but it must be put down as one of those cases of which the surgeon is proud, but in which the patient is not wholly satisfied. Of course the question of compensation enters the problem. If I could obtain as good a result as this, operating seven months after the accident, it seems to me very convincing that similar operations, done immediately, would be very successful.
I have on two occasions explored the bursa in other cases of axillary paralysis and found evidence of partial rupture of the tendon not extensive enough to demand suture. The wound did not in any way interfere with the convalescence, and the power of the deltoids returned satisfactorily.
It may well be asked how we are to know immediately after a shoulder dislocation has been reduced, whether the deltoid is paralyzed or whether there is crepitus in the joint from fragments of chipped tuberosities? Do I recommend churning the joint about and risking redislocation and further traumatization ? Might not a deltoid paralysis disappear within a few days? Would I make it a rule to explore every bursa after every dislocation because the supra-spinatus may be ruptured?
Let me say emphatically that I believe little if any harm could be done by permitting the patient to move his arm immediately after the reduction. Uncomplicated dislocation cannot recur unless the arm is abducted and externally rotated, but to test whether paralysis is present in the deltoid, it is not even necessary to manipulate the arm. One can hold the elbow at the side and ask the patient to make an effort to abduct. If the deltoid can be felt to contract, that settles the question. This test should be applied both before and after reduction, and can do no possible harm. In case of doubt, I should not hesitate to move the elbow away from the side in internal rotation, and then to let the patient hold it there if he can. Unless the arm is externally rotated or carried to the pivotal position, it cannot dislocate.  A case that readily redislocated should certainly be explored.
Electrical testing of the muscle for the reaction of degeneration (i.e., lack of faradic response and persistence of a slow galvanic response) is of no help in the first ten days, for it takes about this time for degeneration to occur. Even later on, the simple test of palpation of the muscle during voluntary effort seems to me nearly as reliable and more practical.
Chips of bone from the facets should be found by the X-ray either before or after the reduction. In at least two of the above cases they were present, as shown by the X-ray and confirmed by operation. Their very presence indicates that exploration is advisable, unless the fragment is large enough to suggest that the base of the bursa is not torn as discussed under fractures of the tuberosity.
The following case will be reported in some detail, not only because it is an illustration of the point we are at present discussing of the desirability of exploration of the bursa in cases of circumflex paralysis following dislocation, but because it illustrates many other points spoken of elsewhere in this book.

CASE  115
On Sept. 10th, 1928, a man of 48 was referred to me by an industrial insurance company. He was a well-built, wiry individual who had never been sick or had any serious accidents, although for most of his life he had been employed as an adzeman in a building and wrecking company, a rather hazardous occupation. On August 21st, 1928, he fell from a second-story roof, and as he fell, caught the edge of the roof of a shed on the first story with his bent and half-abducted right arm, thus sustaining him for a moment while the full weight of his descending body, in an almost upright position, plunged downward. A tremendous force was therefore brought to bear just at the shoulder joint. He was taken to Hospital A, one of our best institutions, where X-rays demonstrated a subcoracoid dislocation. Ether was given, the dislocation reduced and the patient sent home with his arm bandaged. He was attended by a doctor at his home, who readjusted the bandages a few times. On August 29th, this doctor, feeling that there was something still wrong with the shoulder, called the medical clinic of the insurer and requested that they take over the case. On August 30th, a representative of the medical staff of the insurer called to see the patient at his home and found "arm markedly swollen, shoulder black and blue, the entire arm edematous. The appearance of the shoulder at that time looked as though the joint were still out of place. He accomplished none of the usual motions of the shoulder, etc." The doctor then took the patient to Hospital B, where more X-rays were taken, which "conclusively prove that the head of the humerus is in proper relation to the glenoid."   The man received palliative treatment at this hospital for a few days, during which the swelling subsided a little, and he then attended the insurer's clinic, where I saw him on Sept. 10th, and found that his deltoid was paralyzed, that he had "dropping shoulder" and fluid in the joint. I advised having him enter another hospital to be treated with his arm in abduction for a week or two. He entered Hospital C, Sept. 11th, and I took charge of him.
On Sept. 17th, after having reviewed the X-rays taken at all three hospitals, I reported to the insurer's medical department:
"At the first visit I put him up in as near abduction (elevation) as I could, and on each occasion since I have managed to get the arm into still greater abduction. The patient has much improved. The deltoid fibers have contracted so that they are no longer flaccid, and I believe that I can feel a little contraction in them, particularly in the anterior portion.
"When the arm is almost completely abducted (elevated), it is quite evident from my examination and from the patient's feeling that the head of the humerus is in approximation with the glenoid, but when the patient stands or sits up, letting the arm fall, the head of the bone is thrust forward and downward, presenting the peculiar resemblance to disloca tion which had been noticed by Dr. - -. On thinking the case over I have become satisfied that this patient has five different lesions.
"First, he had a rupture of the axillary vein (P. S. I think now that this was probably the axillary artery itself.), or one of the other large veins, causing a hemorrhage which infiltrated the whole upper arm and upper part of the forearm, and also the subcutaneous tissue on the adjacent side of the chest.
"Second, he had a direct trauma to the circumflex nerve, or to the cord higher in the neck, causing paralysis of his deltoid.
"Third, a fracture of the greater tuberosity, which resulted practically in a rupture of the supraspinatus, because the fragment of bone (P. S. A tiny one.) has been left down under the deltoid, and the supraspinatus has retracted under the acromion.
"Fourth, a dislocation of the humerus which allowed the head of the bone to be pushed down into the axilla, while at the same time the fragment of the tuberosity was pushed below under the deltoid by the acromion.
"Fifth, it is possible also that the long head of the biceps is torn; certainly there is something which tends to slip in between the head of the bone and the glenoid as soon as the arm is adducted.
" In my opinion, it would be best for this patient, to do an exploratory operation under local anaesthesia, and open the bursa to see whether the supraspinatus tendon is torn, and if so, whether it can be replaced. It probably would be best to leave the displaced fragment to absorb."
Soon after this I did operate.
"A routine bursal incision was made, and after opening the roof of the bursa, the articular cartilages and joint cavity were directly visible. There was no sign of the torn supraspinatus, which had retracted. The incision was lengthened downwards and upwards, so that it extended from the coraco-acromial ligament downward about two inches; still none of the short rotators were seen. A sheet of tissue resembling joint capsule was cut through in making the incision, and this was not true joint capsule, but light scar tissue, which had formed beneath the deltoid. A large, bare area of bone was exposed at the position of the greater tuberosity. The bicipital groove was visible, but the biceps tendon was not to be seen.   The subscapularis was detached from the lesser tuberosity.
"By pulling down upon the arm a space could be made between the head of the humerus and the glenoid fossa. The finger could be passed completely around the head of the humerus without encountering any attachment of the short rotators. The joint cavity was washed out with warm saline, and the glenoid inspected. Some soft tissue (P. S. The musculo-tendinous cuff.) covered over the glenoid, and the normal glenoid fossa could be palpated beneath it. This tissue was in all probability composed of the short rotators. It was thought inadvisable, if not impossible, to pull out and readjust these rotators. At no time during the manipulation, although only the skin was anaesthetized, did the patient complain of pain.
"This case has been remarkable in many respects. Nothing was accomplished by the operation except to determine the extent of the injury. When the wound was opened it was quite apparent that the nerve supply of all the tissues involved beneath the skin was destroyed. For instance, I could put my finger in between the glenoid and the head of the humerus, and feel all around the head without giving the patient any apparent pain. I could raise the arm in abduction and internal rotation, and move it about at will without starting any pain or any spasm. All the short rotators were evulsed from the bone, and the head could easily have been pushed out through the wound as far as the surgical neck, as we do in excision of the head of the humerus. When the joint was apparently reduced the short rotators and capsule lay across the glenoid in such a way that the head rested on them; therefore, accurately speaking, the dislocation was entirely unreduced, and yet only a film of tissue one-eighth to one-quarter inch thick separated the articular surface of the humerus from the articular surface of the glenoid. The condition was similar to that represented in Fig. 58, except that the fragments of bone were much smaller."

I feel very certain that the force which caused this injury resulted in pushing the head of the humerus straight down into the axilla, with such violence that the whole capsule together with the short rotators and biceps was evulsed entirely, probably in one piece from the attachments on the tuberosities. The infraspinatus and teres minor were torn as well as the subscapularis and biceps tendon. As the head of the bone descended into the axilla, it ruptured an axillary vessel, or probably a large artery. At the same time a chip from the greater tuberosity was pushed by the acromion into the space beneath the deltoid, and when the dislocation reduced, this chip still stayed down there as shown in the X-ray.   It was the same force and the same leverage which usually results in fracture or dislocation, but in this case the bone, except for a bit of facet, held, and all the soft parts gave way.
The problem of surgical treatment after I had exposed the condition was too difficult to solve. I could have cleaned out the glenoid, but if I had done so, I could not have gathered the ends of the short rotators and resutured them to the tuberosity, even by drilling holes in it, for the tuberosity itself was too much damaged.
The only operation that I can conceive of doing in this case, and this might still be done, would be to use a sabre-cut incision, dissect out the short rotators separately, clean out the glenoid, pass a strip of fascia lata through the head of the humerus, and attach the short rotators to it.   (Fig. 52.)
I did not feel that I could perform such a difficult operation under the circumstances. It seemed to me better to leave the arm in the condition that it was, hoping that a false joint would develop which would permit him to use the other motions of his arm without abduction.
The patient was put to bed with the arm in an abducted position, and I let him remain in this position until the wound was healed and the power of the deltoid had returned. This resulted in the patient's feeling much encouraged, so that he would not consent to having another operation performed, feeling that eventually he would recover the remaining use of his arm. Finally, believing that he could get a more useful arm, I urged him to have an arthrodesis performed, but he would not consent to this and insisted on returning to his birthplace in Newfoundland, where he could live cheaply on his savings. He settled with the insurer and left. On May 23, 1932, he wrote me that there was no improvement but that there was no sign of axillary aneurysm. At any time he could have an arthrodesis done which would give him a painless, useful arm, although with the arc of motion limited fifty per cent. I should have done this operation in the first place. He may still develop an axillary aneurysm.

Among the instructive things about this case were:
That there was no anaesthetic skin area larger than a fifty cent piece, and this was down at about the middle of the deltoid. Yet when the skin was anaesthetized, the whole joint could be manipulated without any feeling on the part of the patient. This is to be explained by the fact that the nerve supply of the joint is from the deep branches of the axillary and also largely from the suprascapular, which was removed from the field by its retraction with the capsule over the glenoid. The seat of incision in the skin was supplied by the cervical plexus, which was not injured. Although this case showed all the common complications of dislocation, I feel that many cases have the main one of rupture of the supraspinatus.
As a matter of fact, after satisfactory reduction of an uncomplicated dislocation, the patient does not need immobilization, and a certain amount of active and passive motion is desirable, and neither painful nor harmful in any way. I believe that fixation in the sling position for ten days or two weeks after dislocation is actually harmful, and that routine exploration of the bursa in every case would be preferable. Yet I do not advocate routine exploration, although I believe it should be done in all cases of deltoid paralysis that cannot voluntarily abduct the arm, in all cases where evulsed facets are demonstrated by the X-ray, and in all cases where the surgeon is uneasy as to whether the dislocation is properly reduced. Any such rule may have exceptions.
I have never known or seen a case of deltoid paralysis which completely disappeared in a few weeks, let alone in a few days; it always takes weeks or months for the complete recovery. If the patient is to be laid up some time, why not make the exploratory incision at once, and if no rupture is found, get the benefit of the rest with the arm elevated?
The reader may question my dictum that when the supraspinatus is not injured the patient can abduct his arm by the use of this muscle alone. My evidence comprises a number of cases personally observed and a few cases from the literature.
Perhaps the most convincing case which I can report was that of a young Italian laborer who had absolutely no deltoid muscle, but who could elevate his arm, not only easily, but with great power, with an hypertrophied supraspinatus. This patient had been seen by a number of other doctors, and the question of the existence of a bone sarcoma had been brought up, because the shoulder was so misshapen that the appearance suggested a tumor just above the scapula. Some one also had made the diagnosis of progressive muscular atrophy. The following is a copy of my report to the insurance company.

Sept. 30, 1926. This patient is a rather small Italian laborer, age 26, whose face is distorted and scarred. He claims that this condition of his face is due to wounds received during the war in Italy. Otherwise than that, he says he has been well, until April 29, 1926, when he was climbing a ladder, holding a pail in one hand, and a rung broke and he fell. He does not remember how he fell, nor on what he landed, but the records submitted with him state that it was three stories. He was taken to a hospital and treated for fracture of two of the left lower ribs and an abrasion of the hand. He was soon after discharged from the hospital, but within a week after this developed pneumonia and had to return.
With the request for the examination of this patient you were kind enough to submit a folder containing a portion of his record. This folder does not contain records of his case prior to August, so that I am unable to ascertain either from the record or from the patient just what was the condition of his shoulder during the first few weeks after the accident. It appears from your record that the tumor in the supraclavicular fossa was not noticed until August. I can only give my impression from the examination at this date without a real history. The X-ray, which you also kindly sent, rules out any lesion of the shoulder bones and indicates that the tumor is subfascial.
Examination: The scars on the left forehead and cheek indicate that he had an old wound resulting in entire disappearance of the left masseter muscle and perhaps some loss of bone. The bulging side of his face is the normal one, and the disparity of the two sides is due to the contrast of the normal with the atrophied side, rather than vice versa, as one would guess at first sight. The deformity of the face is so great as to suggest a "facial hemiatrophy." One must consider the possibility that this was a congenital condition and that it was not related to the wound and scars.
The examination of the shoulder discloses a most unusual condition, namely, a complete atrophy of the whole deltoid muscle without the involvement of the neighboring muscles, except as shown by a mild fibrillation. It is very interesting that the patient can perform complete abduction of the arm with the supraspinatus alone without the deltoid. He does this so easily that it suggests that the present condition has existed much longer than since last April. Another point which suggests this conclusion is that the patient's arms are covered with tattoo marks, which are not misshapen in any way, as they would be if they had been done before the atrophy of the deltoid occurred. He states that these tattooings were done in 1923.
Referring to the tumor in the supraclavicular fossa, there is certainly a hard mass at this point, but I do not feel sure that it is a tumor in the sense of a new growth. It is subfascial, firmly fixed to the upper ribs, but not to the scapula. It is not tender to any great extent. It is immovable, smooth, hard and not elastic. It is covered more or less with muscle and is difficult to describe accurately. I am not sure that it is not a peculiar curvature of the ribs due to the unusual shoulder condition which may have existed since infancy.
There is one other finding which may have some bearing, and that is a partial if not complete paralysis of the left serratus magnus, causing a slight angel wing appearance of the posterior edge of the scapula.
Discussion: This case has puzzled me a great deal, but I have come to the conclusion that it is an instance of an old infantile paralysis, and that the recent injury in April had little or nothing to do with the condition of the shoulder.   I do not think that the diagnosis of progressive muscular atrophy is correct, although I would admit that it might be if good proof could be obtained that the patient possessed a deltoid within the last few years. The extraordinary development of the supraspinatus muscle is very much against this hypothesis. I am even inclined to doubt that the facial condition is due, as the patient says, to wounds received in the army. I would be much more inclined to think that the man "got by" in a physical examination and entered the army, as many of our own men did, without a thorough looking over. On the whole, I am of the opinion that no treatment will do this patient any good, and that he, himself, knows that he is trying to put over conditions which he previously had knowledge of, as results of the recent accident. I can feel slight irregularities on some of the lower ribs which suggest that they have been fractured, but nothing that I would be willing to declare were evidence of fracture.
The patient had noticed no tumor in the supraclavicular fossa, nor does he complain of symptoms from it, nor does the X-ray show any definite indication of a true tumor. From the patient's point of view, exploration of this tumor might be worth while. The possibility of its being a neurogenic fibroma or sarcoma has to be considered, but I am inclined to think that exploration would show it to be a compensatory deformity of the rib, due to the use of the arm without the deltoid since childhood. I cannot, however, believe that it is a part of the duty of any insurance company to have this done for the patient.
Notice the similarity of development of the two hands and forearms. This is consistent with a deformity of the shoulder in infancy, and not with one beginning April last.

I finally convinced the neurologist by an X-ray comparing the two scapulae which showed that of the affected side to be much smaller than the other, and he withdrew his tentative diagnosis of progressive muscular atrophy. The upper three ribs were bowed outward and gave the appearance of tumor. As a matter of fact, the cause of the atrophy of the deltoid in this case is unimportant for my argument. Whatever its cause, the deltoid muscle was gone, and the supraspinatus was observed to function as a powerful abductor.
I have from time to time seen other cases in which the supraspinatus was able to perform abduction in spite of a paralyzed deltoid. Quite recently I saw such an instance in a patient of my own, who was riding a motor cycle and collided with a truck. Besides minor cuts and bruises, he had a definite paralysis of the deltoid, but in spite of this he could elevate the arm to an upright position. After several months the deltoid returned to normal, and a year after the injury was as well as ever. In this case, also, the sensory area corresponding to the circumflex distribution was no larger than a half dollar, if we may judge from the skin anaesthesia.

SENSORY LESIONS OF THE SHOULDER

Before leaving the subject of injuries to the brachial plexus, something should be said in regard to whether the sensory roots may be affected without involvement of the motor roots. So far as I know, such cases have not been described, and it is even very rare to find any mention of sensory involvement in the descriptions of cases of motor paralysis of the upper type. In the lower type the skin anaesthesia is in the hand and arm, and not in the shoulder. Probably most neurologists would at once suspect hysteria, if anaesthesia over the shoulder without motor involvement followed an accident, yet I am convinced that such symptoms may arise from bona fide organic causes.
The fact that anaesthesia so seldom accompanies motor injuries is an additional argument to support Dr. Stevens' contention that ruptures of the plexus are usually external to the snubbing on the transverse processes. If the injury extended within the spinal canal, the posterior sensory roots should be involved. But may these roots, or their posterior sensory branches, not be involved separately? I am inclined to think that they may, perhaps not within the spinal canal, but after they have emerged from the bone and are perforating the deep layers of fascia on their way to the skin.
In certain cases I have found areas of extensive paresthesia in the regions supplied by the posterior branches of the cervical and brachial plexus over the dorsum of the shoulder. There was localized anaesthesia or an intense hyperesthesia in this area. There was no definite muscular paralysis, yet the individuals were incapacitated on account of pain and soreness on the use of the shoulder. I am not able to state exactly what this condition is, but I am inclined to interpret it as an injury to the posterior sensory roots of the brachial plexus at a point between the dura and the place where they penetrate the deep fascia in the back near the vertebrae. It seems possible that a tearing of the heavy fascia at this point might stretch or pull off a number of these roots, without doing any damage to the motor roots.

Case 1. W. J. A muscular, strongly-built teamster of 37. On Feb. 7 th, 1929, he jumped up several inches from the floor to pull down a lever in a factory and felt a sudden, sharp pain in his neck and was immediately unable to use his left arm. He saw many doctors and had various forms of palliative therapy. I saw him on July 31st, 1929. He stated that there had been no great change in his condition since he was injured.

Examination showed a powerfully built man in apparent health, who held his head and shoulders in a peculiar manner as if dreading any twist or turn of his body. The posterior muscles of the right side of the neck were very prominent, as contrasted to the depressed condition of those on the left. It seemed to me that this lack of symmetry was due to lack of function of some of the left muscles rather than to spasm of the ones on the right, yet the trapezius could be contracted to hunch the shoulders so that the muscles affected, if any, must be the deep group. No special muscle could be identified as paralyzed. I found an area of intense hyperesthesia to light stroking of the skin of the back of the left side of the neck and chest, corresponding to the distribution of the dorsal branches of the cervical and brachial plexus; yet this area was not sensitive to a pin prick.

A second examination was made Feb. 3rd, 1930. There had been slight improvement, but the condition was essentially the same. Motions of the joint and the development of the muscles were normal.

FIGURE 66.    AREAS OF SENSORY DISTURBANCE UNACCOMPANIED BY PARALYSIS
The disturbed sensation area in Case 1 involved only the back. In Case 2 it involved the back and shoulder. In Case 8 it involved the back, shoulder and outer and anterior portions of the arm. There was no definite evidence of paralysis of any of the muscles, although the writer could not absolutely determine that there were no paralyses of the deep muscles of the neck. The curved posterior margin on the back was identical in all three cases.

Case 2. J. M. A red-haired, strong-looking Irish laborer of 24 was struck unexpectedly from behind by a huge roll of leather, which was immediately followed by another roll which also struck him. He was knocked to the floor unconscious and taken to a hospital. He sustained injuries to the hip and ribs and to his left shoulder. I saw him on June 27th, 1929, nearly six months after the accident. He stated that the symptoms had been the same ever since the accident, so far as the shoulder was concerned.  He had completely recovered from his other injuries.
Examination showed that the left shoulder joint and the muscles about the shoulder were normal. He, too, held his neck in the same peculiar position. There was tenderness about the upper cords of the plexus and pain in the rhomboid region. There was anaesthesia to a pin prick over the whole area supplied by the posterior branches of the left cervical plexus, and by the circumflex and posterior branches of the upper five or six thoracic nerves. The posterior outline of the anaesthesia was similar to the outline in Case No. I, but the area of anaesthesia extended over the circumflex area also. I saw this patient again on December 10th, 1929, and the anaesthesia remained the same. This case was considered to be hysterical by a neurologist, but I feel sure it was not.

Case 3. J. D. On October 14, 1929, a longshoreman of 42 was struck on his left shoulder and left side of his neck by a heavy load swinging on a hoist, and was knocked about fifteen feet. I saw him on March 3rd, 1930, nearly six months later. He stated that his condition had been about the same since the accident. He complained about inability to use his left arm without pain.
Examination showed a similar paresthesia to that in Case No. 2, except that in addition to the area involved in Case No. 2, the areas supplied by the median and radial nerves in the forearm and hand were also involved. In this case also there was no paralysis or wasting of the muscles in the arm. They were, however, somewhat weak. There was some delayed sensation in the ulnar supply of the little and ring fingers and ulnar region of the forearm. This would seem unlikely in an hysterical case.

Several other similar cases have come under my observation. They are mentioned in this connection because my belief is that this group of cases constitute a real clinical entity, although the peculiar character of their sensory symptoms, without motor symptoms, suggests hysteria. I am sure that similar cases will be met by other surgeons who see industrial cases, and feel that they merit study and discussion. In the three cases the posterior outline of the paresthesia was the same.  Unfortunately I have no treatment to suggest.
Within six months after writing the above, I saw two more very similar cases of this puzzling type. They would have escaped my notice had I not had the previous experience. I feel that it is important to test the dorsal region of the neck and shoulder for anass-thesia or hyperesthesia, particularly in strong, muscular individuals, such as all these men were. They were not at all of hysterical type, and yet the only findings to account for their great and continued complaint of pain were these unusual areas of paresthesia.
There is a possibility that these areas of paresthesia represent overuse of physiotherapy. All these cases had had prolonged treatment. I am convinced that "Baking," whether by hot water bottles or electric pads and lamps, may produce similar disorders of the nerve terminations in the skin. However, these patients all stated that their symptoms were the same or worse soon after their accidents. Although I cannot explain the exact mechanism of the injury in the cases described, I am loath to believe that previously sound, muscular men, after admittedly serious injuries, should succumb to hysteria and exhibit its symptoms by skin paresthesia in this region with a definite posterior border arching away from the spine. The fact that the posterior branches of so many different nerves are involved suggests a long, vertical rent in the deep fascia of the neck.


REFERENCES

I know of no writings on the subjects considered in this chapter.
 

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