RECONSTRUCTIVE SURGERY OF 
THE UPPER EXTREMITY 
Ai 11 ;,i b x. STEiN D L& R RECONSTRUCTIVE SURGERY 
OF THE UPPER EXTREMITY RECONSTRUCTIVE SURGERY 
OF THE UPPER EXTREMITY 
DY 
ARTHUR STEINDLER, M.D., F.A.C.S. 
PROFESSOR OF ORTHOPEDIC SURGERY, IOWA STATE 
UNIVERSITY MEDICAL SCHOOL 
SURGICAL MONOGRAPHS 
UNDER THE EDITORIAL SUPERVISION OF 
DEAN LEWIS, A.B., M.D. EUGENE II. POOL, A.B., M.D. 
PROFESSOR OF SURGERY, RUSH MEDICAL COLLEGE ATTENDING SURGEON, NEW YORK HOSPITAL 
ARTHUR W. ELTING, A.B., M.D. 
PROFESSOR OF SURGERY, ALBANY MEDICAL COLLEGE 
D. APPLETON AND COMPANY 
NEW YORK :: 1923 :: LONDON COPYRIGHT, 1923, BY 
D. APPLETON AND COMPANY 
PRINTED IN THE UNITED STATES OF AMERICA TO 
DR. JOHN RIDLON OF CHICAGO 
THE TEACHER 
THE ADVISER 
THE FRIEND PREFACE 
This book is written as a record of personal experience rather than 
as a textbook on the orthopedic surgery of the upper extremity. The 
fact that it is a monograph on a definite subject will serve as an explan- 
ation for the rather perfunctory treatment which has been given some 
of the chapters. This is especially true of those pertaining to tubercu- 
losis and chronic arthritis. 
Subjects of general orthopedic nature, such as heliotherapy, and so 
on, are only referred to shortly as the occasion arises, and should be 
looked up in a general textbook of orthopedic surgery. 
It is hoped that the keen interest in the orthopedic ailments of the 
arm and hand which prompted the writing of this book will find response, 
and that it will be a factor in stimulating contributions of more ex- 
haustive and more valuable nature covering the many problems and 
questions of this field of surgery. 
Acknowledgment and appreciation are due to Miss M. Prosser, in 
charge of the muscle educational work, for her valuable aid given in the 
writing of the chapter on physiotherapy; to Dr. R. V. Funsten for his 
help in arranging photographs and records; and to Dr. F. L. Knowles 
for most of the drawings. 
A. Steindler 
Iowa City, Iowa. INTRODUCTION 
Orthopedic surgeons are finding it hard to define the scope of their 
specialty. No designation has been found which is at the same time 
sufficiently limiting and sufficiently inclusive. It is becoming more and 
more the functional surgery of the extremities and the spinal column. 
Much has been written on the surgery of the spine. The corrective 
surgery of the lower extremity has also received much attention. The surgery 
of the shoulder girdle, arm and hand has been less thoroughly considered and 
there is great need for such consideration. 
It is natural that improved locomotion and weight bearing have 
seemed the first requisites. Rarely, however, can locomotion be so 
bettered as to compete with the normal, and often this improvement adds 
little to wage-earning capacity. We would do well to consider the 
material increase in this capacity which even slight improvement in the 
function of the upper extremity makes possible. 
This deserved consideration has been given in this book by Professor 
Steindler. 
I shall never forget the stimulation which I received from a visit to 
Dr. Steindler’s clinic at the University of Iowa. I had expected much, 
for I had appreciated the careful work which the author’s many previous 
contributions to orthopedic surgery have evidenced. But I had hardly 
expected to find such ideal conditions for the standardization of methods 
of procedure for the betterment of the cripple. An enthusiastic, thought- 
ful, and skillful chief of clinic, excellent hospital facilities, few distracting 
social obligations or scattered private patients and an enlightened state 
government providing sufficient support and assuring beneficent control 
of cases, to make “follow up” and real end-result studies possible. 
The book proves that good use of these facilities has been made. 
One cannot escape the impression that the principles herein advocated 
must be sound. If any exception can be taken to the style, it is that 
scarcely an unnecessary word has been employed. There is no “pad- 
ding.” Each sentence must be read with attention. No cursory skim- 
ming of the well-illustrated pages will make one master of the knowledge 
which they contain. They are largely reports of personal experience, 
not reviews of other men’s work. 
Especially valuable and commendable are the descriptions of the 
muscle dynamics of the shoulder, and the careful anatomical review of 
the action and relative importance of the muscles controlling the finer 
movements of the hand. The bearing which these considerations have 
on tendon transplantation is of supreme importance. 
IX INTRODUCTION 
X 
There are excellent sections on physiotherapy, muscle re-education, 
and substitutionary movements. The simple apparatus and methods of 
recording progress are most practical. 
It is a book which every one who contemplates performing opera- 
tions for the restoration of function in the upper extremity should read 
and, usually, should follow. Its frank report of personal work, by no 
means always successful, gives a judicial tone which medical books too 
often lack. No attempt is made to prove a preconceived theory, but 
many original methods are described; methods which demand a trial 
because of their rationality and the convincingly successful results which 
the author has obtained. 
This is the type of book we need; unspectacular, straightforward, the 
conclusions of a thoughtful man who believes his experience in a limited 
field has taught him certain things which it is his duty to pass on to his 
colaborers in the art of healing. 
Robert B. Osgood 
372 Marlborough St., 
Boston, Mass. CONTENTS 
CHAPTER PAGE 
I. Subacromial Bursitis i 
II. Congenital Deformities of the Shoulder . .12 
Birth-palsy, 12—Congenital elevation of the scapula, 22. 
III. Paralysis of Shoulder and Elbow 36 
Paralysis of scapulothoracic muscles, 36—Paralysis of scapulohumeral muscles, 
39—The flail elbow, 56. 
IV. The Paralytic Hand 70 
Traumatic paralysis, 88. 
V. Contractures of Wrist and Fingers 103 
Chronic inflammatory contractures, 103—Dermogenetic scar contractures, 109— 
Neoplasty of thumb and fingers, 122—Ischemic contractures, 126—Madelung’s 
deformity of the wrist, 145—Dupuytren’s contracture, 149. 
VI. Spastic Paralysis ' 159 
VII. Tuberculosis of the Upper Extremity 187 
VIII. Chronic Arthritic Deformities of the Upper Extremity .... 200 
IX. Congenital Malformations and Deformities 210 
X. Traumatic Deformities 250 
Traumatic deformities of hand and fingers, 250—Traumatic deformities of the 
elbow, 256—Arthroplasty of the elbow, 263—Tendon ruptures, 270—Habitual 
dislocations, 273—Snapping joints, 277—Writers’ cramp, 279. 
XI. Physiotherapy of the Upper Extremity 283 
Kinesiology and mechanotherapy, 283—Muscle education and occupational 
therapy, 293. ILLUSTRATIONS 
PAGE 
Plate I 9 
1. Subdeltoid bursitis. 
2. After conservative treatment. 
3. Subdeltoid bursitis; after forcible correction. 
4. Subdeltoid bursitis; after forcible correction. 
Plate II 25 
1. Birth-palsy with posterior dislocation of the shoulder. 
2. Birth-palsy with posterior dislocation of the shoulder. 
3. After operative reduction in cast. 
4. After secondary osteotomy of the humerus. 
Plate III 27 
1. Birth-palsy with posterior dislocation of humerus. 
2. X-ray of dislocated shoulder. 
3. Birth-palsy; whole arm type. 
4. After resection of pronator and internal rotators of shoulder. 
Plate IV 31 
1. Winged scapula. 
2. Congenital elevation of scapula. 
3. X-ray, showing elevation of left scapula, wedge formation of vertebra and fusion 
of ribs. 
Plate V 49 
1. Incision and skin flap. 
2. Osteotomy of acromion with deltoid flap turned down; capsule opened, show- 
ing tendon of long head of biceps. 
3. The placing of wires through denuded head and base of acromion. 
4. Transverse suture of capsule; wires tied over it. 
Plate VI 51 
1. Paralytic flail shoulder. 
2. After arthrodesis of shoulder. 
3. Paralytic flail shoulder and wrist. 
4. After arthrodesis of shoulder and wrist. 
Plate VII 53 
1. Paralytic flail right shoulder. 
2. Paralytic flail right shoulder after arthrodesis. 
3. Paralytic flail shoulder, wrist and elbow. 
4. After arthrodesis of shoulder, elbow plasty, arthrodesis of wrist, and interosseous 
transplantation of flexors. 
5. Paralytic flail right shoulder. 
6. After arthrodesis of shoulder. 
XIII XIV 
ILLUSTRATIONS 
PAGE 
Plate VIII 55 
1. Paralytic flail left shoulder, elbow and wrist. 
2. After arthrodesis of shoulder, flexor plasty of elbow and arthrodesis of wrist. 
3. Paralytic flail shoulder and elbow; thenar palsy. 
4, 5. Result of thumb plasty for thenar palsy. 
6. Result of plasty of elbow. 
7. Result of arthrodesis of shoulder and plasty of elbow. 
Plate IX 63 
1. Stripping of flexor origin from internal condyle of humerus. 
2. Transposition upward and insertion to supracondyloid ridge. 
Plate X 65 
1. Paralytic flail shoulder and elbow; result of elbow plasty. 
2. Result of arthrodesis of shoulder, elbow plasty and arthrodesis of wrist. 
3. Total paralysis of arm. 
4. Result of arthrodesis of wrist. 
5. Result of arthrodesis of shoulder, muscle plasty of elbow and arthrodesis of 
wrist. 
6. X-ray of arthrodesis shoulder showing fusion. 
Plate XI 67 
1. Paralytic flail shoulder and elbow. 
2. Result of elbow plasty. 
3, 4. Technic of elbow plasty. 
5. Paralytic flail right shoulder and elbow. 
6. Result of elbow plasty and arthrodesis of shoulder. 
Plate XII 81 
1. Incision and exposure. 
2. Dissection of radius and carpal bones; lines of osteotomy. 
3. Removal of bone wedge; placing of wires. 
4. Tying of wire sutures; closure. 
Plate XIII 83 
x. Paralytic flail wrist; result of arthrodesis. 
2. Paralytic flail wrist; result of arthrodesis. 
3. Paralytic flail wrist. 
4. Result of arthrodesis. 
Plate XIV 87 
x. Splitting of the tendon of the flexor pollicis longue. 
2. Periosteal suture of outer half of tendon to base of basal phalanx. 
Plate XV 85 
1. Scar contractures of wrist. Live-wire burn. After plasties of flexor tendons. 
2. Scar contracture of hand. Live-wire bum. After plasty of flexor tendons. 
3. Trick motion; extension of fingers by flexion of wrist. 
4. Flexion of fingers by extension of wrist. 
Plate XVI 97 
1. Traumatic paralysis of thumb. After flexor plasty of thumb. Result of opera- 
tion. 
2. Result of operation. 
3. Result of operation. 
4. Scar contracture of thumb. 
5. Result after flexor plasty. ILLUSTRATIONS 
XV 
PAGE 
Plate XVII 99 
1. Musculospiral palsy. Drop wrist. 
2. After arthrodesis of wrist and interosseous transplantation of flexors. 
3. Traumatic paralysis of brachial plexus. 
4. Musculospiral palsy. Drop wrist. 
Plate XVIII hi 
1. Scar contracture of elbow (bum). 
2. After Italian flap plasty. 
3. Scar-bound extensor tendon of fourth finger before operation. 
4. Scar-bound flexor tendon. After tendon plasty. Good closure of fist. 
5. Pieri method for relief of scar contracture of thumb. 
Plate XIX 113 
1. Tenosynovitic contracture of thumb. After operation. 
2. Tenosynovitic claw-hand before tenoplasties. 
3. After tenoplasties. 
4. Supination splint (Dr. Funsten). 
5. Ring finger splint. 
6. Author’s glove traction splint. 
7. Tenosynovitic contracture of hand. Scar-bound cutaneous (Ulnar) nerve. 
Plate XX t 115 
1. Tenosynovitic contracture of fourth finger. 
2. After tenoplasty. 
3 Tenosynovitic claw-hand. 
4. Tenosynovitic claw-hand; glove traction splint. 
5, 6. Result of conservative treatment. 
7. Tenosynovitis; scar-bound flexor tendons. 
8. After tenoplasties. 
9. Ankylosis of wrist following tenosynovitis. 
10. After arthrodesis of wrist. 
Plate XXI 119 
1. Incision. 
2. Raising of flaps. 
3. Suturing of flaps. 
Plate XXII 121 
1. Extension contracture of wrist (bum). 
2. After Italian flap plasty. 
3. Extension contracture of wrist (laceration). 
4. After Italian flap plasty. 
5. Scar-bound flexor tendons of wrist. 
6. After tendolysis and tendon plasty. 
Plate XXIII 133 
1. Exposure of pronator teres. 
2. Resection of pronator teres. 
3. Section of pronator quadratus. 
Plate XXIV 137 
1. Ischemic contracture. 
2, 3. After tendon lengthening and thumb plasty. 
4. Ischemic contracture. 
5. After plastic lengthening of flexor tendons. 
6. Ischemic contracture. 
7, 8. After tendon plasty and pronator resection. XVI 
ILLUSTRATIONS 
' PAGE 
Plate XXV 139 
1. Ischemic contracture. 
2. Glove traction splint. 
3. Result of tendon lengthening and Jones’ treatment. 
4. Ischemic contracture. 
5. After plastic lengthening. 
6. Ischemic contracture. 
7. After treatment. 
8. Ischemic contracture. 
9. After treatment. 
Plate XXVI 141 
1. Ischemic contracture. 
2. After tendon plasty. 
3. Ischemic contracture. 
4. After tendon plasty and pronator resection. 
5. Microphotograph of muscle in ischemic contracture; interstitial myositis. 
6. Microphotograph inflammatory myositis. 
7. Microphotograph peripheral palsy. 
8. Microphotograph of infantile palsy. 
Plate XXVII 153 
1. Dupuytren’s contracture. 
2. Dupuytren’s contracture. 
3. Spastic hemiplegia. 
4. After Stoffel’s operation and arthrodesis plus interosseous transplantation. 
Plate XXVIII 167 
1. Severe spastic paralysis, meningo encephalitic type. 
2. Spastic hemiplegia. 
3. After tendon lengthening and arthrodesis of wrist. 
4. Spastic hemiplegia. 
5. After tendon lengthening. 
6. After tendon lengthening and resection of pronators. 
7. Spastic hemiplegia. 
8. After arthrodesis of wrist. 
9. Spastic hemiplegia. Spastic closure of fist. 
Plate XXIX 169 
1. Spastic hemiplegia. 
2. After resection of pronators and thumb extensor plasty. 
3. Spastic hemiplegia. 
4. After arthrodesis of wrist. 
5. Spastic monoplegia. 
6. After interosseous transplantation of flexor carpi ulnaris. 
Plate XXX . 173 
1. Technic of thumb extensor plasty. 
2. Suture of extensor indicis tendon to extensor pollicis longus. 
3. Trick motion: supination by extension of elbow; pronation by flexion of elbow. 
4. Trick motion: extension of fingers by flexion of wrist; flexion of fingers by 
extension of wrist. 
Plate XXXI 175 
1. Spastic contracture of hand. 
2. After tendon lengthening. 
3. Spastic fist closure. 
4. After additional thumb extensor plasty. 
5. Showing technic of thumb extensor plasty. 
6. Spastic monoplegia. 
7. After thumb extensor plasty. ILLUSTRATIONS 
XVII 
PAGE 
Plate XXXII 179 
1. Spastic hemiplegia; polioencephalitis. 
2. After Stoffel’s operation. 
3. Spastic hemiplegia; encephalomeningitis. 
4. After splint and muscle educational treatment. 
Plate XXXIII 185 
1. Spastic hemiplegia trick motion: pronation by flexion of elbow. 
2. Trick motion: supination by extension of elbow. 
3. Spastic hemiplegia; trick motion: pronation by flexion of elbow. 
4. Trick motion: supination by extension of elbow. 
Plate XXXIV 207 
1. Infectious arthritis, wrist and fingers. 
2. Ankylosis, elbow and wrist; infectious arthritis. 
3. Infectious arthritis. Cast for correction of finger deformities. 
4. Traumatic arthritis; bone erosions. Adduction contracture. 
5. Following operative treatment (arthrolysis and tenotomies). 
6. Infectious arthritis; fingers, elbow, wrist and shoulder. 
7. Subluxation of wrist in infectious arthritis. 
8. Finger contractures; infectious arthritis. 
Plate XXXV 219 
1. Bilateral, congenital, radial club-hands. Defect of radius. 
2. Bilateral, congenital, radial club-hands; absence of radii; thumbs missing 
(X-ray). 
3. Bilateral, congenital, radial club-hands. 
4. Contracted club-hands. 
5. Congenital, ulnar club-hand, left. Absence of ulna. 
6. Contracted club-hand, syndactyl, left. 
7. X-ray of contracted club-hand. 
8. Contracted club-hands. 
Plate XXXVI 221 
1. Rachitic contracted club-hands. 
2. Congenital contracted club-hands. 
3, 4. X-rays of contracted club-hand. 
5. Congenital contracted club-hands. 
6. Rachitic contracted club-hands. 
Plate XXXVII 223 
1. Acquired club-hand (osteomyelitis). 
2. Acquired club-hand (osteomyelitis). Acquired club-hand; loss of thumb. 
3. Neoplasty of thumb, Italian flap method. 
4. End result. 
S, 6. X-rays. 
Plate XXXVIII ...... 227 
1. Congenital, bilateral, lobster claw-hand. 
2. Ectromelia and ectrodactylia. 
3. Ectromelia and ectrodactylia. 
4. X-ray. 
5. Right, lobster claw-hand. 
6. X-ray, showing fused third and fourth finger (giant finger). XVIII 
ILLUSTRATIONS 
PAG* 
Plate XXXIX 
1. Syndactylia. 
2. Final operative result. 
3. Syndactylia, left hand, complete. 
4. X-ray, showing skeleton complete except basal phalanx III and all end phalanges. 
5. Acrosyndactylia. 
6. Syndactylia. 
Plate XL ... 235 
1. Syndactylia before operation. 
2. Syndactylia after treatment. 
3. Syndactylia before operation. 
4. Syndactylia after operation. 
5. Syndactylia after operation. 
6. Syndactylia after operation. 
Plate XLI 239 
1. Cutaneous syndactylia and symphalangism. 
2. X-ray. Fusion of mid-phalangeal joints 3, 4 and 5. 
3. X-ray. Symphalangism. Fusion of mid-phalangeal joints 3, 4, and 5. 
4. Polydactylia. Rudimentary accessory, fifth finger, bearing nail. 
5. Polydactylia. Part of polydactylous thumb removed. 
Plate XLII . 243 
1. Congenital partial ankylosis elbows. Contractures shoulders and wrist. 
2. X-ray, right elbow. Deformity of joint. 
3. Congenital fusion of radius and humerus, right. 
4. Fusion of both elbows. Ectrodactyly. 
5. Left elbow. Fusion of radius and humerus, absence of ulna. 
6. Right elbow. Fusion of ulna and humerus, absence of radius. 
Plate XLIII 245 
1. Congenital contracture of thumb. 
2. After operation. 
3. Amniotic furrowing of fingers. 
4. After operation. 
Plate XLIV 259 
1. Fracture deformity of elbow. 
2. X-ray before treatment. 
3. After arthroplasty. 
4. X-ray after operation. 
Plate XLV 261 
1. Cubitus varus traumaticus. 
2. X-ray before operation. 
3. After operation. 
4. X-ray after operation. 
Plate XLVI ...... 267 
1. Fracture ankylosis of elbow. 
2. Motion of elbow after operation. 
3. X-ray after operation, spur removed. 
4. Fracture ankylosis of elbow. 
5. X-ray, showing fragment. 
6. Fracture of scaphoid. ILLUSTRATIONS 
XIX 
PAGE 
Plate XLVII 291 
1. Mobilization of elbow. 
2. Mobilization and massage of shoulder. 
3. Abduction exercises of shoulder. 
4. Massage of hand. 
5. Dumb-bell exercises for shoulder. 
6. Extension exercises of shoulder. 
7. Pronation and supination exercises. 
8. Exercises for forearm and finger flexors (wrist roll). 
Plate XLVIII 297 
1. Equipment for cube and peg drill. 
2. Exercises with 2-inch cubes. 
3. Peg exercises. 
4. Arm-raising exercises: push and pull, ascending oval, horizontal oval, compact 
oval. 
5. Jig saw and file. 
6. Drill, awl, plane and file. 
7. Weaving, basketry and caning. 
8. Class in occupational therapy. 
Plate XLIX 301 
1. Arm-raising rhythmic drill. Percentage of defective right arm. 
2. Arm-raising rhythmic drill. Push-and-pull exercise. 
3. Arm-raising rhythmic drill. Ascending oval. 
4. Arm-raising rhythmic drill. Compact oval. 
5. Cube and peg drill (2-inch cubes). 
6. Cube and peg drill (i-inch cubes). 
Plate L 393 
1. Cube and peg drill (J-inch cubes). 
2. Cube and peg drill (J-inch pegs). 
3. Cube and peg drill (j-inch pegs). 
4. Cube and peg drill (i-inch cubes). 
5. Cube and peg drill (3-inch pegs). 
6. Cube and peg drill. 
7. Cube and peg drill (2-inch, i-inch and J-inch cubes). RECONSTRUCTIVE SURGERY 
OF THE UPPER EXTREMITY 
CHAPTER I 
SUBACROMIAL BURSITIS 
Synonyms.—Subdeltoid bursitis; periarthritis humeroscapularis (Duplay); 
luxation de la longue portion du muscle biceps humeral (Jarjavey). 
Anatomy.—The subacromial bursa extends from the upper third of 
the deltoid muscle to the under surface of the acromion process. It 
separates the greater tuberosity from the deltoid muscle, the acromion 
process and the coraco-acromial ligament. By plaster-of-Paris injections 
of the bursa, T. T. Thomas found that, in most cases, the bursa itself 
is circumscribed to the greater tuberosity and to the region of the supra- 
spinatus and infraspinatus tendons. Only a small portion, about half an 
inch, extends under the acromion. In outward rotation, the subdeltoid 
portion is much smaller than in inward rotation. The sac does not 
communicate with the shoulder joint. Kuester, from dissections or 
observations on one thousand shoulder joints, reports only two instances 
of communication between the bursa and the joint. Due to its situation, 
any effusion in the bursa is bound to cause a prominence of the deltoid 
muscle, and an outlet for the fluid contained would most likely be situated 
at the anterior edge of this muscle. It is here where effusions can be 
reached most conveniently. 
The main function of this bursa consists in its mechanism as a gliding 
apparatus, which is indispensable for the abduction and rotation move- 
ment of the humerus. In abduction, it disappears under the acromion; 
and in adduction, it assumes a position under the deltoid muscle. In the 
rotatory motion of the humerus, it also constantly changes its configura- 
tion, acting then as gliding apparatus placed between the deltoid and 
the rotators attached to the upper end of the humerus. The outlines of 
the bursa are therefore constantly changing and its walls forever gliding 
over each other during the act of motion in the shoulder joint. 
Synovial fluid secreted by the endothelial lining of the wall takes care 
of free and easy motion between the walls. The bursa cannot be dis- 
sected out as a whole because its walls are very closely connected with, 
and adherent to, the under side of the acromion.  RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
2 
Pathology.—The bursa is subject to the same inflammatory changes 
as any other bursa in the body. In acute inflammation of the bursa, a 
serous, hemorrhagic, or purulent exudate accumulates in the bursa, 
making aspiration, or sometimes incision, necessary. The chronic 
inflammations of the bursa are of greatest orthopedic interest, as they 
may lead to severe chronic disabilities of the shoulder. In the different 
stages of development of chronic bursitis, we observe hyperemia of the 
wall, thickening, and the formation of adhesive strands, which finally 
may obliterate the bursa entirely. Sometimes, villous enlargements will 
be found in the interior of the bursa (Painter), or nictitating folds such as 
seen in other synovial cavities. They, as well as the thickened wall, are 
often responsible for the impairment of the free gliding mechanism 
which is the chief function of this bursa. To these changes are to be 
added the aggregation of lime salts sometimes found in the form of 
granules within the bursal wall. These granules are partly surrounded 
by giant cells, and partly directly overlie the epithelioid cells of the wall 
(Painter). 
The earlier writers concentrated their entire attention upon the bursa 
itself as the seat of the disease. It is only since the observations of 
Codman and others that attention has been paid to neighboring 
structures such as the floor of the bursa and the adjacent tendons. The 
most important of these tendons is that of the supraspinatus muscle. 
Coming from the supraspinous fossa of the scapula, it finds its insertion 
at the uppermost facet of the greater tuberosity of the humerus. It 
assists the deltoid muscle in abduction, acting upon the humerus as a 
lever of the first order; and it has also a backward extending action upon 
the humerus. The tendon of this muscle is closely aligned with the floor 
of the subdeltoid bursa. Codman found that tears occur in the supra- 
spinatus tendon which are followed by hemorrhage, the extravasation 
of blood, and, finally, the formation of a scar in the tendon. In addition 
to this, Wrede found that necrobiotic changes take place in the tendon 
tissue following these tears, with the result that irregular bodies of lime 
salts are deposited in the tendon. In the recognition of the extrabursal 
location of these lime deposits, a decided step forward has been made 
in our knowledge of the pathology of this disease. Brickner devoted 
very extensive studies to this condition, calling attention to “certain 
prevailing fallacies as regards our conception of subacromial bursitis.” 
He also finds the calcareous deposits beneath the bursa imbedded in the 
supraspinatus or infraspinatus tendons, following small tears of these 
tendons which lead to necrobiotic changes of the tendon tissue. 
One must, therefore, in the pathology of subacromial bursitis, con- 
sider first actual bursitis with thickened walls, adhesions, and a non- 
descript content of detritus. These cases give no X-ray evidence, nor 
do those bursae which contain scar tissue, adhesions, or fluid. 
Then there are definite calcareous deposits now considered to be 
largely sub-bursal, and situated in the supraspinatus tendons. These 
cases do give X-ray evidence. They show a distinct shadow overlying SUBACROMIAL BURSITIS 
3 
the head of the humerus, in outlines distinct from it and without definite 
bone structure. The lime deposits are found in sandlike particles or in 
larger plaques, and sometimes they have penetrated the tendon diffusely. 
They consist of calcium carbonates and oxalates. This depositing of 
lime salts into necrotic tendon tissue following a tear of the tendon is 
not a unique feature. We find the same condition in the triceps, brachi- 
alis anticus, and especially in the adductors of the femur and in the 
extensor quadriceps muscle. In all these instances, the deposits follow 
traumatism and tears in the tendons. 
The onset of subacromial bursitis is often acute following a distinct 
trauma. Common among the causes is sudden sprain of the shoulder 
from forced abduction. In other instances the onset is insidious and the 
traumatism of a more chronic or occupational nature. Stretching the 
arm above the head, strap hanging, or other instances of mild traumatism 
have been mentioned as inducing or causing subdeltoid bursitis. 
Symptoms.—The most important symptom is pain. It is the most 
prominent as well as the most persistent feature. There is, first of all, a 
local tenderness to pressure over the deltoid muscle, usually situated over 
the middle portion or in front of it directly below the acromion process. 
Pain in the shoulder becomes most marked, however, when motion 
is carried out in certain directions, namely, those of abduction and out- 
ward rotation. When the arm is abducted, the pressure point under the 
acromion often disappears (Dawburn’s sign). This can be explained by 
the fact that in abduction the bursa disappears partly under the acromion 
and, therefore, is not so accessible to palpation. 
It is often possible to abduct the patient’s arm to the horizontal with- 
out pain; but when attempting to hold the arm in this abducted position, 
the patient complains (Codman). 
Radiation of pain is very common. It follows most often the dis- 
tribution of the internal cutaneous nerve, also that of the external 
cutaneous nerve. In some cases that came within my observation, 
manipulation of the arm was followed by distinct pain in the elbow joint, 
though no motion of that joint had been undertaken. The patients are 
usually very uncomfortable at night, finding it impossible to assume a 
proper posture, and sleeping upon the affected side is usually out of the 
question. They often speak of peculiar nocturnal attacks and exacer- 
bations of pain. 
It has already been stated that motion of the shoulder joint is very 
much restricted. Active abduction is almost totally lost. Outward 
rotation is nearly impossible. Passive abduction of the arm is possible 
only to a limited extent. Beyond this it is soon stopped by pain, and the 
automatic contracture of the adductor muscles will stop further motion. 
Still, in this partial loss of motion, we find a point of great importance 
for the differential diagnosis between subdeltoid bursitis and affections 
of the shoulder joint itself. 
If an effusion exists in the shoulder joint, or in any other form of 
arthritis, the shoulder joint will, as Lange has pointed out, assume a 4 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
pathognomonic position. This position is slight abduction of about 25 ° 
or 30°, and slight forward flexion, similar to what we observe in the hip 
joint, if the latter is affected. If the arm is allowed to fall to the side of 
the body, in cases of arthritis, this position is only apparently one of 
complete adduction. The arm is still in actual abduction of 250, and the 
apparent adduction is carried out by rotation of the scapula over the 
sternoclavicular joint. This fact becomes evident by the obliquity of the 
vertebral border of the scapula when the patient is seen from behind. 
As soon as the scapula is righted 
so as to maintain a position sym- 
metrical to the other side, the true 
position of the shoulder joint is 
established. . 
In subacromial bursitis, the 
condition is entirely different. 
Very slight motion is possible in 
all directions passively, but the 
further ranges of abduction and 
inward rotation are inhibited by 
pain and muscle contractures. 
This we believe is a very useful 
point in differential diagnosis, and 
more attention should be paid to 
the true position of the shoulder- 
blade when a distinction between 
extra-articular and intra-articular 
pathologic changes is to be made. 
It can readily be seen that, 
under these circumstances, the 
patients find themselves in a state of considerable helplessness. The 
hand cannot be carried easily above the waistline, nor back of the frontal 
plane, and only very small circumductory motions are possible in the 
shoulder. The patient is unable to dress himself or to carry out the 
most common activities of life. 
A great deal of discussion has arisen about the interpretation of X-ray 
findings. As already stated, synovitis of the bursa itself, with thickening 
of the walls and adhesions, gives no X-ray evidence, while cases of lime 
deposits in the supraspinatus tendon give distinct X-ray findings. On 
the other hand, X-ray shadows may be present without any symptoms 
whatsoever (Frauenthal). 
Brickner also reported transitory shadows, disappearing in intervals 
of from 25 days to 14 months. In 4 of Painter’s cases, shadows were 
present, and of 100 cases reported by Brickner, 19 showed shadows, and, 
on operation, also calcareous deposits.1 
Subacromial Bursitis 
1 Osgood states that he is impressed with the frequent disappearance of lime salts in 
the tendon without operation (personal communication). SUBACROMIAL BURSITIS 
5 
Differential Diagnosis.—There are a number of conditions which 
produce symptoms similar to those of subdeltoid bursitis. While there 
is no great difficulty in determining lesions of the humerus itself, such 
as fracture of the greater tuberosity, the scapula, the acromion, or the 
outer portion of the clavicle, it is quite different with the lesions concern- 
ing the soft structures surrounding the shoulder joint. Various sprains 
and tears may occur in the neighborhood of the humeral head; similar 
to the tears found in the supraspinatus tendon, there occur also those 
of the tendons of the latissimus dorsi and pectoralis major. All these 
are liable to cause adduction contracture of the arm combined with a 
distinct tenderness over the insertion of these tendons. In these cases 
of sprain to the pectoralis major or latissimus dorsi, the pain elicited by 
outward rotation can be strictly located on the inner side of the arm close 
to the axillary fold. 
It is also possible that extensive scar formation, even to the point 
of involving the nerve plexus, might follow tears of these muscles and 
tendons, and in consequence there may be neuritic symptoms of such 
severity as completely to overshadow the original lesion. This has 
been the case in one of the author’s observations in which an acute 
strain or tear of the pectoralis and latissimus dorsi muscles, at their 
point of insertion, produced neuritic symptoms of a very marked degree 
extending over almost the entire brachial plexus. 
There are also the various sprains of the shoulder ioint itself, espe- 
cially of the inner and anterior capsule, to be taken into consideration. 
Such sprains or tears of the capsule may occur in trauma not violent 
enough to cause a dislocation of the head; they are mostly induced by 
a forced motion of overabduction. The portion of the capsule most 
frequently and most violently exposed to strain by movement of the 
arms is the lower and inferior, or axillary, part (T. T. Thomas). One 
often finds, after reduction of a traumatic dislocation, a residual tender- 
ness and swelling of the deltoid muscle. It is difficult to see in these 
cases to what extent the subdeltoid bursa may have participated in the 
joint injury, and also what part the neighboring muscles and tendons 
might have played. Protracted immobilization following injuries of the 
shoulder is likely to produce a picture of adduction contracture such as 
seen in subdeltoid bursitis. The condition of the deltoid muscle itself, 
however, will often give valuable information. Atrophy of this muscle 
in cases of sudeltoid bursitis is never extreme and does not reach the 
degree of inflammatory reflex atrophy seen in cases of arthritis of the 
shoulder joint. 
Treatment.—There is almost unanimity of opinion that acute cases 
yield to fixation in splints or plaster casts.2 As the condition persists, 
the prognosis of subdeltoid bursitis becomes more and more uncertain. 
Cases of not too long standing readily yield to manipulation by which 
• tvpes of acute cases subside very frequently under heat and rest alone, even 
without abduction splint, motion being gradually instituted within a few days (Osgood, 
personal communication). 6 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
the arm is placed in abduction or outward rotation, if necessary, under 
an anesthetic. The forcible breaking up of adhesions is not to be recom- 
mended (Brickner) and it is preferable to stretch muscles gradually and 
to obtain the desired position of abduction and outward rotation by 
steps. Brickner advises a very simple method of obtaining this abduc- 
tion, by keeping the patient in bed with the afflicted arm fastened to 
the pillow, and the bed so inclined as to allow the patient to slide down 
gradually. In this way, a position of abduction and outward rotation 
is gradually obtained. It is often necessary to manipulate under anes- 
thesia and with relaxation of the muscles. The procedure then is, as 
a rule, a very simple one and does not require any violent effort. It 
is essential to procure immediate fixation in the desired position as soon 
as the latter is obtained, lest the advantage of the procedure be lost. 
Within a very few days after manipulation, that is, as soon as the 
tenderness subsides, the after treatment should begin. When the arm 
is held up by a well-fitted splint, it is essential to see that the position 
of abduction and outward rotation should be lessened very gradually 
and only to the degree which the development of the abductors and 
outward rotators will permit, so that the active maintenance of any 
position obtained be secured (Dunlop). The writer has seen several 
instances in which the brisk letting down of the arm has brought about 
a recrudescence of the symptoms. In the rare instances in which the 
bursa is found distended by contents of serous or purulent nature, the 
aspiration of the fluid can be done by reaching the bursa through the 
lateral or anterolateral portion of the deltoid muscle. 
There seem to be a number of resistant cases in which open opera- 
tion becomes necessary. Painter considers all cases operative which 
show deposits in the supraspinatus tendon, as well as all those of six 
months’ duration or more, which persistently resist conservative treat- 
ment. Baer reported 4 cases of excision of the bursa and considered 
this the method of choice in chronic cases; but the difficulty of this 
procedure has already been referred to. The method of removing lime 
deposits in the tendon is best followed with the technic given by Brick- 
ner. An incision is made over the external surface of the deltoid muscle 
from the middle of the acromion downward. After the division of 
the fascia, one proceeds through the muscle by blunt dissection. The 
roof of the bursa is now incised and the edges secured by fine forceps. 
In a similar manner, one proceeds through the floor of the bursa and 
underneath it the lime deposits imbedded in the supraspinatus tendon 
can be seen. This deposit is then carefully removed with a curette and 
the roof and floor of the bursa are sutured. The retracted halves of 
the deltoid muscle are allowed to fall together, and the wound is closed. 
The arm is put up in abduction and external rotation, and after treat- 
ment is instituted as soon as the wound is closed. SUBACROMIAL BURSITIS 
7 
Cases of Subdeltoid Bursitis 
Observed, 21. Treated, 11. 
Conservatively, 9 
Operatively, 2 
Onset Results 
Spontaneous, 5 Improved, 5 
Twisting of the shoulder, 2 Cured, 5 
Fall upon the shoulder, 4. • Not improved, 1. 
Ages of patients, 19 to 70 years (Plate I, 1, 2, 3, 4, 5). Neither of 
the 2 operative cases showed a calcareous deposit, and the subsequent 
improvement probably was due as much to the fixation as to anything 
else. 
Of the symptoms, pain on active and passive abduction beyond a 
certain level, and tenderness over the subdeltoid bursa below the acro- 
mion process or at a point in front of it, were by far the most constant 
features. Pain radiating into the arm and forearm was observed in 2 
cases. In 2 cases, adhesions were felt breaking under manipulation. 
Deltoid atrophy was not prominent in any case. One of the cases 
developed following influenza. This case showed a distinct shadow 
over the head of the humerus at the seat of the subdeltoid bursa. Lime 
deposits were seen in the X-ray picture in 3 of the 21 cases. None of 
these cases was operated upon, but 2 of the 3 were treated conserva- 
tively with marked improvement. The treatment of choice for the 
majority of cases of subdeltoid bursitis is the elevation of the arm in 
splints in a position of abduction and outward rotation, combined with 
massage and physiotherapy. Passive motion should be carried out 
with the greatest care, and active motion should be encouraged very 
early and to the extent possible without causing pain. Manipulations 
should never be carried out with any amount of force, and two or three 
days of rest should be given before active motion is begun following 
manipulation. The operative treatment should be reserved for cases of 
long standing or cases showing lime deposits and not yielding to con- 
servative methods. 
Scapular Grating.—A degree of similarity exists between subdeltoid 
bursitis and a condition known as creaking or grating scapula; a dis- 
turbance of the free motion, at the upper inner angle, between scapula 
and thoracic wall. Boinet, in 1867, was the first to publish a case of 
scapular grating, and, after considerable period of obscurity, this con- 
dition was again brought to attention by publications of Kuettner and 
Axman (1904), Mauclaire (1905), Lotheisen (1908), Habermann 
(1911), and Lobenhoffer (1913). 
Physiologically, there is audible friction at the upper inner angle of 
the scapula in 70 per cent of the cases. Under pathological condition, LEGEND FOR PLATE I 
Fig. i.—C. S. Subdeltoid Bursitis. 
Fig. 2.—C. S. After Conservative Treatment. 
Fig. 3.—P. S. Subdeltoid Bursitis; after Forcible Correction. 
Fig. 4.—P. S. Subdeltoid Bursitis; after Forcible Correction. PLATE I 10 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
this friction may increase to a distinct shoulder creaking or grating, 
occurring upon the slightest movement of the shoulder and being audible 
or palpable when the ear or hand is placed upon the inner angle of the 
scapula. Up to 1913, there were reported, according to Betke, 31 such 
cases. The scapular grating is ascribed to a bursitis of the suprascapular 
bursa, situated at the upper inner angle of the scapula between the 
upper portion of the serratus magnus and the levator anguli scapulae. 
This bursa was found to be present in one out of every eight bodies 
examined by Groover. The scapular bursa, situated between the 
scapula and the subscapularis muscle, may also cause scapular grating, 
especially when rice bodies are present within the bursa. 
Atrophy or congenital defects of the muscles between the scapula 
and the thorax are likewise considered as causes for scapular grating; 
finally, exostoses of a bony or cartilaginous nature have been found at 
the upper angle of the scapula which have given rise to the symptom 
of scapular grating. Habermann 3 reported 2 cases of the latter kind. 
The symptoms are those of creaking or grating of the scapula on 
motion, accompanied by little or no pain, but a considerable weakness 
or heaviness of the arm is often complained of. 
Treatment.—In the case of Lobenhoffer, the removal of a tumor on 
the bone, half as large as a cherry and containing a mucous fluid within 
its thick walls, brought about a cure. Betke and others used muscle 
transplants taken from the rhomboid muscles and placed them between 
scapula and ribs to overcome the friction and grating. Other and similar 
methods of muscle plasty were applied by Mauclaire, Kuettner, and 
Lotheisen. The writer has observed one case. The patient complained 
of pain in both shoulders. The pain was mostly elicited by elevation 
of the arms above the horizontal and was accompanied by a peculiar 
cracking in both shoulders between the middle and posterior part of 
the deltoid, where there was a distinct diastasis of the muscle fibers. 
In addition to this, a very distinct grating of the scapula was notice- 
able on the left side. This phenomenon was centered around the upper 
inner angle of the shoulder-blade near the origin of the levator anguli 
scapulae. It was audible as well as palpable. As it was not attended 
by any disturbing symptoms in the function of the shoulder, this fea- 
ture of his disability was not subject to treatment. 
* Attention is called here to manifestations of pain caused by pressure of the scapula 
against the ribs as described by Goldthwaite (Am. Journ. Orth. Surg., 1908, V). The 
pain is described as acute when the shoulder-blades are retracted backwards, but appears 
to be relieved when the shoulders are allowed to sag. Brachial neuralgia is, according 
to the same author (Am. Journ. Orth. Surg., May, 1909), occasionally caused by a sharp 
forward flexiem of the supraspinous portion of the scapula. SUBACROMIAL BURSITIS 
11 
BIBLIOGRAPHY 
Baer, W. S. Operative treatment of sudeltoid bursitis, Johns Hopkins Hosp. 
Bull., June, July, 1907, 282. 
Berry, J. McW. Observations on the presence of roentgenological shadows 
associated with subdeltoid bursitis, Am. Journ. Orthop. Surg., 1916, 
14:476. 
Betke. Uber Scapularkrachen, Beitr. z. klin. Chir., 1913, 88:31. 
Brickner, W. M. Prevalent fallacies concerning subacromial bursitis; its 
pathogenesis and rational treatment, Am. Journ. Med. Sciences, 1915, 
149:35!- 
• A simple, easily regulable method of applying abduction in the treat- 
ment of shoulder disabilities, Med. Rec., January 2, 1915. 
Brown, A. J. A contribution to the study of stiff and painful shoulder, Surg. 
Gyn. Obst., October, 1919, 29:4. 
Codman, E. A. Complete rupture of the supraspinatus tendon; operative 
treatment with report of two cases, Boston Med. and Surg. Journ., May 
18, 1911, 708. 
On stiff and painful shoulders, Boston Med. and Surg. Journ., 1906, 
No. 22, vol. 94. 
Dunlop, J. Report of a case of deposit in the supraspinatus muscle simulating 
subacromial bursitis, Am. Journ. Orthop. Surg., 1916, 14:102. 
Flint, J. M. Acute traumatic subdeltoid bursitis, Journ. Am. Med. Assoc., 
April, 19, 1913, 1224. 
Frauenthal, H. W. Subacromial bursitis, Internat. Clinic, Philadelphia, 1918, 
Series 2, 28:60. 
Habermann. Ursache und Bedeutung des Scapularkrachens, Berl. klin. 
Wchnschr., 1911, No. 14. 
Harsha, W. M. Subacromial bursitis, Internat. Clinic, Philadelphia, 1919, 
Series 2, 29:66. 
Kuester, E. Uber Bursitis subacromialis (Periarthritis humeroscapularis), 
Arch. f. klin. Chir., 1902, 67:1012. 
Lange, F. Schultergelenksdistorsion, Miinchen. med. Wchnschr., 1912, No. .23, 
vol. 26. 
Lobeniioffer. Uber Scapularkrachen, Beitr. z. klin. Chir., 1913, 83:484. 
Painter, C. F. Subdeltoid Bursitis, Boston Med. and Surg. Journ., March 14, 
1907. 
Wrede, L. Uber Kalkablagerungen in der Umgebung des Schultergelen’kes und 
ihre Beziehung zur Periarthritis scapulohumeralis, Arch. f. klin. Chir., 
1912, 99:259. CHAPTER II 
CONGENITAL DEFORMITIES OF SHOULDEF 
BIRTH-PALSY 
(Obstetrical Paralysis) 
It has been known since the middle of the eighteenth century that a 
paralysis of the upper extremity follows at times the delivery of a child 
when complicated by certain obstetrical difficulties which necessitate forcible 
manipulation upon the upper extremity of the baby. In 1872, Duchenne, 
describing this condition, recognized it as a laceration process of the shoulder 
following forcible delivery, but the true anatomical basis of the lesion was 
not known to Duchenne himself. His observations, however, instigated a 
series of clinical reports in the following decades, which were inspired by 
Duchenne’s work as well as that of Erb, and to the latter we also owe a 
classical description of the condition. The older observers were inclined to 
see the cause of the paralysis in a direct compression of the cords of the 
brachial plexus by the forceps. Later observers were inclined to consider 
the local injury to the shoulder joint as of prime importance, referring to 
the symptoms of paralysis as secondary to the shoulder-joint injuries. Finally, 
in the last two decades, investigations of a neuropathological nature were 
made, which brought forth a certain amount of new information bearing 
on the pathology of this condition. The latter investigations tended to 
show that the primary seat of injury was the spinal roots of the brachial 
plexus, especially the fifth and sixth, which are the ones most often con- 
cerned in the lesion. This distribution of the motor paralysis to the fifth 
and sixth cervical roots covers the great majority of cases of obstetrical 
paralysis and is now know as the Duchenne-Erb type of brachial palsy. 
Excessive traction upon the nerve roots of the brachial plexus may result 
in rupture of some of the cords. Twenty years ago Stone described obser- 
vations and experiments bearing out the influence of traction upon the roots 
of the brachial plexus. The experiments of Sever carried out on the 
cadavers of infants seem to show that traction upon the arm in abduction 
will put the upper cords of the plexus which arise from the fifth and sixth 
cervical roots under the greatest amount of tension, causing them to stand 
out like bowstrings among the rest of the plexus cords. Therefore, he 
concludes, a force tending to pull the head of the humerus laterally, which 
at the same time immobilizes the shoulder, is likely to bring about a rupture 
of these upper cords. 
When the clavicle is intact, a very considerable force is necessary to 
injure the plexus, and in this case the suprascapular nerve is first to break. CONGENITAL DEFORMITIES OF SHOULDER 
13 
In Sever’s experiments, even with considerable force, the fifth and sixth 
cervical roots could not be completely torn, but were rather frayed out inside 
their sheaths; but when the clavicle was removed, the weight of the arm 
coming directly upon the plexus, much less force was necessary to produce 
the injury. Even then, according to Sever, it was hardly possible to put 
the eighth cervical and first dorsal roots on a stretch, much less to rupture 
them. Sever was also unable in his experiments to rupture the joint capsule, 
to separate the humeral epiphysis, or to produce a dislocation of the head 
of the humerus. This difference between the conditions with intact and 
broken clavicle had already been pointed out by Stoner, who found that 
there was little danger to the nerves from pressure of the clavicle, and that, 
when the clavicle was intact, breaking of the upper roots was very difficult; 
but when the clavicle was broken and the plexus alone held the shoulder, 
a lesser pull was sufficient to break the upper roots. On the other hand, 
these findings should be correlated carefully with the opposite views ad- 
vanced bv T. T. Thomas. It is not possible to go into a discussion of the 
etiology of this condition with any amount of clearness without carefully 
scrutinizing these two views, one of which is represented mainly by A. S. 
Taylor and J. W. Sever, namely, the Neurogenetic Theory; while the other 
is represented by T. T. Thomas and many others who adhere to the view 
that the joint injury is the primary factor in obstetrical paralysis. This joint 
theory has numerous adherents, among whom Sachs (1904) may be men- 
tioned, who calls attention to the subluxation of the head; Whitman (1914) 
who finds that, in a large proportion of ordinary cases of birth-palsy, there 
are evidences of injury of the shoulder joint in the nature of strains or 
sprain; Lange (1912) who considers most cases of birth-palsy as due to 
laceration of the shoulder joint; and Vulpius (1914) who ascribes these cases 
to injuries to the epiphyseal cartilage. T. T. Thomas considers as the 
primary and most essential cause of the trouble the injuries to the shoulder 
joint. When this injury is remedied early enough, he says, one need not 
be concerned about the paralysis. The joint injury is primary and the 
paralysis secondary, and the latter is caused by the inclusion of the branches 
of the brachial plexus in the axillary inflammation consequent upon the joint 
injury. He bases his views upon facts of an experimental as well as a 
clinical nature. Clinically, almost all shoulder-joint injuries are associated 
with palsies; and the disappearance of paralysis which is almost regular 
in the Duchenne-Erb, or so-called upper arm type, is to him a proof of the 
absence of a rupture of the nerve roots. He also points out that, in obstet- 
rical paralysis, there is a severe, if not a complete, paralysis of the whole 
limb, and takes issue with the Duchenne-Erb distribution of paralysis (fifth 
and sixth cervical roots). 
It cannot be denied that extravasation of blood and synovial fluid into 
the axilla will lead later to cicatricial tissue, all of which will probably 
be absorbed in time, and this would account for the disappearance of the 
paralysis. But the most perplexing discrepancy is seen in the experimental 
findings. Contrary to Sever’s experiments, Thomas finds that forceps trac- 
tion cannot be responsible. In the first place, because, when traction of the 14 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
arm would be applied, the head is already delivered; second, because there 
are a number of cases of normal delivery included in the series of birth- 
palsies (32 of 471 reported by Thomas and Sever) ;and, finally, T. T. Thomas’ 
experiments show that even very extreme traction of the head with forceps 
was not able to produce any visible rupture at any point of the plexus. 
When we again consider the experiments of Prout, who found rupture 
of the perineural sheaths immediately surrounding the nerve bundles and 
described minutely the histological changes occurring immediately after a 
rupture of the neuraxes in birth-palsy, and finally the reports of A. S. 
Taylor of operative findings revealing rupture of the fifth and sixth cervi- 
cal roots, one might be led to think that the neurogentic theory is proved 
without doubt. But against this unqualified acceptance, there stand out sev- 
eral questions in the controversy which have never yet been answered satis- 
factorily by the adherents of the theory of nerve injury. In the opinion of 
G. G. Davis, the shoulder contracture following the birth-palsy is proof 
positive that there is a peri-articular lesion. Why is it that the flail-joint, 
which characterizes deltoid paralysis, due to anterior poliomyelitis or other 
causes, is never found in cases of birth-palsy? 
It is maintained by the followers of the neurogenetic theory that the 
subluxation is not noticeable until at least three weeks after birth; but it 
is hard to conceive that the posterior dislocation of the humerus, as seen in 
some cases, is entirely a paralytic deformity. To sum up, therefore, it must 
be conceded that there are discrepancies of fundamental nature and that 
the findings of the different observers cannot all be explained fully by either 
of the two theories. In the face of positive and trustworthy observations, 
both of the root lesions and the local joint complications, one must assume 
that neither of the theories can be accepted to the entire exclusion of the 
other, and there seems to be no reason why a gross lesion of the shoulder 
joint might not, in a number of cases, be combined with injuries to the nerve 
roots. 
Clinical Pathology—Upper Arm Type.—Shortly after birth, sometimes 
within a few days, it is noticed that the affected arm hangs limply at the 
side of the body. The elbow is held in slight flexion and the forearm in 
pronation. The child is completely unable to abduct the arm. During the 
first week, there may be some swelling or tenderness in the region of the 
deltoid. This, however, usually subsides, and there remains only a paralysis 
of the deltoid and supraspinatus muscle, occasionally complicated by paralysis 
of the biceps, coracobrachialis, infraspinatus and supinator longus. With 
the existing inability of abduction and external rotation, a contracture soon 
develops, due to the unopposed action of the adductors and inward rotators 
of the shoulder. But this paralysis of the deltoid and supraspinatus is, in 
the great majority of cases, only temporary, and with the repair of the 
injured nerves, these muscles take up function again. Still, at the time 
when nerve repair is completed, a condition of contracture in adduction and 
inward rotation is already established and remains as the permanent dis- 
ability of the shoulder. The internal rotation is maintained mostly by the CONGENITAL DEFORMITIES OF SHOULDER 
15 
subscapular is muscle, while in the adduction the contracted pectoralis major 
and latissimus dorsi are mainly involved. 
Some cases undoubtedly go on to complete recovery without the estab- 
lishment of residual contracture, but in the large majority of cases of this 
group, the adduction and inward rotation develop as residual deformity. 
Again, there are cases in which there is no repair of the nerve lesion and, 
consequently, no recovery of the paralyzed muscle. But these cases also 
form a small minority, so that one may say that the typical course of the 
upper arm type of birth-palsy is that of a temporary paralysis followed by 
a permanent contracture. 
In a certain number of cases, the contracture is complicated by sublux- 
ation or dislocation of the humerus. The displacement is posteriorly and 
slightly upward, so that the head of the humerus lies directly below the 
spine of the scapula. If this condition is to be explained—according to 
some observers—as the result of muscular contraction, it must be assumed 
that the contracted subscapularis muscle forces the head backward and that 
the relaxed posterior capsule of the joint and the relaxed tendon of the 
paralyzed supraspinatus muscle permit the head to leave the glenoid cavity 
and to appear posteriorly and slightly below the acromion process. The 
latter is often hooked downward over the glenoid fossa so that it forms a 
considerable obstacle to the replacement of the dislocated head. 
The statistics on the frequency of posterior dislocation or subluxation 
are rather misleading. In any degree of paralysis of the deltoid muscle, 
the relaxed capsule is liable to permit a state of subluxation without allow- 
ing the head actually to give up contact with the glenoid fossa. But this 
is not the condition which prevails in the cases of dislocation associated 
with birth-palsy. There is no relaxation of the shoulder joint. One is 
decidedly impressed by the rigidity of the contracture and the permanency 
with which the head is placed subspinous and retrospinous, in its posterior 
dislocation. 
The Whole Arm Type.—In a minority of cases of obstetrical paralysis, 
the lesion extends throughout all the cords of the brachial plexus, involving 
in the paralysis not only the shoulder, but also the arm, the forearm, and 
the hand. In these cases, the paralysis of the flexors and extensors of the 
fingers, and a decided atrophy of the intrinsic muscles of the hand, is liable 
to persist together with that of the muscles of the shoulder. The lesion 
involves not only the fifth and sixth cervical roots, but also the lower cords 
of the plexus, especially the ulnar and median nerves, to the eighth cervical 
and first dorsal roots. The extremity shows the same position of contracture 
in the shoulder as do the cases of the upper arm type, but, in addition to 
this, there is a pronation contracture of the forearm, and often a drop-wrist 
with very limited motion of the fingers. The elbow is usually held in slight 
flexion, the pronated forearm crossing the abdomen (stomach-ache posi- 
tion). This group forms a small minority of the cases. 
The Fore Arm Type.—In other cases, however, there is a total involve- 
ment of the upper extremity, followed by quick recovery of the muscles of 
the upper arm or Duchenne-Erb group, while the lower segments of the 16 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
plexus remain more or less permanently paralyzed. The resulting paralysis 
is then that of the inferior radicular group, a form which has been described 
first by Mme. A. Klumpke (1885). 
While, in the upper arm lesion, no sensory disturbances are present, this 
is not the case in the whole arm nor in the lower arm type. The anesthesia 
is complete usually along the forearm extending beyond the elbow in a 
more or less irregular line, involving the upper arm only occasionally. The 
internal aspect of the arm as well as the shoulder are almost always found 
intact, as long as the lesion is strictly limited to the brachial plexus. This 
is to be explained by the distribution of the intercostohumeral nerves and 
the internal cutaneous nerves of the arm (Klumpke). Another symptom, 
not found in the Duchenne-Erb type but regularly in the inferior radicular 
type, is the oculopupillary signs of myosis (pupillary contraction) and of 
retraction of the eyeball. These symptoms are produced by lesion of the 
inferior roots and especially of the first dorsal, according to Klumpke’s 
experiments on dogs. Of the motor nerves, the ulnar is more severely 
involved than the median. In the cases reported, the paralysis of the fore- 
arm muscles as well as that of the hand had remained permanent, and the 
outlook for improvement in cases of this type is even less favorable than 
it is in cases of whole arm type. This group is more exceptional than the 
other two, and T. T. Thomas in his series records only 2 cases. The 
atrophy may be considerable in extreme cases, but it never reaches the degrees 
seen in infantile paralysis. 
As regards complications in and surrounding the shoulder joint, fracture 
of the clavicle as well as separation of the humeral epiphysis occasionally 
are seen. The fracture of the clavicle greatly facilitates, as experiments seem 
to show, a rupture or tear of the plexus, especially of the lower cords. The 
displacement of the head of the humerus is, as a rule, posterior, and ref- 
erence has already been made to the details of this complication. Anterior 
displacement of the humerus, however, has been seen and reported. 
In the earlier literature, we find references to congenital dislocation of 
the shoulder. This, if it exists at all, is certainly an extremely rare deform- 
ity. Porter (1900) reported from the literature 29 cases of congenital dis- 
location of the shoulder. A close scrutiny of this series, however, showed 
that a majority of the cases were extremely doubtful and that they apparently 
belong to the group of birth-palsy or possibly of traumatic dislocation caused 
by injury during birth. Such cases are reported by Robinson, who has seen 
2 cases of congenital dislocation of the head of the humerus, one posterior 
and subspinous, the other posterior. 
Lewis (1895) reported a case of subspinous and posterior dislocation 
of the shoulder, then considered congenital, but apparently a complication 
of obstetrical paralysis. Some observers make a distinction of the disloca- 
tion into different types; a paralytic dislocation due to the paralysis of the 
deltoid and the contracture of abductors and inward rotators, a traumatic 
dislocation occurring during delivery, and a true congenital dislocation con- 
current with the paralysis and distinguished by malformation of the head 
of the humerus and the glenoid fossa (Stone). Such distinctions, however, CONGENITAL DEFORMITIES OF SHOULDER 
17 
do not shed much light upon this vexed question. The only positive evidence 
of congenital dislocation of the shoulder which might withstand all crit- 
icism is a missing or rudimentary glenoid cavity, or a distinct malformation 
of the humeral head. 
Smith, quoted by Hoffa, reports 2 cases of subcoracoid dislocation 
of the humerus on both sides in which anatomical findings were obtained. 
The head of the humerus was found located at the coracoid process, the 
glenoid cavity on the left side was missing and on the right side rudimentary. 
A new articular surface had been established on the under side of 
the coracoid process, with which the head of the humerus articulated. The 
humerus itself was thin and atrophic. The long head of the biceps origi- 
nated at its normal place at the lower border of the glenoid fossa. The 
second case of Smith’s was one of subacromial dislocation with a new articu- 
lar facet located at the neck of the scapula. 
A case of double congenital dislocation of the shoulder is also described 
by Kuester in a one-year-old child. Other cases reported under that head- 
ing are doubtful and probably represent dislocations accompanying birth- 
palsy. In cases of severe whole arm type of obstetrical palsy, a con- 
tracture of the short head of the biceps and the coracobrachialis muscle 
is not uncommon. In one of the cases observed by the writer, the con- 
tracted biceps caused a flexion contracture of the elbow and an anterior 
dislocation of the head of the radius. Pronation contracture of the fore- 
arm occasionally complicates the inward rotation of the humerus so that 
the whole extremity appears to be rotated strongly inward with the palm 
pointing backward and outward (the policeman’s tip position). 
Sever’s statistics show the following distribution: 
Upper arm type 400 
Whole “ “ 64 
Mixed “ “ 9 
Sever found no deformity and no displacement of the humerus in the X-ray 
in all cases under one year. He also found that the hooking of the acromion 
and the posterior subluxation of the humerus appear later. 
Prognosis.—A small minority of cases recover almost completely after 
three months, and it is impossible clinically to establish the definite extent 
of the lesion at an early date. Only after the lapse of a year or more 
does the permanent extent of the paralysis become apparent. In all cases 
of the upper arm type, the prognosis may be said to be good, while in all 
cases of lower arm type and of the whole arm type, the prognosis is bad, 
as regards restoration of function. 
Treatment.—The treatment must start at the earliest possible date. 
Mild cases will improve promptly on conservative treatment, consisting 
of proper splinting of the extremity in abduction and outward rotation; 
contractures will in these cases also yield to simple stretching with or with- 
out anesthesia. The splint applied must hold the arm in proper position, 
and its proper application should be constantly supervised. The after 
treatment begins immediately. It consists in massage and passive motion, 18 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
and, in addition to it, in active motion in older children. Cases with severe 
contractures which do not yield to bloodless stretching require an open opera- 
tion for the relief of the contracture. The best method is the one advocated 
by Sever; the technic of it is given here as follows: 
An incision is made from the acromion downward over the anterior 
aspect of the shoulder joint. After dissection of the fascia, one proceeds 
bluntly between the deltoid and pectoralis muscle, the former being retracted 
outward and the latter inward. The upper edge of the pectoralis muscle 
is then incised downward at or near its tendon of insertion, in order to 
gain better approach to the head of the humerus. The subscapularis tendon 
is then located as it swings around the head of the humerus close to the 
capsule, to reach the greater tubercle. A blunt director is then passed under- 
neath the tendon between it and the capsule and the tendon is severed over 
it. At this moment the arm will usually allow of complete outward rota- 
tion. The retracted muscles are allowed to fall together, the wound is 
closed and the arm is put up in plaster in abduction and outward rotation. 
There it should remain for two weeks, then the cast should be replaced 
by a splint, and exercises and massage should be instituted. In Sever’s 
operation the capsule is not opened. If the coracobrachialis muscle and the 
short head of the biceps are tight, these tendons are severed also. For the 
relief of the inward rotation, Sever’s operation is the method of choice 
and undoubtedly the most valuable. Other authors advocate the osteotomy 
of the humerus with subsequent outward rotation (Stone, Lange, Vulpius). 
The reduction of the dislocation of the humerus by bloodless manipulation 
will be possible only in a limited number of cases. In the majority, espe- 
cially in those in which bony obstacles, such as hooking of the acromion, 
prevent reduction, an open operation with arthrotomy must be done, and 
the acromion process must be severed with the osteotome in order to allow 
the replacement of the dislocated head. In order to hold the humeral head 
in place, Phelps advocated the use of arthrodesis of the shoulder joint. 
He deepens the glenoid cavity, pares ofif a portion of the humeral head and 
then obtains fixation by stitching the relaxed posterior portion of the capsule. 
Plexus Operations.—The indications for operative repair of the in- 
jured nerve roots are a matter of considerable uncertainty. Theoret- 
ically, such interference would be indicated in all cases of birth-palsy 
in which there is more or less complete paralysis, especially in those 
cases which extend to the forearm and in which the first few weeks do 
not bring any spontaneous return of the muscle function. It is very 
difficult to decide how long one should be justified in waiting. Most 
of the observers agree that, in severe cases, one should not wait more 
than a few weeks, and if no sign of improvement should appear within 
that time, then at least the exploratory operation and the dissection of 
the injured nerve roots would be indicated. The technic of this pro- 
cedure is given by Taylor as follows: 
An incision is made along the posterior border of the sternocleido- 
mastoid muscle obliquely downward. The platysma and the deep fascia 
are divided, exposing the omohyoid muscle and the deep subscapular CONGENITAL DEFORMITIES OF SHOULDER 
19 
vessels. The latter are double tied as is also the transversalis colli, and 
the thickened and adherent deep fascia is divided and the nerves are 
exposed. The damage will usually be found at the junction of the fifth 
and sixth cervical roots. These appear indurated. The mass of scar 
tissue should then be incised with a sharp scalpel or tenotome. The 
use of scissors in cutting the nerves and the handling of nerves with 
forceps is to be condemned. After incision of the cicatricial tissue, the 
nerve ends are then brought together by lateral sutures of fine silk, 
the sutures being passed through the nerve sheaths only. The nerves 
are then wrapped with Cargile membrane around the anastomoses.1 
The omohyoid muscle is sutured with catgut. A plaster-of-Paris splint 
is then applied which keeps the head and shoulders approximated to 
release tension. In some extensive lesions, it is necessary to divide the 
clavicle and the subclavian muscle. By elevating the shoulder and in- 
clining the head toward the plexus, it is possible to bridge a distance 
up to 3 cm. In some instances, there is a buckling inward of the torn 
perineural sheath interposing a mass of connective tissue which prevents 
regeneration of the torn neuraxons (A. S. Taylor). One specimen of 
J. J. Thomas’ showed incomplete rupture of the perineural sheath with 
hemorrhage. In this case, it could be assumed that spontaneous recov- 
ery would have followed the nerve injury. Usually, the fifth and sixth 
cervical roots are found imbedded in fibrous tissue; more rarely, the 
seventh and eighth. In Thomas’ report of 9 cases, 2 died soon after 
operation, and of the remaining 7, 3 showed improvement. This author 
considers the time of the operation to be from 6 to 12 months of age. 
Sharpe’s reports cover a series of 56 operations, and he failed to find a 
nerve lesion in only 1 case. He is, therefore, an ardent advocate of the 
early plexus operation; if possible at the age of one month, since there is 
then less formation of scar tissue and less retraction of nerves. 
Reviewing these operative reports on the brachial plexus, especially 
the statistics of Sharpe, one cannot suppress the argument that, in a 
child one month old, there is no possibility of judging the eventual spon- 
taneous reappearance of motion through natural repair of the damaged 
roots. In the writer’s series of 17 cases of birth-palsy, the types rep- 
resented were as follows: 
Upper arm type 13 
Whole “ “ 4 
Lower “ “ none 
Of the upper arm type, 7 cases had difficult delivery or birth trauma 
recorded in the history. In all of the whole arm type cases (4), birth 
trauma is reported. This trauma consisted uniformly in the pulling of 
the arm laterally. Of these cases 2 of the upper arm type showed a 
dislocation of the humerus and 1 of the whole arm type a dislocation of 
the head of the radius. 
1 As a result of war experience, it is now generally conceded that wrapping nerves with 
foreign material causes unnecessary adhesions and rather impedes recovery. 20 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Summary.—Of the 17 cases seen and examined, 10 were treated. 
Conservative Treatment: 4 cases of upper arm type. 
1 case of whole arm type. 
Treatment consisted in redressment under ether—1 case. Applica- 
tion of splint in abduction and outward rotation—4 cases: 
Results: Good in 3 cases. 
Fair in 2 cases. 
Operative Treatment.—Sever’s operation was carried out in 2 cases 
of upper arm type, and in 1 case of the whole arm type. 
Open reduction of the shoulder was done in 1 case of the upper arm 
type. 
Plasty of the paralyzed elbow joint prior to arthrodesis of the shoul- 
der in whole arm type—1 case. 
Operative Results: In regard to correction and function: 
Good in 3 cases. 
Fair in 1 case. 
Poor in 1 case. 
The poor result was due to interruption of the treatment. 
Total: 6 Upper arm types 6 good results. 
4 Whole arm types 3 fair results. 
1 poor result. 
The case of the posterior dislocation of the humerus was that of 
a boy 9 years old. The history records instrumental delivery with palsy 
noticed within 4 days, involving the entire extremity. At the age of 
il/2 years, he could flex the fingers and the wrist but could not extend 
the wrist. He could not abduct the arm and shoulder. The patient, 
on admission, had adduction and inward rotation contracture of the 
shoulder. There was also a posterior dislocation of the head of the 
humerus with hooking of the acromion, and a residual paralysis of the 
musculospiral nerve with inability to extend the wrist and fingers. There 
was no deltoid paralysis. The forearm was held in pronation contrac- 
ture. The operation consisted in open reduction of the dislocated head 
from a posterior incision with osteotomy of the acromion, followed by 
stretching of the subscapularis tendon. The wrist drop will have to be 
taken care of by arthrodesis and the pronation contracture by resec- 
tion of the pronators. 
Another case was one of the whole arm type in a boy who had been 
seen, ofif and on, between the ages of 8 weeks and years. At 8 
weeks, he had complete brachial palsy of the entire right upper ex- CONGENITAL DEFORMITIES OF SHOULDER 
21 
tremity, no motion in either shoulder, elbow or fingers. Six months 
later, his motion had greatly improved. Flexion and extension appeared 
in hand and fingers and some power of abduction in the shoulder. 
When the boy was years old, his father consented to treatment. 
At this time, the residual deformities and paralyses had been well 
established. The flexion of the fingers was good, the extension poor, 
the forearm was held in pronation contracture, biceps and triceps 
were working well. Elevation of the arm was possible to the horizontal 
by action of the deltoid. There was, however, a contracture of mod- 
erate degree of the pectoralis and subscapularis muscles. The X-ray 
showed a dislocation forward of the head of the radius. The operative 
treatment consisted: (1) in Sever’s operation for the relief of the inward 
rotation contracture; (2) in arthrodesis of the wrist for the drop wrist; 
(3) in the operative reduction of the dislocated head of the radius. 
In reviewing this case, one cannot escape the conclusion that a 
fracture of the right clavicle sustained at the time of the birth injury had 
something to do with the extent of the paralysis. The originally very 
extensive paralysis cleared up to a remarkable degree, leaving practically 
nothing except a partial paralysis of the musculospiral nerve. There 
were, however, residual contractures in the shoulder, namely, adduction 
and inward rotation, and residual pronation contracture of the forearm. 
A. G., a girl 14 years old, presented herself for treatment for deform- 
ity and disability of the right arm. The history states that on the 3d day 
after birth an extensive palsy of the right arm was noted. The entire 
extremity was found shortened, the upper arm lacking 2 inches and the 
forearm also 2 inches, in measurement, compared with the sound arm. 
There was extreme inward rotation in the shoulder together with adduc- 
tion contracture so that the arm could not be lifted away from the body 
more than about four or five inches. There was distinct action of the 
deltoid. The forearm was in extreme pronation contracture to the ex- 
tent that the palm was turned forward being rotated almost in a full 
circle from the position of full supination. Active flexion of the elbow 
was impossible. 
This case was treated operatively; first, for the relief of the extreme 
pronation contracture, a resection of the pronator radii teres was done 
as well as a section of the pronator quadratus. The hand was then 
rotated back in a position which came within 40° of full supination. 
This was as much as was compatible with the undisturbed circulation 
of the forearm; then, the adduction and inward rotation contracture 
of the shoulder was remedied by Sever’s operation of sectioning of the 
subscapularis tendon to which the severance of the coracobrachialis and 
short head of the biceps was added (Plate II, 3, 4; III). 22 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
CONGENITAL ELEVATION OF THE SCAPULA 
(Sprengel’s Deformity) 
Attention was first called to this condition in the seventeenth century 
(Underberg, 1693) when 3 cases of congenital elevation were reported 
as dislocation of the scapula. A similar case was reported by Eulenburg 
(1863). Earlier reports of this nature were made by Willet and 
Walsham in England and by McBurney and Sands in America, the 
latter classifying the condition as a congenital deformity due to malpo- 
sition of the scapula. Eulenburg in his report calls attention to an 
exostosis at the upper border of the scapula as well as to the inability 
of the patient to abduct the arm beyond the horizontal level. A case 
of Heinecke, 1886, also deserves mention as the author believed that he 
had reduced the scapula by manipulation. The deformity bears the 
name of Sprengel’s Deformity because of this author’s publication (1891) 
in which he gave a clear description of the condition, reporting 3 cases 
of the ages from 1 to 7 years. In these he found one scapula 2 or 
3 cm. higher than the other. The motion of the arm was impaired 
and 1 case showed a small exostosis which this author considered to 
be a rib, and for the presence of which he ventured no explanation; 
but Koelliker, immediately following, called attention to the fact that 
this bony substance takes its origin from the inner border of the 
scapula developing from a bony nucleus attached to this inner border.2 
According to the statistics of Zesas (1906), there were 100 cases 
reported in the literature at that time; 48 in males, 34 in females, while 
in 18 the sex was not given. Of these cases, only 11 were bilateral. 
The ages of the patients ranged from 3 months to 41 years. In order 
to understand the pathology of this condition, it is necessary to refer 
to the normal topographical relations between the scapula and the 
vertebral column. The upper border of the scapula reaches up to the 
second rib, the lower angle is situated at the level of the seventh and 
eighth rib. The root of the spine of the scapula at its vertebral border 
is situated at the level of the fourth rib and opposite to the third thoracic 
spine. The normal scapula has a triangular shape with a long vertical 
and a short horizontal diameter. In an embryo of 11 mm. length, the 
scapula lies opposite the lower fourth cervical vertebra and the first and 
second dorsal vertebrae. In the course of development, the scapula 
migrates caudalward so that in an embryo of 14 mm. length, less than 
one half of this bone lies higher than the first rib. Furthermore, with 
the growth of the embryo, the scapula changes its shape from a greater 
horizontal diameter to a greater vertical diameter. 
2 A case of elevation of the scapula in a boy of eleven is reported bv Ridlon. The 
deformity developed at the age of one year and followed whooping cough. It was found 
to be due to spastic contracture of the trapezius, levator anguli and rhomboid muscles 
and disappeared entirely under anesthesia. CONGENITAL DEFORMITIES OF SHOULDER 
23 
In the full-term human fetus, there still exists a high position of the 
scapula which appears also much more nearly in the sagittal plane than 
it does in adults (Chivietz). The whole upper limb, in fact, is in its 
origin a cervical appendage and retains this position in fetal life. It 
is not until the beginning of extra-uterine life that mechanical influences 
come into play which produce a permanent modification of the fetal 
condition. According to Dwight, the scapula of man is remarkable for 
the development of the infraspinous part making the vertebral border 
very long and the inferior angle very prominent. 
In congenital elevation of the scapula, certain changes occur in the 
configuration of the bone as well as in its relative position to spine and 
ribs. These alterations consist first in a decrease of the vertical diameter 
and an increase of the horizontal, thus giving the bone the character 
of a reversion to a lower type or of the retention of a more fetal form 
(developmental arrest). Another anatomical change noticeable in this 
deformity is the curving forward of the superior border and of the 
supraspinous part of the scapula. According to Horwitz, this anomaly 
is seen in about 18 per cent of the cases. The upper outer angle of 
the bone is also drawn out presenting a hooklike appearance, accord- 
ing to the observations of Koelliker and Sprengel. A large percentage 
of cases also show fibrous or cartilaginous attachments of the scapula 
to the vertebral column. Another series of cases show bony articulations 
between the scapula and the vertebral column. This articulation usually 
runs from the upper inner angle of the scapula or from its median border 
to one of the transverse processes of the cervical spine. It represents 
a bone of more or less triangular shape resting upon the scapula, with 
the apex pointed toward the transverse process of the spine. 
About the nature of this bony articulation, many views have been 
expressed. It was argued that this bone might be the outgrowth of 
the spinous process or that it might be formed both by the spine and 
the scapula. In the opinion of Willet and Walsham, this bridge of bone 
is an abnormal development of the suprascapular epiphysis normally 
existing as a narrow bridge of bone along the posterior border of the 
scapula and corresponding to the suprascapular bone of some of the lower 
vertebrates. Other authors believe that these articulations are to be 
considered as degenerated muscle bands with centers of ossification 
appearing in the rhomboid muscles. 
Other features of this deformity are defects and anomalies in ribs 
and vertebrae. Instances of this kind are reported by Roger, Graetzer, 
Horwitz and many others. Such defects in the normal development 
of ribs seem to point to a more elementary developmental error than a 
mere failure of the scapula to descend would represent. Of the muscular 
changes seen in congenital elevation of the scapula, the most notice- 
able are those of the trapezius muscle. Complete absence of this muscle 
has been reported (Kirmisson). It is very often found contracted and 
in many cases plays a part in the asymmetry of posture of the head 
and in the development of a scoliosis. LEGEND FOR PLATE II 
Fig. i.—F. J. Birth-Palsy with Posterior Dislocation of the Shoulder. 
Fig. 2.—F. J. Birth-Palsy with Posterior Dislocation of the Shoulder. 
Fig. 3.—F. J. After Operative Reduction in Cast. 
Fig. 4.—F. J. After Secondary Osteotomy of the Humerus. PLATE II LEGEND FOR PLATE III 
Fig. i.—J. S. Birth-Palsy with Posterior Dislocation of Humerus. 
Fig. 2.—J. S. X-ray of Dislocated Shoulder. Note Small Head and Shallow Socket. 
Fig. 3.—A. G. Birth-Palsy; Whole Arm Type. Note Extreme Inward Rotation. 
Fig. 4.—A. G. After Resection of Pronator and Internal Rotators of Shoulder. PLATE III 28 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Kayser reported complete absence of the sternocleidomastoid muscle. 
A defective pectoralis muscle has also been noticed. Other muscles in- 
volved occasionally are the serratus magnus, the levator anguli, the 
latissimus dorsi, and the rhomboid muscles. Deformities of the humerus 
and clavicle have been seen and reported. Hibbs mentions a case of 
shortening of the humerus and the clavicle, the shortening of the hu- 
merus being too excessive to be classified as a mere atrophy from disuse. 
Considering the changed position of the scapula, it is not difficult to 
account for a shortening of the clavicular bone. 
A complete dissection of a case of congenital elevation of the shoul- 
der-blade is described by Fetterolf and Arnett. They report such ex- 
tensive anatomical changes that a short review of their findings does 
not seem out of place. The scapula was normal in size. On its vertebral 
border, just below the spine, there was a triangular facet articulating 
with a bony projection from the sixth cervical vertebra. The articulation 
was partly responsible for the restricted upward movement of the arm. 
The osseous growth consisted of a strong, markedly curved process of 
bone 4 cm. in length which was of a partially movable type, and at 
its junction with the scapula it was furnished with a capsule containing 
joint fluid. The right laminae of the fifth, sixth, and seventh cervical 
vertebrae, with which this bony process articulated at the other end, did 
not join those on the other side to complete the neural arch so that a 
condition of rachischisis existed. 
The muscle changes were striking. The trapezius consisted of two 
portions, an upper one which was more or less normally developed and 
a lower one which was more or less atrophic and consisted mainly of 
fibrous tissue. The upper part had its usual origin at the occiput and 
the cervical spine; the lower arose from the thoracic vertebrae, its fibers 
intermingling with those of the rhomboid. The levator anguli scapulae, 
slightly below normal size, had a Y-shaped insertion into the scapula, 
one arm fastening into the superior angle and the other into the articu- 
lation. The rhomboids were absent, being represented only by some 
connective tissue. The serratus magnus, instead of fastening to the 
vertebral border of the scapula, went beyond, interlacing its fibers with 
those of the rhomboids. There were also a number of anomalous muscle 
slips. 
In connection with this deformity, all kinds of complicating anom- 
alies and deformities have been observed, such as club-foot, shortening 
of the femur, defects of hand and fingers, maldevelopment of the whole 
upper extremity, cleft palate, etc. In the case of Drenkhahn, there was 
found a synostosis of radius and ulna. Bolten reports a case complicated 
with total defect of the radius and club-hand. 
The clinical symptoms of this deformity center largely upon the 
pathological position of the scapula itself. Combined with this, there 
is often a scoliosis varying from slight to very marked degree (Kirmis- 
son, Mohr). The curvature is usually situated in the lower cervical 
and upper dorsal spine producing a compensatory curve in the dorsal CONGENITAL DEFORMITIES OF SHOULDER 
29 
and lumbar section. The fact that scoliosis exists only in a certain per- 
centage would make it improbable that it is directly due to the high 
scapula. Nove-Josserand considers the scoliosis as an incidental de- 
formity caused by the same general arrest of development. In the 
same way, torticollis is seen in a certain percentage of the cases either 
with or without facial or cranial asymmetry. Nor does this seem to 
be directly caused by the high position of the scapula. 
In at least one-half of the cases, the function of the shoulder as 
regards motion is found to be unimpaired. Where it is impaired, it is 
the abduction of the arm which has suffered, the patient being unable 
to abduct beyond the horizontal. This can be readily understood if one 
considers that motion in the scapulohumeral joint is possible only to 
the horizontal and that beyond this plane, the scapula itself must rotate 
in order to allow the arm to be raised from the horizontal position to 
the vertical position upward. This rotation is taken care of normally 
by the combined forces of the trapezius and serratus magnus muscles. 
When these muscles are contracted or shortened, such rotation of the 
scapula will become impossible. 
But even in cases of bilateral deformity, the range of motion of the 
arm is not necessarily restricted to a marked degree. In these bilateral 
cases of Sprengel’s deformity, the high position of the scapulae gives 
the shoulders the appearance of being forcibly drawn up. The neck 
appears short and the normal contours of neck and shoulder line are 
changed. 'They do not show the gentle slope seen in the normal erect 
posture, but the shoulders form more nearly a right angle with the side 
of the neck. 
As to the pathogenesis of this deformity, a number of theories have 
been formulated. Sprengel himself considered the position of the fetus 
in utero as responsible for the deformity, not recognizing that there 
was a failure of the scapula to descend. The shape of the superior border 
of the scapula, especially the forward inclination of the suprascapula, is 
considered by Rager to be the reason for the incomplete descent, while 
Lange believes the contraction of the trapezius muscle to be instru- 
mental in this deformity. Some hold the defect of the trapezius muscle 
responsible (Kausch, Hoedlmoser, Neumann); others speak of polio- 
myelitic paralysis (Bloch). Of all the theories, that of developmental 
arrest seems the most plausible and is most generally accepted. Those 
authors, like Chivietz, who have paid close attention to the ontological 
development of this bone adhere to the theory of the reversal to lower 
type or retention in a fetal position. 
One word must be said about what some authors term a pseudo- 
Sprengel deformity. They are inclined to distinguish between a true 
congenital elevation in which there is a primary contraction of the 
muscles with disturbance of function, and a pseudo-Sprengel deformity 
in which the bone is held in place by bands or exostoses and in which 
there is no disturbance of function nor contraction of muscles. This LEGEND FOR PLATE IV 
Fig. i.—E. T. Winged Scapula. 
Fig. 2.—H. A. Congenital Elevation of Scapula. 
/ 
Fig. 3.—H. A. X-ray, Showing Elevation of Left Scapula, Wedge Formation of 
Vertebra and Fusion of Ribs. PLATE IV 32 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
distinction into different groups and subdivisions seems hardly justified 
and is likely to bring confusion in the conception of this condition. 
Treatment.—In milder cases, treatment by gymnastic exercises and 
stretching of the contracted muscles was carried out successfully 
by Goldthwaite, Painter, Gibney, and others. In cases in which con- 
servative methods do not produce results and where the contractures 
of the muscles are severe enough to interfere considerably with the 
function of the arm, or in which a considerable functional damage is 
caused by bony adhesions and articulations, operative methods are in- 
dicated. The removal of articulations has been carried out repeatedly 
(Brackett, Lovett, Jones, Wilton, and Rough). 
Technic of Operation for Removal of Articulations.—Incision over 
the vertebroscapular articulation, resection of bone bridge, freeing of 
scapula. The trapezius and rhomboid muscles have to be dissected off 
their places of insertion. This, in a number of cases, will render the 
scapula freely movable so that it can be held down in proper position 
(Wilson and Rough). In some cases, the hooked superior angle of the 
scapula had to be resected (Koelliker, Froelich, and others). After 
division of trapezius, which often consists of dense fibrous bands 
in its lower portion, and of the rhomboids and the levator anguli, the 
cartilaginous bands attached to the upper inner angle of the scapula are 
then removed. This mobilizes the shoulder-blade completely and it may 
then be depressed downward and reduced (Ashhurst). Gill found in 
his case a plate of bone after dividing the skin and fascia. It extended 
from the middle of the vertebral border to the sixth cervical spine. Even 
after complete removal of this articulation, the scapula could not be 
brought down to normal position until the trapezius was separated from 
the posterior portion of the spine of the scapula, and the two rhomboids 
as well as the levator anguli were also detached. In addition, he had 
to loosen the supraspinatus muscle from its posterior attachment and, 
lastly, he had to overcome the obstacle offered by the hooking of the 
external angle, by resecting the entire upper portion as far as the supra- 
scapular notch. These reports show that operative correction of the 
deformity may be extremely difficult and often calls for very extensive 
resections of both bone and muscles. Such extensive interference is 
hardly justified unless the deformity entails grave functional impairment 
in the use of the shoulder. 
Case Reports.—K. K., 3 years; complaint of patient is a shortened and 
rather stiff neck. On examination, both scapulae are found high, their 
upper border opposite the lower cervical spine. This shortness of the 
neck is explained in the X-ray by wedge formation of the cervical 
vertebrae as well as by the high position of the scapulae. There is no 
limitation of motion of the humerus but the side motion of the head is 
rather restricted. Under gymnastic treatment, this restriction of motion 
improved, however, to a considerable extent. 
K. R., 9 years; a sister of the patient just reported. This child also 
shows a short neck with restriction of rotation and lateral motion of CONGENITAL DEFORMITIES OF SHOULDER 
33 
the head. The X-ray shows a lack of bony union of the neural arches 
of the cervical spine, with flattened vertebral bodies. There is fusion 
of the ribs in two places, both scapulae are high. On gymnastic treat- 
ment, the motion of the head improves so that rotation becomes com- 
paratively free while side motion is still somewhat restricted. 
P. Y., 6 years. At the age of 5 years, it was noted that the patient’s 
left shoulder stood higher than the right and that there was some 
restriction in the elevation of the arm. The examination shows the left 
shoulder elevated 2 inches and rotated forward. The trapezius and 
levator anguli are contracted. There is no articulation of the scapula 
with the vertebral column. The X-ray shows the scapula elevated 2 
inches. It is of apparently normal configuration and has no abnormal 
bony attachment. There is a distinct fissure in the dorsal spine. It is 
most pronounced in the first dorsal vertebra, the body of which is divided 
into 2 cuneiform halves, the left one being higher and carrying with it 
the first rib. Functionally, there is slight lack in active elevation of 
the arm though passive motion is perfectly free. Patient is treated by 
massage and gymnastic exercises. 
H. A., il/2 years. Elevation of the left scapula \]/2 inches. Abduc- 
tion of the arm fairly free but not complete. The X-ray shows elevation 
of the left scapula with forward curving of the upper border. It shows 
also the following anomalies: fusion of the third and fourth rib on the 
right side; fusion of the seventh and eighth rib on the left side, and 
wedge formation of the sixth cervical vertebra. The case is also com- 
plicated by congenital contraction of the fingers and of the wrist, with 
syndactylism. 
In all four cases reported, vertebral anomalies, fusion of the ribs, 
etc., were present, and in no case was the elevation of the scapula 
the only deformity existing (Plate IV, 2, 3). 
BIBLIOGRAPHY TO BIRTH-PALSY 
Asiihurst, A. P. C. Traumatic injuries of the shoulder, Ann. of Surg., 1917, 
66:610. 
Bramann, F. Behandlung der angeborenen retroglenoidalen Schultergelenks- 
luxation, Arch. f. klin. Chir., 1906, 81:351. 
Hoffa, A. Lebrbuch der orthop. Chir., 1898, 472. 
Klumpke, A. Contribution a l’etude des paralysies du plexus brachial, Revue 
de Medicine, 1885, 591. 
Lange, F. Distorsion des Schultergelenkes, Munchen. Med. Wchnschr., June, 
1912. 
Lewis, B. Congenital dislocation of the shoulder, Phila. Med. News, 1895, 183. 
Porter, J. L. Congenital dislocation of the shoulder, Transact. Am. Orthop. 
Assoc., 1900, 13. 
Scheel, P. F. Zur operativen Behandlung der Schultergelenksdistorsion im 
Sauglingsalter, Ztschr. f. orthop. Chir., 1916, 35:808. 34 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Scudder, C. L. Congenital dislocation of the shoulder joint, Am. Journ. Med. 
Sciences, February, 1898. 
Sever, J. W. Obstetrical paralysis, an orthopedic problem, Am. Journ. Orthop. 
Assoc., August, 1916. 
Taylor, A. S. and Casamajor, L. Traumatic Erb’s paralysis in adults, Ann. 
of Surg., 1913, 58:577. 
Thomas, T. T. Pseudoparalysis of the shoulder joint, Am. Journ. Med. Sciences, 
1920, 159:207. 
Tubby, A. H. Deformities including diseases of bones and joints. Macmillan 
and Co., 1912, 116. 
Watson, E. G. Paralysis of the upper extremity due to compression of the 
brachial plexus by scar tissue, Surg. Gyn. Obst., 1918, 27:629. 
Wyeth and Sharpe. The field of neurological surgery in a general hospital, 
Surg. Gyn. Obst., 1917, 24:34. 
BIBLIOGRAPHY TO CONGENITAL ELEVATION OF SHOULDER 
Ashhurst, A. P. C. Congenital Elevation of Scapula, Ann. of Surg., 1911, 
54: 126. 
Bolten, J. Uber den angeborenen Hochstand des einen Schulterblattes, Zen- 
tralbl. f. Chir., 1892, 48: 1010. 
Eulenburg. Hochgradige Dislocation der Scapula, bedingt durch Retraktion 
des Musculus levator scapulae, Arch. f. klin. Chir., 1863, 4:304. 
Gill, A. B. Congenital elevation of scapula, Ann. of Surg., 1920, 71:229. 
Gross, H. Erworbener Hochstand der Scapula, Beitr. z. klin. Chir., 1899, 
24:810. 
Heinecke. Eine seltene Verschiebung des Schulterblattes, Zentralbl. f. Chir., 
1886, vol. 2. 
Hirscii, K. Ein Fall von doppelseitigem angeborenen Hochstand der Scapula, 
Ztschr. f. orthop. Chir., 1904, vol. 12. 
Hoedlmoser, K. Sprengelsche Difformitat mit Cucullarisdefekt, Wien. klin. 
Wchnschr., 1902, vol. 52. 
Hoffa, A. Ein Fall von angeborenem Hochstand des einen Schulterblattes, 
Wuerzburger phys.-med. Gesellsch., 1892, vol. 7. 
Honsell, B. Doppelseitiger Hochstand der Schulterblaetter, Beitr. z. klin. 
Chir., 1899, 24:815. 
Horwitz, A. E. Congenital elevation of scapula; Sprengel’s Deformity, Am. 
Journ. Orthop. Surg., 1908, vol. 6. 
Jouon et Kirmisson. Nouvel example de refoulement congenital de l’omoplate 
en haut, Rev. d’orthop., 1899, 10:246. 
Kausch. Cucullarisdefekt als Ursache des kongenitalen Hochstandes der 
Scapula, Zentralbl. f. Chir., 1901, vol. 28. 
Kennard, H. W. Congenital elevation of scapula, Am. Journ. Orthop. Surg., 
Transactions, 1911, 12:75. 
Kirmisson, E. Nouvel example de malformation congenitale de l’omoplate, 
Rev. d’orthop., 1897, vol. 5. 
De quelques malformations congenitales de l’omoplate, Rev. d’orthop., 
1893, 4:343. 
Koelliker. Zur Frage des angeborenen Hochstandes des Schulterblattes, Zen- 
tralbl. f. Chir., July, 1895. CONGENITAL DEFORMITIES OF SHOULDER 
35 
Koelliker, T. Bemerkungen zum Aufsatz von Dr. Sprengel, Arch. f. klin. 
Chir., 1891, 4: 925- 
Lewis, F. T. Anatomy of 12 mm. pig, Am. Journ. Anatomy, 1902. 
Milo. Ein Fall von doppelseitiger Sprengelscher Difformitaet, Ztschr. f. 
orthop. Chir., 1899, 6:242. 
Mohr, H. Uber kongenitalen Hochstancl der Scapula, Ztschr. f. orthop. Chir., 
1904, 11:331. 
Neumann. Zur Frage der aetiologischen Bedeutung des Cucullarisdefektes fiir 
den Schulterblatthochstand, Wien. klin. Wchnschr., 1903, vol. 36. 
Pitsch. Ein Fall von angeborenem Hochstand der Scapula, Ztschr. f. orthop. 
Chir., 6:52. 
Putzu, F. Sopra un caso di scapola alta congenita, La Chir. degli organi di 
movimento, 1919, 3 : 578. 
Rager, W. Drei Faelle von angeborenem Hochstand der Scapula, Ztschr. f. 
orthop. Chir., 1901, vol. 9. 
Ridlon, J. N. Report of a case of Deformity in the Shoulder, Med. Rec., Sep- 
tember 13, 1890. 
Rough, J. T. Sprengel’s Deformity of the shoulder, Ann. of Surg., 1914, 60:654. 
Sainton, R. Sur un nouveau cas de deplacement de l’omoplate, Rev. d’orthop., 
1898, 9:467. 
Schlange. Ein Fall von Hochstand der einen Halfte des Schultergiirtels, 
Zentralbl. f. Chir., 1892, vol. 13. 
Schlestnger, H. Zur Lehre vom angeborenen Pectoralis-Rippendefekt und 
dem Hochstand der Scapula, Wien. klin. Wchnschr., 1900, 25. 
Skillern, P. G. Serratus Magnus Palsy, Ann. of Surg., 1913, 53:909. 
Sprengel. Angeborene Verschiebung des Schulterblattes nach oben, Arch. f. 
klin. Chir., 1891, vol. 42. 
Wilson, A., and Rough, J. T. Two cases of anomalous spinous process of 
the seventh cervical vertebra articulating with scapula, Ann. of Surg., 
April, 1900. 
Wolffheim. Uber den angeborenen Hochstand des Schulterblattes, Ztschr. f. 
orthop. Chir., 1896, vol. 4. 
Zesas, D. G. Uber den angeborenen Hochstand des Schulterblattes, Ztschr. f. 
orthop. Chir., 1906, vol. 15. CHAPTER III 
PARALYSIS OF SHOULDER AND ELBOW 
PARALYSIS OF SCAPULOTHORACIC MUSCLES 
(Muscle Dynamics of the Scapula) 
The movements of the scapula may be either translatory or rotatory. 
In the first case, all points move parallel to each other—up and down- 
ward, back or forward motion; in the second case all points rotate about 
either the inner or the outer upper angle as the center of motion. There 
is, therefore, a call for unusual mobility of the scapula, and, conse- 
quently, for a very complicated muscle machinery. On the other hand, 
the great force displayed in the different motions of the upper extremity 
calls for great stability of the shoulder-blade. Since the only bony 
connection of the scapula is a syndesmosis with the clavicle, one may 
readily see that the task of stabilizing the shoulder-blade as well as 
of moving it in all possible directions falls upon the muscular apparatus. 
The latter, therefore, is exceedingly complicated and voluminous. 
The rotatory motion is carried out by the trapezius and serratus 
magnus. Both muscles are turning the scapula in the same direction, 
approaching the upper border of the bone nearer to the median line. 
The serratus executes this rotation around the upper and outer angle 
of the scapula as the center, while the trapezius rotates around the 
upper inner angle. In contracting, the serratus also forces the scapula 
closely to the posterior thoracic wall, in this way acting as stabilizer 
of this bone, in support of the latissimus dorsi. If we consider that in 
right angle abduction the action of the deltoid muscle proper is com- 
pleted and the humerus locked in this position against further abduc- 
tion, by the scapulohumeral joint, by the tension of the lower portion 
of the capsule, and by the teres major muscle, it becomes clear why the 
rotatory motion of the scapula is so necessary to complete the elevation 
of the arm from the horizontal position to the perpendicular. It is also 
clear why this motion is so amply provided for by such powerful muscles 
as the trapezius, in its upper and middle fibers, and the serratus magnus. 
In the combined contracture, these muscles lock each other against the 
back and forward shifting of the scapula in which respect they are 
antagonists, and there remains only their synergistic component, which 
rotates the scapula.1 
1 Isolated paralysis of the trapezius muscle is very rarely observed in anterior polio- 
myelitis. But it occurs occasionally from peripheral lesions to the spinal accessory nerve 
following dissections of the neck. In these cases there exists a dropping as well as a 
forward displacement of the shoulder-blade. PARALYSIS OF SHOULDER AND ELBOW 
37 
The Winged Shoulder.—In the case of an isolated paralysis of the 
serratus magnus muscle, one may readily appreciate the handicap which 
exists in abduction motion of the arm. With the rotatory action of 
the serratus muscle eliminated, there is quite a preponderance of the 
antagonistic rotators of the scapula, which rotate in the opposite di- 
rection, namely, the rhomboid muscles and the levator anguli. They 
lower the upper outer scapular angle and, with it, the arm; they 
draw the lower angle and the vertebral border nearer to the midline. 
The paralysis of the serratus magnus produces a peculiar position of 
the scapula in relation to the thorax. This appears principally in the 
forward motion of the arm. When the arm is brought diagonally or 
straight forward, the scapula is seen to leave the thoracic wall with its 
vertebral border coming strongly into relief (winged shoulder). There 
is then a disability of the arm to be abducted laterally beyond the hori- 
zontal line, and sometimes abduction to the horizontal becomes difficult. 
There is a noticeable drooping of the acromion forward and downward 
while the inferior angle of the scapula projects into the back muscles 
when the arm is flexed forward in the sagittal plane. Sometimes the 
inferior angle of the scapula, which is usually covered by the upper 
border of latissimus dorsi, will slip out from under this muscle sheet 
(Skillern). 
Regarding the treatment, fixation of the winged scapula by proper 
braces has been considered, and a simple apparatus consisting of two 
firm pads pressing against the shoulder-blades and united by steel bands 
in front, with counter pads over the acromioclavicular junction and 
heavy shoulder straps to hold the shoulder-blade down, has been de- 
scribed by Neumeister. However, most of the favorable reports have 
been obtained in the operative treatment. Eiselsberg (1898) was the 
first to attempt operation in winged scapula. He operated on two 
patients, his procedure consisting in suturing together the two vertebral 
borders of the shoulder-blades in the midline. As this did not give 
satisfactory results, the superior inner angle was also united in a second 
step and the final results were reported to be good. It is easy to be 
seen that this method severely handicaps the free mobility of the shoul- 
der-blade and that it is open to grave objections. In 1903, Duval 
reported an operation in which he sutured the vertebral border of the 
bone to the adjacent ribs. He tried to avoid the inhibition of abduc- 
tion incidental to the fixation of the scapula by slanting off the inner 
border downward and outward in the direction in which the combined 
trapezius and serratus action would turn it, so that an elevation of the 
acromion would result. He makes an incision over the vertebral 
border with the bone in normal position. The incision reaches from 
the root of the spine of the scapula downward to the inferior angle. 
A vertical incision of the trapezius and rhomboid along the spinal border 
is made and the latissimus dorsi is retracted downward. At the internal 
surface of the scapula, the periosteum is incised near the border and 
deflected together with the serratus magnus, and this periosteum-muscle 38 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
flap is resected. This is done to prevent interposition of a soft tissue 
flap between the places of fixation. Then the periosteum is stripped 
off from the sixth and seventh ribs at some distance from the midline, 
and two silver wires are passed around the ribs and through the drill 
holes in the scapula and tied, fixing the scapula to the ribs. Finally, 
the trapezius and rhomboid muscles are re-sutured to the scapula and 
the wound is closed. 
Skillern reports a case in which an inoculation of a healthy nerve 
into the distal end of the injured long thoracic nerve was made in a 
case of serratus paralysis. The short subscapular nerve was used for 
this purpose. The nerve is reached from a horseshoe flap incision over 
the hollow of the axilla in front, with the base corresponding to the 
anterior fold or lower border of the pectoralis major; this flap, including 
the underlying axillary fascia, is raised and reflected over the anterior 
wall. Then the long thoracic nerve is dissected along the middle of the 
inner wall of the axilla and beneath the fascia covering the serratus 
magnus. It is then traced upward to the apex of the axilla beneath 
the great neurovascular bundle which is retracted forward. Then the 
three subscapular nerves are readily seen underneath the fascia resting 
upon the subscapularis muscle and are traced to the posterior cord. The 
uppermost of the three is now found one-half inch from the long thoracic 
nerve. It is approximated, both nerves severed, and the proximal end 
of the subscapular nerve is united end to end with the distal end of 
the long thoracic nerve. The line of suture is wrapped with egg mem- 
brane. No end results of this method have been reported. 
Case Reports.—E. K., 18 years. Complains of deficiency in the right 
shoulder for the last 6 years which had greatly increased until it reached 
a stationary point 2 years ago. The difficulty consisted in raising the 
arm above the horizontal line. This was impossible unless done by 
swinging motion. When this was done, the shoulder-blade seemed to 
rotate about the vertical axis so that its median border became sep- 
arated from the ribs and came strongly into relief. There was paralysis 
of the serratus magnus muscle, the cause of which could not be de- 
termined. 
E. T., 8 years. This patient had an attack of infantile paralysis 2 
years ago which involved his left shoulder. He was able to elevate his 
arm up to the horizontal, but it was difficult to go beyond. When 
elevating his arm, especially in a forward plane, the scapula was seen 
to rotate about a vertical axis, the inner border leaving the contact with 
the thorax (Plate IV, 1). 
Neither of the two cases was treated, because there was no func- 
tional deficiency extensive enough to warrant an operative procedure. PARALYSIS OF SHOULDER AND ELBOW 
39 
SCAPULOHUMERAL MUSCLES 
Deltoid Paralysis.—Of the deficiencies caused by paralysis of the 
scapulohumeral group of muscles, the one due to paralysis of the deltoid 
is by far the most prominent both in frequency and in degree of its dis- 
abling effect. The question why paralysis of any one muscle should 
be fraught with such grave consequences to the function of the joint 
as is the deltoid paralysis is readily answered from considerations arising 
out of the knowledge of the physiology and dynamics of this muscle. 
The deltoid is practically the only abductor of the arm capable of 
doing any substantial amount of work. It arises from the outer side 
of the clavicle, the free border of the acromion, and the lower lip of 
the spine of the scapula. It is inserted into the middle of the outer 
side of the humerus, its widespread fibers converging into a strong and 
narrow tendon of insertion attached to the deltoid tuberosity of the 
humerus. This muscle consists of three portions with more or less 
distinct individual function. The middle portion is a direct outward 
elevator; the anterior and posterior portions abduct the arm as well as 
carry it forward or backward, respectively. In this work, the muscle 
is assisted by the supraspinatus muscle coming from the supraspinous 
portion of the scapula, which is inserted into the highest facet of the 
greater tuberosity of the humerus. This latter muscle is adherent to 
the capsule, preventing plication of its upper portion which might con- 
stitute an impediment in the act of abduction. 
It is the function of the deltoid muscle to elevate the arm up to an 
angle which differs in the various planes of abduction. In forward 
abduction, it carries the arm up to a height of about 130° ; in abduction 
in the frontal plane, its range is up to 90°, or the horizontal; while in 
abduction in an oblique posterior plane, its elevating power is about 450. 
Further elevation beyond the ranges mentioned is checked, besides, by 
the overhanging edge of the acromion, the lower portion of the capsule 
and, in the anterior planes of abduction, also by the tension of the 
teres major. 
Abduction of the arm beyond the ranges of the deltoid is taken care 
of by rotation of the shoulder-blade, as has been stated before. In this 
work the trapezius muscle plays the most prominent part. Its action 
begins when that of the deltoid ends or is checked by contact of the 
humerus with the acromion and by capsular and muscular tension. 
But the loss of function of the deltoid results in inability to elevate 
up to the point where the trapezius and other scapulothoracic mucles 
begin their work of abduction. The greater majority of cases of del- 
toid paralysis are cases of anterior poliomyelitis, the paralyses, as a 
rule, being associated with flaccid paralysis of other muscles of the 
body. 
In the writer’s series of 883 cases of infantile paralysis, 70 cases 
involved the upper extremity, or 8 per cent. Of the 70 cases involving 40 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
the upper extremity, not less than 56 cases involved the shoulder joint 
either alone or in conjunction with other joints. All the shoulder joints 
involved, except one (serratus paralysis) had a paralyzed deltoid muscle. 
The first question which offers itself is, whether or not the paralysis 
of the deltoid, found after the attack of anterior poliomyelitis, is a 
permanent or a temporary one; whether the second, if permanent, entails 
an absolute inability to abduct the arm? 
The first question may be answered best by referring to the statis- 
tics of Lovett, which show that permanent and complete paralysis of 
muscles in infantile paralysis are by far in the minority as compared 
with temporary and partial paralysis, the ratio being 1 to 6. This fact 
carries very considerable weight in regard to our attitude of treatment 
of paralysis of the deltoid muscle in the earlier stages of anterior 
poliomyelitis. If the chances of spontaneous recovery are as favorable 
as the statistics show, it follows that the most serious consideration 
must be given to the conservative treatment which will guarantee the 
best possible preservation of latent muscle power and the most favor- 
able muscle development under a proper reeducational management. 
Out of the series of 56 cases of deltoid paralysis, 16 were classified as 
more or less recent cases. By this is meant that the cases ranged any- 
where from 8 weeks to 2 years after the onset of paralysis. It seems 
perfectly proper to qualify a case as a recent case within this period of 
time from the viewpoint of the advisability of conservative treatment; 
some cases will seem to be doubtful as to whether the paralysis is a 
permanent one or not after a period of 2 years. Other cases will show 
such changes of atrophy, shrinkage, etc., after a much shorter period 
of time that there can be little doubt as to the fact that the muscle is 
irretrievably lost. Of these 16 cases in the series, 4 were not treated 
and 12 were treated. 
Of the 12 conservatively treated cases, a complete recovery of the 
deltoid muscle was obtained in 3, and a decided improvement in the 
power of this muscle was obtained in 4 cases, making a total of 7 cases 
recovered or markedly improved. A noticeable recovery of the deltoid 
muscle was noticed in one case as late as 2 years after the onset of the 
paralysis, although 1 year had passed between the onset of the disease 
and the beginning of the proper treatment. In another instance, the 
treatment began 6 weeks after the onset of the paralysis, the patient 
recovering the use of the lost deltoid muscle almost entirely, being 
able to elevate actively to 90° and to hold the arm abducted. In other 
cases, a recovery was noted after an interval of 2 or 3 months had 
passed between the onset of the disease and the beginning of the 
treatment. 
Conservative Treatment—Attitudes of Rest.—For the deltoid muscle, 
the attitude of rest is that of abduction of 90° with the scapula rotated 
backward. It is best to maintain this position by means of a so-called 
aeroplane splint which allows abduction of the arm at 90° and outward 
rotation and also holds the elbow in a position of right angle flexion PARALYSIS OF SHOULDER AND ELBOW 
41 
and the forearm in a position midway between pronation and supination. 
This position is preferable to the one obtained by what is called a 
platform splint in which the arm is also abducted to 90°, but the fore- 
arm is allowed to rest horizontally upon the extremity of the splint 
with the forearm pronated. The first-named position takes care of the 
outward rotation of the humerus, thereby relaxing the infraspinatus 
muscle and the teres minor, and preventing such contractions of the 
rotators as might occur on the part of the subscapularis muscle, the 
latissimus dorsi, and the teres major. It is necessary for the patient 
to maintain this position without interruption, and the splint must never 
be removed except for treatment and then only with special precautions. 
The patient must lie down with his arm held abducted so that the del- 
toid muscle may always be relaxed. 
Muscle Educational Treatment.—In regard to this treatment which 
must accompany the treatment of rest, it is well to keep in mind the 
points given in the excellent book of Bowen and McKenzie. Whatever 
active motion is instituted must begin near the position of rest and 
from there work gradually to the more remote positions of the arm; 
that is to say, the attempt at motion of the deltoid should first be carried 
out with the arm abducted and only as the power increases may abduc- 
tion be allowed to follow gradually. With these precautions, one is 
often surprised to see remarkable results in a very short time. The 
first attempt of active motion of the deltoid must naturally be carried 
out in the recumbent position. It is not uncommon to detect slight 
power in this muscle when the patient is lying down, whereas it seems 
to be entirely absent when the patient is sitting up with the arm hang- 
ing by the side. In fact, no deltoid muscle should be declared completely 
paralyzed from a failure to carry out abduction so long as the patient 
is in the sitting or upright position. In order to elicit the feeble action 
of the deltoid, which is very often present, it is indispensable to have 
the patient prone or supine on the table. 
Substitutionary Motion.-—In the event that the deltoid muscle fails to 
present any signs of activity or life, in the event of no functional or 
electrodiagnostic response, in the event of degeneration of the muscle 
with atrophy and subluxation of the head of the humerus, the re- 
covery of this muscle and its reeducation to functional ability is beyond 
hope. 
Before a surgical operation to supplant the lost deltoid is contem- 
plated, it is necessary to establish the fact whether or not abduction 
of the arm is possible to a sufficient degree in spite of the absence of 
deltoid action; if abduction of the arm could be procured without the 
deltoid, the disability would not be absolute. This leads us to a study 
of substitutionary motion in deltoid paralysis and to the analysis of the 
different mechanisms applied. The patient may force the arm away 
from the body, in an attempt of abduction, by a side and forward swing 
of the body which starts with a contracture of the coracobrachialis 
muscle. This latter effects a forward swing of the arm which may be 42 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
carried out with sufficient force to throw the forearm into flexion until, 
in acute flexion, it is balanced against gravity, bringing the hand near 
the face; a substitutionary motion which serves the paralyzed deltoid 
as well as the flail elbow. Almost without exception, this substitute 
is laborious, unsightly, and only of lesser practical value to the patient. 
Another mechanism of substitutionary motion in deltoid paralysis 
is based upon the stabilization of the shoulder joint. According to 
Poirier, the great stabilizer of the shoulder joint is the triceps muscle. 
Although the long portion of this muscle contributes only feebly to the 
extension action of the elbow, its main function is that of maintaining 
the head of the humerus firmly within the glenoid fossa. The stabiliza- 
tion may be carried out in two ways: either by active contraction of 
the triceps muscle, extending the elbow; or by passive tension of the 
triceps muscle acutely flexing the elbow. We have seen patients use 
both of these methods. They are sometimes able to abduct the arm 
by contraction of the triceps and sometimes by acute flexion. In either 
event, the head of the humerus is pressed firmly against the glenoid 
cavity, making a mechanical unit, as it were, out of the humerus and 
scapula, which is then moved by the trapezius muscle. It is evident 
that such action cannot carry with it any great force and that the best 
the patients can do is to elevate the arm to about 30° or at most 450 
from the body with comparatively little gravitative stress at this angle. 
I have never seen any greater amount of abduction being accomplished 
by this mechanism unless the patient is in a recumbent position. This 
sort of substitutionary motion naturally presupposes a good function 
of the triceps as well as the flexors of the elbow, but these muscles 
quite often are also involved in the paralysis. 
After all, these substitutionary motions offer, even with the great- 
est skill on the part of the patient, only a slight and insufficient sub- 
stitute for a lost action of the deltoid. When compared with the opera- 
tive result which will be shown later, the functional advantage derived 
from such substitutionary motion is rather limited. 
Operative Treatment.—Permanent inability of abduction and failure to 
replace the deltoid action by substitutionary motion to a degree of sat- 
isfaction constitute the indication for operative methods. Generally 
speaking, two ways are open: first, tendon transplantation; second, 
fixation (arthrodesis) of the shoulder joint. 
Tendon Transplantation.—It has been mentioned that deltoid pa- 
ralysis is hardly ever strictly isolated. The table on page 43 gives a review 
of the extent of paralysis in the writer’s series. 
The proximity of abundant muscle material has invited a number 
of methods of muscle transposition and transplantation. One of the 
earliest is a method of Winiwarter who used the clavicular fibers of the 
pectoralis major as the substituting muscle. Hoffa used the trapezius 
and pectoralis major for implantation upon the paralyzed deltoid and 
was able to report some favorable results. Hildebrandt likewise made 
use of the pectoralis major to supplant the paralyzed deltoid. His PARALYSIS OF SHOULDER AND ELBOW 
43 
technic consisted of an incision upward from the junction of the fourth 
rib and the sternum to the sternoclavicular joint and from there at 
right angle outward along the upper border of the clavicle, reaching 
as far as the acromion. He then effected a separation of this sterno- 
clavicular portion of the pectoralis major, being very careful not to 
injure the anterior thoracic nerves. This gave him a free flap of the 
pectoralis major which was turned over and fastened to the lateral 
third of the clavicle and the acromion. By this operation, he was able 
to produce active elevation of the arm forward to the horizontal. The 
preservation of the thoracic nerves and vessels reaching the pectoralis 
major from the under side is an absolute essential for the success 
of the operation. It is also a factor which makes for considerable 
technical difficulties. Possibly it was on account of the latter fact that 
the methods of muscle transplantation never gained general acceptance. 
It can also be seen that the results were by no means uniform and 
none of the methods has been developed to a degree where it would 
offer a reliable average of functional results. 
Unilateral 
Bilateral 
Total 
Deltoid and supraspinatus 
12 
5 
*7 
Deltoid and trapezius 
i 
1 
Deltoid and wrist and fingers 
2 
2 
Deltoid and flexors of the elbow 
Deltoid and flexors and extensors of the 
* IO 
IO 
elbow 
Deltoid and flexors and extensors of the 
9 
i 
IO 
elbow and hand 
Deltoid and flexors of the elbow and mus- 
IO 
IO 
cles of the thumb 
Deltoid and extensors of the elbow and 
3 
3 
extensors of the wrist 
i 
i 
2 
Deltoid and extensors of the wrist 
Deltoid and extensors of the wrist and 
i 
1 
flexors of the wrist 
i 
1 
57 
Shoulder-joint Fixation.—The fixation of the paralytic shoulder by 
means of silk ligaments is a method advocated by Bartow and Plummer 
(1913). The technic as given by these authors is as follows: 
An incision one inch long is made on the top of the acromion one- 
half inch from its end. This incision extends down to the bone and 
runs along the line between the insertion of the* trapezius and the 
deltoid muscle. Then a suitable drill having an eye at its point is 
entered on top of the acromion one-half inch from its tip and is pushed 
downward through the bone into the shoulder joint. The drill is next 44 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
made to engage into the head of the humerus on its external aspect 
and near the anatomical neck. It is then pushed through the head of 
the humerus and the greater tuberosity to the base of the latter, emerg- 
ing on its surface external to the bicipital groove. The drill is then 
carried through the deltoid muscle to the skin where a short incision 
is made. Both ends of a piece of fine, bronze wire are threaded into 
the drill eye and, on withdrawing the drill, the wire is pulled through 
the bones, its loop and ends protruding. Then the drill is again inserted 
into the acromion, this time three-fourths of an inch back of the first 
puncture, and a similar parallel tunnel is made, the drill emerging three- 
fourths of an inch backward from the first tunnel on the posterior 
aspect of the greater tuberosity. Where the drills have penetrated the 
deltoid, a loop of wire is passed under that muscle from puncture to 
puncture. Then a double strand of No. 14 or 16 paraffin Lange silk 
is attached to the wire loop and pulled through this outer tunnel. 
The distal end is then dropped into the loop of wire, passed under the 
deltoid and pulled through to the opposite incision. Lastly, the silk is 
pulled through the posterior tunnel, and finally the strands are tied on 
top of the acromion, while the head of the humerus is being slightly 
abducted. 
The operation is technically not difficult and the cases reported by 
Bartow and Plummer were successful and a considerable amount of 
abduction was obtained. In a measure, the method may be considered 
as a partial arthrodesis. Late end results are not reported. 
But the only method which may be relied upon to give permanent 
results is the arthrodesis of the shoulder joint. Even Lorenz, who gen- 
erally condemns arthrodesis, is an advocate of it in the treatment of 
the flail shoulder. The first arthrodesis was performed by Albert 
( Bradford, Whitman, and, above all, Robert Jones, are advo- 
cates of the arthrodesis. Vulpius in 1912 reported 12 cases of flail 
shoulder treated by arthrodesis, in which he exposed the head of 
the humerus from an anterior longitudinal incision, and then pro- 
ceeded to the denudation of the head and the glenoid fossa. Silver 
wires finally secured the position between humerus and glenoid fossa 
which was one of abduction, slight forward flexion, and inward rotation. 
The average amount of forward flexion was 75°, the average amount 
of straight lateral abduction 6o°, and the average amount of lateral 
backward extension was 30°. 
Before entering into the details of the operation, the proper age 
for performing it is to be considered. Some authors, among them Lange, 
maintain that one should wait until the fourteenth or eighteenth year 
in arthrodesis of the shoulder for reasons of growth, following the general 
rule which applies to other large joints of the body. This we think 
is wholly unnecessary. If one considers that the problem of perma- 
nently dealing with the flail shoulder sometimes arises in very young 
children, the loss of eight or ten years in waiting must have a consid- 
erable influence upon the development of the extremity. It must be PARALYSIS OF SHOULDER AND ELBOW 
45 
remembered that during all this time the flailness of the shoulder is a 
grave obstacle to the functional development of the entire arm. Even 
if elbow and hand are in good condition, the total inability of abducting 
the arm from the body makes it impossible to give any educational 
training to the hand and forearm. Jones advocates the arthrodesis as 
early as six or eight years of age. It is true that when done at that 
age a greater amount of bone must be removed from the articular ends 
of the bones, in order to procure ankylosis; but this loss is outweighed 
by the advantage of early functional development of the extremity. 
It is still a question whether or not it is necessary to have complete 
bony fusion in order to pbtain satisfactory function. It is, of course, 
by far the more desirable kind but we believe that a degree of fibrous 
ankylosis in smaller children is acceptable. As will be shown in 
our series later on, such fibrous ankylosis in younger children gives 
good functional results, which compare not unfavorably with the 
ankylosis produced in older children and in adults. 
Lastly, one must decide at what angle the fusion should be accom- 
plished and what the position should be in which the arm is held in the 
plaster-of-Paris cast following the operation. Lange proposes 6o°; 
Vulpius the right-angle position; Vacchelli, who recently reported a 
series of cases ranging from five years to fifteen years, also fixes the 
arm at right angle with the body. It has been the custom of the writer 
to adopt a right-angle abduction as it seems to be the safer procedure 
and as one is apt to lose some of the abduction later on during the 
first few weeks of plaster fixation. Especially is this true in younger 
children where bony ankylosis cannot so thoroughly be relied upon. 
Technic of the Operation.—The position of the patient is that of 
lying upon the sound side with the shoulder supported by sandbags. 
During the operation, it is necessary to exert a downward pull upon 
the shoulder. This is taken care of by one of the assistants standing 
on the side opposite the operator. The incision is made from the spine 
of the scapula forward, circling the acromion, and ending anteriorly over 
the coracoid process. After severing the skin and fat, the tissues are 
thoroughly liberated and turned upward in a semicircular flap. The 
liberation of this flap should be high enough to expose the edge of 
the acromion for a distance of one to one and a half inches upward. 
One then proceeds bluntly to divide the fibers of the deltoid muscle 
anteriorly and posteriorly at places corresponding to the edges of the 
middle portion. This separation is carried upward directly to the acro- 
mion and downward to the insertion of the deltoid muscle. In many 
cases, there is nothing left of the deltoid but a fibrous sheet while 
in others, there may be an amount of muscle material present. One 
then inserts a grooved director under the muscle, freeing the edges 
thoroughly until the instrument plays freely from the deltoid insertion 
upward to the acromial attachment of the middle portion. The acro- 
mion is now incised transversely three-fourths to one and a fourth 
inches from its edge and the bone is here cut through with an osteo- 46 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
tome. One now has a flap consisting of the middle portion of the del- 
toid muscle to which is attached the severed end of the acromion. This 
bone-muscle flap is turned downward. As this is done, the entire 
anterior surface of the shoulder joint capsule comes into view. This is 
opened by a longitudinal incision to which are added two short trans- 
verse incisions at the acromial end in order to procure better access to 
the glenoid cavity. The edges of the capsule are carefully secured by 
forceps and are widely retracted. Now, as the assistant pulls the arm 
downward, the glenoid fossa is seen in its entity and also most of the 
head of the humerus is visible. The long tendon of the biceps can be 
seen just in front of the incision of the capsule passing through the 
joint. The next step is the denudation of all cartilage covering the joint. 
First the cartilage covering the glenoid fossa is completely removed. 
One then proceeds to the removal of cartilage from the head of the 
humerus and to this end the head may be pushed through the incision 
in the capsule. One should see that the two articulating surfaces now 
fit into each other in the position of abduction. The next step is the 
insertion of chromic gut (No. 3 or 4), into the bone. The head of 
the humerus is drilled and the opposing portion of the acromion, also, 
and the catgut is then passed through both drill holes. Two of these 
sets of drill holes are made; one anteriorly and one about one-half inch 
posteriorly to the first. The sutures now passed through both drill 
canals are for the moment left untied. The capsule is closed by sutur- 
ing the longitudinal slit transversely. This at once reefs and tightens 
the anterior capsular wall. Then the drill-hole sutures are tied over 
the capsule with the arm held in abduction, a position which from now 
on must be maintained continuously by one of the assistants until the 
shoulder rests safely in the plaster cast. Then we usually fasten the 
bone muscle flap, consisting of deltoid and the attached piece of the 
acromion, to the spine of the scapula instead of back to its place; in 
this way, the flap can be made to serve as a posterior check which 
counteracts any tendency of the humerus toward posterior displace- 
ment. The wound is now closed in layers and a plaster cast is applied 
reaching from the shoulders to the hips and encircling both arm and 
forearm. The position is that of abduction in the shoulder, inward rota- 
tion of the arm, and flexion of the elbow. The cast is left in place from 
two to three months, the wound being taken care of through a window 
in the cast. At the end of this time, the cast is removed and a plat- 
form splint already at hand is immediately applied. From this time 
on, the mechanical after treatment begins. This after treatment consists 
of massage of the muscles of the shoulder, especially the trapezius, and 
also of massage of the arm and forearm, to promote their recovery 
after the prolonged fixation (Plate V, 1,2, 3, 4). 
Together with massage, the active exercises are begun at once. 
They must be carefully timed and during the first weeks must be carried 
out under the strictest supervision. The details of the muscle educa- 
tional treatment will be discussed again in a later chapter. It may be PARALYSIS OF SHOULDER AND ELBOW 
47 
mentioned here briefly that active elevation is encouraged by system- 
atic writing exercises on the blackboard and other educational move- 
ments of the shoulder. Not until one is sure that active elevation of 
the entire extremity is possible and that the arm can be held in abduc- 
tion for some time is the angle of the splint changed. When the splint 
is first taken off for muscle educational treatment, the patient must 
be in a recumbent position and only later is he allowed to take his 
muscle exercises sitting or standing up. Even then the assistant must 
carefully support the elbow during exercises until sufficient muscle 
power has been gained. Only when active elevation is assured, and 
this may take anywhere from four to six weeks after the removal of 
the cast, can the arm be left elevated without further support. We 
now begin with the gradual lowering of the angle of the splint by 
bending it down from time to time until within about three months 
after the removal of the cast, or within five or six months after the 
operation, the arthrodesis is solid enough and the development of the 
shoulder muscles complete enough to allow the definite discarding of 
the splint. Under these precautions, we have not seen any relaxation 
of the ankylosis nor any diminishing of the power of abduction on the 
part of the patient. 
A table follows which contains data on 17 cases operated by this 
method (Plates VI, 1-4; VII, 1-6; VIII, 1-7). 
A combination method of both mtra-articular suspension and muscle 
plasty is that given by Kiliani. He uses the long tendon of the biceps 
for fixation of the head in the glenoid cavity. In addition, he carries 
out a muscle plasty by supplanting the trapezius for the paralyzed del- 
toid. An incision is made nine inches in length over the anterior border 
of the deltoid. The capsule is exposed and severed horizontally at its 
insertion to the humerus, the incision reaching three-fourths over its 
circumference. The biceps tendon is not cut. Now the free upper 
border of the capsule is pulled down and sutured to the humerus at a 
line two and one half inches below, while the arm is held horizontally. 
Then the long tendon of the biceps is pulled forth through the sulcus 
intertubercularis, out of the capsule, and its surplus length is used to 
make a double loop which is sewed together. In this way, the biceps 
is made tight and, together with the tightened capsule, it draws the 
head of the humerus firmly against the glenoid cavity. He then pro- 
ceeds to the muscle plasty. The deltoid is dissected entirely from the 
clavicle and the acromion, so that its upper border is free. Then the 
insertion of the trapezius is severed from its corresponding attachments 
at the clavicle and at the acromion. Lastly, the free edges of the two 
muscles are united by interrupted catgut sutures, thus making one 
muscle. He reports that he obtains a moderate active abduction. 
There is also a considerable cosmetic effect as the subluxation of the 
humerus is corrected and the shoulder assumes the full contour of a 
normal shoulder. LEGEND FOR PLATE V 
TECHNIC OF ARTHRODESIS 
Fig. i.—Incision and Skin Flap. 
Fig. 2.—Osteotomy of Acromion with Deltoid Flap Turned Down; Capsule Opened, 
Showing Tendon of Long Head of Biceps. 
Fig 3.—The Placing of Wires through Denuded Head and Base of Acromion. 
Fig. 4.—Transverse Suture of Capsule; Wires Tied over It. PLATE V LEGEND FOR PLATE VI 
Fig. i.—J. B. Paralytic Flail Shoulder. 
Fig. 2.—J. B. After Arthrodesis of Shoulder. 
Fig. 3.—H. S. Paralytic Flail Shoulder and Wrist. 
Fig. 4.—H. S. After Arthrodesis of Shoulder and Wrist. PLATE VI LEGEND FOR PLATE VII 
Fig. i.—D. H. Paralytic Flail Right Shoulder. 
Fig. 2.—T. S. Paralytic Flail Right Shoulder after Arthrodesis. 
Fig. 3.—M. McG.—Paralytic Flail Shoulder, Wrist and Elbow. 
Fig. 4.—M. McG. After Arthrodesis of Shoulder, Elbow Plasty, Arthrodesis of 
Wrist, and Interosseous Transplantation of Flexors. 
Fig. 5.—M. C. Paralytic Flail Right Shoulder. 
Fig. 6.—M. C. After Arthrodesis of Shoulder. PLATE VII LEGEND FOR PLATE VIII 
Fig. i.—B. F. Paralytic Flail Left Shoulder, Elbow and Wrist. 
Fig. 2.—B. F. After Arthrodesis of Shoulder, Flexor Plasty of Elbow and Arthro- 
desis of Wrist. 
Fig. 3.—B. R. Paralytic Flail Shoulder and Elbow; Thenar Palsy. 
/ 
Figs. 4, 5.—B. R. Result of Thumb Plasty for Thenar Palsy. 
Fig. 6.—B. R. Result of Plasty of Elbow. 
Fig. 7.—B. R. Result of Arthrodesis of Shoulder and Plasty of Elbow. PLATE VIII 56 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Name 
Sex 
Age 
Dura- 
tion 
Since 
Oper- 
ation 
Side 
Active 
Abduc- 
tion 
Result 
Ankylosis 
J. B. 
M 
21 
8 
8 mo. 
R 
90 
good 
bony 
1 
H. S. 
M 
11 
8 
1 yr. 
L 
120 
good 
bony 
2 
H. F. 
F 
12 
6 
6 mo. 
R 
70 
good 
? 
3 
I. S. 
F 
27 
8 
10 mo. 
R 
90 
good 
bony 
4 
G. 0. 
F 
24 
17 
2 mo. 
R 
? 
undet. 
undet. 
5 
H. 
F 
i5 
8 
2 mo. 
R 
? 
undet. 
undet. 
6 
I. H. 
M 
IO 
3 mo. 
L 
? 
? 
? 
7 
T. 0 
M 
i4 
11 
8 mo. 
R 
100 
good 
bony 
8 
L. B. 
M 
16 
10 
1 yr. 
L 
85 
good 
bony 
9 
B. F. 
F 
12 
9 
i yr. 
L 
65 
good 
fibr. 
10 
H. T. 
F 
I I 
2 
10 mo. 
L 
100 
good 
bony 
11 
E. B. 
F 
9 
2 
3 yr- 
R 
60 
fair 
fibr. 
12 
B. R. 
F 
14 
9 
1 yr. 
R 
100 
good 
bony 
13 
V. M. 
F 
13 
4 yr. 
L 
50 
fair 
fibr. 
14 
B. R. 
F 
20 
1 
6 mo. 
L 
45 
poor 
fibr. 
15 
M. Me. 
M 
8 
4 
6 mo. 
L 
100 
good 
bony 
16 
M. C. 
M 
i5 
12 
1 yr. 
L 
45 
poor 
fibr. 
17 
Degree of Abduction 
120-1 
100-4 
good 
90-2 
85-1 
70-1 
- 65~! . 
> 10 
fair « 
60-11 2 
50-1 1 
poor 
4S~2 
2 
Total 
14 
Type of Ankylosis 
bony 8 
fibr. 5 
undet. 4 
i7 
THE FLAIL ELBOW 
The Interrelation between Shoulder and Elbow Movement.—What 
the ability of lifting the arm means to the function of the shoulder 
joint has been the subject of discussion in the previous chapter. Since 
this ability offers distinct advantages to the use of the elbow joint also, 
a few words may be in order regarding the functional relationship of 
these two joints. The removal of the elbow from the body side at 
once increases the sweep of motion for the forearm, the hand and 
the fingers., The weight of the extremity, in the position of abduc- 
tion, is borne largely from the shoulder joint. The forces of gravity 
interfere very little with the principal motion of the elbow, namely, PARALYSIS OF SHOULDER AND ELBOW 
57 
flexion and extension, and, also, pronation and supination, the strain 
of gravity being considerably lessened when the elbow is elevated. 
Under these mechanical advantages, the substitutionary motions which 
have been mentioned before come much more into their own, when, 
otherwise, they could not carry out their feeble functions against the 
odds of gravitative strain. Of the substitutional motions, the flexion 
of the elbow by the muscles of the forearm and the supination of the 
forearm by the extensors of the elbow may be mentioned. 
Muscle Dynamics of the Elbow.—The flexors of the elbow of the 
first order are: first, the biceps, which is a pure flexor when the fore- 
arm is held in supination; with the forearm in pronation, it is a second- 
ary flexor, the flexor action becoming effective only after supination 
has been completed. Second in importance as flexor of the elbow is 
the brachialis anticus. It is a more energetic flexor, displaying more 
power. Its fibers are short and numerous. The arrangement of the 
insertion of these muscles explains the corelationship existing between 
them. The biceps, having its insertion at a considerable distance from 
the axis of the joint, covers, per space unit of contraction, a shorter 
angular distance of the forearm, but represents a larger momentum 
of force. The brachialis anticus, having its insertion close to the center 
of motion, covers a greater angular distance of the forearm per unit 
of contraction but represents a lesser momentum of force. These 
muscles have the same corelationship to each other which is found in 
the action of biceps and inner hamstrings at the knee. 
The supinator longus is essentially a flexor of the elbow. In con- 
traction, it maintains for the forearm a position midway between pro- 
nation and supination. Flexors of the elbow of the second order, or 
auxiliary flexors, are: first, the pronator teres; up to full pronation, 
it acts as a flexor upon the elbow joint, but in extreme pronation 
again the flexor action of this muscle is practically nil; therefore, in 
order to bring out this flexor action, a midway position between pro- 
nation and supination must be chosen, such as the action of the supi- 
nator longus would represent. There is, therefore, in a sense, a certain 
synergism between the supinator longus and the pronator teres. In the 
same sense, there is also a synergism between the supinator longus 
and the biceps, since the former maintains the forearm in a position 
favorable to flexion action midway between pronation and supination, 
so that the biceps does not spend itself in supination and can therefore 
assert its flexion component. 
Another auxiliary flexor of the elbow is the flexor carpi radialis. 
This muscle which is primarily a flexor of the wrist becomes an aux- 
iliary flexor of the elbow as well as a pronator of the forearm when 
acting from a position of supination of the forearm and extension of 
the wrist. 
The palmaris longus is primarily a flexor of the wrist and, second- 
arily, to a very slight extent, a flexor of the elbow. 
A glance at the conditions of the origin of these muscles at the 58 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
elbow will show that this auxiliary flexor action can only be a very 
feeble one and that it can exert itself at all only when these muscles are 
at their physiological optimum, that is, a position midway between 
flexion and extension or a position of semiextension. But under cer- 
tain conditions, this secondary action of these muscles, although seem- 
ingly very insignificant, may be utilized so that they may act as sub- 
stitutionary flexors of the elbow when the primary flexors of this joint 
are unavailable. 
Pronation.—Pronators of the first order are: 
The Pronator Teres.—This muscle arises from the internal condyle of 
the humerus, and, by its deep head, from the lateral side of the coro- 
noid process of the ulna. It is inserted into the middle third of the 
outer border of the radius. 
The Pronator Quadratus.—This muscle arises from the lower fourth 
of the outer side of the ulna and runs transversely into the lower fourth 
of the anterior surface of the radius. It produces pure pronation and 
it is at its physiological optimum when the forearm is in extreme supi- 
nation. 
As auxiliary pronators act: first, the flexor carpi radialis, the action 
of which muscle has already been considered. There is also the supi- 
nator longus which maintains the forearm in mid position between 
pronation and supination. A further auxiliary pronator is the flexor 
carpi ulnaris, primarily a flexor of the wrist with a secondary action of 
pronation of the forearm and flexion of the elbow. Its pronation com- 
ponent is still weaker than its flexion component on the elbow but may 
become more prominent under certain conditions. 
Supination.—A supinator of the first order is the biceps. When 
the forearm is in pronation, this muscle is primarily a supinator and 
then a flexor of the elbow. When the forearm is in supination, the 
muscle is primarily a flexor of the elbow. The supinator brevis collab- 
orates with the biceps in the flexion of the elbow because it maintains 
the elbow in the supinated position in which the flexor action of the 
biceps becomes more effective. The supinator brevis arises from the 
external condyle of the humerus and from the lateral surface of the 
ulna and inserts into the outer border of the upper half of the radius 
immediately above the insertion of the pronator teres. This muscle is 
a true supinator in the same way as the pronator teres is a true pro- 
nator. A glance at the arrangement of pronators and supinators of 
the forearm reveals a peculiar situation. Both pronation and supina- 
tion are represented by two muscles, one a long muscle (pronator teres 
and biceps) and one a short one (pronator quadratus and supinator 
brevis). The long muscles combine with their pronatory and supi- 
natory action that of the flexion of the elbow. The meaning of this 
arrangement becomes clear if one considers that pronation and supina- 
tion is a movement which must be carried out at any point of flexion 
or extension of the elbow. Just as much as the supination of the fore- 
arm is favorable for the flexion of the elbow, so the flexed position of PARALYSIS OF SHOULDER AND ELBOW 
59 
the elbow is most favorable for the action of the supinator brevis. In 
this position, the biceps is already in a state of contraction, and its 
potential power as supinator is much lessened. It is, therefore, in this 
situation of flexion that the cooperation of the supinator brevis is 
especially advantageous. On the other hand, let us suppose that the 
arm is held in flexion and the necessity of pronating arises. The pro- 
nator teres will be found similarly shortened, as the biceps was in the 
former instance, and its potential power as pronator is similarly dimin- 
ished. It is, therefore, in this position of flexion of the elbow that the 
smaller muscles, namely, supinator brevis and pronator quadratus, come 
into the foreground in carrying out their respective functions of pro- 
nation and supination. 
This system of double muscle arrangement to carry out the same 
motion in the joint can be followed through the different joints of the 
body where action in two or three planes is centered in one joint, 
though one will hardly find it as beautifully demonstrated anywhere 
else as it is in the muscle arrangement of the elbow. 
The substitutionary motions for pronation and supination are not 
exhausted with the mechanisms just described. Rotation in the 
shoulder joint itself is also a factor in substituting pronation and supi- 
nation. This motion is carried out by the inward and outward rotators 
of the shoulder joint. As auxiliary supinators, there should also be 
mentioned the extensors of the thumb, namely, the extensors pollicis 
longus and brevis. 
The writer’s series of elbow paralysis embraces 42 cases. Distribu- 
tion of the paralysis: 
Cases 
Flail elbow alone 2 
Flail elbow plus flail shoulder 18 
Flail elbow plus paralysis of the hand 1 
Flail elbow plus paralysis of the hand and wrist, plus flail 
shoulder 21 
Total 42 
The distribution of the elbow paralysis was as follows: 
Cases 
Biceps, partial paralysis 15 
Total paralysis 24 
Total 39 
Triceps: Partial 15 
Total 17 
Total 32 
Brachialis Anticus: 
Partial paralysis 14 
Total 21 
Total 35 60 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Treatment.—The conservative treatment of the flail elbow follows 
the principles indicated in the discussion of the conservative treatment 
of the flail shoulder. Relaxation of the muscles involved is the first 
requisite. This can be done only by appropriate and constant splinting. 
When combined with paralysis of the shoulder, the splinting of the 
elbow is done most advantageously by a platform splint which not only 
provides for abduction position in the shoulder, but also for flexion 
in the elbow, and, for the forearm, a position midway between pro- 
nation and supination. 
The problem of operative treatment of the flail elbow offers many 
difficulties. There is no muscle material at hand to serve for tendon 
transplantation. Arthrodesis of the elbow, on the other hand, is diffi- 
cult, and very doubtful in younger individuals, and there seems to be 
no reliable method which could be applied to the juvenile and adolescent 
patient. 
Bartow and Plummer’s silk ligament suspension method has been 
applied to the elbow. It has the same disadvantage, already men- 
tioned for the shoulder, that it does not seem to accomplish a lasting 
fixation. Robert Jones advises the resection of a diamond-shaped piece 
of skin from the fold of the elbow and suturing of the edges in trans- 
verse direction. This procedure holds the elbow in a suitable position 
of flexion. 
For a number of years, the writer has attempted to cope with the 
situation by applying a method of muscle transposition which makes 
use of the auxiliary flexors of the elbow, namely, the flexors of the 
wrist and fingers. In order to increase the effectiveness of these 
muscles upon the elbow joint, a method of transposition was devised 
whereby their point of origin is carried upward to a point mechanically 
more favorable for the leverage of these muscles upon the elbow joint. 
The technic is as follows: An incision is made on the inner side of the 
humerus beginning three inches above the internal epicondyle between 
brachialis anticus and triceps muscles. This incision is carried down 
to the internal condyle and from there, in an obliquely downward and 
outward direction, over the anterior aspect of the forearm. After dis- 
section of fat and fascia, the ulnar nerve is first located behind the 
internal epicondyle and then drawn backward. Next, the insertion of 
the flexor muscles of the forearm at the internal epicondyle is care- 
fully dissected and the muscles are stripped off the bone in one mass. 
This mass comprises the superficial head of the pronator teres, the 
flexor carpi radialis and the palmaris longus. One may go as far as 
an inch or an inch and a half from the internal condyle downward 
in the dissection of the origin of these muscles. At this point one must 
stop, because here the nerve supply from the median nerve enters these 
muscles from below. It is possible, however, to mobilize this muscle 
mass sufficiently so that a muscle flap can now be lifted up and trans- 
planted upward two inches above the internal epicondyle into the 
intermuscular septum which divides the triceps muscle from the bra- PARALYSIS OF SHOULDER AND ELBOW 
61 
chialis anticus. In this dissection one should proceed with the greatest 
caution not only because of possible injury to the ulnar nerve, but also 
on account of the proximity of the brachial artery. The muscles having 
been safely anchored to the septum, the wound is now closed in layers 
and the arm is put up in flexion and in a position midway between 
pronation and supination. In some cases one may carry out a similar 
procedure on the outer side of the forearm using the supinator longus 
in the same way, and, by transplanting its origin higher up, increasing 
its leverage upon the elbow joint; but in as much as the supinator 
longus already acts as a flexor of the elbow joint, it will seldom be 
necessary to give it additional strength by transposing its point 
of origin. 
The position of flexion should be maintained for at least two months, 
but the cast may be removed after two or three weeks to be immedi- 
ately supplanted by an appropriate splint. The after treatment consists 
in active motion and massage carefully apportioned and constantly 
supervised so as to protect the muscles from strain and exhaustion. 
Under no circumstances must flexion of the elbow be allowed to 
decrease abruptly (Plate IX, i, 2). 
The one prerequisite which governs the indication of this operation 
is the integrity of the flexor muscles of the wrist and fingers. This is 
so stringent a condition that its neglect almost invariably leads to failure 
of the operative result. The flexor muscles of the forearm which are 
to be used as flexors of the elbow should not show any marked degree 
of paralysis or weakness if their transposition is to be accompanied 
by functional result. When these patients begin motion, it is noted 
very often that they can carry it out only with the fingers tightly closed 
and with the wrist hyperextended, in which position dynamic conditions 
are at their best regarding the forearm flexors. Even then one will 
notice that flexion of the elbow is very difficult at the beginning and 
requires considerable effort. As the muscles develop, however, the 
difficulty becomes less and in a majority of our cases we observed that 
a useful amount of active flexion of the elbow was attained. It is a 
matter of importance for the success of this secondary flexor action that 
the shoulder be capable of carrying out active abduction. With this, 
the elbow can be lifted to a horizontal position and the force of gravity 
will then not militate against the flexion power of the elbow. For 
this reason, the operation has proved most successful in cases in which 
there was either no paralysis of the shoulder or, as was true in the 
majority of cases, in which paralysis of the shoulder had previously or 
simultaneously been taken care of by arthrodesis. The operation of 
transposition of the forearm flexors was carried out in 15 cases (Plate 
X, 1-6; Plate XI, 1-6). LEGEND FOR PLATE IX 
TECHNIC OF ELBOW PLASTY 
Fig. i.—Stripping of Flexor Origin from Internal Condyle of Humerus. 
Fig. 2.—Transposition Upward and Insertion to Supracondyloid Ridge. PLATE IX LEGEND FOR PLATE X 
Fig. i.—L. B. Paralytic Flail Shoulder and Elbow; Result of Elbow Plasty. 
Fig. 2.—L. B. Result of Arthrodesis of Shoulder, Elbow Plasty and Arthrodesis 
of Wrist. 
Fig. 3.—V. M. Total Paralysis of Arm. 
Fig. 4.—V. M. Result of Arthrodesis of Wrist. 
Fig. 5.—V. M. Result of Arthrodesis of Shoulder, Muscle Plasty of Elbow and 
Arthrodesis of Wrist. 
Fig. 6.—V. M. X-ray of Arthrodesis Shoulder Showing Fusion. PLATE X LEGEND FOR PLATE XI 
Fig. i.—I. T. Paralytic Flail Shoulder and Elbow. 
Fig. 2.—I. T. Result of Elbow Plasty. 
Figs. 3, 4.—Technic of Elbow Plasty. 
Fig. 5.—E. M. Paralytic Flail Right Shoulder and Elbow. 
Fig. 6.—E. M. Result of Elbow Plasty and Arthrodesis of Shoulder. PLATE XI 68 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Table of Operations for Flail Elbow (Flexor Plasty) 
Case 
Sex 
Age 
Time of 
Para- 
lysis 
Time 
Since 
Operation 
Side 
Technic 
Function 
Result 
Remarks 
A. T. 
F 
n 
9 years 
i 
year 
Left 
Flexor 
Act. fl. 
Good 
Arthr. of shoulder 
plasty 
f 
Reason of failure: 
M. Me 
M 
5 
2 
3 
years 
Right 
do 
No act. fl. 
Poor ] 
extensive paraly- 
l 
sis hand and wrist 
B. F. 
F 
12 
9 
10 
mos. 
Left 
do 
Act. fl. F. 
Fair 
Arthr. of shoulder 
L. H. 
M 
8 
7 
i 
mo. 
Right 
do 
Undeter’m 
Und’d 
Died i month after 
oper. of influenza. 
S. S. 
M 
4 
2 
i 
year 
Left 
do 
Good 
Good 
E. N. 
F 
9 
2 
i 
year 
Right 
do 
Good act. Fl. 
Good 
Arthr. of shoulder 
D. B. 
M 
IO 
I 
3 
mos. 
Left 
do 
Act. fair 
Fair 
Arthr. of shoulder 
refused 
I. I. 
F 
8 
4 
2 
| mos. 
Right 
do 
Good act. 
Good 
Arthr. of shoulder 
refused 
M. S. 
F 
7 
5 
6 
mos. 
Left 
do 
Good act. 
Good 
r 
Arthr. of shoulder; 
B. R. 
F 
20 
2 
i 
year 
Left 
do 
F. poor 
Poor j 
cause of failure: 
l 
par. hand and wrist 
J. B. 
M 
21 
13 
6 
mos. 
Right 
do 
Act. good 
Good 
Arthr. of shoulder 
B. R. 
F 
14 
9 
2 
years 
Right 
do 
Good 
Good 
f 
Arthr. of shoulder; 
L. H. 
M 
6 
4 
mos. 
Right 
do 
No act. Fl. 
Poor j 
cause of failure: 
l 
par. hand and wrist 
T. G. 
M 
14 
ii 
6 
mos. 
Right 
do 
Good act. 
Good 
Arthr. of shoulder 
M. W. 
F 
6 
i 
i 
| mos. 
Right 
do 
Fair 
Fair 
Summary of 15 F. P. of the Elbow 
Results 
Good 8 
Fair 3 
Poor 3 Cause of failures: Paralysis of forearm flexors: 3 cases 
Undecided 1 
Total 15 
Secondary flexor plasty established fair function of elbow. 
BIBLIOGRAPHY 
Bartow, B. Shoulder and arm paralysis of poliomyelitis, New York Med. 
Journ., 1913, 97:910. 
Bartow, B. and Plummer, W. W. Further observations on the use of intra- 
articular silk ligaments in paralytic joints of poliomyelitis, Am. Journ. 
Orthop. Surg., May, 1913. 
Bowen and McKenzie. Applied anatomy and kinesiology; the mechanism of 
muscular movement. Lea and Febiger, Philadelphia and New York, 1919. 
Bucilholz, H. C. Arthrodesis of the shoulder joint, Am. Journ. Orthop. Surg., 
1918, vol. 16. 
Dionis du Sejour, P. Contribution a l’etude du traitement des epaules bal- 
lantes, Rev. de chir., 1919, 57:229. PARALYSIS OF SHOULDER AND ELBOW 
69 
Durner. Die Freilegung des Schultergelenkes in der Achselhoehle von der 
Riickseite her, Beitr. z. klin. Chir., 1911, 74:585. 
Gocht, H. Zur Kenntnis der Arthrodesenoperation am Schulter, Hiift und 
Kniegelenk, Beitr. z. klin. Chir., 1914, 92:768. 
Hildebrandt. Eine neue Methode der Muskeltransplantation, Arch. f. klin. 
Chir., 1903, 78: 75. 
Kiliani, O. G. T. Open operation for paralyzed shoulder due to infantile 
paralysis, Ann. of Surg., 1910, 51:79. 
Lovett and Martin. Vermont Medicine, February, 1916. 
Journ. Am. Med. Assoc., March 4, 1916. 
Meyer, A. Das paralytische Schultergelenk und seine Behandlung, Ztschr. f. 
orthop. Chir., 1916, 35:851. 
Poirier and Charpy. Traite d’anatomie humaine. Masson and Co., Paris, 
1904. 
Serafini, G. Artrodesi della spalla per paralisi scapolare di origine spinale, 
La Chir. degli organi di movimento, 1920, 4:1. 
Skillern, P. G. Paralysis of both trapezii, Ann. of Surg., 1917, 66:619. 
Steindler, A. Operative treatment of paralytic conditions of the upper ex- 
tremity, Ann. Journ. Orthop. Surg., 1919, 1:608. 
Vacchelli, S. L’artrodesi scapolo-omerale nella cura delle paralisi polio- 
mielitiche della spalla, La Chir. degli organi di movimento, 1920, 4:253. 
Vulpius, O. Treatment of infantile paralysis. Transl. J. J. Clark, W. Wood 
and Co., 1912. CHAPTER IV 
THE PARALYTIC HAND 
With the increased complexity of function, the muscle mechanical 
problems become more complicated and more difficult to handle. The 
analysis of the primitive motion of the hand must again precede the 
discussion of pathological conditions. The so-called primitive motions 
are in themselves complicated enough, but as the entire reconstruction 
work of the paralyzed hand is built up systematically upon the restitu- 
tion of certain primitive movements both operatively and educationally, 
it is from this angle that we believe the problem is best approached. 
The first of the primitive functions of the hand is the ability to close 
the fingers together and to relax them. A second is the forceps action 
of the thumb against the fingers, or of the fingers against the thumb. 
A third is the rotation of the hand in pronation and supination. A 
fourth is the flexion and extension movement of the wrist. 
Turning our attention to the position of the wrist as the foundation 
for a subsequent play of the thumb and fingers, we shall start with the 
physiological postulate, so well emphasized by Robert Jones, that the 
proper position of the wrist for functional use is that of dorsiflexion. It 
is generally recognized that the grip of the finger is at best with the 
wrist in dorsiflexion and that, on the other hand, palmar flexion of the 
wrist diminishes the gripping power of the fingers. When the wrist is 
in hyperextension, the tone of the flexor muscles of the fingers is such 
that the greatest amount of power can be displayed per unit of con- 
traction. As the wrist goes into position of flexion, the gripping power 
of the fingers greatly decreases owing to the loss of tension of the finger 
flexors. We have found experimentally that fully three-fourths of the 
potential contractile power of the fingers was exhausted by the time 
the wrist had moved from extension into full flexion. It is, therefore, 
necessary that a provision should be made to guarantee the hyperex- 
tension or dorsiflexion position for any hand, the function of which we 
aim to improve. It is equally essential that the wrist once placed in 
this position should be able to hold it rigidly. In other words, that 
there should be a firm stabilization of the wrist in this position of choice. 
From this point of view, we may anticipate that the normal wrist 
must be endowed with powerful extensors, so arranged that they 
will hold the balance against the flexor force in exactly this position 
of hyperextension. We know that any muscle of the body exerts its 
functions in two components. One acting vertically upon the lever 
arm moves the joint; the other, parallel to the axis of the lever, stab- THE PARALYTIC HAND 
71 
ilizes the joint. The rotating component oi the muscle and its stabiliz- 
ing component always maintain a certain mathematical relationship 
which can be expressed by the sine of the angle between the longi- 
tudinal axis of the muscles and the longitudinal axis of the part moved, 
that is, the angle of insertion. In other words, the smaller this angle, 
the greater is the stabilizing and the smaller the rotating component 
of this muscle, and vice versa. Applying these considerations to the 
muscles attached to the wrist, we find them so arranged that there is 
a numerical as well as dynamic preponderance of the extensors of the 
wrist over the flexors. According to Frohse and Frankel, the respective 
dynamic values of the extensors of the wrist and of the flexors are as 
2 to i ; that is, the sum total of the combined power of the extensors is 
twice as great as that of the flexors. 
What is the meaning of this arrangement? Hyperextension means 
contraction of the extensors and passive tension of the flexors. Con- 
traction decreases the potential power while, to a certain point, tension 
increases it. In this play between flexors and extensors of the wrist, 
there must be, then, a point in which the decreased potential power 
of the contracted extensors equals the increased power of the distended 
flexors, and at this point, there is complete equilibrium between the 
dynamic forces of the flexor muscles and the dynamic forces of 
the extensor muscles of the wrist. Owing to the preponderance of the 
extensors over the flexors, we must expect this point to be reached 
in a position of hyperextension of the wrist. 
Theoretically, this hyperextension might, in a paralyzed hand, be 
procured in two ways. The one expedient is that of supplying the 
paralyzed or weakened extensors with necessary muscle power from the 
flexor group by means of tendon transference. In the case of a 
flail hand, the first question to be decided in this connection will be 
whether or not there is enough muscle material available for such trans- 
plantation; and, if available, if it will be sufficient not only to secure 
the desired position but also to maintain it with a considerable degree 
of stability? In the case of infantile paralysis of the hand, it may be 
said without restriction that the instances wherein such muscle material 
is available are extremely few and, therefore, that the problem of pro- 
curing the extensible wrist by muscle transplantation will usually col- 
lapse in itself for the lack of sufficient material. 
The only other alternative is the stabilization of the wrist by arthro- 
desis. If the wrist is so stabilized, it is given a position which it will 
not only be able to maintain but maintain also against considerable resist- 
ance, and reliably enough to serve all practical purposes of finger 
motion. The only question arising is to what extent is the hand inca- 
pacitated by being unable to carry out flexion and extension motion as 
it would be in the case of arthodesis? Observation leads us to believe 
that the disability of the hand incurred by the loss of active flexion- 
extension power in the wrist is comparatively slight. With the excep- 
tion of special occupations in which free wrist motion is essential, we 72 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
find that the arthrodesed wrist is suitable for most of the ordinary occu- 
pations in life especially if at least part of the pronation and supination 
power of the forearm is preserved. 
A second elementary motion is that of closure of the fingers and 
their release. This motion depends first upon a free action in the meta- 
carpophalangeal joints. Dorsal retraction of the fingers in this joint is 
a great obstacle, as it makes the contact between fingers and thumb 
very difficult. The balance between flexors and extensors of the fingers 
is so measured, however, that flexion of the wrist in itself is a factor 
contributory to hyperextension in the metacarpophalangeal joints by 
virtue of the passive tension brought about upon the extensor muscles 
of the fingers. It is one of the agencies of claw-hand formation seen 
in paralytic conditions as well as in ischemic and other contractures of 
the fingers. The loss of proper use of the finger flexors involves impair- 
ment of the intrinsic muscles of the hand, namely, the interossei and 
the lumbricales. These muscles are direct antagonists of the extensors 
of the fingers. Their primary function is the flexion of the metacarpo- 
phalangeal joint, and they also extend the mid and end phalangeal joints 
of the fingers. A hand deprived of the use of the lumbricales and 
interossei would find itself in a position of having to balance the exten- 
sors of the fingers against the long flexors of the fingers alone. But 
the long finger flexors, we know, have very little purchase upon the 
metacarpophalangeal joints. They flex the mid phalangeal joints 
(superficial flexors) and the end phalangeal joints (deep flexors). With 
these latter joints flexed, the action of the extensors will come princi- 
pally upon the metacarpophalangeal joints forcing these into a position 
of hyperextension. So it becomes evident that the flexion of the wrist 
is, directly and indirectly, an important agency in bringing about this 
claw-hand contracture in the metacarpophalangeal joints. 
But with the wrist in extension or hyperextension, the conditions 
are entirely different. The extensor tendons are relaxed and their 
strain upon the metacarpophalangeal joints is considerably lessened. 
On the other hand, the long flexors of the fingers being extended are 
in a state of increased tension and increased potential power, which 
gives them not only greater force of flexing the mid and end phalangeal 
joints, but procures also a much more advantageous condition for the 
action of interossei and lumbricales. In this manner we again find in 
the hyperextension position of the wrist an agency which counteracts 
the tendency of claw-hand formation, just as we could recognize in the 
hyperflexion of the wrist an agency favoring claw-hand contracture. THE PARALYTIC HAND 
73 
THE PREHENSILE FUNCTION OF THE HAND; THE 
APPROXIMATION OF THE FINGERS TO THE THUMB 
Muscle Dynamics of the Thumb.—The action of the flexor pollicis 
longus is greatly influenced by the fact that there is a deflection of its 
tendon at the point of its contact with the trapezium. This latter bone 
projects into the course of the tendon acting as a fulcrum over which 
the tendon deflects obliquely outward until it reaches the end phalanx 
of the thumb. This arrangement greatly increases the power of this 
muscle. The short flexor muscles of the thumb dominate flexion of 
the first phalangeal joint; the long flexor of the thumb controls mainly 
the flexion of the end phalanx. This is an arrangement similar to that 
seen in the fingers, where the superficial flexors control flexion in the 
mid phalangeal joints, while the deep flexors control that of the end 
phalangeal joints. Between the action of the short and long flexors 
of the thumb and the extensors, there exists a peculiar relationship. 
If flexion of the basal phalanx is accompanied by flexion of end phalanx 
(long flexor action), then the carpometacarpal joint of the thumb goes 
into extension; if, however, flexion of the basal phalanx is accompanied 
by extension of the end phalanx, then the carpometacarpal joint goes 
into flexion (short flexor action). In the first case, the short flexor 
is checked by the extensors of the thumb and the motion is dominated 
by the long flexor; in the second case, the long flexor is checked by 
the long extensor of the thumb and motion is dominated by the short 
flexor and other thenar muscles. This fact is of prime importance for 
a substitutionary motion of opposing the thumb when the action of the 
opponens pollicis has been lost. In this case, the short flexors will 
flex the metacarpophalangeal joint; the end phalanx is held extended 
and the thumb crosses the palm. 
In paralytic conditions, the instances in which opposition of the 
thumb to the fingers is lacking are quite numerous. The mechanism 
which normally opposes the thumb to the finger is rather a complicated 
one. Practically all muscles of the thenar take part in it, the short 
abductor of the thumb as well as the short flexor initiating the move- 
ment. Then the opponens of the thumb itself acts, and finally the 
motion is concluded by action of the adductor. Substitution for the 
lost opponens of the thumb, on the other hand, is rather difficult. It 
is possible for the patient to oppose the thumb by contraction of the 
adductor, so that objects may be held between thumb and index finger, 
but this movement is forced and laborious and only inadequately sub- 
stitutes for the natural attitude of opposition. When the other muscles 
of the thenar are also involved, then we find the thumb placed hope- 
lessly in a position of adduction in which it maintains the same plane 
with the palm of the hand and cannot, therefore, be used in the forceps 
action so essential for the play of the fingers. While this is a distinct 74 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
loss for the function of the hand, it may be met to a large measure by 
operative methods. 
To a certain extent, the plastic methods of thumb reconstruction 
have advanced to a degree where considerable hope may be placed 
upon rebuilding this function by these methods. A proper space will 
be given to discussion and description of such methods. 
In spastic paralysis one is often confronted with another disability 
arising from a flexion and opposition spasm. In these instances, motion 
of the thumb against the fingers and across the palm is carried out 
with such force and rapidity that in closing the fingers the thumb 
becomes caught under them. While there is no inability of opposition, 
the latter movement cannot properly be timed and coordinated, so that 
the tip of the thumb will not meet with the tip of the fingers. This also 
constitutes a considerable handicap for the function of the hand (see 
Chapter VI). 
An instance of subtitutionary motion for the loss of interossei can 
be found in the action of the extensors of the fingers. These muscles 
are able to abduct the fingers from the midline, thereby substituting 
for the action of the dorsal interossei. When one examines a hand 
for ulnar paralysis, this point must be kept in mind. In this instance, 
the only true and reliable index will be the inability of the fifth finger 
to become abducted from the midline, since this motion is carried out 
by the abductor of the fifth finger entirely which is supplied by the 
ulnar nerve. 
Flexion of the fingers can also be brought about passively by exten- 
sion of the wrist. This mechanically stretches the flexor muscles and 
produces a passive pull upon the tendons of the long flexors of the 
fingers. In paralysis, this mechanism is widely used, and the patients 
who have no active power of the long flexors of the fingers will bring 
the wrist in the position of hyperextension in which the middle and 
end phalangeal joints will become flexed without any active contraction 
of the flexor muscles. On the other hand, substitutes can be used for 
extension of the fingers, as is seen often in cases of musculospiral 
paralysis. Here it is the acute flexion of the wrist which brings about 
the tension of the extensor tendons in a similar manner and this tension 
produces a passive extension of the fingers. 
Finally, lateral motion of the fingers, which is a function of the 
interossei, can, in the case of the loss of these muscles, be brought about 
by the combined action of the extensors with the flexors of the finger. 
This motion is naturally much weaker than the original abductory 
and adductory action of the interossei. But it might on examination 
be confusing enough to misrepresent the true condition of the inter- 
ossei. The loss of the interossei action can easily be detected if one 
causes the patient to attempt abduction of his fingers when the mid 
phalangeal joints are flexed. In this position, the extensor actions will 
not come into play, and abduction and adduction can be carried out 
by interossei only. THE PARALYTIC HAND 
75 
Among the 70 cases of infantile paralysis observed in the upper 
extremity, the distribution of the paralysis in the hand was as follows: 
Cases 
Involvement of hand and wrist 36 
Involvement of hand alone 4 
Involvement of hand and elbow 2 
Involvement of hand and shoulder 3 
Involvement of hand, shoulder and elbow 25 
Total 70 
Distribution of Paralysis by Muscle Groups 
{Investigation of 37 Cases) Cases 
Flexors of wrist and fingers 2 
Extensors of wrist 1 
Extensors of wrist and fingers 16 
Extensors of wrist and fingers and thenar flexors 1 
Thenar muscles 6 
Extensors of wrist and fingers plus thenar muscles 1 
Flexors of wrist and fingers plus extensors of fingers 3 
Extensors of fingers plus flexors of wrist 1 
Extensors of wrist and fingers plus flexors of wrist and fingers 4 
Total paralysis of the hand 1 
Isolated paralysis of radial flexor of the wrist 1 
Total 37 
Distribution of Paralysis of tiie Hand in Poliomyelitis 
Distribution of Paralysis by Individual Muscles 
(.Investigation of j6 Cases) 
Total 
Partial 
Sum 
Flexor carpi radialis 
11 
14 
25 
Flexor carpi ulnaris 
7 
13 
20 
Flexor pollicis longus 
6 
16 
22 
Flexor digitorum profundus 
3 
17 
20 
Extensor pollicis longus 
IO 
14 
24 
Abductor pollicis longus r 
16 
8 
24 
Extensor digitorum communis 
13 
16 
29 
Extensor pollicis brevis 
18 
9 
27 
Extensor carpi ulnaris 
J3 
7 
20 
Extensor carpi radialis 
14 
8 
22 
Interossei 
13 
9 
22 
Thenar muscles 
14 
14 
Sum total of muscles paralyzed 
138 
131 
269 76 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Cases 
Flail hand 
8 
Drop hand 
17 
Contracted hand or claw-hand 
4 
Total 
36 
Distribution of Deformities 
As may be seen in this table of individual muscle distribution of 
the paralysis, there is a preponderance of the total paralysis over the 
partial paralysis in the extensor group and a preponderance of the par- 
tial paralysis over the total paralysis in the flexor group of the wrist 
and fingers. 
The Paralytic Drop-hand.—The most frequent problem to be dealt 
with in spinal paralysis of the hand is that of paralytic drop-hand 
deformity due to paralysis of the extensors alone or to the preponder- 
ating paralysis of the extensors over that of the flexors. This prepon- 
derance of the extensor paralysis over the flexors, as encountered in old 
cases of infantile paralysis of the hand, is not merely the expression of 
the original distribution of the poliomyelitis, but also represents the 
subsequent damage to the muscles occurring in the chronic stage of 
paralysis which is brought about by the passive stretching of partially 
weakened extensor muscles. In this respect, the situation is entirely 
at par with that commonly observed in the extensor muscles of the foot. 
Here we know that the enormous preponderance of the extensor 
paralysis is partly due to a secondary loss of muscle power occurring 
during the chronic stage of the disease when the proper support or 
protection of the weakened extensor muscles has been neglected. 
The most immediate requirement in the treatment of the drop-hand 
following poliomyelitis, as well as any other type of paralysis, is the 
preservation of the weakened extensor muscles by proper splinting. 
The hand must be splinted immediately and must be held in a hyper- 
extended position. This is best done by a cockup splint (Robert Jones) 
reaching over the wrist to the first interphalangeal joint. It is not 
necessary to run a splint to the end of the fingers and beyond because 
the extensor muscles have little to do with the extension of the end 
and mid phalangeal joints. On the other hand, this position would be 
very conducive to producing a hyperextension in the metacarpopha- 
langeal joints which, as will be seen later, is very hard to overcome and 
is very disabling in effect. It is very gratifying to see recent cases of 
infantile paralysis regain power in the extensor muscles, both of the 
wrist and of the fingers, under early and properly continued splinting 
in this position. Results are greatly enhanced by timely massage and 
active movements of the fingers. Massage may properly begin as soon 
as the tenderness has subsided and active motion should follow closely. 
The latter, however, should be very carefully supervised and should 
begin very insidiously, and great restrictions should be placed upon the THE PARALYTIC HAND 
77 
time of treatment as well as its frequency because of the danger of 
exhausting the extensor muscles. Under this treatment we have seen 
motion return in the extensors of the wrist and fingers a considerable 
time after the onset of the paralysis. It is safe to say that one year 
should be the minimum time for such conservative attempts to restore 
motion. However, one should not be guided by the amount of time 
elapsed alone but also by the clinical symptoms such as shrinkage, 
atrophy, and especially the electrical reactions. 
When a residual drop-hand paralysis has been definitely established, 
the problem of dealing with the disabled hand becomes largely a sur- 
gical one. For the restoration of the lost function, two possibilities 
are open. The first is the transplantation of muscles to the back of 
the hand and wrist to substitute for the lost extensors. We believe 
that in infantile paralysis there are only exceptional cases which will 
lend themselves to the treatment by transplantation methods alone, 
because the muscle material available for transplantation is in most 
cases not sufficient to take care of extension of the wrist as well as 
that of the fingers. For this majority of cases, the other alternative 
must be considered, namely, the arthrodesis of the wrist joint; although 
no function is imparted to the wrist by arthrodesis, it is an excellent 
means of restoring the wrist to a high degree of stability in a desired 
position. In the writer’s opinion, the stability of the wrist is so indis- 
pensable a requirement for the function of the fingers that no thought 
of any operative method should be entertained which does not fully 
guarantee a stable wrist, and this stability in proper position must be 
procured first. The arthrodesis which meets these requirements also 
makes available for transplantation use the flexor muscles of the wrist; 
these may then be carried upon the dorsum of the hand and used to 
procure active extension of the fingers. 
The Technic or Arthrodesis of the Wrist.—An incision is made on 
the dorsum of the wrist between the tendons of the extensor indicis 
proprius and that of the long extensor of the thumb. After division 
of the fascia, the ligamentum carpi dorsale is divided. One now pro- 
ceeds between the compartments of the long extensor of the thumb and 
that of the extensor of the index finger, drawing these muscles to the 
side. By stripping off the ligamentous apparatus as well as the capsule 
from the bones of the wrist, the lower end of the radius is exposed as 
well as the scaphoid and the os lunatum. From these bones a wedge 
is taken out with the osteotome. This wedge has a dorsal base and 
its slant is so calculated as to bring about complete adaptation of the 
raw bone surfaces in a position of hyperextension of 250 or 30°. 
This position is further secured by passing heavy sutures of chromic 
gut through drill holes in the bone or through the periosteum and by 
tying the sutures with the hand in hyperextension. The wound is 
now closed in layers and a plaster cast is applied reaching from the 
palm of the hand to midway between elbow and shoulder. Active 
motion of the fingers is begun in the cast within a week, or as soon 78 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
as the tenderness has disappeared. After a period of two months, the 
cast is removed and supplanted by a cockup splint. This latter is never 
removed except for treatment and it should remain for an additional 
three or four months, making the entire period of fixation about six 
months. There is not much danger from the adhesions of the extensor 
tendons if active motion is carried out early. We find that opening 
and closing the finger is not interfered with by arthrodesis (Plate XII, 
1-4). 
Regarding the proper time for the operation, it may be stated that 
it can be performed successfully at the age of eight years or even 
sooner. In younger children, the arthrodesis is naturally not complete, 
and passive extension beyond the position at operation is often pos- 
sible to some slight degree. In none of the cases, however, was there 
a relapse into the flexion position after a point had been made of main- 
taining carefully the initial position of hyperextension in the cast and 
letting the latter remain for a sufficient length of time. Older children 
show, regularly, good bony fusion and a very stable wrist with no 
motion. 
Reviewing the operative methods so far mentioned for the recon- 
struction of flail arm and hand, the situation may be briefly summed 
up in the following manner: The arthrodesis of the shoulder, provid- 
ing for the arm a wide circle of motion and freeing it from its close 
adherence to the body line, is the keystone to the rehabilitation of the 
flail upper extremity and with it of the flail hand. It elevates the 
extremity to the horizontal plane wherein the member can be brought 
closer to the eye and the movements better controlled by vision. It also 
lifts the extremity out of the line of direct pull from its own weight. 
The strain of weight of the forearm rests upon the hinged joint of 
the elbow. By imparting motion to the elbow by means of the muscle 
plasty already described, control is given of the back and forward 
movement of the forearm, though this is done only with a limited degree 
of power. The pronation and supination movement, if it cannot be 
obtained by direct muscle action, may yet be supplanted by substitu- 
tionary motion of the shoulder-blade. In this respect, the alternating 
action of the trapezius, the pectoralis major on one side, and the rhom- 
boid muscles and the latissimus dorsi on the other side, are especially 
valuable. The development of this substitutionary rotatory motion is 
of high importance in the after treatment of the paralytic extremity. 
The arthrodesis of the wrist finally provides that stability to the 
wrist and hand which is so essential for the play of the fingers. Upon 
the basis of this stabilizing operation, tendon transplantation may be 
carried out with much better promise of functional improvement than 
would be likely without the arthrodesis of the shoulder and wrist joint. 
Even in cases of total paralysis of the entire extremity, the possibility 
of giving some limited use to the arm by arthrodesis should be kept 
in mind. Several of these cases have been seen by the writer in which 
there was not a single muscle of the extremity preserved except some of THE PARALYTIC HAND 
79 
the scapulothoracic muscles. By carrying out arthrodesis in the three 
principal joints of the extremity, it is possible in some cases to create 
a condition in which at least as much function could be obtained as 
in instances of forearm amputations, when a suitable prothesis is being 
worn. In such a case, the motion of the extremity can be guided by 
the motion of the shoulder girdle, and the arm can be used similarly 
to a forearm stump or wrist stump and be made suitable for a number 
of simple operations. Some patients entertain the idea of amputation 
of their apparently entirely useless limb, but considering that one might 
procure a very stable arm with all joints in suitable position, a good 
deal may be gained by following this course. 
Arthrodesis of Wrist in Infantile Paralysis 
Name 
Sex 
Age 
Dur. 
Par. 
P. 0. 
Observ. 
Condition 
Operation 
Result 
Additional 
Operations 
J.B. 
M 
21 yrs. 
8 yrs. 
8 mos. 
flail wrist 
arth. of wrist 
good 
plasty elbow 
arth. of shoul- 
der 
H. S. 
M 
21 yrs. 
8 yrs. 
8 mos. 
flail wrist 
arth. of wrist 
good 
arth. of shoul- 
der 
V. N. 
F 
13 yrs. 
10 yrs. 
2 yrs. 
par. drop wrist 
arth. of wrist 
good 
plasty elbow 
and thumb 
L. B. 
M 
16 yrs. 
10 yrs. 
1 year 
flail wrist 
arth. of wrist 
good 
plasty elbow 
arth. of shoul- 
der 
B. F. 
F 
12 yrs. 
9 yrs. 
10 mos. 
flail hand 
tendon trans. 
of wrist 
poor 
P. IC. 
M 
9 yrs. 
7 yrs. 
4 mos. 
flail wrist 
arth. of wrist 
good 
T. G. 
M 
14 yrs. 
7 yrs. 
4 mos. 
flail wrist 
arth. of wrist 
good 
flexor plasty 
elbow 
H. G. 
M 
8 yrs. 
? 
par. flail hand 
arth. of wrist 
und’d 
arth. of shoul- 
der 
Types 
Number of 
Cases 
Results 
Number of 
Cases 
Arthrodesis alone 
2 
good 
6 
Arthrodesis of wrist combined 
poor 
i 
with arthrodesis of shoulder. . . 
2 
undetermined 
i 
Arthrodesis of shoulder plus 
elbow plasty 
4 
8 
Total 
8 
OPERATIONS 
(Plate XIII, 1-4). 
Tendon Transplantation.—Tendon transplantation has a wide field 
in the reconstruction work of the paralytic hand, especially in the reha- 
bilitation of the fingers. It has already been pointed out that motion 
may be imparted to the fingers directly from the muscles of the wrist LEGEND FOR PLATE XII 
TECHNIC OF ARTHRODESIS OF WRIST 
Fig. i.—Incision and Exposure. 
Fig. 2.—Dissection of Radius and Carpal Bones; Lines of Osteotomy. 
Fig. 3.—Removal of Bone Wedge; Placing of Wires. 
Fig. 4.—Tying of Wire Sutures; Closure. PLATE XII LEGEND FOR PLATE XIII 
Fig. i.—L. D. Paralytic Flail Wrist; Result of Arthrodesis. 
Fig. 2.—T. G. Paralytic Flail Wrist; Result of Arthrodesis. 
Fig. 3.—E. S. Paralytic Flail Wrist. 
Fig. 4.—E. S. Result of Arthrodesis. PLATE XIII 84 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
both from the flexors of the wrist and the extensors. Successful tendon 
transplantation generally presupposes a safe amount of available muscle 
material which is to be redistributed about the joint in such a manner 
as to procure not only motion but a satisfactory degree of muscle equi- 
librium as well. In the paralytic hand, the paralysis is rarely limited 
to the extensors alone and, even if so, the problem cannot readily be 
solved by tendon transplantation without arthrodesis. For instance, if 
we aim at independent extensor action of wrist and fingers, there would 
be required for transplantation at least four muscles to be taken from 
the flexor group; in infantile paralysis of the hand, these four muscles 
are rarely available. It is here where the arthrodesis of the wrist fur- 
nishes an excellent basis upon which further transplantation could be 
carried out with satisfactory results. All the flexors of the wrist become 
at once available for transplantation use. 
Tendon Transplantation of the Flexor Carpi Ulnaris to the Extensors 
of the Fingers and of the Flexor Carpi Radialis to the Extensors of the 
Thumb.—An incision is made on the radial side of the flexor carpi ulnaris 
from the wrist halfway up the forearm. The flexor carpi ulnaris is dis- 
sected and isolated up to its insertion into the pisiform bone. The ulnar 
nerve and artery, lying under this tendon, are carefully dissected and 
retracted outward. The entire tendon of the muscle is then isolated and 
severed at its insertion into the pisiform bone. By retracting the flexor 
muscles of the fingers to the radial side, one then proceeds into the depth 
until the interosseous membrane is reached. The fibers of this mem- 
brane run obliquely from the ulna down to the radius. At a suitable 
distance above the upper border of the pronator quadratus, this mem- 
brane is perforated by a blunt instrument which is pushed forward on 
to the dorsal surface of the forearm in a direction corresponding to the 
line from the inner condyle of the humerus to the middle of the dorsal 
surface of the wrist. A dorsal incision is then made which exposes the 
extensor tendons of the fingers. The flexor carpi ulnaris is led through 
this incision and fastened side to side to the finger extenso'rs. To this 
end, it is advisable to split the tendon into two halves, applying each 
half to the two inner and the two outer individual tendons of the common 
extensor of the fingers, respectively. The suture is carried out at a 
moderate tension of both the ulnaris tendon and the extensor tendons, 
and the extension position of the fingers is secured. The wound is then 
closed in layers. In six cases so operated, we have found no essential 
difficulty in the technic, the only point of importance being that, in 
isolating the ulnar artery with the nerve, it is necessary to retract it 
radialward so that it will lie between the flexor ulnaris and the common 
flexors of the fingers. When this detail is neglected, the ulnar artery 
will lie between the transplanted tendon and the ulna, and we occa- 
sionally found considerable circulatory disturbances immediately after 
operation caused by the impingement of the artery against the radial 
border of the ulna. This, however, never assumed a very serious degree 
and circulation was soon reestablished. Active motion is begun as soon THE PARALYTIC HAND 
85 
as the condition of the wound permits, that is, from a few days to a 
week after the operation. From the viewpoint of innervation, there 
seems to be no difficulty in bringing about extensor action of the flexor 
carpi ulnaris. This is possibly due to the fact that this muscle normally 
contracts in forced extension of the fingers against resistance, because 
it is then used as a stabilizer of the wrist joint and therefore is, in a 
way, always in cerebral association with the motion of the extensors 
of the finger. In some cases, active extension of the fingers could be 
carried out distinctly within a week after operation. One should warn 
the patient, however, against overexertion. 
When the flexor carpi radialis is used, it can be brought readily 
around the radial border of the radius to the dorsal surface of the thumb 
after it has been severed close to its insertion. This muscle will then 
maintain a practically straight course from its insertion to the dorsal 
surface of the radial metacarpal, and it can be brought out at the dor- 
sum of the hand and fastened to the long extensor of the thumb by 
a short dorsal incision. 
In the 6 cases in which transplantation of the flexor carpi ulnaris 
has been carried out, 5 concerned patients with poliomyelitic drop- 
hands. Of these the interosseous route for the flexor carpi ulnaris has 
been used in 3 cases, while in 2 cases the transplanted muscles were 
carried around the ulna and radius, respectively. The results were as 
follows: good or fair extension of the fingers was obtained in 3 cases; 
doubtful extension of the fingers in 1 case; and no extension of the 
fingers in 1 case. 
There are some rare instances of extension contracture of the hand 
in poliomyelitic paralysis. These cases offer possibilities for tendon 
transplantation. The best result was obtained in a case in which trans- 
plantation of the extensors of the wrist to the flexors of the finger was 
carried out, supplemented by an arthrodesis of the wrist. The flexor 
motion of the fingers was rather weak at first but improved considerably 
under long-continued muscle educational treatment. 
Thenar Paralysis.—The paralysis of the thenar muscles incapacitates 
the hand to a considerable degree. Even the more primitive motions 
of the hand depend upon opposition movement of the thumb, which 
is one of the principal functions of thenar muscles. To some extent, 
failure of opposition may be compensated by substitutionary motion, 
as has been stated previously. The lack of the abductor and short 
flexor muscles may be compensated partly by the action of the adductor 
of the thumb together with the long flexor. These muscles are not 
only capable of pressing the thumb toward the radial side of the index 
finger, making the hand capable of holding objects between these two 
fingers, but a sort of opposition of the thumb is also possible to a smaller 
degree. This will be accomplished better if the short flexor of the 
thumb is also working. In this event, flexion in the metacarpophalangeal 
joint can be carried out which, together with the adduction motion of 
the adductor of the thumb, will cause the thumb to cross the palm and LEGEND FOR PLATE XIV 
TECHNIC OF FLEXOR PLASTY OF THUMB 
Fig. i.—Splitting of the Tendon of the Flexor Longus Pollicis. 
Fig. 2.—Periosteal Suture of Outer Half of Tendon to Base of Basal Phalanx. PLATE XIV 88 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
place itself near the base of the little finger. But, in most cases, the 
involvement of the muscles of the thenar is too extensive to make this 
substitutionary motion possible. 
A simple method which will produce a motion of the thumb akin 
to that of the opponens pollicis, although as a rule not as forcible and 
not as complete, is the following: 
An incision is made on the volar side of the thumb from the middle 
of the end phalanx downward to the middle of the thenar lying over, 
or better, slightly to the side of, the long flexor of the thumb. When 
making this incision, one should be careful not to carry it down too 
far so as not to interfere with the innervation by the thenar branches 
of the median nerve of such muscles of the thumb as might have escaped 
paralysis. The median nerve sends off its branches for the innervation 
of the opponens, abductor, and radial half of the short flexor of the 
thumb, at a point lying in the proximal half of the thenar eminence. 
After the long flexor muscle of the thumb is exposed, its sheath 
is incised and the edges of it are held by fine forceps. Then the tendon 
is lifted out of its sheath and split longitudinally in two halves. The 
outer or radial half of the tendon is severed at its distal end, deflected 
upward, and the sheath of the long flexor is then reunited over the 
remaining ulnar half. Then the free radial half of the tendon is carried 
through a tunnel made in the soft parts, around the outer side of the 
metatarsal of the thumb to a point at the base of the basal phalanx well 
upon the dorsal surface. A short incision is made at this point. The 
tendon is drawn through, the periosteum of the basal phalanx exposed, 
and the tendon is sutured to the periosteum as dorsally as possible and 
close to the base of the basal phalanx. Then the wounds are closed. 
This simple procedure procures a secondary attachment to the long 
flexor of the thumb. When this muscle contracts, this attachment will 
cause the thumb to swing in a circle over the trapezium as a pivot, 
and this motion will bring the end of the thumb in opposition to the 
little finger to a degree sufficient for most of the ordinary motions of 
the thumb. This procedure was carried out in 9 cases, 5 of which were 
cases of infantile paralysis. Only in 1 case was the result doubtful. In 
the other 4, a satisfactory degree of opposition was obtained. By a care- 
ful muscle educational after treatment, the power of opposition can be 
developed to a considerable degree (Plate XIV, 1, 2). 
Traumatic Paralysis.—Paralysis following injury of the peripheral 
nerves has come very much into the foreground due to the wide and 
extensive experiences which were amassed in the surgery of the recent 
war. The last few years have been productive of a great number of 
valuable contributions. In as much as they concern neurological or 
neurosurgical problems, it is not the intention of the writer to expatiate 
upon them in this treatise strictly devoted to orthopedic problems. 
However, there is no escape from the fact that many of the instances 
of peripheral paralysis from nerve lesions ultimately lead to distinctly 
orthopedic conditions and call for orthopedic measures of relief. THE PARALYTIC HAND 
89 
Excellent contributions in regard to the pathology and the treatment 
of peripheral nerve lesions as such have been made. The work of Tinel 
and others may serve as a source of reference for any of the patho- 
logical and clinical features presenting themselves in this type of 
neurological lesions. In the last analysis, the outcome of peripheral 
nerve lesions is based upon the question whether there is a complete 
or a partial interruption of the nerve. In cases of peripheral paralysis 
resulting in complete degeneration, both the faradic and galvanic cur- 
rent give evidence of what is known as reaction of degeneration. The 
typical feature of the latter is the inexcitability of the nerve to the 
faradic and galvanic currents, the inexcitability of the muscle to the 
faradic current, and the hyperexcitability of the muscle to the galvanic 
current at its motor point, with polar inversion and slow contraction. 
It seems that this slow contraction is of the greatest importance, as it 
is sufficient to characterize reaction of degeneration even without a 
distinct degree of hyperexcitability and without polar inversion. 
On the other hand, the returning regeneration of the nerve following 
complete or partial interruption ushers in symptoms in exactly the 
opposite order. Galvanic hyperexcitability diminishes, polar inversion 
becomes polar equality, finally returning to normal form. There is an 
acceleration of the slow contraction. Then follows a reappearance of 
the faradic sensibility and faradic contraction and finally the normal 
excitability of the nerve returns. It is the merit of later investigators, 
especially Tinel, to have pointed out the difference between the syn- 
dromes of complete and those of partial interruption. In the latter 
instances, there is a reaction of partial degeneration. There may be a 
hvpo-excitability of the nerves and muscles to the faradic current. There 
may be a hyperexcitability of the muscles to the galvanic current and 
total inexcitability of the nerves. There may be only one factor lacking 
for complete reaction of degeneration, for instance, the contraction of 
the muscle not being very slow or slow to the positive and quick to 
the negative pole. Polar inversion also may fail. All authors agree 
that the differentiation between partial and total degeneration of the 
nerve is of greatest importance in determining the state of the injured 
nerve and indirectly the indications for treatment. It is generally rec- 
ognized that evidence of complete severance of the nerve is an indica- 
tion for operative repair. 
From the syndrome of partially or totally injured nerves, the symp- 
toms of nerve exhaustion should be separated. These may be found 
in a weakened muscle or in a muscle in a state of exhaustion or oftener 
during the process of muscle regeneration and consist in unequal re- 
sponses to successive faradic irritation, the muscle missing from time 
to time in its contractions. 
Finally, signs of hyperexcitability of the muscles should also be 
noted, since they are present occasionally in cases of neuritis or nerve 
irritation. This condition is characterized mainly by tonic contractions 
persisting after galvanic exitation has ceased. 90 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Subject to reaction of degeneration are all muscles paralyzed by 
injury to the peripheral or lower motor neurone, that is, lesions of the 
peripheral nerves, lesions of the anterior roots, or, finally, lesions of the 
anterior horn cells themselves, as is the case in infantile paralysis. 
It is now being generally recognized that the surgical procedure of 
choice to be applied to severed peripheral nerves is that of end-to-end 
suture. All other operative methods, such as splicing, cable towing, 
nerve interposition, etc., are of extremely doubtful value. The only 
reliable method in which acceptable percentages of return of power 
have been observed is that of end-to-end suture. The statistics of D. 
Lewis, Blencke, and many others show the superiority of this operative 
method over the others. 
In formulating statistical conclusion, the element of time is of great- 
est importance. The time allotted for regeneration of peripheral nerves 
has generally been too short. Especially in long nerves which are in- 
jured at a considerable distance from the neuromotor end, a very con- 
siderable time is required for regeneration, not infrequently one and 
a half to two years or more. For this reason, the statistics of the late 
war promise to improve as the time goes on. 
From the orthopedic point of view, two problems are of special inter- 
est: the first is the preservation of the muscle during the period required 
for regeneration of the nerve. The relaxation of the apparently 
paralyzed muscle is of greatest importance, just as it is in the early 
treatment of infantile paralysis. Muscles involved in the peripheral 
nerve paralysis must be kept rigidly in a position which will facilitate 
their regeneration by the time the neuromotor conduct is reestablished. 
Only by proper splinting, which prevents pull and strain on the muscle, 
can such an end be accomplished. 
In discussing the surgery of peripheral nerves, Sir Barkeley Moyni- 
han sums up his experiences gathered during the Great War in the 
following statement: 
An early examination should be made of all wounds in which division 
of the nerve trunk is probable. In cases of secondary suture following 
Carrel-Dakin treatment, nerve suture should be included in the operative 
plan. 
He emphasizes that nerve grafting or any other of the more or less 
fantastic methods which have been devised from time to time are of 
no value whatsoever. This includes the splicing of the nerves as well 
as the formation of nerve flaps. 
The situation becomes purely orthopedic in many instances in which 
nerve suture is either impossible or, if carried out, is not followed by 
regeneration of nerve or muscles; in this event, the choice must be made 
between the methods of tendon transplantation and those of joint fixa- 
tion, or a combination of both. 
Musculospiral Paralysis.—According to common experience, mus- 
culospiral paralysis is the most common of the peripheral nerve lesions THE PARALYTIC HAND 
91 
in civil as well as in military surgery. It constitutes about 25 per cent 
of peripheral nerve lesions. Its frequency is explained largely by the 
frequency of injury to the humerus and the close proximity of the nerve 
to the bone which makes a lesion of the nerve a very frequent occur- 
rence. Out of 22 cases of traumatic peripheral paralysis seen by the 
writer in four years, 6 were cases of musculospiral paralysis following 
fracture of the humerus. One additional case of musculospiral paralysis 
followed a contusion of the humerus without fracture. 
The fracture being situated more often in the upper third of the 
humerus, it is often followed by complete musculospiral paralysis of 
the hand and forearm. The supinator longus, the supinator brevis, 
and the extensors of the wrist, the extensors of the thumb, the extensor 
ossis metacarpi pollicis, and the extensors of the fingers are paralyzed. 
In establishing the seat of nerve injury as w'ell as the extent of the 
paralysis, it is necessary to make a dissociative diagnosis in cases in 
which the exact location of the paralysis does not become evident from 
direct traces left by the trauma. 
Musculospiral paralysis above the supinator longus involves this 
latter muscle and besides the radial extensors, the extensor carpi ulnaris, 
the extensors of the fingers, leaving the triceps muscle untouched as 
this muscle receives its innervation higher up. Total paralysis, on the 
other hand, involves the triceps muscle and abolishes the olecranon 
reflex. 
Where the seat of injury is below the level of the supinator longus, 
the preservation of this muscle is demonstrated by its active contrac- 
tion which raises it into strong relief on the radial side of the elbow. 
Very close to the supply of the supinator longus is that of the extensor 
carpi radialis, so that in paralysis of the nerve below the supinator 
longus, at least, the long radial extensor may escape injury. Below 
the radial extensors, the seat of injury may be located by the fact that, 
while the hand can be put into dorsal flexion, the fingers cannot, since 
all the dorsal wrist-extensors escape injury except the extensor carpi 
ulnaris which receives its nerve branches at a much lower level. 
Nerve lesion below the branches for the extensor digitorum com- 
munis will preserve the ability of extension of the wrist as well as of 
the fingers, but the extensor ossis metacarpi pollicis and the long 
extensor of the thumb as well as the extensor of the index finger are 
paralyzed, indicating that the seat of injury is at a level between the 
supply of the common extensors and the supply of the latter named 
muscles. 
A difficulty arises quite often from the peculiar faculty of the patient 
to supply by substitutionary motion what has been lost by paralysis 
of the musculospiral nerve. Extension of the wrist is often accomplished 
by a forced flexion of the fingers. Therefore, the simultaneous exten- 
sion of the wrist and extension of the finger is a valuable test for the 
integrity of the musculospiral nerve as far as its supply to the forearm 
muscles is concerned. 92 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
On the other hand, extension of the lingers is often accomplished 
by forcible flexion of the wrist. In the latter instance, the extension 
of the linger is entirely mechanical, due to the passive stretching of 
the extensor tendons when the wrist goes into flexion. 
In splinting the hand following a musculospiral paralysis, the prin- 
cipal point is that the hand be placed in hyperextension in the wrist 
and that the splint should reach up to the proximal phalangeal joints 
of the fingers and not any farther, because, as has been mentioned 
already, the extensors of the fingers have no part in extending the 
middle and end phalanges, this being strictly a function of the interossei 
and lumbricales. It is, therefore, not necessary to extend the splint up 
to or beyond the tips of the fingers and it is often detrimental as it 
predisposes to other deformities. 
Case Reports.—B. N., 7 years. Traumatic musculospiral paralysis. 
The patient broke his left arm by fall 2 months ago. Has had very 
little use of the hand since injury. The examination showed a paralysis 
of the extensors of the finger of the left hand and a partial paralysis 
of the extensors of the wrist. The patient was at once placed in a 
splint, which held his wrist and palm in hyperextension. After 4 
months, there was complete disappearance of paralysis and normal 
extension of fingers and wrist. 
C. B., 38 years. The patient had an operation on the left breast a 
year ago followed by a secondary operation for local recurrence 10 
months ago, and a third operation 8 months ago; the latter was per- 
formed for the removal of glands in the axilla. Following the third 
operation, the patient developed a paralysis of the left arm with loss 
of control of the finger motion. The examination showed a partial 
paralysis of the musculospiral and median nerves. 
The hand was put in a cockup splint and the patient instructed in 
massage. When seen 2 months later, there was good action of both 
extensors of the wrist and those of the fingers. There was still slight 
atrophy of the thenar muscle but practically all the motion of the thenar 
had returned. These cases demonstrated the possibilities of conserva- 
tive treatment in cases of partial paralysis of the musculospiral nerve. 
The question of operative treatment of the permanent musculo- 
spiral paralysis not remediable by nerve suture, or not remedied by it, 
is so entirely an orthopedic problem that we believe its closer consider- 
ation to be justified. Among the operative measures, arthrodesis of 
the wrist is again in the foreground. It is the most valuable and most 
reliable procedure to procure both stability and position, two advan- 
tages which will go a long way to offset the disadvantage of lost wrist 
motion. The technic of arthrodesis has already been described in the 
chapter on the poliomyelitic flail hand. 
The indication for arthrodesis, we believe, arises in cases of total 
musculospiral paralysis of the wrist and fingers where it would be 
doubtful that both wrist extension and finger extension could be pro- 
cured by tendon transplantation. THE PARALYTIC HAND 
93 
As regards this latter procedure, several methods have been advo- 
cated, the foremost of which is that of Robert Jones: 
The pronator radii teres is transplanted to the extensor carpi radi- 
alis, longior and brevior. 
Then, the flexor carpi ulnaris is transplanted to the extensor tendons 
of the three ulnar fingers. 
Lastly, the flexor carpi radialis is transplanted to the extensor of 
the thumb and index finger. 
A modification of this method is that of Harold Stiles. He trans- 
plants the palmaris longus to the extensor ossis metacarpi pollicis and 
extensor pollicis brevis; the flexor carpi radialis is transplanted to the 
extensors of fingers and thumb; finally, the pronator radii teres is 
transplanted to the extensor carpi radialis, longior and brevior. In 
this method, all these muscles are swung around the radial border of 
the radius and can be reached from one volar incision. 
Stoffel transplants the flexor carpi radialis to the extensor carpi 
radialis, longior and brevior, the flexor digitorum sublimis to the 
abductor pollicis longus and extensor pollicis brevis, and the flexor carpi 
ulnaris to the extensor digitorum communis and extensor pollicis longus. 
There are many, however, who include a stabilizing operation on 
the wrist in the operative plan of tendon transplantation. Baisch, for 
instance, performs a tenodesis of the wrist and a transplantation of the 
flexor carpi radialis and ulnaris to the extensor pollicis longus and 
extensor digitorum communis. 
In several oases, the writer has combined both the methods of 
arthrodesis and tendon transplantation. 
H. W., 25 years. Total musculospiral paralysis due to compound 
fracture of the left humerus occasioned by the arm being caught in a 
rotating belt. There was a paralytic drop-hand involving all extensors 
of the wrist as well as of the fingers and of the thumb. An area of 
anesthesia was present on the radial side of the dorsum of the forearm 
wrist and hand. The operation consisted in : 
I. Arthrodesis of the wrist. 
2. Tendon transplantation of the flexor carpi radialis around the 
radius to the extensor pollicis longus. 
3. The transplantation of the flexor carpi ulnaris to the extensor 
digitorum communis through the interosseous route. 
This latter method has been described on a former occasion. The 
result was satisfactory, active extension of the thumb and fingers being 
possible (Plate XVII, 1, 2). 
Traumatic Paralysis of the Brachial Plexus.—Severe injuries to the 
shoulder joint, lacerating wounds, or gunshot injuries to the inner side 
of the humerus or the axilla, may be complicated by severe lesions of 
the nerve trunks constituting the brachial plexus. Several cases of this 
kind have come to the writer’s observation. In the case of a young 
boy 13 years old, the brachial plexus was injured by the cut of a barbed- 
wire fence, causing complete interruption of all the main trunks of the LEGEND FOR PLATE XV 
Fig. i.—F. N. Scar Contractures of Wrist. Live-wire Burn. After Plasties of 
Flexor Tendons. 
Fig. 2.—H. S. Scar Contracture of Hand. Live-wire Burn. After Plasty of Flexor 
Tendons. 
Fig. 3.—H. S. Trick Motion; Extension of Fingers by Flexion of Wrist. 
Fig. 4.—H. S. Flexion of Fingers by Extension of Wrist. PLATE XV LEGEND FOR PLATE XVI 
Fig. i.—P. H. Traumatic Paralysis of Thumb. After Flexor Plasty of Thumb. 
Result of Operation. 
Fig. 2.—P. H. Result of Operation. 
Fig. 3.—P. H. Result of Operation. 
Fig. 4.—E. G. Scar Contracture of Thumb. 
Fig. 5.—E. G. Result after Flexor Plasty. PLATE XVI LEGEND FOR PLATE XVII 
Fig. i.—H. W. Musculospiral Palsy. Drop Wrist. 
Fig. 2.—H. W. After Arthrodesis of Wrist and Interosseous Transplantation of 
Flexors. 
Fig. 3.--D. C. Traumatic Paralysis of Brachial Plexus. 
Fig. 4.—J. O. Musculospiral Palsy. Drop Wrist. PLATE XVII 100 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
brachial plexus together with severance of the brachial artery (Plate 
XVII, 3-4). 
Regarding this latter point, we know that a severance of the brachial 
artery, if not too high in the axilla, does not necessarily mean ischemia 
of the limb with subsequent gangrene. Two cases were observed in 
which this artery was cut and the collateral circulation proved sufficient 
to preserve the life of the limb. 
Primary nerve suture was carried out in the case mentioned, both 
on the musculospiral and median nerves, though no return of function 
has been observed at the time of this writing. In cases of failure 
to restore function by nerve suture when the three main trunks of the 
brachial plexus are severed, there remains a total paralysis of the limb 
and the situation will parallel that of total paralysis of the arm follow- 
ing poliomyelitis. These extreme cases warrant the attempt to perform 
an arthrodesis in the three principal joints of the extremity in position 
advantageous to function, namely, abduction of the shoulder, flexion 
of 70° to 90° in the elbow, and extension of the wrist. 
Traumatic Paralysis of the Thenar.—In a number of cases, traumatic 
paralysis of the thenar was observed, occasioned by injury to the median 
nerve at its point of entry into the thenar with destruction of the nerve 
branches which supply the thenar muscles. The result of such injury 
is a severe disability of the thumb. It is held adducted in the same 
plane with the palm, having entirely lost its power of opposition, and 
there is no possibility of a gripping action of the figners. The thenar 
muscles are found atrophic. While the use of the hand is thus greatly 
limited, objects can still be held between thumb and index fingers by 
action of the adductor of the thumb supplied by the ulnar nerve. This 
condition can be improved operatively by the same method which has 
been employed in thenar palsy following anterior poliomyelitis. One 
will find after this operation that the function of the hand becomes 
noticeably increased, and especially if a thorough course of muscle 
educational exercises follows the operation, the gripping power of the 
hand will become continuously better. 
H. S., 16 years. Live-wire burn received 5 years ago, injuring both 
median and ulnar nerves. A dense scar reaching almost to the bone 
at the lower end of the forearm not only destroyed the ulnar nerve but 
also the median and with it the total supply to the thenar. The result 
of this combined nerve lesion was first an ulnar claw-hand deformity 
with hyperextension at the metacarpophalangeal joints and flexion of 
the fingers due to the loss of interossei and lumbricales. Aside from 
this, there was also a marked degree of atrophy in the palm and dorsum 
of the hand in the spaces between the metacarpals. The thumb was 
adducted in a plane slightly behind that of the palm of the hand, and 
the power of opposition of the thumb absolutely lost. In this case, 
the injury of the long flexor tensors was first repaired by tendon plasties 
in the forearm. The disability of the thumb was then taken care of 
by flexor plasty, making use of the functionating long flexor tendon THE PARALYTIC HAND 
101 
of the thumb in a manner already described. The result was ability 
of opposing the thumb, which was one of the principal factors of the 
subsequent functional improvement of the hand, to which was added the 
gradual increase of flexor motion in the fingers (Plate XV, 1-4). 
The situation of the adducted thumb due to thenar palsy will be 
encountered on further occasions just as it has been found in polio- 
myelitic thenar palsy and in traumatic paralysis of the thenar. The 
method described has given thorough satisfaction in all situations in 
which the tendon plasty of the long flexor tendon of the thumb was 
indicated. Only in cases of error in technic, or of functional impair- 
ment of the long flexor tendon of the thumb itself (errors of indication), 
did the operation fail of its purpose of procuring opposition power to 
the thumb (Plate XVI. 1-5). 
BIBLIOGRAPHY 
Agata, G. D. Neurolisi del plesso brachiale e simpaticectomia periarteriosa del 
’omerale in un caso di paralisi del plesso brachiale, La Chir. degli organi 
di movimento, 1919, 3:55. 
Baiscii. Sehnentransplantation bei Radialislahmung, Deutsche med. Wchnschr., 
1918, 44: 368. 
Batten, H. E. Treatment of drop-wrist by tendon transplantation, Med. 
Press, April 30, 1919. 
Boehm, M. Der Musculus Triceps als Kraftquelle, Miinchen. med. Wchnschr., 
1918, 65:1351. 
Delbet and Cauchoix. Les paralysies dans la luxation de l’epaule, Rev. de 
Chir., 1910, vol. 41. 
Dreyer, L. Moglichkeit sofortiger Bewegungsaufnahme nach Sehnennaht, 
Beitr. z. lclin. Chir., 1910, 70:581. 
Hunt and Ramsey, J. Thenar and hypothenar atrophy of the hand, Am. Journ. 
Med. Sciences, 1911, 141:224. 
Jones, Robert. Notes on military orthopaedics, 1917, 18 ff. 
Law, A. A. Brachial plexus suregry, Journ. Am. Med. Assoc., 1916, 856. 
Lewis, Dean D. Peripheral nerve surgery, Surg. Clin., Chicago, 1919, 3:769. 
Mauclaire, P. Nouveau cas de paralysie radiale definitive traitee par le 
raccourcissement des tendons extenseurs et l’anastomose en fronde des 
tendons extenseurs et du cubital anterieur avec les tendons extenseurs 
au-dessus de leur raccourcissement; bon resultat, Bull, et mem. Soc. de 
chir. de Paris, 1918, 44:782. 
Anastomoses tendineuses pour remedier aux paralysies radiales defini- 
tives, partielles on totales, Presse Med., Paris, 1919, 27:509. 
Morris, R. T. Injury to the musculospiral nerve, Ann. of Surg., 1919, 69:338. 
Mueller, E. Zur Behandlung der Radialslahmung, Beitr. z. klin. Chir., 1915- 
1916, 98:263. 
Munch, E. Eine neue Stiitzschiene fur Radialislaehmung, Deutsche med. 
Wchnschr., 1918, 44: 159. 
Pearson, W. Tendon transplantation in drop-wrist due to nerve injury, Brit. 
Med. Journ., 1919, 1: 752. 102 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Pennell, V. Tendon transplantation in drop-wrist due to nerve injury, Brit. 
Med. Journ., 1919, 1:704. 
Perthes, G. Weiterer Beitrag zur Sehnenoperation der irreparablen Radialis- 
lahmung, Zentralbl. f. Chir., 1919, No. 25. 
Putti, V. Sopra un caso di paralisi recidivante bilaterale del radiale. 
SeraFini, G. Sul trapianto tendineo nella cura della paralisi traumatica del nervo 
radiale, La Chir. degli organi di movimento, 1918, vol. 2. 
Spitzy, H. Hand und Fingerplastik, Ztschr. f. orthop. Chir., June, 1919. 
Stiles, H. Operative treatment of nerve injuries, Journ. Orthop. Surg., 1918, 
vol. 16. 
Stoffel. Sehnenplastiken bei Radialislahmungen, Deutsche med. Wchnschr., 
1918, vol. 44. 
Stookey, B. Surgical considerations of peripheral nerve injuries, Surg. Gyn. 
Obstet., 1918, 27:362. 
The futility of bridging nerve defects by nerve flaps, Surg. Gyn. 
Obstet., 1919, 29:287. 
Stopford, J. S. B. The variations in distribution of the cutaneous nerves of 
the hand and digits, Journ. Anat., London, 1918-1919, 53:14. 
Stracker, O. Ergebnisse der Operationen an peripheral Nerven, Beitr. z. 
klin. Chir., 1919. 
Thomas, T. T. Laceration of the axillary portion of the capsule of the shoulder 
joint in the etiology of the traumatic combined paralysis of the upper 
extremity, Ann. of Surg., 1911, 53:77. 
Vernoni, C. Sopra un caso di paralisi del radiale da neuriti apoplectiforme, etc., 
La Chir. degli organi di movimento, 1920, 4:29. CHAPTER V 
CONTRACTURES OF WRIST AND FINGERS 
CHRONIC INFLAMMATORY CONTRACTURES 
The contractures of the hand and fingers which follow inflammatory 
conditions of the structures of the fingers, hand and forearm, owe their 
pathological development to an extension of the inflammatory process 
along certain anatomical channels, foremost of which are the systems 
of the tendon sheaths and the fascial spaces. 
When the tendon sheaths surrounding the thumb and fingers 
become involved in infection, their endothelial lining disappears and 
synovial cavities become obliterated. Finally, a complete fibrous union 
is established between the tendons and their sheaths. In the case of 
the finger flexors, which are the tendons most commonly involved, this 
means a position of flexion in mid and end phalangeal joints, rigidly 
maintained by peritendinous adhesions. At the wrist, the inflammation 
involves the radial and ulnar bursa and extends from here into the 
intermuscular spaces of the forearm. The ulnar and radial bursae 
finally become completely obliterated and the tendons are clustered 
together in a common bundle. In the palm, the tendons of index, 
middle, and ring finger may be isolated as they have their individual 
tendon sheath, but the sheath of the little finger and of the thumb 
commonly communicates with the ulnar and radial bursa, respectively, 
so that inflammations of these bursae will usually result in severest 
contractures of the two marginal digits. 
On the dorsum of the hand, the tendons become a part of the con- 
nective tissue mass and their isolation becomes extremely difficult. It 
is quite common in the course of infection that inflammation extends 
into the interphalangeal joints and not infrequently it involves the wrist 
joint also. In this event, the phalangeal joints will be found firmly 
fixed in flexion; the metacarpophalangeal joint, usually not involved, 
remains in hyperextension. The numerous periarticular adhesions, as 
well as the changes occurring in the joints themselves, make the at- 
tempts at correction very difficult. In severe cases, the involvement of 
the wrist joint leads to ankylosis of the wrist in distorted positions. The 
muscles of the forearm themselves take part in inflammatory changes. 
They may be found indurated by a marked proliferation of connective 
tissue and in extreme cases the muscles are transformed into a dense 
mass of scar tissue. In the palm itself, the changes in the interossei 
and lumbrical muscles are most prominent. Frequently they are entirely 
103 104 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
destroyed either by direct action of the inflammation or by grave circu- 
latory changes incident to it. 
The study of the finger contractures of inflammatory nature is by 
no means a simple problem. A contracted or deformed hand develops 
from a combination of factors, biological and mechanical; and not only 
the pathological process but the dynamic forces also must be considered 
in the development of contractures. 
Starting with the position of the wrist, it must be kept in mind that 
the latter largely influences the subsequent position of the fingers. If 
the infection of the bursa or the forearm spaces spreads into the wrist 
joint and causes a suppurative arthritis, the immediate pathological 
result will be a contracture in flexion position, which, in time, may 
become flexion ankylosis. In some cases the infection remains con- 
fined to the wrist joint alone; it may destroy the articular surfaces 
and cause the wrist to become ankylosed in flexion. But more often 
the infection follows the synovial sheaths and also involves the joints 
of the fingers; then the resulting deformity will be one of flexion of the 
fingers in the mid and end phalangeal joints also. The metacarpo- 
phalangeal joints are singularly exempt from involvement in the inflam- 
matory process, presumably because they have very strong ligamentous 
reinforcements which separate these joints from the inflamed sheaths 
of the flexor tendons. 
So much for the purely .pathological origin of the contracture. But 
there are also at work dynamic forces which must be considered. The 
flexion position of the wrist and fingers, whether purely contractural 
or inflammatory, carries with it such a relaxation of the flexor muscles 
that the equilibrium invariably shifts towards the side of the extensors 
of the fingers with the result that- the metacarpophalangeal joints 
become hyperextended. The result is the characteristic claw-hand atti- 
tude, seen in some of the inflammatory contractures. In many other 
cases, flexion contracture exists in wrist and fingers without hyper- 
extension in metacarpophalangeal joints; in these instances, however, 
the contractures are, as a rule, not extreme, especially the flexion in 
the wrist. 
The clinical picture of postinflammatory contractures is so charac- 
teristic that it can hardly be mistaken. The glossy, atrophic skin, the 
atrophy of the thenar and hypothenar muscles, and the atrophy of the 
interossei are the most prominent symptoms. The induration of the 
forearm and shrinkage of the forearm muscles furnish further evidence, 
to which are finally added the characteristic contractures already 
described. Finally, numerous operative scars usually testify to the more 
or less adequate attempts made during the acute stage to localize the 
infection. The thumb takes part in the deformity by flexion contracture 
of the end phalangeal joint, and, to a lesser degree, of the basal phalanx 
also. 
Returning to the contractures of the individual fingers, it has already 
been said that, especially in the fifth, the flexion contracture may become CONTRACTURES OF WRIST AND FINGERS 
105 
extreme in mid and end phalangeal joints. To a lesser degree, we find 
flexion contractures in the third, fourth, and index finger, yet all these 
fingers may show motion in metacarpophalangeal joints. The severity 
of the case depends very largely upon the degree to which there is an 
upward spread of the infection with involvement of the wrist and the 
forearm spaces and muscles. Such a complication means the destruction 
and cicatrization of tendons over a long distance, and also the contrac- 
ture and shrinkage of the forearm muscles so essential in producing the 
most intractable claw-hand deformities. 
In a number of cases, in which the tendon sheath infection has 
become more localized, contractures develop to a much lesser degree; 
the synovitic adhesions are much less rigid, the play of the fingers is 
less impaired. The contractures of the fingers are not nearly so extreme 
as in cases where the infection had spread upward to the wrist and into 
the forearm spaces. 
Adequate knowledge of the anatomy of the synovial extensions and 
fascial spaces in forearm and hand is indispensable for the early surgical 
treatment of these deformities. Although not within the scope of 
this writing, the prophylaxis of inflammatory contractures of hand and 
fingers must at least be mentioned. It is the prophylactic measures 
upon which are centered the best hopes for the salvage of the hand. 
This means not only very early interference, but one that is guided by 
precise knowledge of anatomy of structures affected and the routes of 
inflammatory extension (Kanavel, Beye). 
Prevention of deformity is the keynote to the treatment of hand and 
forearm infections. But the frequency of postinflammatory contractures 
furnishes a peculiar comment on this principle. Many of these infections 
are so difficult to handle in their acute stages that deformity is nearly 
unavoidable. Nevertheless if more stress were laid upon the details of 
position and splinting, a good deal of deformity could be prevented. 
From the viewpoint of the orthopedic surgeon, the problem involves 
the correction of already established contractures and deformities. They 
may yield to conservative or operative methods, or may resist either. 
In the choice of the method and the time for its application, in the 
planning of postoperative measures to secure and advance operative 
results, a good deal of careful judgment is necessary. It is especially 
desirable that the after treatment be carefully planned and every detail 
be covered by thorough consideration. 
Conservative Methods.—In selecting the time for the correction of 
deformities following infections, one is, first of all, greatly restrained 
by the fact that the tissues involved very likely harbor latent foci of 
infection. In the soft tissues, and especially in the bones and joints, 
foci of residual inflammation are present, ready to break out into vio- 
lence upon slight provocation. Foremost among such cases are com- 
pound fractures of gunshot wounds of the fingers, wrist, or forearm. 
These call for a great amount of precaution. Inflammation of the 
tendon and tendon sheaths following wounds of hand and fingers, and 106 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
especially those which follow crushing injuries often complicated by 
involvement of the joints, require above all the greatest amount of 
care. As a rule one may say that the time limit set before any forcible 
manipulation or operation is undertaken should be not less than one 
year after subsidence of all inflammatory symptoms, in the case of 
osteomyelitis and joint involvement, and six months if the inflammation 
involves the soft parts only. So great is the danger of recurrence of 
the inflammatory condition that even for the performance of merely 
corrective manipulations a liberal time limit after subsidence of active 
symptoms must be allowed. For instance, in correcting the faulty posi- 
tion of the wrist following extensive tendosynovitis and infection of the 
fascial spaces, the manipulation of the wrist joint is often followed by 
violent flare-ups with disastrous consequences. In case of doubt it 
is good practice to apply a gentle massage to the fingers and wrist and 
very careful passive motion. If well tolerated this can be increased 
gradually, and finally go the extent of passive correction with or with- 
out anesthesia. 
If the condition of the hand is ready for the application of manipu- 
lative correction, the question arises, how much can be accomplished 
by it? Contractures of the phalangeal joints due to peritendinous adhe- 
sions, if not extreme, as well as periarticular adhesions, yield to mod- 
erate passive stretching under ether. No great amount of force should 
ever be applied. But in several instances, the writer observed the giving 
of adhesions about the finger joints by gentle stretching under anesthesia 
and the result of correction could be maintained subsequently by proper 
splinting and physiotherapy. 
It is much more difficult to correct hyperextension in the metacarpo- 
phalangeal joints. It is here that often one has to resort to operative 
methods. In the wrist the flexion contracture is usually so great and 
the shortening of the powerful flexors so considerable that operative 
means are needed even if there is no direct involvement of the wrist 
joint. Where the wrist joint is involved and true ankylosis is estab- 
lished, nothing short of resection will restore proper position. Fibrous 
and periarticular adhesion often yield to manual correction. 
In maintaining the correction obtained by passive manipulation, the 
postoperative management is a most important factor. One must never 
forget that breaking up adhesions is often followed by hemorrhage into 
the synovial sacs which will promptly furnish new adhesions by organ- 
ization of the blood-clots, and nothing would be gained unless external 
splinting is so applied that it will, from the very beginning of correc- 
tion, counteract the tendency to contracture. For the fingers, the writer 
used to great advantage individual finger splints, which consist of a 
distal ring with a dorsal tongue and are made of malleable steel so that 
they can be adapted readily to the position of the finger joints (Grund). 
These splints are used with or without forcible correction. When the 
finger correction is attempted gradually, these splints are bent into 
proper shape and care is taken that the pressure upon the knuckles of CONTRACTURES OF WRIST AND FINGERS 
107 
the fingers is not too great and does not cause complications. It is 
better to treat fingers individually than to have a common splint for 
all. 
For the correction of contracture in the metacarpophalangeal joints, 
a splint is used which combines both the cockup and traction arrange- 
ment. The latter consists of a strong glove pulled over the fingers and 
a system of traction straps attached to the glove. The straps, sewed 
to the glove, pull the basal phalanges of the finger into flexion and are 
attached to a rod which is fastened at an angle to the upper end of the 
cockup splint. One will find that a fair number of cases of synovitic 
finger contractures is amenable to correction by bloodless methods. The 
milder cases yield to passive stretching without anesthesia, combined 
with proper splinting and good after care. The latter is always an 
indispensable part of the treatment, without which no permanent results 
are possible. 
The after treatment following forcible correction of finger joints 
should begin as soon as the tenderness disappears and the swelling sub- 
sides. In some cases it is advantageous to apply a plaster cast for a 
few days following forcible correction, because of the better immobiliza- 
tion. After a few days the cast may be replaced by splints and massage 
and active motion may be started. Active motion of the fingers should 
be encouraged from the very moment the tenderness subsides. One 
should wait with passive motion until the postoperative signs of irri- 
tation have disappeared (Plates XIX, XX). 
Operative Methods.—In many cases the contraction of fingers or 
wrist joints is resistant either to mechanical treatment or forcible ma- 
nipulation. This is especially true in contraction involving the thumb 
and little finger, as well as in contractures involving the wrist. All 
instances of true ankylosis and many of fibrous ankylosis in the joints 
will require surgical interference. 
For the relief of contractures due to shortened finger tendons, the 
operative lengthening of tendons, rather than the subcutaneous teno- 
tomies, should be considered. 
Tenoplasty.—Tenoplastic. technic in contractures of the wrist and 
fingers should be guided first of all by the general principles governing 
tendon surgery. A faultless asepsis is, above all, a condition without 
which no operation can hope to gain any results. Regarding the special 
technic, the following rules should be observed: 
Avoid if possible median incision, because this invites the formation 
of adhesions between skin and tendon. 
Handle the tendons with greatest care and gentleness; they are often 
friable and fray out easily in chronic inflammatory conditions. 
Suture accurately and thoroughly. 
One should attempt to reconstruct the tendon sheath; surrounding 
fascial tissue is to be used, if available; if not, the sheaths should be 
reconstructed with the aid of free fascial grafts. 
The adhesions covering the tendons must be carefully resected, and 108 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
for this purpose the use of a cataract knife or a very fine scalpel is 
necessary. 
The lengthening itself is best carried out by a Z-shaped incision 
which splits the tendon, allowing the two halves to glide over each 
other. Very fine catgut is a good suture material. The sutures must 
be laid with great care in a way which will avoid cutting through. 
Bunnell’s method of suturing tendons is the most accurate procedure. 
He uses specially made metal clamps which hold the tendon while the 
suture is applied. The needle is carried through slots in the clamp in 
such a fashion that a cross stitch results which tightly grips the tendon 
without cutting it. Of the greatest importance is the proper attention 
given to the tendon after it has been lengthened. There must be a 
certain medium tension which should be great enough to give the 
muscle potential power and yet it must not be so great as to interfere 
with the tendon suture on the one hand and with the vitality of the 
muscle tissue on the other, because we know that overtension is of 
paralyzing influence upon the muscle tissue and favors muscle atrophy 
and degeneration (Mayer). 
In forearm plasties, enough fascial tissue is at hand, in most cases, 
to cover the surface of the tendon against the superficial fascia and 
skin. Where this is not the case it is advisable to transplant fascia from 
the thigh. The necessity of reconstructing, as far as possible, the indi- 
vidual tendon sheath has already been mentioned. 
It is better to apply a plaster cast in proper position following oper- 
ation than to rely upon a splint which never gives the same amount 
of fixation. Within a few days the cast may be replaced by the splint 
and the after treatment begun. With the wound healing progressing 
satisfactorily, a few days or a week is a sufficient time of rest. 
Special Problems— Osteotomy.—The osteotomy of the metacarpals to 
overcome hyperextension position in the metacarpophalangeal joint was 
carried out in one instance: Patient, 25 years of age, had experienced 
several lacerations of forearm, wrist and fingers by an industrial accident. 
The injury resulted in extensive scar formation which brought about 
a contracted claw-hand with flexor contraction of wrist and fingers and 
hyperextension in the metacarpophalangeal joints. The flexion contrac- 
tures were corrected by tendoplasties without special difficulties. The 
hyperextension in the metacarpophalangeal joints resisted all operative 
attempts, such as lengthening of the tendons, resection of scar tissue, 
etc. Correction was finally obtained by osteotomies of the metacarpals 
about three-fourths of an inch proximallv to the head and by subse- 
quently kinking the metacarpal head toward the volar surface (Plate 
XIX, 2, 3). 
Osteotomy and Wedge Resection.—In several cases osteotomy and wedge 
resection were carried out to stabilize the wrist in the desired position. 
The technic varies in no wav from the one already described for arthro- 
desis of the wrist in paralytic cases. CONTRACTURES OF WRIST AND FINGERS 
109 
Tendon Bridging.—Necessity of bridging gaps in tendons arises in 
tendon defects not remediable by simple tenoplasty. 
In one instance the tendon of the palmaris longus was used to fill 
a gap in the flexor of the fourth finger. The operation requires long 
incisions and careful exposure of the tendons. It also requires pains- 
taking suture of the gap and the avoidance of bulky knots. Fascia 
flaps or fat flaps are used to cover the tendon grafts. 
In 19 cases operated, the following methods were used: 
Table of Operations 
Cases 
Flexor plasty of the thumb 1 
Tenoplasties 7 
Tenolysis and sheath reconstructions 3 
Manipulative correction 4 
Subcutaneous tenotomies 1 
Tendon grafts 1 
Osteotomy of wrist 1 
Osteotomy of metacarpal heads 1 
19 operations 
(Plates XVI, XIX, XX). 
DERMOGENETIC SCAR CONTRACTURES 
Cicatricial contractures following burns in the region of wrist and 
fingers offer a fertile field of technical problems. The treatment of 
these contractures is conservative only to a lesser degree, and mostly 
in the formative stages of the contractures when the scar is young 
and will yield to mechanical devices. Suitable splints have been de- 
scribed in previous chapters for the correction of inflammatory contrac- 
tures of the hand. Their application in contractures of this type offers 
no new angles for discussion, except that, in the stage of scar forma- 
tion and in extensive and painful lesions, great difficulties must be over- 
come which severely tax the ingenuity and patience of the surgeon. 
In the chronic stage, many of the cases require operative methods, 
as the stretching of an already formed scar following burns is possible 
only to a very limited extent. 
Scar formations on the dorsum of the hand, even if not involving 
the tendons themselves, are a serious obstacle to flexion of the hand. 
If on the volar surface, an equally resistant flexion deformity will result. 
Extensive burns of the fingers leave the latter usually in a contracted 
position in all joints, and, in some severe cases in which the palm has 
been involved as well as the dorsum of the hand, the fingers are placed LEGEND FOR PLATE XVIII 
Fig. i.—T. McG. Scar Contracture of Elbow (Burn). 
Fig. 2.—T. McG. After Italian Flap Plasty. 
Fig. 3.—S. B. Scar-bound Extensor Tendon of Fourth Finger before Operation. 
Fig. 4.—C. H. Scar-bound Flexor Tendon. After Tendon Plasty. Good Closure of 
Fist. 
Fig. 5.—Pieri Method for Relief of Scar Contracture of Thumb. PLATE XVIII LEGEND FOR PLATE XIX 
Fig. i.—E. G. Tenosynovitic Contracture of Thumb. After Operation. 
Fig. 2.—F. A. Tenosynovitic Claw-hand before Tenoplasties. 
Fig. 3.—F. A. After Tenoplasties. 
Fig. 4.—Supination Splint (Dr. Funsten). 
Fig. 5.—Ring Finger Splint. 
Fig. 6.—Author’s Glove Traction Splint. 
Fig. 7.—G. T. Tenosynovitic Contracture of Hand. Scar-bound Cutaneous (Ulnar) 
Nerve. PLATE XIX LEGEND FOR PLATE XX 
Fig. i.—C. W. Tenosynovitic Contracture of Fourth Finger. 
Fig. 2.—C. W. After Tenoplasty. 
Fig. 3.—T. M. Tenosynovitic Claw-hand. 
Fig. 4.—L. H. Tenosynovitic Claw-hand; Glove Traction Splint. 
Figs. 5, 6.—L. H. Result of Conservative Treatment. 
Fig. 7.—C. D. Tenosynovitis; Scar-bound Flexor Tendons. 
Fig. 8.—C. D. After Tenoplasties 
Fig. 9.—B. C. Ankylosis of Wrist Following Tenosynovitis. 
Fig. 10.—B. C. After Arthrodesis of Wrist. PLATE XX 116 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
in claw-hand formation with extreme hyperextension of the wrist. Of 
special interest are isolated burns in the thenar region. We have seen 
some which produced extreme adduction contracture of the thumb with 
pronounced flexion of end and basal phalanx. 
The method found most satisfactory in dealing with extensive scar 
formation is that of the pedunculated flap, the so-called Italian method. 
The flap is taken from the skin of the abdomen or the chest as a single 
pedicled flap, or the double pedicled, or so-called pocket flap may be 
used, especially in covering a defect on the dorsum of hand and forearm. 
The pedunculated flap method has been used from old Indian times. 
But it is more commonly known as the Italian method, since it was 
first mentioned and described in the book of Tagliacozzi (1546-1599), 
which contains an accurate description of the technic. The pedunculated 
flaps, simple, compound or double-faced, are extensively used in surgery 
of the upper extremity (J. S. Davis, Skillern). Reports by Skillern on 
the use of the pocket flap method are especially favorable. The double 
pedicled furnishes much better condition of nutrition than the single 
pedicled flap. Besides, by slipping the hand or forearm under the raised 
flap, a certain amount of fixation is secured. 
Technic.—In order to secure good nutrition, a flap should not be 
longer than two or three times the width of the pedicle, and the position 
of the latter should be directed carefully by the conditions of blood 
supply. If possible, the flaps should follow the directions of the arteries 
which supply the area of skin used for the flap. Pieri, in his study on 
the location of skin flaps in the upper extremity, gives valuable sug- 
gestions as to the proper placing of skin incisions. Upper abdominal 
flaps should have a centrally located pedicle, whereas, in lower ab- 
dominal flaps, it should be located distally. It is not necessary that 
the flap be made extraordinarily large in order to cover the defect. 
An excess in size by one-half or three-fourths of an inch over the area 
of the defect is, in the medium-sized flaps, usually sufficient. When a 
skin flap becomes suffused with blood due to venous stasis, the scari- 
fication of the flap, according to Mayo’s advice, is a good way to relieve 
the congestion. The adaptation of the flap to the defect formed by the 
excision of the scar should be most painstaking, and, after the flap has 
been placed, absolute immobilization is essential to avoid pulling and 
undue tension. This is best secured by a well-applied plaster cast. In 
the case of chest or abdominal flaps being used for the covering 
of defects of the forearm or hand, the cast should reach from the 
pelvis to the shoulders and include arm, forearm, and hand. For the 
suture of the flap, horsehair or fine catgut should be used. No anti- 
septic should be applied, but the skin should be carefully covered by 
strips of gutta-percha coated with sterile vaseline. As to the time when 
the flap should be liberated from the pedicle, the writer believes that 
an interval of two or three weeks is, in general, most appropriate. At 
any rate, the pedicle should not be cut before ten days have elapsed, 
and sometimes it is advisable to carry out the separation of the pedicle CONTRACTURES OF WRIST AND FINGERS 
117 
gradually, in several steps. During the period of fixation in plaster, 
it will be necessary to dress the wound several times because of the 
profuse secretion. This can be done from a window in the cast or 
by removing the cast temporarily under precautions and having it sub- 
sequently reinforced when the dressing is done. 
The writer has used the method to good advantage in cases of 
extension contracture of the hand. 
Case Reports.—Male patient, 33 years, with bad scar from burn situ- 
ated at the dorsum of the wrist. The scar prevented flexion of the 
wrist, completely holding the extensor tendons fixed in such a position 
that closure of the hand could not be accomplished. Operation was 
performed with the use of the Italian flap method and carried out in 
2 steps, to which 2 months later an additional flap operation was added 
to complete the covering of the skin defect by elastic skin. Both flaps 
took well, leaving an entirely soft and pliable skin on the dorsum of 
the hand which allowed of sufficient flexion of the wrist to make a good 
grip possible (Plate XXII, 1, 2). 
Girl, 3 years. Contracture of the wrist from dorsal scar due to burn 
years previously. The scar was excised and covered with a pedicled 
flap taken from the chest. In this case, the result was not as satisfactory 
because the excision of the scar on the dorsum had not been extensive 
enough, leaving a margin of scar tissue. The flap took well, however, 
and the remaining skin was pliable and soft (Plate XXII, 5, 6). 
Child, 2 years. Having received, year previously, a severe burn 
in the palm of the hand resulting in contracture of the thumb which 
was drawn tightly against the palm. The scar was resected and the 
defect covered by a flap cut from the left hypogastric region. The 
result was satisfactory and the thumb could be abducted. 
Scar contractures of the fingers from burns were treated by pedicled 
flaps from the chest, in one instance, and by simple skin plasty, in 
another. In taking a flap from the hypogastric region to cover a defect 
on the volar side of the finger, one must take care not to get the flap 
too heavily padded with subcutaneous fat. In one case, the flap, though 
healing perfectly, caused considerable raising of the skin due to under- 
lying fat, which, contrary to expectation, did not atrophy. This neces- 
sitated a secondary operation in which the resection of the subcutaneous 
fat was carried out. It seems that in general too much reliance is placed 
on subsequent atrophy of subcutaneous fat in flaps taken from the chest 
or the anterior abdominal wall. An abundant layer of fat is not neces- 
sary to secure the nutrition of the flap, although the latter must not be 
stripped too close, and must retain its layer of subcutaneous tissue. From 
the standpoint of cosmetics, there are certainly serious objections to the 
use of a flap too heavily endowed with underlying fat tissue (Plate 
XXII). 
Scar Contractures of the Elbow.—Scars from burns in the elbow in 
the cubital fold cause very resistant flexion contractures. These cases 
lend themselves very well to the application of the Italian flap method. LEGEND FOR PLATE XXI 
TECHNIC OF SKIN PLASTY OF CONTRACTED THUMB 
Fig. i.—Incision. 
Fig. 2.—Raising of Flaps. 
Fig. 3.—Suturing of Flaps. PLATE XXI LEGEND FOR PLATE XXII 
Fig. i.—F. J. Extension Contracture of Wrist (Burn). 
Fig. 2.—F. J. After Italian Flap Plasty. 
Fig. 3.—D. M. Extension Contracture of Wrist (Laceration). 
Fig. 4.—D. M. After Italian Flap Plasty. 
Fig. 5.—H. G. Scar-bound Flexor Tendons of Wrist. 
Fig. 6.—H. G. After Tendolysis and Tendon Plasty. PLATE XXII 122 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Case Report.—Woman, 26 years old, received a gasoline burn 6 months 
previously, followed by cicatricial contractures of the left elbow, among 
other severe contractures. Motion of elbow was limited to a range of 
flexion from 450 to 90°. The elbow could not be extended beyond the 
right angle. A broad flap was cut from the epigastric and upper 
abdominal region and placed upon the skin defect, obtained after com- 
plete excision of the scar in the elbow. The flap was cut loose from its 
pedicle after 21 days. Result was an increase of the extension of the 
elbow from 90° to 150° (Plate XVIII, 1, 2). 
The pocket flap is a two-bridge flap with pedicles above and below, 
and is raised from the abdominal wall by two parallel incisions. The 
flap is held up by retractors and the hand can be slipped readily under 
it so that it will serve especially well to cover a defect on the dorsum 
of the hand. The edge of the flap is sutured to the edges of the defect, 
the best suture material being, according to Stiles, silkworm gut. The 
dressing is carried out with dry sterile gauze. Stiles allows a consider- 
able time for the establishment of circulation between flap and hand, 
and he divides the pedicles not less than twenty-three days after the 
first operation. 
Some difficulty is sometimes encountered in drawing together the 
abdominal skin when a large abdominal flap is cut, and the defect on 
the abdominal wall is to be covered. In order to avoid undue tension 
in such cases, it is sometimes advisable to make parallel incisions some 
distance from the edge of the flap incision so that the skin can be 
mobilized with greater ease. Dr. Christian Fenger of Chicago was the 
first who used pedunculated flaps in injuries of the hand. 
NEOPLASTY OF THUMB AND FINGERS 
The Neoplasty of the Thumb.—In case of partial or total loss of 
the thumb, several methods of substitution are possible. They may 
be divided into: (i) methods in which the new thumb is formed from 
tissues taken from other parts of the body, the method of thumb plasty 
proper; (2) methods in which the thumb is substituted by exchange of 
other fingers, Nicoladoni’s finger exchange method; and (3) by methods 
in which the metacarpal is used for the formation of a finger, the Italian 
phalangization method. 
Material for the new-formed thumb can be obtained most easily by 
a flap from the abdominal wall into which a bony transplant is inserted 
taken from the tibia or the ribs; a new digitlike formation is first made, 
properly pedicled so as to receive ample nutrition; this structure is then 
implanted into a properly prepared base at the place of defect. A 
method of this kind is used by Albee, who describes it as follows: 
A pedicled flap is taken from the abdominal wall and the material of 
bone taken either from the finger phalanges or metacarpals, if those are CONTRACTURES OF WRIST AND FINGERS 
123 
available, or, if not, a bone transplant is taken from the fibula. This is 
inserted into the pedicled flap raised from the abdomen, in a second 
operative step. In a third and fourth sitting, the severance of the flap 
from its abdominal base is carried out. 
Technic of Schcpelmann.—A section of the fibula is removed and trans- 
planted into the abdominal wall. Then, by raising the integument 
around it, this is gradually mobilized until there is obtained a pedicled 
skin flap containing the bone transplant in the center. At a third step, 
this pedicled flap is sutured to the properly prepared base of the muti- 
lated or missing finger, and the position secured by plaster bandage. 
After ten days, a gradual separation of the pedicle from the abdominal 
wall is carried out. This author also made observations on the late 
condition of neoplastic fingers. The cases were followed up for a 
number of years and it was found that the bone transplant firmly united 
with the metacarpal of the missing finger. The circulation in the new- 
formed finger improved and the initial bluish discoloration of the finger 
gradually disappeared. Sensation of the finger developed from the skin 
of the host, finally including fully two-thirds of the new-formed thumb. 
Case Report.—This method was used by the writer in one case of con- 
genital defect of the thumb. 
R. G., 8 years. Congenital defect of the thumb with radial club-hand. 
Partial defect of the radius. The club-hand deformity was taken care 
of by previous operation. The method used for substituting the missing 
thumb was as follows: 
A circular flap was raised from the abdominal wall with the base 
pointing to the side opposite to that of the defect. Into this flap, there 
was inserted a piece of the seventh rib, previously resected from under 
the flap. The skin flap was closed around the rib to form a sort of roll, 
and the end of the protruding rib was fastened to the metacarpal of 
the thumb by wire suture carried through drill holes. The free ends 
of the flap were then sutured to the prepared base of the missing thumb. 
At the second step, the abdominal pedicle of the new-formed thumb 
was severed three weeks after the first operation. Up to that time, 
the position had been secured by plaster cast. The result obtained was 
a thumb shorter than had been desired, a fact which was due entirely 
to incomplete technic. But the patient was able to hold objects between 
his fingers and the new-made thumb, and had just begun to use it in 
the course of a persistent after treatment when he was lost sight of. 
Other instances of reconstruction of the thumb by this so-called 
skin roll plasty from the chest are reported by Payr, Nicoladoni, Ritter, 
and others. 
The second method is that of substitution of fingers by other fingers 
or by the toes. This method is ascribed first to Nicoladoni, who reported 
several cases. The method consists in exchange of the missing finger 
for one of the toes, preferably the big toe. In the first step, the scar 
covering the defect is resected and the base is properly prepared after 
dissecting the flexor and extensor tendons of the stump. Then a curved 124 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
incision is made over the metatarsophalangeal joint of the big toe, the 
extensor tendon is divided, and the toe dislocated in the metatarsopha- 
langeal joint. The toe is then brought into apposition with the prepared 
base of the thumb, the former being attached to its original site by the 
structure of the plantar surface only. The capsule is now sutured to 
the base of the defect and the peripheral end of the extensor of the 
toe is united to the central end of the extensor of the thumb. The skin 
is closed and position secured in plaster. At the second step, after 
ten to eighteen days, the volar skin bridge is gradually severed and 
again the distal end of the flexor of the toe sutured to the central end 
of the flexor of the stump. 
Oehlecker, Riedel, Muehsam, and others have followed this method 
with gratifying results. 
Substitution of the thumb may also be accomplished by implantation 
of a finger from the other hand. An operation of this type is described 
by Joyce (1918), who used the ring finger of the opposite hand to sub- 
stitute the missing thumb, applying a two-step method. The result 
of this case ranks among the best reported in the literature. He ob- 
tained a functionating, and very sightly neoplastic, thumb with good 
gripping power. Verrall reports transplantation of the remainder of 
the index finger of the same hand to the metacarpal of the missing 
thumb. 
The third method which has been used for thumb substitution is the 
so-called phalangization method reported by Pieri. 
In the case of loss of thumb and index finger, the isolation of the 
first metacarpal is carried out first, then the second metacarpal is 
entirely resected. This leaves a broad interdigital space between the 
first and third metacarpals. The isolation of the second metacarpal is 
carried out from a curved flap and the bone is disarticulated at its base. 
In isolation of the first metacarpal, it is important that all muscles of 
the thenar eminence be left intact. The simultaneous removal of the 
second metacarpal is carried out in order to obtain sufficient skin to 
cover the space completely on both the ulnar and radial side of the cleft. 
The radial artery must be properly protected from injury at the 
proximal ends of the first and second metacarpals where it crosses these 
bones to form the deep carpal arch. In two cases reported by Pieri, 
the function of the thumb so formed was quite satisfactory, the hand 
attained the faculty of gripping, and the thumb could be opposed. The 
conservation of the opponens pollicis allows of some inward rotation, 
adduction, and opposition of the metacarpal. Some pure adduction was 
also possible in spite of the fact that the adductor pollicis had been sac- 
rificed. This was due to the concerted action of the long flexor and 
long extensor of the thumb. It should be mentioned that, in 1914, 
Lyle already had reported a case in which the loss of the thumb was 
met by a method similar to what was later reported by Pieri. Incision 
of the soft parts was made in the first intermetacarpal space with best 
possible preservation of the thenar muscles. The skin of the dorsum CONTRACTURES OF WRIST AND FINGERS 
125 
of the hand was carried around the second metacarpal and united to 
the palmar skin. A similar procedure is reported by Wierzejewski in 
1919, who split the first intermetacarpal space, preserving also the thumb 
muscles. His reports cover four cases: one with loss of thumb, one 
with loss of thumb and index finger, one with thumb, index finger, and 
end phalanx of third and fourth fingers lost, and one with all fingers 
lost except the fifth. In all these cases, phalangization of the thumb 
was carried out and the first patient especially, who had lost the thumb 
only, had an excellently functionating hand which enabled him to play 
the piano. 
In a case of loss of all fingers except the fifth, Quetsch split the 
metacarpals full length to the wrist forming a two-fingered forceps with 
abduction power. The latter method already approaches the forcipiza- 
tion methods of the forearm, as described by Putti, Delitala, and Kruck- 
enberg, applied to cases of loss of the entire hand. 
It is not within the scope of this essay to go into the details of the 
methods which have been devised for the mobilization of stumps fol- 
lowing amputation. But, warranted by the close relationship to ortho- 
pedic interests, there should be at least short mention made of an 
ingenious method known as cinematization of stumps. 
In 1896, Dr. G. Vangetti, an Italian physician, turned his attention 
to the unfortunate condition of his countrymen who were mutilated in 
the Abyssinian War. Realizing that there were still intact muscles of 
the forearms, which were now rendered useless after amputation of the 
hand and forearm by being bereft of their natural levers, he conceived 
the idea of isolating the distal and tendinous parts of the muscle and 
inclosing them with a covering of skin. In this way he attempted to 
produce a terminal arrangement capable of voluntary contraction which, 
if formed into the shape of a peg or loop and attached to a specially 
constructed prothesis, could be made to bring about coordinate motion. 
This latter would be differentiated into one or two cardinal motions, 
possibly antagonistic to each other, so that opposition movements in 
a single plane could be carried out. With the outbreak of the World 
War, this method was further elaborated and perfected by Sauerbruch 
of Zurich and by a number of Italian surgeons. These were the 
beginnings of what is now known as kinoplastic surgery, which has 
received a powerful impetus from the abundant material produced by 
the late war. V. Putti of Bologna further developed and improved the 
original methods, and in 1918 he was able to report on 50 cases. His 
best results were obtained in arms which had been amputated either 
above the wrist or above the elbow. 
Between these latter methods and those of phalangization of the 
thumb, which was mentioned before, stands the method of Kruckenberg, 
elaborated by Putti, Delitala and others. It is called the method of forcip- 
ization of the forearm. It consists essentially in a splitting of the fore- 
arm between radius and ulna and subsequent mobilization of the radius. 
A rather elaborate technic, too complicated to be mentioned in brief, 126 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
takes care of the covering of the bones with skin material. By means 
of systematic muscle education, an actively moving forceps or pincer 
arrangement is obtained which consists essentially of two big fingers 
like the hands of a shears, which move against each other and are 
capable of holding light objects such as the handle of a fork, a knife, 
a glass, etc., between them. It is hardly necessary to add that such a 
forearm, though useful, is an extremely hideous and ungainly thing, and 
many patients are reported as refusing the operation for cosmetic 
reasons. 
Putti and Delitala have improved upon this method in a manner which 
partly meets these objections. Delitala distinguishes between a “mano- 
carpica” and “mano-metacarpica” according to whether the cleft is carried 
into the metacarpals or higher up into the carpus and above, depending 
upon how much of the hand has been preserved. Some forceps action 
can be obtained to great advantage when at least part of the metacarpus 
has been saved. We are referring to Kruckenberg’s and Delitala’s pub- 
lications for the study of the details of this method. 
ISCHEMIC CONTRACTURE 
(Volkmann’s Contracture; Ischemic Paralysis) 
In 1875, R. Volkmann described a contracture occurring in the fore- 
arm and hand, which followed the use of constricting bandages or splints 
applied for fracture of the forearm or fractures of the humerus near 
the elbow joint. The condition is now generally known as Volkmann’s 
ischemic contracture, or, better, as ischemic myositis, because the 
underlying condition is essentially that of an interstitial myositis. It 
develops under the influence of circulatory disturbances subsequent 
either to the fracture itself or to the constricting bandages applied later. 
In order to understand the condition, one must first consider how 
the muscles of the forearm react to interference with their blood supply 
in various degrees. We know that, deprived of their oxygen supply, 
the muscles finally disintegrate and coagulate. A number of investi- 
gators have busied themselves with the study of the influence of ischemic 
conditions upon the life of the muscles. Stenson noted a paralysis of 
the lower extremities after ligature of the abdominal aorta. Leser and 
Babinski were able to obtain paralysis in rabbits by tight bandaging, but 
they could not obtain contractures, and, similarly, in Lossen’s experi- 
ments, there appeared paralysis after six hours of constriction, only to 
disappear again within three months. Zur Verth reports a case of 
paralysis of all muscles of the forearm following the use of a rubber 
bandage which had been left applied for an hour and a half in order 
to control hemorrhage from the ulnar artery. We note that the latter 
report already approaches the clinical picture prevailing in cases of 
ischemic contracture. By various observers it has been pointed out CONTRACTURES OF WRIST AND FINGERS 
127 
that the involvement of the ulnar and median nerves shares equally in 
the formation of the paralytic contractures. No doubt a large number 
of cases exist in which the nerves are directly injured, and the condition 
is then primarily one of peripheral paralysis. These cases we believe 
can be differentiated clinically from those in which the nerve injuries 
play no part. In fact, it has been mentioned by Volkmann himself that 
direct injury to the nerves, while a frequent occurrence, is not at all a 
necessary factor as far as this affection of the forearm muscles is con- 
cerned. The involvement of the intrinsic muscles of the hand, it is true, 
can be explained only by direct injury to the ulnar nerve, which, of 
the nerves of the forearm, is the most frequently affected (G. G. Davis). 
Volkmann as well as other observers called attention to an interval 
of time between injury and the occurrence of paralysis. Lorenz and 
Webber quote cases in which ulnar paralysis appears very gradually 
and after many years following an elbow injury. In this connection, 
we may call attention to reports of so-called delayed ulnar palsy, which 
have been more recently brought to attention by Leriche. The expla- 
nation of this delayed ulnar palsy is that a peripheral neuritis develops 
some considerable time after the original injury. We felt that this 
condition should be mentioned in particular so as not to give room for 
confusion with true ischemic paralysis. 
The clinical syndrome of this contracture is so characteristic that the 
diagnosis will rarely be missed even if not supported by the history of 
trauma. 
In the majority of cases, the injury is located in the lower epiphysis 
of the humerus following a fall or a blow. The fracture of the lower 
epiphysis causes an extensive injury to the soft parts in the fold of the 
elbow with a very considerable subcutaneous hematoma. This is fol- 
lowed by the development of severe contractures of the wrist as well 
as the fingers and, in severer cases, the ultimate formation of a claw- 
hand deformity. The flexion contractures of fingers and wrist are very 
persistent and often defy all imaginable efforts to correct them. They 
develop in a typical sequence and, in all cases coming under the writer’s 
observation, the stages in which the contracture appeared were as 
follows: first, there appeared a flexion deformity of the wrist; then, 
very shortly afterwards, or simultaneously with it, a flexion deformity 
' of the fingers developed in the mid and end phalangeal joints; and, 
lastly, hyperextension appeared in the metacarpophalangeal joints mak- 
ing the claw-hand deformity complete. The flexion contracture of the 
wrist is most extreme in severe cases and from the viewpoint of muscle 
mechanics has a powerful influence upon the development of the claw- 
hand deformity. This has been pointed out before in the discussion 
of the paralytic deformities and it may be repeated that the tension 
upon the extensor muscle of the fingers from the hyperflexion of the 
wrist is such that hyperextension in the metacarpophalangeal joints is 
practically unavoidable even though the extensor muscles are usually 
not involved in the myositic changes. 128 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
There is general evidence of severe disturbances of the circulation. 
The skin is blue, cold, and clammy. Severe cases show atrophy of the 
skin and ulceration, the sores being located mostly over the knuckles 
of the mid phalangeal joints. Sensory disturbances are very frequent 
and are most noticeable in the area of distribution of the ulnar nerve. 
In severe cases, the contractures are extremely rigid, especially those 
of the flexors of the wrist. There is a striking and very considerable 
atrophy of the entire forearm muscles and occasionally also of the 
muscles of the thenar and the intrinsic muscles of the hand. The 
muscles of the forearm feel hard and indurated. 
The elbow is fixed in flexion due to the myositic contractures in 
the fold of the elbow and it is here where the induration, as a rule, 
is most noticeable. 
Micropathology.—Comparatively few observations have been made 
as regards the pathological anatomy of the muscles involved. The most 
common feature is the increase of connective tissue within the muscles. 
Barnays finds the muscle fibers of unequal thickness, irregularly ar- 
ranged, and many of them show vacuoles. In many places, there is an 
absence of the nuclei of the sarcolemma. Transverse striation is lost. 
Round-cell infiltration is seen abundantly and there is ample formation 
of young connective tissue which eventually becomes transformed into 
scar tissue. 
This interstitial fibrosis of the muscle parenchyma has also been de- 
scribed by Rowlands and Powers. The muscles have a marked trans- 
lucent and brown yellowish color. Muscle fibers removed from various 
areas show a varying amount of connective tissue. The muscle fibers 
are everywhere degenerated, but most markedly so where the connective 
tissue proliferation is most advanced. The fibers are shrunken, of wavy 
outline, and, for the most part, devoid of cross striation. Frequently, 
they are broken up in coarse granules. In areas which are less involved 
by the connective tissue infiltration, the muscle fibers appear more 
normal in structure and at times one finds intact cross striation. 
From the histological observations made by the writer, it can be 
stated that there is a distinct interstitial as well as interfibrillar con- 
nective tissue infiltration, with entirely uniform shrinkage of the muscle 
fibers which are reduced to from two-thirds to one-half of their normal 
size. The contours show frequent interruption. It is peculiar that 
longitudinal striation maintains itself largely in spite of the almost uni- 
versal loss of cross striation. In the tissues taken from the part most 
severely involved in the fibrosis, one finds almost nothing but connective 
tissue with a single muscle fiber here and there interspersed. The 
pathology of these ischemic contractures becomes more apparent in 
sections taken from moderately involved areas rather than from those 
of complete fibrosis. There can be no doubt that the pathological basis 
is that of interstitial myositis. 
If we compare these changes with those found in old cases of in- 
fantile paralysis or in peripheral nerve lesions on the one hand, and CONTRACTURES OF WRIST AND FINGERS 
129 
of polymyositis on the other, the myositic character of this lesion will 
be more fully appreciated. In myositis, the connective tissue infiltration 
with shrinkage of the individual muscle fibers is general and evenly 
distributed and, in this respect, quite corresponds to the picture seen 
in ischemic contractures. 
On the other hand, in peripheral or in poliomyelitic paralysis, the 
histological picture of the muscle is very different. There is, in both 
of these conditions, a certain amount of interstitial connective tissue 
infiltration. But by far the most marked factor is the infiltration of 
fat. The muscle fibers also show a great inequality in the diameter of 
individual muscle cells. Some are shrunken to one-tenth of their normal 
size, while others present apparently normal dimensions. In traumatic 
peripheral paralysis, especially, the dominant feature is that of muscle 
degeneration, with only a moderate and secondary infiltration of con- 
nective tissue. 
These histological findings ought to dispel any doubt that the 
ischemic contracture of Yolkmann is a myositic process, which sets up 
a tremendous infiltration of connective tissue in the muscle substance 
with general induration and scarring of the muscles (Plates XXVI, 
XXVII, 1-4). 
The condition is not as rare as might appear from the rather .scarce 
literature on the subject. In the last ten or twelve years, more atten- 
tion has been paid to this condition and the reports have become more 
frequent. J. J. Thomas, in 1909, published a very accurate review of 
the literature up to that time, collecting 107 cases. Of these, a large 
majority was caused apparently by constricting bandages. He found 
claw-hand formation in 62 cases. Pressure sores after plaster bandages 
were found in 79 per cent of the cases according to Alivisatos and Eco- 
nomos, who compiled 144 cases in the literature up to 1916. To what 
extent constricting bandages are responsible for the occurrence of this 
contracture is a matter still under discussion. Surely a large percentage 
of cases is brought about in this way, but one must not lose sight of 
the fact that a number of cases coming under observation never have 
been treated either by constricting bandages or by splints, the fracture 
often having remained undiagnosed at that time. In those cases, it 
must be that the pressure from the subcutaneous hematoma is in a 
large measure responsible for the myositic changes and the subsequent 
contractures. From this point of view, the question is to be considered 
whether one is not justified, in cases where a considerable hematoma 
is present, in performing an early incision to release the hematoma. 
This seems to be an entirely rational procedure and we believe it should 
be carried out more often. 
Treatment—Prophylactic.—During the stage of the development of the 
deformity, it is possible to overcome the danger by timely and proper 
splinting. The constricting cast must be removed at once. The repair 
of the bone is usually already fully developed when the first sign of 
contractures set in. 130 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
A great many cases of ischemic contracture will respond to con- 
servative treatment. Where the line is to be drawn between the cases 
which will yield to passive stretching and those which will not is dif- 
ficult to determine. One may say, in general, that the contracture of 
the wrist is often so firm that no amount of passive manipulation will 
relieve the deformity unless preceded by operative methods. 
The conservative treatment has made considerable progress since the 
general acceptance of the method of Robert Jones. The principle of 
this method consists in the gradual, continued stretching of the con- 
tracted joints by malleable iron splints. The wrist is first placed in 
extreme flexion so as to relax the flexion contracture of the fingers as 
much as possible. Then, by means of individual finger splints, the 
gradual correction of each individual finger is accomplished. When 
the flexion contracture of the fingers has been overcome, the contracture 
of the wrist is taken care of in a similar manner by correcting this 
deformity in steps with the aid of a malleable volar splint. Of all con- 
servative methods applied, this seems to be the most efficient. Gold- 
thwaite has reported very favorable results obtained by this method. 
Volkmann himself advocated the stretching of the contracted tendons 
under anesthesia, but he was not very optimistic as to the possibilities 
of correction, speaking of the almost unmanageable claw-hand deformity 
as a feature of ischemic contracture. But since Jones’ method has been 
more widely accepted, the reports of good results obtained by conserva- 
tive means are more numerous, and—aside from Goldthwaite—Alex- 
ander, Watts, Froelich and others have recommended this method of 
gradual correction with individual finger splints. The value of this 
method seems to lie especially in the principle which holds that these 
contractures are to a certain extent amenable to correction, when wrist 
and finger deformities are taken up separately; and that, by flexing the 
wrist in the extreme, the fingers are relaxed. It is essentially a gradual 
splint correction divided into two distinct stages. 
There are, however, definite limits to the efficacy of the conservative 
method alone. The most serious obstacle to correction is the flexion 
contracture of the wrist itself. In severe cases it is of such rigidity that 
either forcible or gradual stretching becomes out of the question; and 
in such cases one has to resort to operative methods. 
The methods generally applied might be divided into two classes: 
plastic operative methods of the soft structures, and bone plasty. 
Earlier operators tried incisions through the contracted muscle fibers 
(Drehmann). Systematic lengthening of the contracted flexor tendons 
was reported first by Schramm in 1904 and his results were very favor- 
able. Other authors attempted the release of contracted muscles by 
edgewise incisions into the muscle, making in this way a sort of pen- 
nated muscle. A good method, reported by Aberle, deserves mention. 
From the common head of the flexor muscles at the ulnar epicondyle, 
he severs the superficial layer in a flap containing the flexor carpi radialis, 
palmaris longus, and flexor digitorum sublimis. The pronator teres CONTRACTURES OF WRIST AND FINGERS 
131 
is left intact. After dissecting these muscles from their point of attach- 
ment, with careful preservation of their blood and nerve supply, the 
tendons of the flexor profundus are lengthened further distally and 
now the hand is fully extended. As this is done, the muscle flap pulls 
off from the internal epicondyle and is drawn downward. The subse- 
quent overcorrection following this operation was carried out by means 
of articulated splints. 
It seems to the writer that the methods applied for the release of 
the deformities in ischemic contractures should, above all, be simple 
and purposeful. If operative methods are required, and they are, prob- 
ably, in a large number of the cases, they must be considered only as 
an initial step in the correction which takes care of obstacles insur- 
mountable for the splint treatment alone. The method most commonly 
applied in the writer’s series was that of tendon plasty. 
A longitudinal incision is made on the volar surface from the middle 
of the wrist up to the middle of the forearm. On reaching the deep 
vaginal fascia, one is struck by the considerable thickening of this 
structure. The tendons of the flexor muscles are then picked out one 
by one. They will be found in different degrees of induration, often 
matted together, and identification of the individual tendons sometimes 
is not an easy matter. It is necessary to lengthen both flexors of the 
wrist, the common flexors of the fingers, and usually, also, the long 
flexor of the thumb. 
The individual tendons can be lengthened readily by longitudinal 
splitting, Z-shape fashion, making the halves of the tendons glide over 
each other as the wrist is corrected. The ends may be sewed side to 
side with very fine catgut. When the tendons are taken care of, the 
fascial compartments should be restored as much as possible under the 
circumstances. At any rate, sufficient covering should be given the 
tendons to prevent adhesions to the subcutaneous tissue and the skin. 
In cases of marked pronation contracture, plastic lengthening or section 
of the pronator teres and pronator quadratus should be done. The 
first muscle can be reached easily from a median incision on the volar 
side of the forearm. In order to reach the pronator quadratus, one 
must proceed into the depths between the deep flexors of the finger 
and isolate this muscle which is easily recognizable by its transverse 
fibers (Plate XXIII, i, 2, 3). 
When the operation is completed, a plaster cast is applied in the 
best possible position, reaching from the basal phalanges to below the 
shoulder joint. The position of the hand most desired is hyperextension 
of the wrist, slight flexion of the metacarpophalangeal joint and exten- 
sion of the phalangeal joints. In most of the severe cases, it is not 
possible to accomplish this position at the time of the operation. Cir- 
culatory conditions especially forbid forcible correction beyond a cer- 
tain point. But it is not the object of the operation to take care of 
the deformity with one stroke. It must be again repeated that the 
Operation is only the means of rendering the deformity amenable to LEGEND FOR PLATE XXIII 
TECHNIC OF RESECTION OF PRONATORS 
Fig. i.—Exposure of Pronator Teres. 
Fig. 2.—Resection of Pronator Teres. 
Fig. 3.—Section of Pronator Quadratus. PLATE XXIII 134 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
conservative treatment. The latter is absolutely indispensable and must 
be carried out just as faithfully and persistently as though the case had 
been treated by conservative methods from the start. Opponents to 
plastic operations point out the lack of functional recovery which is seen 
even in cases in which anatomical correction has been obtained. A lack 
of functional result must be expected from the degree and nature of 
the deformity, and it should not be laid against the operation. On the 
other hand, during the long continued after treatment, an improvement 
in the function is seen which is often beyond the initial expectations. 
Where there is a choice, the conservative method would of course be 
preferable, but a large number of cases is not amenable to the conserv- 
ative method alone. 
There are cases of marked flexion contracture of the wrist in which 
the shortening of the muscles is so great that correction even by tendon 
lengthening seems improbable. Such a situation arises occasionally 
when nerves and vessels of the forearm are shortened to the extent that 
a forced correction would carry with it the danger of grave circulatory 
disturbances. Garre, in 1895, recommended the resection of the forearm 
bones as a method to be applied in these cases. Rowlands and Watts, 
Kleinschmidt and others reported favorably upon this method. 
A piece of bone of suitable length is resected from the continuity of 
the lower third of the ulna and radius. Both ends of the bone are then 
drilled and pulled together by wire. This procedure shortens the fore- 
arm and allows a certain degree of correction of the flexion deformity, 
usually greater than could be obtained by the plastic lengthening of the 
tendon. It is difficult to determine at just what point the deformity 
becomes too extreme for tendon lengthening and requires the resec- 
tion of forearm bones. One often sees cases of most severe contracture 
of the wrist which yield after plastic lengthening under the influence 
of splint treatment, and it seems that the method of bone resection 
should be restricted to exceptional cases. In the writer’s series, the 
method of tendon lengthening has received the preference. CONTRACTURES OF WRIST AND FINGERS 
135 
Table of Cases of Ischemic Contrature 
Name 
Age 
Dura- 
tion 
Trauma 
Treated 
Onset of 
Deformity 
Treatment 
Deformity 
Result 
Degrees 
T. N. 
14 yrs. 
7yrs. 
fracture 
elbow 
splint 
in splint 
plastic length 
good; almost nor- 
mal motion; ob- 
served 2 years 
mild 
L. D. 
9 yrs. 
3 mos. 
fracture 
elbow 
splint in 
flex. 
contracture 
after 6 wks. 
resection pron. 
ter.; plastic 
length; flex, 
thumb plas- 
improved in func- 
tion ; deformity 
corrected; ob- 
served two yrs. 
moderate 
V. T. 
7 yrs. 
3 mos. 
supra-con- 
dyl. frac- 
ture 
splint in 
flex. 
contracture 
dev. after 
1 month 
plastic length 
perfect correction; 
much improved 
function; observ- 
ed 3 mos. (inter- 
rupted) 
severe 
H. C. 
6 yrs. 
3 mos. 
supra-con- 
dyl. frac- 
ture 
splint in 
flex. 6 
wks. 
contracture 
after 6 wks. 
plastic length 
correction good; 
function fair; ob- 
served 1 month 
(interrupted) 
severe 
M. H. 
7 yrs. 
14 mos. 
supra-con- 
dyl. frac- 
ture 
cast 6 
wks. 
after re- 
moval cast 
pre ssure 
sores 
plastic length 
correction good; 
function good; 
observed 16 mos. 
severe 
E. D. 
6 yrs. 
2 yrs. 
fracture 
humerus 
splint 
after few 
wks. 
resection pron. 
ter.; plastic 
length 
correction good; 
function fair; ob- 
served 8 mos. 
severe 
R. W. 
9 yrs. 
4 mos. 
supra-con- 
dyl. frac- 
ture 
splints 
(tight) 
after some 
wks. fol- 
lowing spl. 
plastic length 
correction good; 
function good; 
observed 6 mos. 
severe 
F. P. 
15 yrs. 
7 yrs. 
supra-con- 
dyl. frac- 
ture 
splints 
(tight) 
after sev- 
eral wks. 
plastic length 
(insuff.) re- 
section fore- 
arm bones 
correction fair; 
function fair; ob- 
served 1 yr. 
severe 
0. K. 
14 yrs. 
6 yrs. 
fracture 
e xternal 
condyle 
cast 9 
days 
deformity 
after re- 
moval cast 
resection pron. 
ter. and pron. 
quadr.; plas- 
tic length 
correction good; 
function fair; ob- 
served 6 mos. 
severe 
J. M. 
14 yrs. 
7 yrs. 
supra-con- 
dyl. frac- 
ture 
splint 
Deformity 
after sev- 
eral wks. 
plastic length 
correction good; 
function good; 
observed 2 yrs. 
moderate 
M. G. 
28 yrs. 
compound 
No fix- 
deformity 
resect, pron. 
correction good; 
very 
6 yrs. 
fracture 
humerus 
ation; 
injury 
brachial 
artery 
after sev- 
eral days 
ter.; plastic 
length 
function poor; 
observed 1 yr. 
severe 
D. P. 
6 yrs. 
3 mos. 
supra-con- 
dyl. frac- 
ture 
splint in 
acute 
flexion 
deformity 
2 wks. after 
removal of 
splint 
plastic length 
correction good; 
function fair; ob- 
served 1 yr. 
moderate 
L. 
18 yrs. 
dislocation 
no fix- 
ation 
deformity 
2 wks. after 
dislocation 
Conserv. 
correction good; 
function good 
mild 
C. K. 
14 yrs. 
11 yrs. 
birth-palsy 
forcible 
attempt 
at reduc- 
tion of dis- 
location 
no fix- 
ation 
deformity 
after ma- 
nipulation 
Thumb flexor 
plasty 
thumb good; fur- 
ther treatment 
refused 
severe 
(Plates XXIV, XXV, XXVI). LEGEND FOR PLATE XXIV 
Fig. i.—L. D. Ischemic Contracture. 
Figs. 2, 3.—L. D. After Tendon Lengthening and Thumb Plasty. 
Fig. 4.—J. M. Ischemic Contracture. 
Fig. 5.—J. M. After Plastic Lengthening of Flexor Tendons. 
Fig. 6.—O. K. Ischemic Contracture. 
Figs. 7, 8.—O. K. After Tendon Plasty and Pronator Resection. PLATE XXIV LEGEND FOR PLATE XXV 
Fig. i.—R. W. Ischemic Contracture. 
Fig. 2.—R. W. Glove Traction Splint. 
Fig. 3.—R. W. Result of Tendon Lengthening and Jones’ Treatment. 
Fig. 4.—D. P. Ischemic Contracture. 
Fig. 5.—D. P. After Plastic Lengthening. 
Fig. 6.—M. .W. Ischemic Contracture. 
Fig. 7.—M. W. After Treatment. 
Fig. 8.—V. T. Ischemic Contracture. 
Fig. 9.—V. T. After Treatment. PLATE XXV LEGEND FOR PLATE XXVI 
Fig. i.—H. C. Ischemic Contracture. 
Fig. 2.—H. C. After Tendon Plasty. 
Fig. 3.—M. G. Ischemic Contracture. 
Fig. 4.—M. G. After Tendon Plasty and Pronator Resection. 
Fig. 5.—Microphotograph of Muscle in Ischemic Contracture; Interstitial Myositis. 
Fig. 6.—Microphotograph Inflammatory Myositis. Note Fibrous Infiltration. 
Fig. 7.—Microphotograph Peripheral Palsy. Note Atrophy of Muscle Fibrillae. 
Fig. 8.—Microphotograph of Infantile Palsy. Note Selective Atrophy of Muscle 
Fiber and Fat Infiltration. PLATE XXVI 142 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
SUMMARY 
Cases 
Treated conservatively i 
Treated operatively 13 
Not treated 2 
Total number of cases 16 
Nature of Bone Injury 
Cases 
Supracondyloid fracture 11 
Fracture of external condyle 1 
Fracture of forearm 1 
Compound fracture of the humerus with injury to 
brachial artery 1 
Dislocation of the elbow 1 
Dislocation of the shoulder with attempt at forcible 
correction 1 
16 
Time Elapsed 
Between Injury and Appearance of Contracture, 
2 days to 3 months. 
Between Injury and Treatment of Contracture, 
1 month to 7 years. 
Original Treatment of the Injury 
Cases 
Constricting- casts were applied 3 
Constricting splints were applied 5 
Nonconstricting splints were applied 4 
Neither splints nor casts 4 
16 
Deformity 
Cases 
Flexion of the wrist and pronation 7 
Flexion of the wrist, pronation and claw-hand deformity 9 
16 CONTRACTURES OF WRIST AND FINGERS 
143 
Treatment Applied 
Cases 
Tendon plasty 7 
Tendon plasty plus resection of pronators 3 
Flexor plasty of thumb alone (further treatment re- 
fused) 1 
Tendon plasty plus pronator resection, plus thumb plasty 1 
Resection of forearm bones 1 
Conservative treatment alone 1 
14 
Not treated 2 
16 
Results (Functional) 
Cases 
Cured 5 
Improved considerably 6 
Improved moderately 3 
14 
In one instance, the ischemic paralysis and contracture followed the 
attempt at reduction of an obstetrical dislocation of the shoulder. It 
was stated in the history that motion of the fingers and hand had been 
present before the attempt was made. This is a rather unique etiology 
of an ischemic contracture for which we have not found a parallel in 
the literature. 
In another instance the damage to the circulation occurred higher 
up, in the upper third of the humerus, and was occasioned by a severe 
injury to the brachial artery from a gunshot wound. 
The remainder of the cases were caused in a typical way, by injuries 
to the elbow and forearm bones. Only in 1 case was a dislocation of 
the elbow mentioned in the history, but this could not be verified at 
the time of examination. 
In some cases it was stated that the deformity began to appear 
while the cast was still being worn. A remarkable fact with regard 
to the fixation is that, among the 15 cases, only 3 had constricting casts 
according to the history. But 5 more cases had tight splints applied, 
showing that constriction might be brought about by tight splints as 
well as by tight casts. On the other hand, there are 4 cases in which 
splints were worn but no constriction by the splints was observed and 
in 3 other cases there were neither casts nor splints applied. This is 
not in accord with the general opinion that external constriction is 
responsible in 80 per cent of the cases, since, in the writer’s series, in 
only 8 out of 15 cases could external constrictions be established in 144 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
the history, and constriction by cast in only 3. It would seem, therefore, 
that the internal pressure from the hematoma plays a more important 
part in the production of the ischemic symptoms than is generally as- 
sumed. It should also be remembered that, in supracondyloid fracture 
of the humerus with the presence of a large hematoma, fixation at an 
acute angle may increase the pressure; the position must sometimes 
be modified to some extent in order to take care of this, contingency. 
A majority of the severe cases (9 out of 15) showed hyperextension 
in the metacarpophalangeal joints, although not all cases showing this 
hyperextension had an actual involvement of the intrinsic muscles of 
the hand with loss of function of the interossei. In fact, when the 
correction is completed, the interossei are generally the first ones to 
resume function before the flexors of the finger, except, of course, in 
those cases where the interossei are lost, due to involvement of the ulnar 
nerve. The claw-hand deformity, therefore, is not by any means attrib- 
utable to the loss of the interossei function only, but more generally 
to the condition of the equilibrium between extensors and flexor muscles. 
To this hyperextension, the extreme flexion of the wrist bears a close 
etiological connection; the details of this syndrome have been described 
before. 
Impairment of sensation was noted in 7 cases, 3 of which were 
associated with cyanosis, and 2 showed trophic ulcers. It is remarkable 
that the nutrition of the hand greatly improves with the correction of 
the deformity. Trophic ulcers heal, the cyanosis disappears and sensa- 
tion becomes reestablished to a considerable degree. 
After Treatment.—Emphasis has already been laid upon the fact 
that the surgical treatment of this deformity is only the first stage. 
Intensive after treatment must follow the operation for months and 
even years. 
After treatment should begin as early as possible after operation. 
Active motion may be instituted within a few days after operation, even 
while the limb is in the cast. As soon as feasible, the plaster cast applied 
at operation is replaced by a splint. This splint must meet the follow- 
ing requirements: the hyperextension of the wrist must be secured by 
a cockup arrangement; flexion of the metacarpophalangeal joints should 
be obtained by traction; and finally the forearm should be secured in 
supination by a splint so arranged that its application will force supi- 
nation position. In order to meet all these requirements, a rather com- 
plicated splint would be necessary. But the extension of the wrist, the 
flexion in the metacarpophalangeal joint and the extension of mid and 
end phalangeal joints can be accomplished by combination of a cockup 
splint with a traction system which acts upon both the basal and end 
phalanges. The writer has used a so-called glove traction splint which 
has a volar cockup band and in which traction is applied by a double 
system of straps attached to a strong glove pulled over the hand. These 
systems of traction straps attached to the glove are arranged in two 
rows; one bends the basal phalanges into flexion, and the other extends CONTRACTURES OF WRIST AND FINGERS 
145 
the mid and end phalanges, both systems forming an angle of about 
45 . These straps can then be attached to a curved rod, the proximal 
end of which is fastened to the cockup splint attached to the forearm. 
This splint completes the correction of what deformity remains after 
operative interference. Massage and passive motion are given daily 
while this splint is worn, and the patient is early encouraged to execute 
active motion and to begin his regular course of muscle educational 
treatment (Plates XIX, 6; XX, 4; XXV, 2). 
The results obtained were, as a rule, not unfavorable. Improvement 
obtained in 5 cases was so complete that the hand regained practically 
normal function. These, of course, were the milder cases of ischemic 
contracture, though some of them were of long standing. The other 
9 cases showed improvement in various degrees; a satisfactory correc- 
tion was obtained in practically all of them, but in some the flexion 
power of the fingers was rather poor. 
The persistence with which the after treatment is carried out has 
a great deal to do with the final result. The function of the fingers is 
somtimes slow in developing. It was observed that flexion of the 
fingers in severe cases is first carried on by the interossei, and later the 
superficial and deep end flexors of the finger become more pronounced 
in asserting their action. In more than one-half of the cases the muscle 
development progressed to a point where complete closure of the hand 
was possible and the gripping power was good. Determined persistence 
in the after treatment is, as mentioned before, an absolute essential for 
the ultimate result. The average time of treatment is hardly less than 
one year. 
MADELUNG’S DEFORMITY OF THE WRIST 
The earliest observation of the unusual deformity of the forearm 
known as Madelung’s deformity dates back to Dupuytren (1839), who 
found this condition in workers of all kinds and especially in those 
whose work required strain of the wrist joint as in pressers, cloth 
workers, washerwomen, or teamsters. Although mention of this de- 
formity was already made by Beguin in 1825, Dupuytren’s report is 
probably the first independent report on record. He was inclined to 
connect this trouble with a certain relaxation of the joint capsule and 
the reinforcing ligaments. 
There is an anatomical description of this deformity at hand from 
the pen of Jean (1875), who found the lower extremity of the radius 
bent forward toward the vola of the hand, and the lower extremity of 
the ulna projected into the dorsum. 
In 1878, there appeared the description of this disease by Madelung, 
which has given the name to this type of deformity. Madelung also 
lays stress upon the lower bend of the radius which causes the hand to 
be deflected toward the vola and the lower end of the ulna to become 146 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
distinctly prominent in the dorsum of the hand. The anteroposterior 
diameter of the hand appears increased and there is sometimes a slight 
lateral deviation. The flexor tendons, especially the flexor carpi radialis 
and the flexor pollicis longus, are distinctly prominent. No abnormal 
mobility is noted between the radius and the hand. There is an im- 
pairment of the dorsiflexion of the hand, whereas the volar flexion is 
usually normal or even increased. Occasionally one finds a great deal 
of tenderness over the wrist, but distinct pressure points are rare. 
Madelung was able to report on 12 cases, of which 9 were unilateral. 
He also noticed the preponderance of female patients over male pa- 
tients, the former being twice as numerous in his collection as the latter. 
In Madelung’s series, the disease developed insidiously and slowly 
between the thirteenth year in the youngest, and the twenty-third year 
in the oldest of his cases. Speculation has been rife as to the etiology 
of this condition. Among 85 cases mentioned by Estor, there were 
11 hereditary instances, and in one group of Guepin, 15 members of one 
family are mentioned. Fere mentions a case of mother and 2 daughters; 
Jagot—heredity in 3 generations. Of Estor’s 85 cases in the literature, 
there were 10 observations of traumatism (Malgaigne, Madelung, 
Duplay, Redard, Kirmisson, and others). In 17 of the 85 cases of 
Estor, occupational strain is mentioned. Finally, mention of rickets as 
a contributing or etiological factor is made by Duplay, Delbet and 
Fere, and others. 
The prominent pathological feature of this deformity is a disturbance 
of growth in the lower end of the radius. It seems that this transfor- 
mation of the bone is accompanied by pain, especially noticeable in the 
formative stage of the deformity. Later, pain disappears and the 
patients are again able to take up their work. The curving of the 
radius is sometimes uniform and distributed over its entire length in- 
stead of involving the lower end only, as in typical cases. The scaphoid 
and semilunar are not dislocated but retain their normal relationship 
to the radius except for the change of direction which is brought about 
by the forward bend of the lower end of the radius. 
There is, however, a change in the relation between the ulna and the 
carpal bones. This is due to the fact that the ulna, not following the 
forward incurvation of the radius, becomes dorsally displaced, so that 
there is a secondary dislocation in the ulnotriquetral articulation. Such 
displacement of the ulna is by no means confined to Madelung’s de- 
formity alone. In arthritic hands, in which there is a strong flexion 
contracture of the wrist, dorsal displacement of the ulna is often 
observed. It is due to the fact that a forward bend of the radius de- 
veloping in arthritic conditions causes a volar deflection of the hand, 
leaving the ulna behind in its original position. Some authors distin- 
guish between the true Madelung’s deformity and the so-called radius 
carvus; in the latter type the bend involves the entire length of the 
bone, in the former, the distal portion only. 
A complete review of the literature up to 1909 is contained in an CONTRACTURES OF WRIST AND FINGERS 
147 
article by Stetten, covering 64 cases and eliminating carefully those 
about which there is doubt as to their identity. Of these, the radius 
was bent forward in 62 cases. In 2 cases, there was a bend of the radius 
backward so that a sort of silverfork deformity existed similar to that 
observed in Colles’ fracture. One of these cases was reported by Kir- 
misson in a nineteen-year-old girl who showed both backward and 
ulnar displacement of the radius. The same deformity was noted by 
Stetten in a girl of twelve. In a great number of these cases, the for- 
ward deflection is located in the epiphyseal end, but the bend is accen- 
tuated besides by an additional curving of the entire bone. Certain 
changes in the carpal bones are also seen in the X-ray picture. Instead 
of forming an arch as in the normal hand, the bones of the first carpal 
row form an acute angle, with the semilunar at the apex. As a rule, 
the relations between scaphoid, semilunar, and radius remain normal. 
The cuneiform, however, loses its connection with the triangular car- 
tilage due to the fact, already mentioned, that the ulna does not take 
part in the forward bend but remains in its normal position. 
The deformity is overwhelmingly bilateral, 43 bilateral to 20 unilat- 
eral, in the cases of Stetten. With regard to sex, it is much more 
frequent in females than in males, though the ratios given vary between 
2 to 1 and 7 to 1. 
Pain is usually the first feature which calls attention to the trouble. 
It appears gradually and insidiously, as does the deformity itself. Pain 
usually appears upon exertion and is most marked during the formative 
stage of the deformity. As the latter becomes more firmly established, 
the pain gradually disappears. 
Madelung’s deformity is essentially one of the growing age, the 
youngest patient on record being eight, and the oldest twenty-five years. 
At this time there is an increase of the normal growing activity of the 
epiphyseal cartilage. Hereditary, traumatic, and occupational influences 
have already been mentioned. The disease is never congenital. While 
it is now believed that the immediate factor is that of disturbance of 
growth in the lower end of the radius, a relaxation of the capsule and 
ligaments as the cause of deformity was assumed by Dupuytren himself. 
From this point of view, late rickets may be considered as a factor and 
Duplay calls it a rachitic curvature of the inferior extremity of the 
radius. However this may be, this much seems to be certain, that there 
is constant and definite disturbance of growth in the lower end of the 
radius which, with the aid of the pull of the flexor muscles of the wrist, 
brings about this deformity. 
The average time for the full development of this deformity is three 
years. Next to pain, weakness, fatigue, and limitation of motion in 
certain directions are the principal symptoms. In the common type, 
in which there is forward bend of the radius, extension is naturally 
limited, while in the exceptional cases, with backward bend of the radius, 
there is limitation of flexion. There is also a slight restriction of pro- 
nation and supination. 148 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
In some cases it is possible to reduce the ulna back to the level of 
the radius, although in the majority of cases it is not, and even where 
one can reduce the ulna, it cannot be maintained in this position and 
always tends to regain its normal place dorsally. 
From the viewpoint of differential diagnosis, only a few conditions 
must be considered. Colles’ fracture with forward displacement of the 
hand may easily be excluded from the history and the X-ray findings. 
In some cases, arthritic conditions of the hand may come into consid- 
eration, especially since the latter are also able to produce a backward 
dislocation of the ulna. Here again the history and the absence of 
involvement of other joints will bring about the decision. 
In regard to the treatment, Madelung himself did not consider any 
method of especial value. He pointed out that after a period varying 
from one-half to three years from the onset, pain and weakness dis- 
appear and the patients are able to resume their occupations. Neither 
braces nor plaster casts nor tenotomy of the flexors of the forearm as 
practiced by Webber have brought about any appreciable results. 
The only method which has proved successful in advanced degrees 
of the deformity is that of wedge osteotomy such as carried out 
by Redard, or the simple osteotomy of Duplay and Kirmisson, or the 
oblique osteotomy as practiced by Poulson. 
In considering operative interference, two groups of cases should 
be distinguished. In one, there is a simple turning down of the articular 
surface due to the bending of the lower end of the bone; in the other, 
the so-called radius carvus, the entire bone is bent. It seems that the 
first type is more benefited by osteotomy than the second. 
Massage with active and passive motion should always follow opera- 
tive interference and should be carried out with persistence. 
Case Reports.—Girl, 12 years old. Complains of deformity in both 
forearms developing for the last 3 years, not accompanied by pain. 
Both forearms show very remarkable deformity consisting in a sharp 
volar bend of the lower end of radius, causing a notable shortening of 
the forearm. The power of the fingers is intact except for a certain 
weakness in flexion owing to the flexion position of the wrist. X-ray 
shows forward bend of the lower end of the radius, the ulna in its 
normal place and in a position of posterior subluxation in relation to 
the wrist. Osteotomy advised, but refused. 
Woman, 22 years old. At the age of 12 she began to show increas- 
ing deformity of both wrists, following accident in each case. This 
accident was followed by a slow and gradually increasing deformity 
of the same type in each hand. Wrists painful at times. The X-ray 
showed a deformity of the wrist consisting in a volar bend of the lower 
end of the radius and displacement backward of the ulna, while the 
relation between radius and carpus was intact. The peculiar point in 
this case was the statement of injuries received in both wrists which 
did not result in fracture but after which a deformity developed gradu- 
ally, with all the symptoms of Madelung’s deformity. CONTRACTURES OF WRIST AND FINGERS 
149 
Summary.—Madelung’s deformity is characterized by a gradual 
development of a volar bend of the lower epiphysis of the radius during 
the adolescent age. It is most prevalent in women. The deformity 
itself is accompanied by symptoms of ache or pain, attributable to mus- 
cular and ligamentous strain. The pain disappears after the full estab- 
lishment of the deformity. Heredity plays a certain part and predis- 
position and late rickets may be factors in the etiology of the deformity. 
The significance of trauma is uncertain. Milder cases require no treat- 
ment. Cases with distinct functional impairment and with a consider- 
able and localized deformity are greatly benefited by osteotomy. 
DUPUYTREN’S CONTRACTURE 
The description of the first case of this deformity goes back 
to Astley Cooper; but it was Dupuytren in 1831, who first dissected a 
case of this type of contracture which thenceforth took his name. 
The deformity consists in a thickening and contracture of the digital 
processes of the palmar fascia. The main body of the palmar fascia is 
affected secondarily. As a result of the thickening and contracture the 
fingers become more and more drawn into the palm. The flexor 
tendons take no part in the contracture. In extreme cases the inter- 
phalangeal joints may become partially dislocated (Block). 
The contracture begins insidiously and slowly, without any apparent 
cause. There are no signs of inflammation, pain, or tenderness, and 
imperceptibly the flexion position increases. The fourth and fifth are 
the fingers usually involved. The flexor tendons are usually not in- 
volved in the contracture but the latter is entirely extratendinous. For 
this reason the extreme position of flexion of the hand does not add 
to the range of passive extension, but the fingers remain in their con- 
tracted position. The first finger to become involved is the ring finger, 
but the fifth soon follows in the contracture. 
Pathology.—Microscopically the thickened palmar fascia consists of 
fibrous strands intermingled with cellular infiltration. In the earlier 
stages the skin over the thickened fascia appears normal, but later it 
becomes puckered and thickened, owing to the contraction of the fibers 
of the palmar fascia adhering to the skin. 
Tubby believes that Dupuytren’s contracture is nothing more than 
a localized fibrositis occurring in a part of the palm subject to pressure 
and to sudden strains and blows. He also points out the fact that the 
fibrous changes are associated often with the arterial hardening common 
to advancing years. 
The inflammatory condition of the aponeurosis is expressed chiefly 
by increased formation of connective tissue fibers. This proliferation is 
most marked around the arterial sheaths and in the subendothelial layers 
of the capillaries. In this way there appears within the aponeurosis a 
proliferation and thickening of vascular and loose connective tissue 150 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
between the individual bundles or strands of the fascia. At the same 
time, the connective tissue slips of the plantar fascia likewise proliferate 
and cause an intimate adherence of the palmar fascia to the skin and 
subcutaneous fat. 
By some (Krogius), this contracture is ascribed to developmental 
disturbances of the superficial palmar muscles (flexors breves manus 
superficiales) ; just as the palmar aponeurosis should be considered as 
a derivate of these muscles which exist in different mammals and also 
in the human embryo, so the new-formed tissue which causes these 
contractures should be considered as a derivate of embryonal rests of 
this muscle stratum. Such explanations appear to be of a rather con- 
jectural nature, especially since it seems certain that the contracture 
is one of middle or later life and is evidently superinduced, if not caused, 
by continuous strain and stress. 
Statistics.—Black’s figures on 240 cases show that 104 cases were 
bilateral and 136 cases were unilateral. Of the unilateral 
89 involved the right hand, 
47 involved the left hand. 
The statistics of Hume on 118 cases show that 
40 cases were bilateral and 
78 cases unilateral. 
Of the unilateral 
57 involved the right hand, 
21 involved the left hand. 
The statistics of Keene on 184 cases show that 
103 cases were bilateral and 
81 cases unilateral. 
Of the unilateral 
58 cases involved the right hand, 
23 cases involved the left hand. 
These figures reveal not only a preponderance of unilaterality over 
bilaterality but also a decided preponderance of the right hand over the 
left hand, the former being twice as often involved as the left in unila- 
teral cases. 
Treatment.—In the earlier stages one may try the conservative 
treatment consisting in extension, manipulation, massage, hot water, 
Bier’s hyperemia and fibrolysin application. But in all advanced cases, 
especially in those in which flexion contracture has already developed, 
operative measures are necessary. 
Systematic treatment by multiple tenotomies has been advised by 
Adams. He performs his multiple tenotomies first near the carpus, then 
at the metacarpophalangeal joints, and gradually severs all strands and 
extensions of the contracted fascia. The mechanical after treatment is 
begun from four to five days afterwards. All subcutaneous methods so 
far have failed on account of the insufficiency of the resection of the 
palmar fascia. The newer methods consequently all aim at complete 
excision of the palmar fascia. CONTRACTURES OF WRIST AND FINGERS 
151 
Method of Tubby.—In 1904, this author published a method of deal- 
ing with the deformity by incision and clean dissection of all the fascia 
involved so that not a single part of the dense white tissue is left. A 
longitudinal incision is made over the most prominent portion in the 
palm and, if necessary, cross incisions are added. Flaps are dissected 
and turned back. There is some difficulty in doing this and one must 
avoid buttonholing the skin. Every portion of the fascia is dissected 
and hemorrhage arrested by pressure and hot water. Fibrolysin is 
poured into the open wound and thoroughly rubbed in for two minutes. 
The hand is put up in a malleable splint for two weeks. The author 
reports excellent results with this method. 
The treatment advised by Hutchinson is as follows: first, the strands 
of contracted and thickened fascia are dissected out from a palmar in- 
cision; second, a resection of the head of the basal phalanx is performed 
from a semilunar incision, dorsally over the first interphalangeal joint, 
after division of the extensors; and finally, the extensors are re-sutured. 
This author is an ardent opponent of splinting because of its stiffening 
effect upon the joints of the affected fingers. Among his cases he found 
arthritis and contracture of all the joints of both hands following splint- 
ing. 
In order to avoid adhesions of tendons after operative correction of 
the contracture, Spitzy uses injections and applications of animal fat. 
He first carries out the dissection of the fascia, then does the necessary 
tendoplasties, and finally greases the tendons with fat and injects it under 
the skin before the last skin suture is applied. A splint is worn for 
one or two days and then motion is carefully started. 
One of the most thorough methods is that of Gill. It consists in 
transverse incision along the distal palmar crease. Through this incision 
a careful dissection is made of the entire palmar fascia, to or beyond 
the crease at the base of the thenar eminence. Distally it is carried to 
the web of the fingers. Buttonholing must be carefully avoided. Then 
the contracted fascia is excised without injury to the underlying nerves 
and vessels. The tendons do not require lengthening. If the first inter- 
phalangeal joints cannot be extended, the head of the basal phalanx 
should be resected through the dorsal incision (Hutchinson). A small, 
free transplant from the thigh is inserted smoothly beneath the palmar 
skin to prevent adhesions to the tendons. 
Under the writer’s observations have come 2 cases, each typical, 
neither of whom consented to operations. 
Man of 54, editor, contracture starting with fifth finger, bilateral 
and symmetrical. At the time of examination the deformity was on the 
increase. Does no heavy manual work. 
Man of 30, civil engineer, contracture starting with fourth and also 
involving fifth finger of right hand. Does considerable heavy manual 
work (Plate XXVII, 1, 2). LEGEND FOR PLATE XXVII 
Fig. i.—J. S. Dupuytren’s Contracture. 
Fig. 2.—S. H. Dupuytren’s Contracture. 
Fig. 3.—H. B. Spastic Hemiplegia. 
Fig. 4.—H. B. After Stoffel’s Operation and Arthrodesis Plus Interosseous 
Transplantation. PLATE XXVII 154 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
BIBLIOGRAPHY TO INFLAMMATORY CONTRACTURES OF HAND 
AND FINGERS 
Alexander, E. G. Treatment of contracted old cicatrices, Ann. of Surg., 1915, 
60:451. 
Bernstein, M. A. The treatment of early and late infections of the hand and 
fingers, with special reference to tendon transplantation, Surg. Clin. 
Chicago and Philadelphia, 1918, 2:1249. 
The surgery of tendon transplantation with special reference to the im- 
portance of the tendon sheath, Surg. Gyn. Obstet., 1919, 29:69. 
Beye, H. L. Deep palmar hand infections, Ann. of Surg., 1918, 67: 152. 
Deep palmar hand infections, Ann. of Surg., 1917, 66:481. 
Biesalski and Mayer. Die physiologische Sehnenverpflanzung. Springer, 
Berlin, 1916. 
Black, J. F. A plea for greater care in hand surgery, Med. Rec., New York, 
1919, 94:775- 
Davis, J. S. Use of pedunculated flaps in reconstructive surgery, Ann. of Surg., 
1918, 68:221. 
Dobbertin. Tendolysis, Deutsche med. Wchnschr., 1918, 44:322. 
Dubreuil et Bardet. Dififormites des mains causees par des cicatrices datant 
de 1’ enfance, Journ. de med. de Bordeaux, August 25, 1920. 
Gross, W. Ersatz beider Fingerbeugesehnen durch Heteroplastik, Deutsche 
med. Wchnschr., 1918, 44:374. 
Grund, G. Uber vollige Strecklahmung in den Interphalangealgelenken und 
einen Fingerstreckapparat zu ihrer Korrektur, Miinchen. med. Wchnschr., 
June 27, 1919, 718. 
Hacker, E. Autoplastischer Ersatz der Streck und Beugesehnen der Finger 
durch entbehrliche Sehnen des Handriickens, Beitr. z. klin. Chir., 1910, 
66:259. 
Holtz. Behandlung von Fingerverletzungen, Miinchen. med. 
Wchnschr., June 17, 1919, 719. 
Kirmisson, E. Yolumineux oedeme de la main gauche avec retraction per- 
manente des tendons flechisseurs consecutif a une lesion du nerve median 
au niveau du poignet, Bull, et mem. Soc. de Chir. de Paris, 1918, 44:689. 
Mayer, L. Recent studies in the physiology of tendons and their application to 
the treatment of poliomyelitis, Med. Rec., New York, 1919, 95:428. 
The physiological method of tendon transplantation, Surg. Gyn. Obstet., 
1916, 22: 182. 
Morestin, H. De la correction des flexions permanentes des doigts consecutive 
aux panaris et aux phlegmons de la paume de la main, Rev. de Chir., 1914, 
vol. 50. 
Quenu. De la reparation autoplastique a l’aide d’un lambeau digital dans 
quelques plaies de la main, Rev. de Chir., 1916, vol. 51. 
Reschke. Zur Behandlung dermatogener Beugekontrakturen, Arch. f. klin. 
Chir., 1918, hi: 589. 
Roberts, J. B. Salvage of the hand by timely reparative surgery, Ann. of Surg., 
1919, 70:627. 
Schede, F. Zur Behandlung der Fingerkontrakturen, Miinchen. med. Wchnschr., 
May 20, 1919. CONTRACTURES OF WRIST AND FINGERS 
155 
Skillern, T. G. Large skin grafts to hand from abdomen, Internat. Clinic, 
Philadelphia, 1919, Series 3, 29:78. 
Verall, P. J. Stiff fingers; with special reference to methods of treatment by 
metal and plaster splints, Journ. Orthop. Surg., 1919, 335. 
Wilson, J. C., and Hyman, C. H. Reconstructive surgery of the hand, Journ. 
Am. Med. Assoc., 1919, 73:1811. 
BIBLIOGRAPHY TO NEOPLASTY OF FINGERS AND THUMB 
Albee, F. H. Orthopedic and reconstructive Surgery. Saunders, 1919, 1016. 
Synthetic transportation of tissue to form new fingers with restored 
funtion of hand, Ann. of Surg., 1919, 69:379. 
Brook, W. F. Vanghetti’s operation, Brit. Med. Journ., 1918, 2:626. 
Bunnell, S. Repair of tendons in the fingers and description of two new 
instruments, Surg. Gyn. Obstet., January 26, 1918, 103. 
Cotte, G. Restauration anatomique ou fonctionelle du pouce, Lyon chirurg., 
1919, 16:45. 
Keith, A. Menders of the maimed. London, 1919. 
Klomm, P. Uber plastische Operationen an den Hiinden, Arch. f. klin. Chir., 
1911, 96: 181. 
Kuemmell. Krukenbergeche Vorderarmamputation; die plastische Unwertung 
der Vorderarmamputationsstiimpfe, Deutsche med. Wchnschr., 1918, 
44:983. 
Lyle, H. M. Formation of a new thumb, Ann. of Surg., 1914, 59:767. 
Manasse, P. Vorstellung eines Falles mit Daumenersatz und Fingerauswechs- 
lung, Berk klin. Wchnschr., 1919, 56:717. 
Muesam, R. Uber Ersatz des Daumens durch die Grosse Zehe, Berk klin. 
Wchnschr., 1918, 55 : 1045. 
Neuhaeser. Daumenplastik, Deutsche med. Wchnschr., 1918, vol. 30. 
Oehlecker. Ein Daumen durch die grosse Zehe nach Nicoladoni ersetzt, 
Deutsche med. Wchnschr., 1918, 44: 1207. 
Pieri, G. Ricostruzione del pollice dal moncone della falange basale, La Chir. 
degli organi di movimento, 1919, 3:325. 
Putti, V. L’utilizzazione dei movimenti rotatori e la forcipizzazione dei 
monconi di avambraccio, La Chir. degli organi di movimento, 1920, 4:65. 
Quetsch. Greifklauenbildung bei ausgedehntem Fingerverlust, Berk klin. 
Wchnschr., 1918, 55:785. 
Riedel. Nicoladonische Daumenplastik, Berk klin. Wchnschr., 1918, 55:559. 
Ritter, C. Die Bildung eines Greiforganes aus der Hand beim Verluste eines 
Fingers, Berk klin. Wchnschr., 1918, 55: 1047. 
Scalone, I. Processo operatorio per la cinematizzazione dei monconi di ampu- 
tazione per una efficace produzione di lavoro, La Chir. degli organi di 
movimento, 1920, 4:50. 
Schepelmann, E. Das spatere Schicksal einer Daumenplastik, Ztschr. f. 
orthop. Chir., 1919, vol. 39. 
Weitere Erfahrungen fiber Fingerplastik, Ztschr. f. orthop. Chir., 1916, 
35:827. 
Sievers, R. Freier autoplastischer Phalangenaustausch in Folge eines Riesen- 
zellensarkoms des Ringfingers, Beitr. z. klin. Chir., 1913, 85:1. 156 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Vanhetti, G. Progressi attuali della plastica cinematica, La Chir. degli organi 
di movimento, 1917, vol. 1. 
Verall, G. P. Three cases of reconstruction of the thumb, Brit. Med. Journ., 
1919, 2:775. 
Wierzejewski, I. Daumenstumpfbildung, Miinchen. med. Wchnschr., 1919, 
66:19. 
BIBLIOGRAPHY TO ISCHEMIC CONTRACTURE 
Aberle, R. Zur operativen Behandlung hochgradiger ] fandgelenkskontrakturen, 
Ztschr. f. orthop. Chir., 1906, vol. 16. 
Alexander, E. G. Treatment of Volkmann’s contracture, Ann. of Surg., 
I9I3- 
Alivisatos, N. and Oeconomos. De la retraction musculaire ischemique, Grece 
Med., vols. 13, 14, 18. 
Barnays, A. C. On ischemic paralysis, Boston Med. and Surg. Journ., 1900, 
vol. 142. 
Binet. Retraction musculaire ischemique de Volkmann, Rev. de Chir., 1910, 
vol. 41. 
Davis, G. G. Transaction Phila. Academy of Medicine, Ann. of Surg., 1913. 
Dreiimann, C. Zentralbl. f. phys., Therapie, 1:9. 
Durau, L. Volkmann’s Contracture, Rev. de Chir., 1914, vol. 49. 
Froelich. Paralysie ischemique de Volkmann, Rev. d’Est, 1914. 
Gillert, E. Uber ischaemische Muskelkontrakturen, Arch. f. klin. Chir., 1919, 
112:413- 
Ginsberg, N. Volkmann’s contracture, Am. Journ. Med. Sciences, 138:4. 
Jopson, J. H. Volkmann’s ischemic contracture, Ann. of Surg., 1911, 53:578. 
Kleinsciimidt, D. Ischaemische Muskelkontrakturen, Deutsche med. Wchnschr., 
1907, vol. 33. 
Lapisky. Deutsche Ztschr. f. Nervenheilk., 1900, vol. 17. 
Leser, E. Volkmanns Sammlung klinischer Vortraege. 1884, 249. 
Lorenz, H. Wien. klin. Wchnschr., 1902. 
Peltesohn, S. Uber Cubitus Valgus mit sekundaeren Stdrungen im Gebiete 
des Nervus Ulnaris, Ztschr. f. orthop. Chir., 1906, vol. 17. 
Petersen. Arch. f. klin. Chir., 1888, vol. 38. 
Powers, C. A. Further account of a previously reported case of ischemic 
paralysis, Journ. Am. Med. Assoc., May 11, 1912. 
Rowlands, R. P. Lancet, 1905. 
Schramm. Uber Volkmannsche Kontraktur, Wien. med. Wchnschr., 1904, Nos. 
27, 28. 
Smietochovsky. Case of Volkmann’s paralysis of hand. Lancet, 1913. 
Tayloer, A. S. Ischemic paralysis and contracture, Ann. of Surg., January, 
I9I7- 
Thomas, J. J. Nerve involvement in Volkmann’s contracture, Ann. of Surg., 
March, 1909. 
Watts, S. Volkmann’s paralysis, Journ. Am. Med. Assoc., vol. 41. 
Weber, R. Zur Aetiologie peripherer Ulnaris und Medianuslahmungen, 
Deutsche Ztschr. f. Nervenheilk., 1899, vol. 15. 
Zur Vf.rth. Drucklahmung saemmtlicher Nerven des Unterarmes und der 
Hand, Miinclien. med. Wchnschr., 1905, No. 25. CONTRACTURES OF WRIST AND FINGERS 
157 
BIBILOGRAPHY TO MADELUNG’S DEFORMITY 
Abadie, J. De la luxation progressive du poignet chez l’adolescent, Rev. 
d’orthop., 1903, Series 4, 2:481. . 
Ardouin, P. Un cas de luxation congenitale incomplete du poignet, Rev. 
d’orthop., 1902, 3 :351. 
Beguin. Difformite radiocarpienne, Dictionaire abrege des sciences medicates, 
1825 (quoted Stetten). 
Binet et Mutel. Radius curvus, Rev. de Chir., 1913, vol. 48. 
Brinsmade, W. B. Madelung’s deformity, Ann. of Surg., May, 1908. 
Knopf. Uber Madelungs spontane Subluxation des Handgelenkes nach vorn, 
Zentralbl. f. Chir., 1903, 30:574. 
Delbet, P. Leqons de clinique chirurgicale faites a l’Hotel Dieu a Paris. Paris, 
1899 (quoted Stetten). 
Duplay, S. De l’osteotomie du radius pour remedier aux difformites du poignet, 
soit spontanees, soit traumatiques, Arch. gen. de med., 1885, Series 7, , 
15:385- 
Dupuytren. Lessons orales de clinique chirurgicale a l’Hotel Dieu de Paris. 
Paris, 1834, 4:197 (quoted Stetten). 
Estor, E. La subluxation congenitale du poignet, Rev. de Chir., 1907, 36: 145. 
Ewald, P. Die Aetiologie der Madelungschen Difformitat, Arch. f. klin. Chir., 
1907, 84:1099. 
Francke, F. Zur Anatomie der Madelungschen Deformitat, Deutsche Ztschr. 
f. Chir., 1898, 48:156. 
Gasne, E. Deformations rachitiques tardives du poignet; subluxation de 
Madelung et radius curvus, Rev. d’orthop., 1906, Series 2, 7:153. 
Gaugele, K. Madelungs Handgelenksdeformitat, Arch. f. klin. Chir., 1909, 
88: 1058. 
Gevaert, G. Subluxation de poignet de Madelung, Rev. d’orthop., 1902, 3:335. 
Guepin, A. Laxite congenitale de l’articulation radiocubitale inferieure et 
subluxation consecutive de la tete du cubitus en arriere, Compt. rendus, 
Soc. de biologie, 1892, Series 9, 4:627. 
Guery. Un cas de luxation progressive du poignet, Rev. d’orthop., 1898, Series 
1, 9:277. 
Homuth, O. Die Madelungsche Deformitat und ihre Beziehung zur Rachitis, 
Beitr. z. klin. Chir., 1911, 74:562. 
Jean, A. Double luxation congenitale complete du cubitus et incomplete du 
radius sur les os du carpe, Bull. Soc. anat. de Paris, 1875, 10:398. 
Kirmisson, E. Subluxation progressive du poignet. Les deformites acquises 
de l’appareil locomoteur pendant l’enfance et l’adolescence. Paris, 1902, 
363- 
Koelliker, Tpi. Die Dupuytrensche und Madelungsche Deformitat des Hand- 
gelenkes, Joachimsthal, Handbuch d. orthop. Chir., 1907, 2:34. 
Madelung, C. Die spontane Luxation der Hand nach vorne, Arch. f. klin. 
Chir., 1879, vol. 23. 
Malgaigne, J. F. Traite des fractures et des luxations (quoted Stetten). Paris, 
1855, 2:711. 
Melchior, E. Uber die Kombination von symmetrischer Madelungscher Hand- 
gelenksdeformitat mit doppelseitiger metakarpaler Brachydaktylie, Ztschr. 
f. orthop. Chir., 1912, 30:532. 158 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Poulson, K. Madelungsche Deformitat der Hand, Arch. f. klin. Chir., 1905, 
75:505- 
Redard, P. Sur une deformation rare du poignet, Arch. gen. de med., 1892, 
2:651. 
Riedinger, J. Wesen, Ursache und Entstehung der Deformitaten, Joachims- 
thal, Handbuch d. orthop. Chir., 1904, 1 :68. 
Siegrist, H. Uber Manus Valga und sogenannte Madelungsche Deformitat 
des Handgelenkes, Deutsche Ztschr. f. Chir., 1908, 91: 524. 
Stetten, De Witt. Zur Frage der sogenannten Madelungschen Deformitaet des 
Handgelenkes mit besonderer Ruecksicht auf eine umgekehrte Form des- 
selben, Zentralbl. f. Chir., 1908, 35:949. 
Idiopathic progressive curvature of the radius or so-called Madelung’s 
Deformity of the wrist, Surg. Gyn. Obstet., 1909. 
Stokes, A. C. Madelung’s deformity, Ann. of Surg., 1910, vol. 52. 
Trillmich, F. Beitrag zur Madelungschen Deformitat, Ztschr. f. orthop. Chir., 
1912, 32:69. 
BIBLIOGRAPHY TO DUPUYTREN’S CONTRACTURE 
Black, K. Dupuytren’s contracture, Brit. Med. Journ., 1915, 1:326. 
Gill, A. G. Dupuytren’s contracture with description of new method of opera- 
tion, Ann. of Surg., 1919, 70:221. 
Hutchinson, J. Dupuytren’s contraction of the palmar fascia, Lancet, 1917, 
1:285. 
Kregius, A. Neue Gesichtspunkte zur Aetiologie der Dupuytrenschen Finger- 
kontraktur, Zentralbl. f. Chir., July 24, 1920, No. 30. 
Spitzy, H. Dupuytren und traumatische Fingerkontrakturen, Ztschr. f. orthop. 
Chir., 1915, 35:550. 
Tubby, A. H. Dupuytren’s contracture successfully treated by open incision 
and Thiosinamin, Brit. Med. Journ., November 8, 1913. CHAPTER VI 
SPASTIC PARALYSIS 
The reason for the scant attention which spasticity of the upper 
extremity has received in orthopedic literature is, no doubt, due to 
the fact that it is one of the most difficult problems to handle, if not 
the most difficult of all. Owing to the greater complexity of the move- 
ment of the arm and hand, it is here all the more difficult to restore 
muscle equilibrium between the different antagonistic forces of the 
muscles, necessary in properly controlled and timed voluntary motion. 
If this is not an easy problem in the flaccid types of paralysis, it be- 
comes much more complicated in spastic conditions where the disturb- 
ance of control lies in the upper motor neurons, so inaccessible to, and 
so difficult to manage by, therapeutic measures. 
Among the different types of spastic paralysis, some will lend them- 
selves more readily to orthopedic treatment than others. Some are 
almost wholly outside the reach of therapeutic means, either by virtue 
of their nature or by virtue of the degree to which spasticity is devel- 
oped. But even in the most favorable groups, the treatment is difficult, 
laborious, and extremely time consuming. There are, nevertheless, 
possiblities of improvement in spastic paralysis of the upper extremity, 
and the matter is deserving, we believe, of more serious endeavor than 
it is generally accorded. 
For the sake of convenience, one may distinguish three principal 
groups of spastic paralysis: (i) the intra-uterine form, (2) the intra- 
partum or birth-spastic paralysis, and (3) the acquired form. In a 
general way, the traumatic spastic paralysis from birth and the acquired 
form offer a more favorable outlook than do the intra-uterine or con- 
genital types. The latter are generally known as Little’s disease and 
to it belong cases of porencephaly, microcephaly, intra-uterine polio- 
encephalitis, meningitis, cysts, etc. 
The injuries received during the act of birth are mostly occasioned 
by the forceps, leading to laceration of the brain vessels and followed 
by hemorrhage, sclerosis, and, sometimes, by chronic meningitis or 
encephalitis. 
In the acquired forms of spastic paralysis, three groups may be dis- 
tinguished: (1) an epidemic polioencephalitis or encephalomeningitis; 
(2) meningeal hemorrhage or embolism from arteriosclerosis; and (3) 
syphilitic thrombosis and encephalitis. Of the first group, the para- 
plegic and diplegic forms usually involve the upper extremity to a lesser 
degree than the lower, but the hemiplegic form, of both the infectious 
159 160 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
and hemorrhagic type, is likely to involve the upper extremity more 
extensively than the lower. It is especially the hemiplegic type of 
spastic paralysis which will be given closer attention in this chapter; 
first, because of the greater involvement of the upper extremity, and 
then because these cases yield more readily to treatment than other 
types, since the lesion is more localized. 
The clinical syndrome of spastic paralysis of the upper extremity 
is so well known that a few remarks will suffice. In the shoulder the 
extremity is usually held in adduction and inward rotation. The elbow 
is held in flexion at acute angle close to the body, and the wrist as well 
as the phalangeal joints are in flexion. The rigidity is expressed by 
exaggerated reflexes, the overexcitability of the muscles, and it some- 
times reaches such degrees that the normal position of the limb cannot 
be restored even by stretching and manipulation. The fingers and 
thumb are often closed so tight that the nails will dig into the flesh 
of the palm. In almost all cases, the rigidity relaxes during sleep and 
at times during waking hours, but the relaxation is only partial and 
is not under the control of the patient. 
In contracture of the shoulder, the muscles mainly concerned are 
the pectorales muscles, the latissimus dorsi, the teres major, and sub- 
scapularis. Contracture in this joint is usually not extreme and some 
active abduction is possible except in very severe cases. In the elbow 
the flexion position is brought about by the spasticity of the flexors 
of the elbow, and also by the increased tonus of the flexors of the wrist. 
The contraction in the elbow joint is as a rule more marked than in the 
shoulder, although active flexion and extension are often possible to 
a moderate degree. 
In the pronation contracture of the forearm, both the pronator teres 
and quadratus take part; the rigidity and contracture of the pronator 
teres is such that very soon a nutritive shortening of this muscle takes 
place, which makes even passive correction difficult, and active correc- 
tion impossible. 
At the wrist, the hand drops into a flexion position which causes 
the flexors of the wrist to become increasingly shortened. Active 
extension of the wrist is entirely impossible; even passive extension 
is often difficult. The finger flexors also contribute to the flexion posi- 
tion of the wrist and hold the fingers in strong contraction. 
Occasionally one may see hyperextension of the metacarpophalangeal 
joints. This occurs in cases in which flexion contracture of the wrist 
is extreme and in which a state of tension exists in the extensors of 
the fingers intensive enough to bring about hyperextension in the meta- 
carpophalangeal joints. It is not unusual to see also a flexion con- 
tracture of the thumb. The latter is turned down and crosses the palm 
of the hand and, when the hand is closed, the fingers cover the thumb. 
The musculature of the forearm shows little shrinkage. Peripheral 
circulation is good as a rule, except in extreme cases, where the pro- 
nounced contractures interfere with the free circulation of the extremity. SPASTIC PARALYSIS 
161 
From the standpoint of prognosis, a differentiation should be made 
between the juvenile and adult hemiplegic forms. The juvenile forms 
are mostly occasioned by polioencephalitis, while those in adults have, 
as a rule, a circulatory basis. The juvenile forms show all degrees of 
spasticity, but a large percentage of them are not extreme and are 
amenable to different forms of orthopedic treatment. 
The adult cases, especially those due to hemorrhage and embolism, 
are actually paralyzed to a much larger degree than is apparent at first 
examination, when the great rigidity of the muscles may be taken for 
muscle power. Especially, the extensor group in cases of long standing 
will be found almost entirely void of contractile power, a fact which 
becomes apparent after correction of the deformity has been accom- 
plished. 
The mental condition of the patient is of the greatest importance for 
prognosis of spastic paralysis in children, next to the degree and exten- 
sion of the spasticity. Mental impairment is usually more marked in 
the diplegic and paraplegic types of the congenital form. In the ac- 
quired type, the mental impairment is much less prominent, although 
two-thirds of these cases occur within the first three years of life. Still, 
some degree of mental impairment or retardation is prominent in the 
majority of cases. According to Sachs, 50 per cent of all hemiplegic 
types are more or less retarded or feeble-minded, while in paraplegic 
and diplegic types, 70 per cent are feeble-minded and from 40 per cent 
to 50 per cent are idiotic. 
Only a few idiotic patients are found in the acquired forms. In 
judging the mentality of the patient, however, it is advisable not to 
be led by first impressions and not to come to hasty conclusions, as 
all children of this type, especially those with congenital spasticity, are 
extremely nervous and are liable to become very much deranged 
mentally by the strangeness of surroundings and the excitement of the 
examination. It is essential to have the patient tone down and to let 
him get accustomed to his surroundings before judgment can be passed 
upon his mentality. Some of these cases show remarkable mental 
traits, especially a very tenacious memory. 
Epilepsy is present in a great number of all forms of cerebral palsy. 
It is not necessarily a grave obstacle to the treatment, although it 
somewhat complicates the prognosis. A much greater obstacle to the 
treatment, which is not infrequently found in cases of spastic paralysis, 
is athetosis of the upper extremity. These cases, though normal men- 
tally, are extremely hard to handle, and therapeutic measures often fail 
because of the impossibility of keeping the limb immobilized. 
In no form of paralysis is the importance of prophylactic measures 
so great in preventing deformities as it is in spastic paralysis; and in 
no form of paralysis has it been so little used and the possibilities of 
prophylaxis so grossly neglected as in this very type. The measures to 
prevent contractures must be instituted at the earliest possible moment. 
This is even more urgent in spastic cases than in flaccid paralysis, where 162 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
the deformities develop more gradually and are, for a longer time, 
amenable to correction. In a case of polioencephalitis in a young child, 
for instance, the splinting must begin early and before actual contract- 
ures occur, that is, within the first week after the attack. 
Splinting is to be followed by massage, passive motion, and such 
active motions as are possible. The efficacy of early treatment by splint- 
ing and mechanotherapy is a matter of record. Elliott and Bernstein 
have reported a case of twenty-one years’ standing which was treated 
along these principles, with the result that considerable improvement was 
obtained, though this improvement was more marked in the lower than 
in the upper extremity. The possibility of recovering motor function 
in cases of spastic hemiplegia of long standing is further demonstrated 
by the article of Sheets and Wilson who reported 5 cases in which con- 
siderable improvement was obtained by methods of splinting. 
For the upper extremity, the splinting must meet the following 
requirements: the shoulder must be held in abduction and outward rota- 
tion. For this purpose, an abduction splint of the shoulder is sufficient. 
As already mentioned, the adduction contracture in the shoulder usually 
does not attain the degree of spasticity which is present in the other 
joints of the extremity-; however, a great deal of the spastic contraction 
can be saved the patient by proper and timely application of an aero- 
plane splint which takes care of the abduction as well as the outward 
rotation of the shoulder. 
The flexion contracture in the elbow is usually not as rigid as the 
contracture in the wrist joints, but, as a rule, more rigid than the con- 
tracture in the shoulder. If the angle of flexion is suitable, one need 
not be especially concerned about changing this angle by means of 
splinting. Alternating the position, however, gives an opportunity for 
relaxation of the contracted muscle groups. 
A most distressing deformity is the pronation contracture of the 
forearm. Usually this attains very marked degrees. It is followed in 
time by a nutritive shortening of the pronator teres which makes even 
the passive reduction of the contracture difficult. For the purpose of 
overcoming this contraction, we have used with advantage a so-called 
pronation splint, that is, a splint devised (by Dr. R. V. Funsten) to 
overcome pronation deformity. This splint consists of an inner upright 
running along the forearm and humerus and provided at intervals with 
crossbands which grip the palm of the hand, the forearm above the 
wrist and below the elbow, and the upper arm above the elbow and 
below the shoulder. The upper arm piece at first appears bent down- 
ward when the arm is in flexion, before the upper splint is applied and 
the forearm piece is attached with the forearm in pronation. Then, 
by giving the splint a half turn in the direction of supination, the upper 
bent-down piece of the splint can be made to swing up in the direction 
of the upper arm, and can there be attached by buckling crossbands 
over the upper arm. Experience will teach how much bending down 
is advisable and how much passive supination can be attained at one SPASTIC PARALYSIS 
163 
time (Plate XIX, 4). The flexion deformity of the wrist is taken care 
of by a cockup arrangement which can very well be attached to the 
pronation splint, and Anally, the flexion contracture of the fingers may 
be taken care of in a similar way by running the palmar end of the 
splint distally beyond the tips of the finger. For the purpose of treat- 
ment, the patient is taken out of his splints twice a day and the mechan- 
ical treatment is applied, which consists of passive motion and gentle 
stretching of the contracted flexor muscle, in massage, and finally in 
active motion. Active movements can be systematically obtained by 
scientific application of muscle educational treatment. 
In the application of massage both the effleurage and friction may 
be applied. According to Oden, the former has a relaxing influence 
upon the musculature and promotes the peripheral circulation. The 
friction influences the nutrition of the muscles. To these are added the 
petrissage, or kneading, and the tapotement, or the tapping of the 
muscles, both of which have a rather stimulating effect. Especially 
the two latter principal movements should be used with the greatest 
care and restriction, because the muscles are already in a state of in- 
creased excitability, and must not be overirritated. Milder cases yield 
to this type of treatment even a considerable time after the onset of 
the disease. The relaxation of contractures and the lessening of the 
hyperexcitability is especially noticeable. One question constantly aris- 
ing is that of how provision is to be made to secure the continuance 
of the treatment for months and years, as it is necessary in most of the 
cases. If such treatment is left in the hands of the parents or people 
surrounding the patient, it is very essential that a system of instruction 
be established by which the parents may be able, not only to apply the 
treatment under supervision, but also to check up on the effect of it 
and to note, carefully and in time, signs of irritation or exhaustion of 
the muscles. 
Operative Treatment.—Established spastic contractures of long 
standing will not yield to conservative treatment unless preceded or 
accompanied by certain operative measures for the relief of the con- 
tracture. 
The operative treatment of spastic paralysis may be divided into 
two classes, according to the aim and object of interference: In the 
first, the treatment aims at the release of contractures. This is accom- 
plished by tenotomies, by tenoplasties, and by methods of tenodesis or 
arthrodesis. In the second, the object is to restore the disturbed mus- 
cular balance of the contracted joints by operations upon the peripheral 
nerves or upon the spinal roots. The general opinion up to this time 
is preponderantly in favor of the simpler orthopedic methods followed 
by long-continued and painstaking after treatment. 
The Operative Orthopedic Treatment—Relief of Spastic Flexion 
Contractures of the Hand.—In the release of spastic contractures of the 
hand, the operative technic follows essentially that used in flexion con- 
tracture of the wrist, in ischemic contracture. 164 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
A long incision is made in the middle of the volar surface of the 
forearm reaching beyond the wrist. From this incision all the flexor 
muscles of wrist and fingers are dissected and picked out one by one. 
Then they are lengthened by a Z-shaped tenoplasty which allows the 
two halves of the tendons to glide over each other until a suitable length 
is obtained. The tendon halves are fastened together side by side with 
fine catgut sutures. In the wrist, it is necessary to lengthen almost all 
the long flexors of the fingers, the flexors of the wrist, and also very 
frequently the long flexor of the thumb. When this is done, the fascial 
compartments covering the tendon's should be reconstructed as nicely 
as possible, and especially should there be a smooth fascial covering 
over the volar side of the tendons to avoid any possibility of secondary 
adhesions (Plate XXIX). 
The Relief of the Pronation Contracture.—Relief of pronation con- 
tracture requires the resection of the pronators, at least that of the 
pronator teres. The pronator teres can be reached by an oblique in- 
cision reaching from the internal condyle to the middle of the outer 
edge of the radius. A piece one to one and one-half inches long is 
resected out from the muscle near its insertion. 
The pronator quadratus can be reached easily, as shown before, by 
incision made in the middle of the volar surface of the forearm over 
its distal fourth. One proceeds on the ulnar side of the flexor carpi 
radialis, dividing the fascia which covers the flexor muscles of the 
fingers. From here on, one may proceed altogether bluntly until the 
interosseous space is reached. The transverse fibers of the pronator 
quadratus become at once visible, and one now proceeds to locate the 
upper edge of this muscle. Here a grooved director is inserted between 
the posterior wall of the muscle and the interosseous membrane, and 
the muscle is severed over it. The interosseous nerve and vessels can 
be spared by using reasonable care. In severe pronation contractures, 
the release of the pronator quadratus by myotomy in the manner just 
described is necessary, while, in more moderate cases, the resection of 
the pronator teres may suffice (Plate XXIII, i, 2, 3). 
Tubby advises an efficient method of tendon transference for the 
correction of pronation contracture. An incision about eight inches 
long is made in the middle of the forearm over the line of the radial 
artery. The inner margin of the supinator longus is then defined and 
this muscle is bluntly separated from the flexor carpi radialis. The 
radial vessels and nerves are found and drawn well to one side. Then 
the pronator radii teres is located, the upper and lower margins of these 
muscles are well cleared and the tendon of insertion with some of the 
periosteum is detached from the bone. The flexor carpi radialis is then 
separated from its neighbors and its tendon is divided about one and 
one-half inches above the wrist. Both this muscle and the pronator 
radii teres are now placed on the stretch and both muscles are sutured 
firmly together. 
The next step is the division of the interosseous membrane with a SPASTIC PARALYSIS 
165 
tenotome, taking care to avoid injury to the interosseous artery and 
nerve. Through the space so made, the joint tendon of the flexor carpi 
radialis and pronator teres is brought around to the back of the radius. 
An aneurysm needle is then passed through the interosseous space and 
around the outer side of' the radius and the tendon is drawn through 
behind the radius. In fixing the conjoined tendons, a hole is drilled 
through the radius from front to back. A silk ligature, which has 
previously been passed through the end of the conjoined tendons, is 
used by threading one end of it on a straight needle and passing needle 
and silk from front backward through the hole in the radius and also 
through the tendon end now lying back of it. Then the ends of the 
ligature are knotted and the tendon fixed in its new position. 
Whitman’s recommendation in flexion contracture is the implanta- 
tion of the flexors of the carpus into the extensors, either around the 
ulnar or radial borders or through the interosseous space; but the at- 
tempt at holding the wrist in the position of hyperextension is, in spastic 
paralysis, a matter of rather problematical outlook, because of the 
rigidity of the flexor muscles. This factor is a constant source of dis- 
turbance to the equilibrium obtained by tendon transplantation, and the 
cases show a great tendency to draw the wrist again into the flexion 
position. 
Considering the good functional result obtained in paralytic drop- 
wrist, the writer undertook to apply the method of arthrodesis of the 
wrist in cases of spastic flexion contracture. The technic in this case 
varied in no way from that adopted in paralytic drop-wrist. It is only 
to be added that, in spastic cases, the arthrodesis should be more thor- 
ough and the ankylosis obtained more rigid than in paralytic cases. 
The only cases which did not give satisfaction with this method were 
those of athetosis of the wrist and fingers in which sufficient immobiliza- 
tion could not be obtained after operation (Plate XXVIII, 1-9). 
Finger Contractures.—In dealing with the flexion contractures of the 
fingers, the problem of flexion contractures of the thumb must be taken 
separately. The thumb is drawn into flexion and opposition so strongly 
that, upon closure of the hand, the thumb finds itself pinned under the 
flexed fingers. Naturally, this makes any gripping action and the grasp- 
ing of objects impossible. A suggestion of Biesalski and Mayer has 
been used to meet this condition and was found very reliable. The 
operation consists essentially in applying a mechanical check to the 
flexors of the thumb by the use of the tendon of the extensor of the 
index finger. 
An incision is made on the dorsum of the hand over the tendon of 
the extensor indicis proprius from the wrist down to the basal phalanx 
of the index finger. This tendon is then dissected and divided at the 
most distal point of the wound just beyond the base of the basal phalanx. 
A second incision is then made over the tendon of the extensor pollicis 
longus reaching from the middle of the snuffbox distally to the middle 
of the basal phalanx of the thumb. The tendon of the index finger is LEGEND FOR PLATE XXVIII 
Fig. i.—A. H. Severe Spastic Paralysis, Meningo Encephalitic Type. 
Fig. 2.—L. McC. Spastic Hemiplegia. 
Fig. 3.—L. McC. After Tendon Lengthening and Arthrodesis of Wrist. 
Fig. 4.—H. O. Spastic Hemiplegia. 
Fig. 5.—H. O. After Tendon Lengthening. 
Fig. 6.—H. O. After Tendon Lengthening and Resection of Pronators. 
Fig. 7.—G. C. Spastic Hemiplegia. 
Fig. 8.—G. C. After Arthrodesis of Wrist. 
Fig. 9.—L. D. Spastic Hemiplegia. Spastic Closure of Fist. PLATE XXVIII LEGEND FOR PLATE XXIX 
Fig. i.—W. E. Spastic Hemiplegia. 
Fig. 2.—W. E. After Resection of Pronators and Thumb Extensor Plasty. 
Fig. 3.—E. O. Spastic Hemiplegia. 
Fig. 4.—E. O. After Arthrodesis of Wrist. 
Fig. 5.—D. Y. Spastic Monoplegia. 
Fig. 6.—D. Y. After Interosseous Transplantation of Flexor Carpi Ulnaris. PATE XXIX 170 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
then grasped by a forceps inserted through the radial wound and pene- 
trating through to the wound over the index finger. The tendon of 
the extensor indicis is then pulled through this tunnel and brought out 
of the wound over the thumb so that it will lie approximated to the 
tendon of the extensor pollicis longus. For a distance of one to one 
and one-half inches the two tendons are now firmly united by suture, 
the thumb being held in a position of hyperextension. Both wounds 
are closed and the hand is dressed with the thumb hyperextended 
(Plates XXX, i, 2; XXXI). 
Operations on the Nervous System.—Operative procedures have 
been devised and recommended upon the skull and brain, upon the 
spinal cord, the posterior roots, and finally upon the peripheral nerves. 
Byrne recommends in the early surgical treatment of spastic hemiplegia 
decompression operations to be performed within from two to four 
weeks, under the following conditions: whenever there is threatening 
a medullary strangulation by intracranial pressure; in extradural hemor- 
rhage, in intradural hemorrhage with cerebral compression, and in intra- 
cerebral hemorrhage. All these operations on the skull are conceived 
with the intention of relieving the intracranial pressure. The cases 
in which such pressure exists are usually well characterized by cranial 
symptoms of convulsions, epilepsy, and cerebral vomiting, and by find- 
ings of intracranial pressure symptoms in the background of the eye. 
One of the foremost advocates of decompression operation in spastic 
paralysis is W. Sharpe who reports 236 cases operated on. Among 
these there were 80 cases of diplegia, 38 of paraplegia, and 117 of 
hemiplegia. Indication for decompression operation is, according to this 
author, the finding of increased intracranial pressure in the eye in the 
form of papilledema of the background. According to his report, all 
cases improved with the exception of 13. Sharpe’s statistics are cer- 
tainly very startling but up to this time his method has found but few 
followers. 
Focrster’s Operation.—In 1908, O. Foerster described an operation in 
which he resected the posterior roots of the spinal nerves with the 
object of relieving the spasticity of the extremities. This idea is based 
upon the knowledge that spasticity of the extremities is caused by the 
immense reflex excitability of the muscles. By elimination of the 
sensory half of the reflex arch, it is reasoned that the tone of the muscles 
must be relaxed. As far as the upper extremity is concerned, the technic 
can briefly be described as follows: the neural arches of the three lower 
cervical and of the first dorsal vertebrae are laid bare by dissection and 
the laminectomy of these vertebrae is performed. After opening the 
dura, the posterior roots of the four lower cervicals and of the first 
dorsal spinal segments are located, and three or four of the spinal roots 
are resected. In the lower extremity, a similar procedure is adopted, 
and after laminectomy the posterior roots from the second lumbar to 
the second sacral nerve are resected. After resection of the posterior 
roots, the relaxation of the muscles is striking both according to SPASTIC PARALYSIS 
171 
Foerster’s own report and according to the few who have followed this 
method. Up to 1914, Gumbel reported no cases in the literature. He 
states that the hopes placed upon Foerster’s operation have not ma- 
terialized. Especially are the cases extremely few where the operation 
has been successfully carried out for the relief of the upper extremity. 
Some surgeons prefer to do this operation in two steps, the first of 
which consists in the laminectomy and the second in the opening of 
the dura and the resection of the nerve roots. It is hardly necessary 
to say that this operation is fraught with great danger and not an incon- 
siderable percentage of the patients succumb to shock immediately after 
operation. Among the contra-indications for this operation are idiocy, 
athetosis, and epilepsy. But few cases of spasticity of the upper extrem- 
ity lend themselves to this operation. It must be borne in mind that 
the method in itself is not as reliable in results as was first believed. 
Following the immediate relaxation of the muscle, there is soon, usually 
within a few days, a gradual increase of the muscle tone, which, how- 
ever, does not reach the degree of spasticity present before the opera- 
tion. It should be pointed out that the originator of the method him- 
self lays the greatest stress upon the mechanical after treatment, with- 
out which no operation for spastic paralysis seems to be of any value. 
A much less dangerous method of dealing operatively with spastic 
paralysis is that advocated by A. Stoffel. His method is one of selective 
and partial resection of certain nerve bundles out of the complex of a 
motor or mixed peripheral nerve. The method is based physiologically 
upon the weakening of the contracted muscles by partially depriving 
them of their normal nerve supply and restoring in this manner the 
balance between the contracted flexors and the relaxed and overex- 
tended extensor muscles. Before considering the details of this method, 
a reference should be made to certain points of biopathological nature. 
It is to be considered whether there is, in spastic paralysis, an absolute 
paralysis of the apparently inactive extensor group or whether the 
paralysis of the extensors appears secondary with the increased con- 
tracture of the flexors. It seems from clinical observation, at least of 
certain groups of spastic cases, that the damage to the extensor muscle 
is not absolute at the time the paralysis develops but that it becomes 
more and more extensive as the deformity increases. This is brought 
out definitely by the fact that the muscle power of the extensors can 
be preserved by preventing contracture in a manner entirely analogous 
to that which is found in infantile paralysis. In fact, the principal argu- 
ment which makes for the early application of methods of splinting is 
the preservation of the weakened extensor muscles in spastic paralysis. 
According to Stoffel, the primary condition of the paralysis only 
relatively and partially lowers the function of these muscles which, 
by a systematic training and especially by prevention of the deformity, 
may regain a considerable part of their activity. Stoffel’s operation is 
directed toward the elimination of the hypertonus of the contracted 
muscle groups and toward the restoration of equilibrium. In order to LEGEND FOR PLATE XXX 
Fig. i.—Technic of Thumb Extensor Plasty. Exposure of Tendons of Extensor Indicis 
and Extensor Longus Pollicis from Two Incisions. 
Fig. 2.—Suture of Extensor Indicis Tendon to Extensor Longus Pollicis. 
Fig. 3.—Trick Motion: Supination by Extension of Elbow; Pronation by Flexion of 
Elbow. 
Fig. 4.—Trick Motion: Extension of Fingers by Flexion of Wrist; Flexion of Fingers 
by Extension of Wrist. PLATE XXX LEGEND FOR PLATE XXXI 
Fig. i.—L. M. Spastic Contracture of Hand. 
Fig. 2.—L. M. After Tendon Lengthening. 
Fig. 3.—L. M. Spastic Fist Closure. 
Fig. 4.—L. M. After Additional Thumb Extensor Plasty. 
Fig. 5.—A. R. Showing Technic of Thumb Extensor Plasty. 
Fig. 6.—D. G. Spastic Monoplegia. 
Fig. 7.—D. G. After Thumb Extensor Plasty. PLATE XXXI 176 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
give practical application to this reasoning, it is, above all, necessary 
that one should be able to identify in the peripheral nerves, at any given 
level, the different bundles of nerve fibers which supply a particular 
group of muscles. In other words, a knowledge of the topographical 
anatomy of the cross section of the nerve is necessary. Stoffel’s own 
careful investigations have added considerably to this anatomical knowl- 
edge of the peripheral nerves, to which additional contributions have 
been made by Pieri and Riquier, and others. Fieri and Riquier, who 
have taken up the study of topographical anatomy of the ulnar nerve, 
find the bundles for the flexor carpi ulnaris and for the deep flexors of 
the two ulnar fingers situated near the inner surface, while those for 
the adductor pollicis are near the dorsal surface and those for the hypo- 
thenar and the interossei near the lateral surface of the nerve. Near 
the ventral surface, there are situated the sensory fibers. These findings 
corroborate, in general, those of Stoffel: 
Musculospiral Nerve.—At the level of the two epicondyles, Stoffel finds 
in the musculospiral nerve on cross section the following areas: 
A palmar bundle containing fibers to the superficial branch of the 
musculospiral. 
A palmar external bundle of fibers to the supinator longus. 
An external bundle of fibers to the extensors of the wrist. 
A dorsal bundle of fibers to the deep muscle branches. 
And, finally, an internal bundle of fibers to the superficial sensory 
branches. 
In the course around the humerus upward, the fibers of the mus- 
culospiral nerve become rearranged so that the superficial branch is now 
antero-internal while the deep branches lie dorsally and externally. In 
the axilla, the nerves to the supinator longus and to the radial extensors 
of the wrist lie on the dorsal aspect of the nerve, while the fibers to 
the deep branches and those to the supinator brevis are antero-internal. 
Median Nerve.—At the level of the middle of the upper arm, the follow- 
ing areas can be distinguished in cross section : 
A palmar external bundle with fibers to the palmaris longus, flexor 
carpi radialis and pronator radii teres. 
A dorso-internal bundle with fibers to the flexor sublimis digitorum. 
A dorsal bundle with fibers to the flexor profundus digitorum. 
A palmar internal bundle with fibers to the thenar muscles. 
The fibers for the pronator teres, the flexor carpi radialis and 
palmaris longus lie anteriorly. The fibers for the flexor profundus, 
flexor pollicis longus, and pronator quadratus form a stout bundle which 
can be traced up to the middle of the upper arm running in the posterior 
part of the nerve. The nerves for the flexors of the fingers run in the 
internal and postero-internal parts of the median nerve in the upper 
arm. 
The~ Ulnar Nerve.—The bundle supplying the flexor profundus lies in 
the internal and posterior part of the nerve at the level of the condyles 
while higher up this position changes to a postero-external. We have SPASTIC PARALYSIS 
177 
then, in the middle of the upper arm, in the postero-external part of this 
nerve, the fibers for the flexor carpi ulnaris, flexor profundus digitorum, 
the hypothenar muscles, and the intrinsic muscles of the hand. 
Upon such careful anatomical investigations, the hope may be based 
that a selective resection of nerve fibers may be carried out intelligently, 
especially if the identity of the nerve bundles is verified at operation by 
the faradic current. But there is still the problem of estimating the 
proper amount of resection necessary to establish the desired equilib- 
rium between the muscles. According to Stoffel, it is possible to measure 
out the nerve supply necessary to maintain equilibrium between the 
extended and the hypertonic muscles, but it will readily be seen that, 
even with topographical knowledge as a basis and the faradic test as 
an aid, such distribution of nerve supply can be only approximately 
correct. The extreme subtleness of the equilibrium as it prevails, espe- 
cially in the upper extremity, is of course beyond the reach of accurate 
dosage. But after all, this method furnishes a rational basis for the 
relief of contractures and one must consider that the inaccuracy of this 
method is not materially greater than that which exists in tendon opera- 
tions where the equilibrium is also disturbed in a measure which is not 
entirely estimable. A. B. Gill reported on 35 cases of Stoffel’s operation 
carried out on the popliteal, the sciatic, the obturator, and also the 
median nerve, of which latter there are 5 cases cited. This author 
and others suggest the transplantation of the separated nerve bundles 
into the extensor group instead of resecting them, thereby deflecting 
the surplus of innervation to the weaker muscle group. We believe, 
however, that such a matter is open to serious objection on the ground 
that the additional nerve supply to already supplied muscles (extensors), 
the so-called hyperneurotization, is extremely problematical. In his 
experiments, the writer was unable to produce hyperneurotization. 
Stoffel’s own statistics embrace 12 cases among which there were 6 
resections of the median nerve for pronator contraction of the forearm. 
In the writer’s series of spastic paralysis of the upper extremity, 3 
cases were operated following Stoffel’s method. 
Case Reports.—J. J. H., 54 years. Spastic hemiplegia following cere- 
bral hemorrhage of 8 years’ standing. The patient suffered from severe 
spastic contractures of the right shoulder, elbow, wrist and fingers, the 
fingers being shut so tight that they could be opened only with the great- 
est difficulty. Technic of operation was as follows: 
Exposure of the median and ulnar nerve. Dissociation of the fibers 
by the faradic needle as follows: 
1. Ulnar nerve: dissociation of sensory and motor fibers; of the 
motor fibers two-thirds were resected. 
2. Dissociation of the median nerve, motor and sensory fibers. Iso- 
lation of the flexors of the wrist from the flexors of the fingers. Re- 
section of one-half of the nerve supply of the finger flexors. 
The immediate result was perfect relaxation of the wrist and fingers 
but no active motion. The patient, however, stated that he had better LEGEND FOR PLATE XXXII 
Fig. i.—M. S. Spastic Hemiplegia; Poliencephalitis. 
Fig. 2.—M. S. After Stoffel’s Operation. 
Fig. 3.—T. M. Spastic Hemiplegia; Encephalomeningitis. 
Fig. 4.—T. M. After Splint and Muscle Educational Treatment. PLATE XXXII 180 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
feeling in the hand and that he felt much more comfortable on being 
freed from the sensation of rigidity and contracture. After a period 
of from 2 to 3 months, slight active motion of the flexors began to 
appear, which at the time of this writing (6 months later) is still im- 
proving. There is, however, no sign of activity of the extensor muscles 
of either the hand or the fingers. The after treatment of the patient 
consisted in massage and such exercises as he is able to perform, and 
the hand is held in a glove splint fixed with elastic dorsal straps. 
M. S., 15 years. Spastic hemiplegia following polioencephalitis 7 
years ago. The residual condition was that of spastic contracture of 
the elbow, pronation contracture and flexion contracture of the wrist 
and fingers. The median nerve was dissected in its lower half of the 
humerus and one-half of the nerve was resected without preceding dis- 
sociation. The immediate result of the operation was a release of the 
contracture. The patient was observed for 2 months only and no in- 
formation could be obtained later. During this time, only very slight 
active flexion motion appeared (Plate XXXII, 3, 4). 
H. B. 27 years old. Spastic hemiplegia of the right side following 
polioencephalitis 3 years ago. The condition was that of flexion con- 
tracture in the elbow, pronation in the forearm and severe flexion 
contractures in wrist and fingers. Operation: The ulnar nerve was 
dissected and its fibers dissociated into sensory bundles, the bundles 
for the intrinsic muscles of the hand, and the bundles for the ulnar flexor 
of the wrist and the flexors of the ulnar fingers. Of the latter, Yz 
was resected. The median nerve was exposed and split up into bundles 
which were also dissociated by faradic current into sensory fibers, fibers 
for the flexors of the wrist, fibers for the flexors of the fingers, fibers 
for the thenar muscles. Of the flexors of the fingers, approximately 
Yz was resected. 
In addition to these, the following operation was performed: arthro- 
desis of the wrist; muscle transference of: flexor carpi ulnaris through 
the interosseous route to the extensors of the fingers; flexor carpi 
radialis around the lower end of the radius to-the extensors of the thumb. 
The immediate result of the operation was complete relaxation of 
all contractures of fingers and wrist; within 3 days after operation slight 
flexion motion began to appear, first in the 4th and 5th fingers, later in 
the 3d and 2d finger and thumb. Very slight extension motion was 
noted 2 weeks after operation. The patient at the time of this writing, 
2 months after operation, still under observation, is steadily improving 
(Plate XXVII, 3, 4). 
A summary of the 3 cases reported permits the statement that the 
true condition of the extensor muscles seems to become apparent only 
after complete relaxation has been permanently established. Often the 
correction of the deformity alone is an advantage to the patient in that 
it improves the sensation and abolishes the annoying state of contracture. 
It seems quite probable that, especially in cases of a polioencephalitic 
character in which the nerve destruction is not so complete, consider- SPASTIC PARALYSIS 
181 
able results may be gained by this method. It is further possible that 
the method may be combined to advantage with methods of arthrodesis 
of the wrist and also with methods of tendon transplantation. 
Another operative method applied in spastic paralysis is that of 
temporarily paralyzing the contracted muscles by the injection of 60 
Table of Cases of Spastic Paralysis Treated by Operations 
Name 
Age 
Diagnosis 
Onset 
Treatment 
Result of 
Operation 
H. 0. 
ii years 
sp. hem. 
polioenc. 
arthrod. wrist 
good 
V. P. 
5 years 
sp. hem. 
polioenc. 
thumb plasty 
good 
J. R. 
7 years 
sp. hem. 
polioenc. 
arthrod. wrist. 
good 
R. A. 
8 years 
sp. hem. 
cong. epil. 
thumb plasty 
good 
D. Y. 
9 years 
sp. hem. 
polio, typh. 
tendon transpl. 
poor 
L. M. 
iS years 
sp. hem. 
polioenc. 
flexor plasty 
fair 
E. F. 
9 years 
sp. hem. 
polioenc. 
thumb plasty 
good 
L. M. C. 
8 years 
sp. hem. 
polioenc. 
tenoplasty 
arthrodesis wrist 
tendon transpl. 
poor 
good 
poor 
C. G. 
40 years 
sp. hem. 
luet. throm. 
resect, pro. ter. 
fair 
G. C. 
6 years 
sp. hem. 
polioenc. 
arthrod. wrist 
good 
M. M. 
14 years 
sp. hem. 
cong. 
tenoplasty and 
arthrod. wrist 
good 
S. H. 
7 years 
sp. hem. 
polioenc. 
pron. transpl. 
fair 
A. K. 
11 years 
sp. monopl. 
epil. 
arthrod. wrist 
poor 
J.B. 
8 years 
sp. monopl. 
cong. 
tenoplasty wrist 
thumb plasty 
fair 
good 
M. H. 
7 years 
sp. hem. 
polioenc. 
tenoplasty 
fair 
D. D. 
13 years 
sp. hem. 
polioenc. 
res. pro. ter. 
good 
M S. 
15 years 
sp. hem. 
polioenc. 
Stoffel’s op. 
fair 
J. H. 
54 years 
sp. hem. 
cer. hem. 
Stoffel’s op. 
poor 
A. K. 
11 years 
sp. hem. 
polioenc. 
diphth. 
arthrod. wrist 
poor 
E. 0. 
15 years 
sp. hem. 
cong. 
flexor plasty 
arthrod. wrist 
good 
good 
D. G. 
10 years 
sp. monopl. 
Men. enc. 
thumb plasty 
good 
T. G. 
6 years 
sp. hem. 
polioenc. 
arthrod. wrist 
good 
I. M. 
14 years 
sp. hem. 
polioenc. 
arthrod. wrist 
good 
L. F. 
7 years 
sp. hem. 
convulsions, 
enceph. 
arthrod. wrist 
good 
R. N. 
7 years 
sp. hem. 
little 
arthrod. wrist 
good 
L. D. 
3 years 
sp. hem. 
polioenc. 
thumb plasty 
good 
M. S. 
42 years 
sp. monopl. 
mening. 
flexor plasty 
fair 
S. E. 
4 years 
sp. hem. 
polioenc. 
flexor plasty 
thumb plasty 
poor 
fair 
A. H. 
S years 
sp. hem. 
Little’s d. 
res. pro. ter. 
fair 
H. B. 
25 years 
sp. hem. 
cerebr. hem. 
Stoffel’s oper. 
good RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
182 
per cent alcohol into the nerve sheath. This method was advocated 
by Allison, who reports that the immediate results of this operation are 
satisfactory. A relaxation appears after operation but, as recovery takes 
place, the contractures reappear again and the method does not seem 
to be productive of permanent results. 
The writer’s own series embraces 60 cases, of which 45 were treated. 
Of these cases, 34 were of the hemiplegic type, 6 of the diplegic type, 
and 5 of the monoplegic type. 
Causes.—The paralysis was due to polioencephalitis or meningo- 
encephalitis in 25 cases, to congenital defects in 10 cases.' 
Cases 
Luetic meningitis or luetic endarteritis 2 
Cerebral hemorrhage 1 
Polioencephalitis following diphtheria 1 
Polioencephalitis following typhoid 2 
Meningitis 4 
Birth trauma and instrumental delivery 2 
Premature birth 1 
Mentality.—The mentality in the 45 cases treated was as follows: 
Cases 
Normal 32 
Subnormal, ranging from slight mental impariment to 
idiocy 13 
Convulsions and epilepsy 8 
Distribution of Contractures. 
Cases 
Flexion contracture of the wrist 31 
Pronation contracture 25 
Flexion contracture of the elbow 23 
Adduction contracture of the shoulder 5 
Flexion contracture of the thumb 8 
Supination contracture of the forearm (congenital) 1 
Operations Performed. 
Cases 
Arthrodesis of the wrist 12 
Tendon transplantation 4 
Extensor plasty of the thumb 10 
Tendon lengthening and tenoplasty 7 
Resection of pronator teres 4 
Stoffel’s operation 3 SPASTIC PARALYSIS 
183 
The results of arthrodesis of the wrist were uniformly good, the posi- 
tion of the hand being secured and its function otherwise depending 
upon the state of the flexor muscles. 
An operation of equal reliability is the extensor plasty of the thumb, 
that is, Mayer’s thumb check operation for flexion contracture of the 
thumb. 
Postoperative After Treatment.—After arthrodesis of the wrist, in 
spastic paralysis, the cast should remain not less than two or three 
months, preferably three months, because of the greater length of time 
necessary to secure complete stability where the muscle tension is liable 
to interfere with the position. During the cast fixation, the fingers may 
be exercised actively and passively. After removal of the cast, a cockup 
splint is provided and massage treatment begun. In the after treatment 
following flexor plasty, an anterior or posterior splint may be used and 
if an extensor plasty of the thumb has been done, or if the thumb shows 
a tendency to contraction, it must be held well out in extension for a 
period of two or three months. In several cases, the extension of the 
thumb was lost because of the fact that splinting had been abandoned 
too soon. For the maintenance of the supination position in cases of 
pronation contracture, with or without resection of the pronators, a 
so-called pronation splint, which has been described before, is used. 
The most potent factor in accomplishing final results is a persistent 
and untiring after treatment which must be carried out for a period 
of months and years. This after treatment begins, practically, within 
a few days after the operation with splinting and active motion to which, 
later, massage and passive motion are added. Muscle educational treat- 
ment also plays an important part in the after treatment. * 
It is in the course of the after treatment that one usually succeeds 
in developing substitutionary motions where the original motion cannot 
be obtained. Such substitutionary motions are very useful and their 
development should be encouraged. One of the most important ones 
is the mechanism of pronation and supination in pronation contracture. 
After the correction of the pronation contracture has been obtained by 
operation or by splint, the patient must learn to carry out pronation and 
supination by the original muscle, if he is able to. If not, he must 
be encouraged to substitute these motions by rotatory motion in the 
shoulder, or by extension and flexion of the wrist and elbow. In this 
latter event, extension of the wrist is accompanied by supination, and 
flexion by pronation. 
Another important substitutionary motion in spastic cases is that 
of closure of the hand and its release. Extension of the fingers may be 
accomplished by hyperflexion of the wrist, and flexion of the fingers 
by hyperextension in a manner similar to that which occurs in some 
cases of flaccid paralysis. When considering, in those cases, whether 
or not to perform the arthrodesis of the wrist, it is well to keep in mind 
the question of substitutionary motion. We have in several cases re- 
frained from arthrodesis of the wrist because the flexion motion of the LEGEND FOR PLATE XXXIII 
Fig. i.—H. O. Spastic Hemiplegia Trick Motion; Pronation by Flexion of Elbow. 
Fig. 2.—H. O. Trick Motion; Supination by Extension of Elbow. 
Fig. 3.—A. H. Spastic Hemiplegia; Trick Motion; Pronation by Flexion of Elbow 
Fig. 4.—A. H. Trick Motion; Supination by Extension of Elbow. PLATE XXXIII 186 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
wrist was essential to the patient in order that he might release his 
fingers. 
On the other hand, pronation contracture of the forearm was usually 
an indication for correction, since it was found that even if active pro- 
nation was impossible following the resection of the pronator muscles, 
such motion could be substituted by rotary motion in the shoulder joint 
(Plates XXX, 3, 4; XXXIII). 
BIBLIOGRAPHY 
Byrne, J. Early surgical and orthopedic treatment of hemiplegia, Surg. Gyn. 
Obstet., 1919, 29:398. 
Cooivilla. Uber die Foerstersche Operation, Munchen. med. Wchnschr., 1910, 
No. 27. 
Elliott, G. R., and Boorstein, S. W. Orthopedic treatment in hemiplegias of 
long standing, Journ. Am. Med. Assoc., 1916, 67:31. 
Foerster, O. Uber eine operative Methode der Behandlung spastischer 
Lahmungen mittels Resektion hinterer Riickenmarkswurzeln, Ztschr. f. 
orthop. Chir., 1908, vol. 22. 
Gill, A. B. Surgery of spastic paralysis, Ann. of Surg., 1918, 67:529. 
Guleke. Foerstersche Operation, Deutsche med. Wchnschr., 1913, 148. 
Gumbel, T. Foerstersche Operation, Berl. klin. Wchnschr., 1914, 51:29. 
Oden, R. Systematic therapeutic exercises in the management of paralysis in 
hemiplegia, Journ. Am. Med. Assoc., March 23, 1918, vol. 70. 
Fieri, G. A., and Riquier, G. C. Contributo alia determinazione della topografia 
fascicolare del nervo cubitale, La Chir. degli organi di movimento, 1919, 
3:336. 
Sharpe, W., and Wyeth, J. A. The field of neurological surgery in a general 
hospital, Surg. Gyn. Obstet., January, 1917. 
Stoffel, A. Am. Journ. Orthop. Surg., May, 1913. 
Munchen. med. Wchnschr., 1911, 58, No. 47. 
Withington, C. F. Pneumonic hemiplegias, Am. Journ. Med. Sciences, 1914, 
147:203. CHAPTER VII 
TUBERCULOSIS OF THE UPPER EXTREMITY 
Garre’s statistics on tuberculosis of the upper extremity, including 
145 cases, show the following distribution : 
Per cent 
Shoulder 25, or 17.2 
Elbow 19, or 51 
Wrist 41, or 28.2 
Shoulder.—Tuberculosis of the shoulder is rare. Only per cent 
of all tuberculous joints involve the shoulder, according to statistics of 
the Vanderbilt clinic; and, according to the figures of the Boston Chil- 
dren’s Hospital, the percentage is only 0.25 per cent. The disease is 
more common in adolescence than in early life. According to Garre’s 
statistics 42 per cent are found in the first decade and 47 per cent in 
the second. 
In the great majority of adult cases, the disease apparently occurs 
in the primary synovial form. The synovial surface is studded with 
tubercles and the entire membrane is thickened and infiltrated. In some 
cases there is formation of a fungus mass. In others there is a sero- 
purulent exudate. Rarely is there a hydrops articuli with fibrinous 
precipitates.1 
In the primary osseous form the seat of the focus is either in the 
head or in the glenoid fossa. The single caseous foci fuse together and 
form cuneiform infarcts. 
The most frequent form of osseous tuberculosis of the shoulder, 
however, is the caries sicca or dry tuberculosis. In this disease, thin 
and avascular granulations are formed, which finally lift off and melt 
down the cartilage covering and ulcerate the head. It does not produce 
suppuration. 
The onset of shoulder tuberculosis is gradual and insidious. In 
Garre’s series 68 per cent came on spontaneously, while trauma was 
mentioned in the history in 32 per cent of the cases. Stiffening of the 
joints is the principal and most prominent symptom, even excelling that 
1 It is quite possible that the older view in regard to the so-called primary synovial 
tuberculosis in adults will have to be modified. E. H. Nichols, in a careful pathological 
study published in 1898 (Transactions Am. Orthop. Assoc., Vol. II), states that the disease 
begins as a rule in the epiphyses of the long bones. A recent study by N. Allison on 
the subject (Arch, of Surg., May, 1921) led that author to the confirmation of Nichols’ 
view, that the disease is primarily osseous. His conclusions are based upon the micro- 
scopic examinations of fifty cases. 
187 188 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
of pain. The symptom of gradually increasing stiffening is especially 
noticeable in the caries sicca in which there is a gradual destruction 
of the head of the humerus with the breaking down of the tissues. 
Finally, all motion of the joint becomes lost. The position of the anky- 
losed shoulder is that of slight abduction, although it is masked, when 
the arm falls to the side of the body by a rotation of the scapula. The 
deltoid atrophy is very considerable and much more pronounced than in 
cases of periarticular lesions, such as subdeltoid bursitis. Tenderness 
is present over the deltoid muscle or can be elicited in the axilla by 
pressing against the head of the humerus. 
In the fungous type the swelling is considerable and the general 
condition usually more involved than in the benign type of caries sicca. 
It is in the fungous forms where the breaking down of the granulations 
finally leads to the large articular abscesses, and later to the formation 
of sinuses opening at the shoulder or in the axilla. 
The frequent complication with pulmonary tuberculosis makes 
tuberculosis of the shoulder a serious condition. In the fungous and 
purulent types, the general condition is much more involved than in 
caries sicca. 
The best final outcome of the tuberculous process is the ankylosis, 
which, if in favorable position, assures a useful joint. One may hope 
for this event in the dry form of tuberculosis of the shoulder; in the 
fungous type, the prognosis becomes much more unfavorable with the 
breaking down of tissue and the formation of abscesses and sinuses. 
Among 5 cases of tuberculosis of the shoulder observed by the writer, 
3 were cases of dry tuberculosis and 2 were of the fungous type. The 
ages varied from 16 to 51 years. The onset of the caries sicca cases was 
insidious, the symptoms being ushered in by pain and ache at irregular 
intervals and then stiffening of the shoulder followed. In one case 
the influence of trauma in the development of tuberculosis of the shoul- 
der was quite evident: a man 51 years old was injured by fall at the 
age of 7; at the age of 17 and during later life, several forcible stretch- 
ings were followed by regular periods of pain. The last stretching, 
5 or 6 weeks prior to examination, caused a similar attack. The pain 
was described as nocturnal, starting at 4 p.m. and interrupting sleep. In 
this case there was extreme atrophy of the deltoid and no motion of 
the shoulder in any direction. The gradual development of the disease 
with stiffening and pain was also noticeable in 2 other cases. 
Characteristic findings in the X-ray picture of caries sicca are: 
atrophy of the bone, disappearance of the joint cartilage, and blotching 
and honeycombing of the head of the humerus. In the fungous form 
the bone destruction is much more extensive and the atrophy of bone 
also reaches higher degrees. 
Treatment.—In the beginning of the shoulder joint involvement in chil- 
dren, and, to some extent, adults also, immobilization in plaster casts 
will not only bring about a subsidence of the acute symptoms but will 
also secure a better position of the joint. This latter can be accom- TUBERCULOSIS OF THE UPPER EXTREMITY 
189 
plished by serial casts, applied at intervals of a few weeks, incasing the 
thorax, the humerus, and the forearm. 
Since the duration of the disease averages two to three years, even 
in most favorable cases, with natural tendency to repair, fixation in 
plaster must necessarily be prolonged over a period of years. Resection 
of tuberculous foci will be possible only in a limited number of cases 
where the foci are situated in the head of the humerus. It is feasible 
only in cases where the tuberculous foci are recognized as extra-articular 
not having penetrated into the joint. In most of the adult cases, con- 
servative methods are inadequate and one has to resort to operative 
means of one form or another. 
The results of treatment are reported by Garre, in a series of 24 
cases of tuberculosis of the shoulder, of which 7 cases were treated con- 
servatively and 17 operatively. 
Of the 7 conservatively treated: 
1 was cured. 
4 improved. 
2 not improved. 
Of the 17 treated operatively, in 5 cases the foci were resected: 
3 were improved. 
2 not improved. 
In 12 cases, resection of the head of the humerus was performed: 
8 were cured. 
3 improved. 
1 not improved. 
The figures show that of the operative methods the resection of the 
head gives the better permanent results. 
Technic of Resection of the Humeral Head.—Two routes may be 
chosen; the anterior and the posterior. 
In the anterior route, the incision is carried from the tip of the cora- 
coid process down to the interspace between the pectoralis major and 
the deltoid. On opening the capsule, the tendon of the long head of 
the biceps is isolated. It is found surrounded by granulation tissue. The 
capsule is freely opened to the tip of the glenoid cavity, and downward 
to the tuberosities of the humerus. Then the muscles attached to 
the tuberosities are elevated until head and neck have been sufficiently 
cleared to allow of resection of the head. 
For the excision of an isolated focus, Harold Stiles gives the follow- 
ing advice: “When a limited focus of the disease is present the curet- 
ting followed by the introduction of iodoform or bismuth paste will 
generally suffice.” In more diffuse foci of the humerus, Stiles recom- 190 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
mends resection, that is, cutting the bone off immediately below the 
focus. In doing this, one must take care not to injure the circumflex 
vessels and, more particularly, the circumflex nerve. 
The anterior route was used by the writer in one case. A man of 
fifty years had a very extensive tuberculosis of the right shoulder of 
the fungous type, with a large abscess and formation of several sinuses. 
Resection by the anterior route was undertaken in order to control 
drainage. The head was resected at the surgical neck. In spite of 
temporary improvement, the patient continued to decline, finally dying 
under the symptoms of general septic infection. The autopsy in this 
case showed a very large abscess at the intersection of the upper and 
middle lobes of the right lung, which communicated with the great 
abscess of the shoulder. In this case the resection of the humerus was 
carried out too late and might have saved the patient had it been per- 
formed in time. 
The other route used for the excision of the shoulder joint is the 
posterior method of Kocher. The incision runs from the tip of the 
acromion process downward and backward to the spine of the scapula 
and is then carried down in a curved direction toward the posterior fold 
of the axilla. The acromio-clavicular joint is now opened. The fibers 
of the trapezius attached to the spine of the scapula are divided and the 
posterior edge of the deltoid is exposed. The posterior fibers of this 
muscle are then drawn forward and outward and the supraspinatus and 
infraspinatus muscles are dissected from the outer border of the spine 
and the root of the acromion, so that the latter can now be divided with 
the chisel, carrying with it the attached fibers of the deltoid muscle. This 
flap is now deflected downwards over the head of the humerus, and a 
full exposure of the joint capsule effected. The latter is opened, care 
being taken not to injure the biceps tendon. The insertions of the 
external rotators are then stripped and held backward while the biceps 
tendon is retracted forward and outward. The head of the humerus 
may now be removed, and, when this is done, one obtains an excellent 
view of the glenoid cavity, and if it shelters any tuberculous foci, they 
may be properly dealt with. The acromion process is finally wired to 
the scapula or, if it has not been divided, the periosteum with the pos- 
terior fibers of the deltoid are carefully sutured into place. Drainage 
is installed for a few days. 
A point should be made of advocating the early resection of the 
tuberculous joint in fungous tuberculosis of adults, especially in sup- 
purative types. The anterior incision is the one most favored by Senn, 
who, in his typical resections, refnoved the head at the surgical or 
anatomical neck. 
The postoperative treatment consists in the application of a plaster 
cast in which the shoulder is left quietly until the wounds have definitely 
healed, or for a period of from four to six weeks. One may then start 
active motion and, later, very careful passive motion for the purpose of 
developing the atrophic deltoid muscle. TUBERCULOSIS OF THE UPPER EXTREMITY 
191 
Tuberculosis of the Elbow.—The elbow joint is more frequently 
attacked by tuberculosis than the other large joints of the upper ex- 
tremity. The statistics of the Hospital for Ruptured and Crippled 
(Whitman) give an incidence of 3 per cent of all tuberculous joints. 
The development of this disease occurs mainly in two types. The 
synovial type is more frequent in adults and leads to early spread of 
the disease throughout the entire synovial membrane, and to secondary 
involvement of the bone. 
The osseous type is more common in children, and, of the points of 
the elbow joint, the one most frequently attacked is the olecranon. Next 
to it is the external condyle of the humerus. The head of the radius 
is rarely involved. The osseous foci found in the olecranon often have 
the wedge shape of a necrotic infarct. 
Koenig’s statistics covered 62 cases, of which 10 were of the primary 
synovial, and 42 of the osseous type. Of the 42 osseous cases, 22 showed 
a focus in the olecranon, 17 in the humerus, and only 1 in the radius. 
In 137 cases reported by Middledorpff, 30 were of primary synovial 
and 107 of the osseous type. 
One of the earliest symptoms of tuberculosis of the elbow is the 
limitation of motion. It is especially noticeable in the range of flexion 
and extension, while pronation and supination may be preserved. This 
is explained by the fact that the radius is rarely, if ever, involved. In 
several cases under the writer’s observation there was complete ankylosis 
in the humero-ulnar joint while the function in the radiohumeral joint 
remained unimpaired. 
Swelling as a rule appears first to the side and posterior to the con- 
dyles of the humerus. With the development of the fungoid masses 
in the interior of the joint, the latter becomes extended and a general- 
ized swelling follows which gives the entire elbow a round or cylindrical 
aspect. Perforation of the joint is most likely to take place in the bi- 
cipital grooves on the inner and outer side of the biceps muscle or 
behind the condyles of the humerus, between them and the tendon of 
the triceps muscle. The swelling is of a peculiar elastic character, due 
to the thickening of the periarticular structures and the synovial mem- 
brane. There is considerable discoloration of the skin just before the 
appearance of the sinuses. The marked atrophy of the muscles which 
accompanies fungoid disease of the elbow adds to the appearance of 
swelling of the joint. 
The pathognomonic position of the elbow is midway between ex- 
tension and rectangular flexion, with the forearm pronated. In cases 
in which the disease is located in the head of the radius, early swelling 
appears over this area on the outer side of the elbow joint and in this 
instance pronation and supination of the forearm become involved very 
early. 
Some observers believe that the general outlook of the disease is 
unfavorable and that the best to be hoped for is ankylosis in a useful 
position. For tuberculosis of the elbow in the adult this is probably 192 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
true. In children the outlook is by no means as serious as it is in adults 
and the possibilities for repair with function are much greater than in 
adults. 
Treatment.—It is especially in children that the fixation treatment brings 
about the best results. The plaster casts applied reach from the axilla 
to the wrist or palm. The casts are put on in the best position which 
can be obtained without strain to the joint and pain to the patients. 
The position most to be desired for the elbow in case of ankylosis is, 
according to Jones, that of flexion at about 70°, with the forearm mid- 
way between pronation and supination. 
The writer’s series comprises 8 cases of tuberculosis of the elbow 
among 400 cases of chronic tuberculosis of all joints, equaling 2 per cent. 
Case Reports.—C. P., 3 years. Tuberculosis of the left elbow. The 
disease started 10 months ago with stiffening of the elbow. On exami- 
nation, the joint was found in a position of 150° extension with very 
little motion in either direction or in pronation and supination. The 
X-ray showed tuberculous erosions of the ulna and a tuberculous peri- 
ostitis in which periosteal bone appeared, laid down in layers separated 
by granulation tissue. Without application of any force or strain, the 
patient was treated with plaster casts. After 2 years X-ray showed that 
the defect in the bone had apparently become filled out. There was 
now almost normal range of motion. Only extreme flexion and extreme 
extension was checked and the patient was practically cured. 
W. K., 8 years. Tuberculosis of the right elbow. Trouble started 
2 years ago with swelling and stiffening of the elbow. When seen, the 
elbow was fixed in 1200 and there was complete loss of flexion-extension 
movement, although slight supination was possible. No formation of 
sinuses. The treatment was again that of successive plaster casts which 
were changed at intervals of 1 to 2 months. After 2 years’ treatment, 
condition was as follows: range of flexion and extension was from 8o° 
to 140°, making the entire range of motion 6o°. The X-ray showed the 
tubercular process apparently healed. 
These cases are cited in order to illustrate the possibilities of con- 
servative treatment in juvenile patients and children. 
Next to the fixation treatment by plaster cast, heliotherapy is the 
method to which elbow and the wrist joint tuberculoses are admirably 
adapted. Rollier, Witmer, and others have reported very favorably on 
results of heliotherapy in elbow tuberuclosis. Splints should be used 
in conjunction with it. Of the modifying injections used, the one of 
10 per cent iodoform glycerine seems to be most reliable in elbow 
tuberculosis as well as in tuberculous joints in general. The value of 
Bier’s hyperemia in this affliction is doubtful, although Bier himself gives 
the percentage of cured as 72.7 per cent and the average duration of the 
treatment as nine months. 
In adults the prognosis is much more serious and, when infection in 
the joint has become generalized, radical operative interference is un- 
avoidable. TUBERCULOSIS OF THE UPPER EXTREMITY 
193 
Methods of Resection of the Elbow.—Kocher’s incision starts above the 
external condyle, goes downward, back of the external supracondyloid 
ridge, to the posterior border of the ulna, about two inches below the 
tip of the olecranon. From there the incision swings across the ole- 
cranon and then inward and upward along the inner border of the triceps 
so that it assumes a J-shape. Complete access to the elbow joint can 
now be obtained by sawing through the tip of the olecranon and turn- 
ing it upward, together with the adherent triceps muscle. In full flexion 
of the elbow, the lower end of the humerus, the ulna, and the head of 
the radius come into view. These bones are now protruded out of the 
wound and resected at any suitable place. 
Langenbeck’s Posterior Incision.—This incision runs along the 
middle of the posterior aspect of the elbow joint and is similar to that 
of Liston, except that the latter’s incision is more to the ulnar side 
of the posterior surface. A most important point in approaching the 
elbow joint is the avoidance of the ulnar nerve. It can easily be dis- 
sected and retracted out of harm’s way after it has been lifted out of 
its groove behind the inner epicondyle of the humerus. After temporary 
resection of the olecranon, the latter must be fastened back to its base 
by catgut suture or wire, especially since it is necessary after operation 
to keep the elbow joint fixed in flexion in the plaster cast.2 Extension 
on the forearm may also be used following operation. It affords the 
advantage of active and passive motion in flexion and extension, a point 
which might considerably favor function of the joint until it can be left 
to be supported in a sling. On the other hand, the plaster fixation of 
the elbow in flexion position reduces the possibility of a flail-joint. Both 
advantages may be combined by the use of splints after resection, and 
active motion may begin early; passive motion of the flexion-extension 
range should wait for some weeks; that of pronation and supination 
range may be taken up much earlier. 
The results in elbow tuberculosis as given in 79 cases by Leonhard 
are as follows: 
Of 17 conservative cases: 
2 were cured. 
14 improved. 
1 not improved. 
Of 19 cases treated by excochleation (focus resection) : 
5 were cured. 
7 improved. 
7 not improved. 
2 Osgood (personal communication) is convinced that the long straight incision through 
the triceps muscle and tendon with subperiosteal dissection of the whole elbow joint is 
the best method of avoiding a flail elbow after resection, and a method which he also 
advocates for arthroplasty of the elbow joint* 194 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
t 
Of 38 cases treated by resection: 
28 were cured. 
4 improved. 
6 not improved. 
The late results were as follows: of 12 conservative cases: 
3 were cured. 
5 improved. 
1 not improved. 
3 died. 
Of 8 cases treated by removal of foci: 
2 were cured. 
2 not improved. 
4 died. 
Of 31 cases resected: 
22 were cured. 
3 not improved. 
6 died. 
The late observations were made from 9 to 14 years after operation. 
These statistics show excellent results following resection. There 
was never a flail-joint following the resection, although a number of 
cases had little motion and a number had ankylosis. 
In adults the operation of choice seems to be resection of the elbow, 
while in children the conservative treatment occupies the first place. 
Of the writer’s 8 cases, 2 were cured by plaster cast treatment (chil- 
dren) ; 2 adults treated by cast, result doubtful; 1 adult, resected, im- 
proved; 1 adult, amputated; and 2 cases were not treated or treatment 
was interrupted. 
Tuberculosis of the Wrist.—The wrist is a comparatively rare loca- 
tion for surgical tuberculosis (8 cases among 400 of surgical tubercu- 
losis, 2 per cent). Among 40 cases reported by Leonhard, 28 had a 
spontaneous onset, while 12 followed trauma. The seat of the focus in 
the wrist joint is, according to this author, distributed as follows: 
Cases 
Radiocarpal articulation 8 
Radio-ulnar articulation 6 
Carpometacarpal articulation 8 
Carpal bones 12 
Lower epiphysis of radius 3 
Lower epiphysis of ulna 1 
Tendon sheath as primary focus 2 
40 TUBERCULOSIS OF THE UPPER EXTREMITY 
195 
As a rule, the disease is not limited to one bone but quickly involves 
synovial membranes and ligamentous structures also, and the small 
carpal bones soon succumb to necrosis and caseation. Suppuration is 
very frequent, and, if sinuses develop, they are usually situated over 
the dorsum of the wrist. 
The numerous tendon sheaths surrounding the wrist joint often bear 
direct relation to the process in the joint, inasmuch as tuberculous 
involvement of the tendon sheaths is a frequent complication, though 
primary tendosynovial tuberculosis is rather rare. 
Mundel calls attention to the prominence of the os magnum as a 
factor in the development of tuberculosis of the wrist. In three of his 
cases he was able to show that the disease started from this bone. This 
he explains is due to the fact that the os magnum is the pivot of the 
carpal bones which, articulating with seven others, receives the brunt 
of traumatism directed to the wrist joint. Besides, tension of the liga- 
ments of the carpus causes strain upon the os magnum and he con- 
siders the early ossification of this bone, as compared with the other 
carpals, as an indication of the greater amount of strain imposed upon it. 
The position of the wrist in tuberculosis is that of semiflexion of 
about 120°. Swelling is first noticed at the lateral aspect of the joint, 
but it soon gains the dorsum and later also appears on the volar surface. 
Pain is usually moderate unless there is secondary infection. Bar- 
well states that, in tuberculosis of the wrist joint, the point of special 
tenderness is on the outer side of the extensor indicis tendon, corre- 
sponding to the junction of the os magnum and trapezium. 
The muscular atrophy, as in all instances of joint tuberculosis, is very 
considerable and occurs early. 
Tuberculosis of the wrist is essentially a disease of adult and later 
life and is usually associated with pulmonary disease. It may occur 
as serous effusion, as caries sicca, or in fungoid form. The latter may 
show all degrees to general fungoid infiltration and formation of large 
abscesses. Primary tuberculosis occurs also in the radius as progressive 
infiltration, or as epiphyseal focus and, finally, also as primary osseous 
tuberculosis of the bases of the metacarpals with secondary extension 
into the carpus. 
Treatment.—The rarer cases of wrist tuberculosis in children and the 
synovial and serous forms in general are the object of conservative 
treatment. In regard to the treatment by plaster cast fixation and 
modifying injections, as well as by heliotherapy, reference is made to the 
textbooks on the treatment of joint tuberculosis. 
The majority of the cases, especially those with destructive changes 
in the bone, call for operative measures. But a prompt cure of the 
local disease can be expected, even from an early operative interference, 
only when the disease is yet limited in extent. 
In accordance with the principle that to cure a tuberculous joint one 
must destroy it, Ely advocates early arthrodesis, using the following 
technic: a dorsal, longitudinal incision is made 8 to io cm. long, from 196 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
the middle of the third metacarpal to 4 cm. proximally to the articular 
surface of the radius. The extensor tendons are retracted and the 
periosteum is stripped back. Then, with the motor saw, parallel cuts 
are made through the wrist joint, radius, and third metacarpal. A graft 
removed from the tibia is then inserted and fitted into the groove so 
that it locks when the wrist is forced in hyperextension. The graft is 
sutured in place, the skin is closed, and a cast is applied which remains 
for three weeks. 
Of the older methods of resection those of Lister, Langenbeck, Ollier, 
and Kocher are the more commonly known. Lister recommended bilat- 
eral longitudinal incisions; one from the styloid process of the radius 
down to the first metacarpal, and another from the styloid process of 
the ulna to the fifth metacarpal. From these incisions he resected the 
carpus by subperiosteal procedure. The incision of Langenbeck is a 
dorsoradial one, about 9 cm. long, beginning at the middle of the second 
metacarpal bone over the dorsum of the epiphysis of the radius. The 
resection is done with the wrist in flexion, removing first the proximal, 
then the distal row of the carpal bones. Ollier used Langenbeck’s 
method to which was added an ulnar incision similar to that of Lister. 
Kocher, finally, used a dorso-ulnar incision, avoiding the extensor carpi 
radialis and the extensors of the thumb. This approach is more difficult 
than the dorsoradial incision. 
Some surgeons advocate early passive motion in order to retain some 
mobility of the wrist. Such a course is not to be recommended, as it 
is contrary to the principles governing the management of joint tuber- 
culosis. On the contrary, the period of fixation should be prolonged, 
and ankylosis of the joint in suitable position encouraged instead of 
being combated. We know that a fixation of the wrist joint in the 
position of choice is no serious obstacle to the functional use of the 
hand and fingers. 
It is of interest to study Leonhard’s table of results in 40 cases of 
tuberculosis of the wrist, and to compare his early findings with those 
made after years of observation. 
Early results. 
Of 13 cases treated conservatively: 
3 cured. 
7 improved. 
3 not improved. 
Of 14 cases for removal of foci: 
10 cured. 
3 improved. 
1 not improved. 
Of 2 extirpations of tendon sheath: 
2 cured. TUBERCULOSIS OF THE UPPER EXTREMITY 
197 
Of 5 partial resections (both carpal rows) : 
3 improved. 
2 not improved. 
Of i arthrectomy: 
i improved. 
Of 5 amputations: 
5 cured. 
Late results. 
Of 28 cases treated: 
11 died. 
6 cured. 
6 improved. 
5 not improved. 
According to these figures, the early and especially the late results 
are discouraging. Among the joints of the upper extremity, tuberculosis 
of the wrist gives the poorest prognosis for cure as well as for life. 
Of the 8 cases in the writer’s series, 6 were improved by conservative 
treatment. A patient, treated by resection, died later of pulmonary tub- 
erculosis; one patient was amputated. 
Tuberculous Dactylitis (Spina ventosa).—The disease is character- 
ized by tuberculous destruction of the diaphysis of the phalanges or 
metacarpals, which are partly extruded in the form of sequestra. A shell 
of bone is formed by the periosteum, but this is often so frail that it 
cannot withstand the pull of the muscles, and, in consequence of it, col- 
lapses. This is especially true in cases in which there is early formation 
of sinuses and a larger amount of bone destruction. The surrounding 
soft tissues soon become involved and with them also the skin. 
The disease has been known for many years and was identified as 
tuberculosis by Renken in 1886. Malgaigne and Velpeau already had 
enucleated the basal phalanges in cases of dactylitis and Velpeau recom- 
mended primary union of the wound by approximating the fleshy parts. 
The radical treatment of tuberculous dactylitis consists in thorough, 
as well as early, removal of all diseased tissue, especially of every bit 
of bone involved. In some cases the periosteal shell is strong enough 
so that it may be left with the expectation of further regeneration. In 
other cases, however, provisions must be made to substitute bone by 
autoplasty. 
Schmieden used autoplastic methods in 13 cases of operations for 
spina ventosa, making use of tibial grafts. His incision is a lateral one, 
saving the tendon, and all diseased soft tissue is carefully removed with 
the knife. Then the diseased bone is resected. In fistulous cases, he 
waits for the healing of the sinuses and performs the autoplasty at a 
secondary operation. 198 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
An osteoplastic method is that of Bardenheuer. In order to bridge 
the defect created by the resection of diseased bone, the basal phalanx 
is split and one-half of it is used as a bridge. 
Albee recommends as the most satisfactory treatment the resec- 
tion of the affected bone with substitution of the destroyed part by 
bone graft: an incision is made on the dorsum of the hand in line with 
the diseased bone. The extensor tendons are retracted. The periosteum 
is incised and elevated together with the attached interossei muscles. 
The affected bone is divided with a small single motor saw, osteotome 
or bone cutter, beyond either end of the diseased bone area, but an 
attempt should be made to save the head of the bone and not to encroach 
on the epiphyseal cartilage or to enter the joint. In the phalanges, lateral 
incisions are employed between the extensor tendons and the digital 
vessels and nerves. The periosteum is elevated, the bone resected, 
and an attempt made to save the head and not to destroy the epiphyseal 
cartilage. The bone defect is replaced by a graft taken from the crest 
of the tibia. A snugly fitting plaster cast is applied to finger and hand, 
remaining in place from eight to ten weeks. 
F. Smoler (1910) reports on 26 cases operated by the method of 
Bardenheuer or its modifications. In 9 of his cases the disease was 
located in the metacarpals and in 10 in the basal phalanges. Of his 
26 cases, permanent results were obtained in 30 per cent. 
Tuberculous Tenosynovitis of the Hand.—Tuberculous synovitis 
occurs in the following types: 
1. As serous effusion. 
2. With the formation of rice bodies. 
3. As fungous disease. 
The first two forms may persist for months without causing any 
serious trouble, while the third form is characterized by early involve- 
ment of the joint. This type progresses steadily, leading finally to the 
formation of cold abscesses and sinuses. 
The tuberculous tenosynovitis does not show any tendency to spon- 
taneous retrogression. Rather, it goes on without interruption to pro- 
duce complications, and especially to involve the neighboring structures 
in the tuberculous process. 
Of the three types, the first, or serous effusion type, will yield to 
puncture and injection of modifying fluids (iodoform-glycerin). 
Removal of the rice bodies and excochleation or scraping of the 
tendon sheath is necessary in the second type. 
The fungous form requires radical resection of the tuberculous 
tendon sheath. 
Case Report.—Man, 36 years old, complained for 8 years of a swell- 
ing on the volar aspect of the left hand and forearm. He had no pain, 
nor any serious trouble in the use of the hand, except that gripping was 
slightly handicapped and the hand tired more easily. The general con- 
dition of the patient was excellent. TUBERCULOSIS OF THE UPPER EXTREMITY 
199 
The examination showed a soft, fluctuating swelling extending 
from the lower fourth of the volar surface of the forearm through the 
wrist into the palm. It was less noticeable under the carpal ligament 
and at the angle between the thenar and hypothenar eminences. But 
in the palm it became quite prominent more distally, along the sheath 
of the flexor tendons of the middle finger. There seemed to be a com- 
munication between the proximal and the distal portion of the swelling. 
There was no tenderness to pressure. At operation 2 incisions were 
made, 1 over the proximal and 1 over the distal portion of the swelling. 
After dissecting down to the swelling, it was identified as the distended 
tendon sheath, and incision of it caused the escape of a clear fluid. This 
was followed by the appearance of rice bodies, which could be squeezed 
out in considerable numbers. The same procedure was followed from 
the upper incision and a number of rice bodies were obtained here also. 
There was a communication between the two halves of the sheaths 
and the bodies could be forced from one part into the other. The ten- 
don sheaths were carefully scraped and cleaned out and the wounds 
were closed.3 
BIBLIOGRAPHY 
Albee, F. H. Orthopedic and Reconstruction Surgery, Saunders and Co., 1919, 
269. 
Bernhard. Miinchen. med. Wchnschr., 1904. 
Ely, L. W. Joint tuberculosis in children, Am. Journ. Orthop. Surg., 1911-1912, 
Transact., 31. 
Hofmeister and Schreiber. Lehrb. d. prakt. Chir., Bruns-Garre-Kuettner, 99, 
263, 433> 437- 
Leonhardt. Die Behandlung der Tuberkulose des Schulter-Elbogen und Hand- 
gelenkes und ihre Erfolge, Beitr. z. klin. Chir., 1913, 87:125. 
Mundell, D. E. Note on the relation of the os magnum to tuberculosis of the 
wrisfl Ann. of Surg., 1900, vol. 32. 
Rollier. La cure du soleil. 1913. 
Schmieden. Deutsche Ztschr. f. Chir., 1904, vol. 95. 
Smoler, F. Zur chirurgischen Behandlung der Spina Ventosa, Beitr. z. klin. 
Chir., 1910, 67:79. 
Witter, A. Die Sonnenbehandlung der chirurgischen Tuberkulose, Beitr. z. 
klin. Chir., 1912, 81:694. 
‘When seen six months later, there was still a slight amount of swelling, though 
considerably less than before operation. CHAPTER VIII 
CHRONIC ARTHRITIC DEFORMITIES OF THE UPPER 
EXTREMITY 
Arthritic conditions of nonspecific character, resulting in deformities 
of the upper extremity, are based upon etiological factors of such vari- 
ance and diversity that, for the sake of clearness, a short classification 
of the subject should precede the discussion of this type of deformities. 
One of the most serviceable is that of L. F. Barker. It is based, not 
only upon the external appearance of the cases and the course of the 
disease, but also upon anatomical and etiological considerations, as much 
as the latter can be correlated with clinical experience. But it neither 
confines itself altogether to gross anatomical findings, which are at 
present too general to admit of a detailed division, nor does it base 
itself upon etiology alone, since here, too, our present knowledge is by 
far too incomplete to permit an adequate classification. 
Arthritis urica. 
Arthropathies of nervous origin, tabes, syringomyelia. 
Osteo-arthritic deformities. 
Secondary chronic arthropathies following infection. 
Luetic. 
Tuberculous (see Chapter VII) 
Gonorrheal. 
Chronic articular rheumatism. 
Chronic progressive polyarthritis. 
For the upper extremity there are to be considered the chronic 
arthropathies following infection, especially the chronic progressive, 
infectious polyarthritis, and also some of the osteo-arthritic deformities: 
Altogether 46 cases of chronic arthritic deformities of the upper 
extremity have come under the writer’s observation. 
They are etiologically divided as follows: 
Cause unestablished: 
Cases 
Shoulder 4 
Elbow 3 
Wrist and fingers . 15 
22 
200 CHRONIC ARTHRITIC DEFORMITIES OF UPPER EXTREMITY 
201 
Sepsis following abscess formation : 
Elbow 1 
Wrist and fingers 1 
2 
Gonorrheal arthritis: 
Wrist and fingers ... 2 
Elbow 2 
4 
Septic metastatic infections: 
Elbow 3 
Shoulder 1 
Wrist and finger influenza 2 
6 
Tonsillar and teeth infection: 
Wrist and fingers 4 
Elbow 5 
Shoulder 1 
10 
Sinus infections: 
Wrist and fingers 2 
46 
Regarding the etiological significance of teeth and tonsillar infection 
in chronic arthritis, while it is not within the scope of this writing to 
enter into this question systematically, yet, in the light of the material 
at hand, brief reference must be made to this matter. It is over a 
hundred years since Benjamin Rush first called attention to the pos- 
sible connection between diseased tonsils and chronic arthritis. The 
teachings of Billings and the investigations of Rosenow have in later 
years stimulated the interest in this problem. Although the early en- 
thusiasm, which followed Rosenow’s discovery of the transmutability 
of streptococcus strains, has given way at the present time to a degree 
of skepticism, the interest in this question is still alive and it is to be 
hoped that it will not be allowed to wane. The opinions are at present 
widely divergent; some hold to the belief in an underlying focal infec- 
tion in any case of chronic arthritis, while others deny the significance 
of this factor. Most orthopedic surgeons hold that the removal of a 
focus in teeth or tonsils, or in the accessory nasal cavities, will produce 
a cure in some, and improvement in a number of cases, and more so 
in acute than in chronic conditions. Hammond’s statistics of 40 cases 
show that there were diseased teeth or tonsils in 29. But in all his 
cases there was only one in which immediate and striking improvement 202 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
followed so closely the removal of the focus of infection that a causal 
connection between focus and arthritis could not be denied. In the 
writer’s series there were 7 cases in which a connection between foci 
in teeth, tonsils, sinuses, or ear was established in the history and in 
which removal of these foci gave no relief. There were, furthermore, 
10 cases in which careful search for a focus was made and in which 
removal of tonsils, clearing of sinuses, etc., did not produce improve- 
ment nor did it check the progress of the arthritis. But there were, on 
the other hand, 9 per cent, or 4 cases, of chronic arthritis of the upper 
extremity, in which decided improvement was obtained after removal 
of tonsils or clearing of sinuses. 
Case Reports.—P. R., 8 years, suffering for 3 years from infectious 
arthritis involving feet and hands. Examination showed sinusitis and 
empyema of right antrum. Operation on sinuses and antrum was fol- 
lowed by distinct improvement which continued during an observation 
of years. 
F. B., 13 years, suffering for years from chronic infectious arthritis 
involving fingers, shoulder, elbows, knees, and ankles. A suppurative 
anterior ethmoiditis was found and treated. This was followed by 
gradual improvement and final arrest of the progress of the disease. 
M. O., 5 years, suffering for 3 years of chronic infectious arthritis 
of all joints. Chronic tonsillitis. Tonsils removed. Antromeatal oper- 
ation. This was followed by marked improvement of the arthritic con- 
dition. 
A. P. J. Infectious arthritis of the right elbow for a number of 
years, with considerable pain. Removal of tonsils 6 years ago was fol- 
lowed by disappearance of pain within 1 month. 
The use of foreign proteins injected intravenously (typhoid vaccine) 
has been recommended in later years (J. Miller, H. B. Thomas). As 
an initial dose in several cases, 25 to 50 million bacteria to 1 c.c. was 
used. Only in two instances was there anything like an improvement. 
In 1 case with involvement of right hand, wrist and elbow showed a 
remarkable improvement after 7 injections from 50 to 125 mm. which, 
after 4 months of observation, still continued. In the other case, 6 in- 
jections up to 75 mm. were used with moderate improvement.1 
Arthritic Deformities of the Shoulder.—The increasing limitation of 
motion in the shoulder soon leads to complete immobilization followed 
by atrophy of the deltoid. The trouble may be recognized as an intra- 
articular lesion and differentiated from extra-articular conditions by the 
position of the shoulder joint, which is, as a rule, that of 250 abduction. 
‘Lately the work of R. Pemberton on the etiology and treatment of chronic arthritis 
has attracted the widest attention. In his numerous publications he emphasizes the metabolic 
nature of this condition. Pointing to the beneficial influence of X-ray, of radium, of 
endocrine therapy, which factors also stimulate metabolism, he thinks it evident that there 
is a definite relation between the food intake and arthritis. This, together with observa- 
tions of low sugar tolerance, and of the favorable influence of starvation and especially 
low carbohydrate diet, lead to the theory that the arthritis is caused by lowered respiratory 
and metabolic capacity of the organism, induced not only by focal infections, but also by 
exposure, chronic intestinal condition, etc. He consequently recommends a generally 
reduced diet with special restriction of the carbohydrates. CHRONIC ARTHRITIC DEFORMITIES OF UPPER EXTREMITY 
203 
This position is masked by rotation of the shoulder-blade but can easily 
be detected by restoring the symmetrical position of the scapula (com- 
pare Chapter I). There is usually a degree of tenderness of the joint 
capsule, most apparent in the axilla where the inferior portion of the 
capsule can be reached. Arthritis of the shoulder joint is to be differ- 
entiated from the following conditions: 
Stiff and Painful Shoulder Following Sprains.—It is usually the anterior 
and inferior portion of the capsule which is involved, the injury being 
acquired in abduction and outward rotation of the arm. The position 
in this case is that of adduction and inward rotation contracture. The 
capsule is tender in the pit of the axilla and evidences of infiltration may 
be found there. 
Sprain and Tears.—Adduction and internal rotation contracture are 
caused by sprains or tears of the pectoralis major and latissimus dorsi 
tendons. The tender points are precisely localized at the sites of inser- 
tions of the tendons. 
Subdeltoid Bursitis.—Limitation of motion is partial as in the other two 
conditions, outward rotation and abduction being inhibited. Local tend- 
erness is found over the subdeltoid bursa or over the anterior portion 
of this muscle. 
Caries Sicca.—In caries sicca, the onset is gradual, accompanied by little 
pain, and stiffness is an early symptom. The contracture is that of an 
intra-articular lesion, that is, in slight abduction. Signs of pulmonary 
tuberculosis are often present. The affliction is usually monarticular. 
Treatment.—The treatment of the chronic arthritic shoulder deformities 
is essentially one of rest and immobilization. In the subacute stages 
the contracture yields more readily to the application of a platform 
splint. By gradually raising the angle the adduction contracture can 
be overcome. Massage, passive and active motion are valuable aids in 
the treatment. Forcible manipulations in arthritic conditions are not 
to be recommended. They are usually followed by an exacerbation of 
the inflammatory condition. Even at best, they contribute nothing to 
the mobility of the joint and they may do considerable harm. From 
this point of view alone, it is important to differentiate between intra- 
articular and extra-articular lesions, as in the latter forcible manipula- 
tions to overcome contracture may be employed. 
Case Reports.—J. N., 14 years. Septic arthritis of the left shoulder 
following mastoid operation 1 year ago. Fixation of the shoulder in 
slight abduction and inward rotation. Atrophy of the deltoid. Treated 
conservatively with splints and massage. Condition after 14 months: 
has active abduction of 70° in the shoulder joint. Almost complete 
rotatory and flexion and extension movement in the shoulder. Con- 
siderable regeneration of the deltoid. 
S. S., 46 years. Chronic arthritis of the shoulder developing for 1 
year. Complained of pain and stiffness. There was rigidity of the 
right shoulder with muscular contraction, the position of the joint being 
30° abduction. 204 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Treated by splints, and massage. After 4 months the right arm 
can be abducted to the perpendicular. 
Arthritic Deformities of the Elbow.—The position of the elbow in 
rheumatoid or infectious arthritis is that of extension to 130° to 150° 
and of pronation of the forearm. It is the object of early treatment to 
avoid the danger of ankylosis in this unfavorable position. 
Fixation of the elbow is best procured by a plaster cast reaching 
from the metacarpophalangeal joints to the axilla, or by a splint of 
similar extent. In earlier stages, and especially in certain types of infec- 
tions, the position can be improved by a series of casts until a position 
of 70° to 8o° flexion and midway between pronation and supination 
is obtained. Corrective casts should include the lower radio-ulnar 
articulation. 
It has been common experience that the forcible breaking up of 
adhesions in the elbow joint is followed by a flare-up of the inflammatory 
condition with subsequent increase of the intra-articular adhesions. 
Gonorrheal adhesions in the elbow joint are among the least likely to 
cause such violent reaction to force, and, for the sake of improving 
the position, the application of moderate force may be justified at times. 
But under no circumstances should an increase of the range of motion 
be expected to follow the forcible mobilization of the elbow joint. This 
procedure is invariably followed by a severe hemorrhage into the joint 
and often by extra-articular hemorrhage also, which leads to an in- 
creased production of fibrous adhesions. 
Cases of ankylosis of the elbow from chronic arthritis: 15. 
Causes: 
Cases 
Ear and throat infections 5 
Erysipelas 1 
General septic infection 3 
Acute articular rheumatism 1 
Gonorrheal infection 2 
Cause unestablished 3 
15 
Degree of ankylosis: 
Total 2 
Partial 13 
15 
Treated conservatively: 
Improved 3 
Not improved 2 
5 CHRONIC ARTHRITIC DEFORMITIES OF UPPER EXTREMITY 
205 
Forcible correction : 
Improved i 
Not improved i 
2 
Arthroplasty: 
Improved 3 
Not treated 5 
Arthritic Deformities of Hands and Fingers.—The position of hand 
and fingers in arthritic contractures is one of flexion in the wrist joint, 
of ulnar deviation of the fingers with either flexion or hyperextension 
in the metacarpophalangeal joints, and of flexion in the phalangeal joints. 
The principles of fixation and gradual correction of the contractures 
should be applied to the wrist and fingers with the same persistence 
as in other joints of the body. Appropriate splinting especially will go 
far to check the increasing contractures of the flexor muscles. The best 
services will be obtained from the volar appliances with individual volar 
finger splints in which the degree of correction can be regulated accord- 
ing to the condition of the individual joint. A dorsal ring splint may 
be applied also, but we have found that pressure upon the first inter- 
phalangeal joint is not well tolerated. 
In some cases the volar flexion of the wrist is extreme; these also 
show a tendency to hyperextension in the metacarpophalangeal joints. 
This deformity reaches, in some cases, a degree where a veritable con- 
dition of subluxation exists between the radius and the carpus; occa- 
sionally the lower end of the radius follows the direction of the con- 
tracture with a volar incurvation and the ulna, not following the radius, 
becomes prominent at the dorsum of the wrist; a condition simulating 
the picture of Madelung’s deformity. 
A chronic, ankylosing arthritis of the wrist joint is often observed 
following injuries of the wrist, that is, Colles’ fractures or even mere 
contusions and sprains. It is marked by spastic contracture of all the 
forearm muscles and the muscles of fingers and wrist. The process 
leads finally to obliteration of all joints of the carpus. It occurs ,more 
often in nervous individuals and in persons of more advanced age, and 
is probably based upon reflex nervous and circulatory disturbances. 
Treatment—The Deformity of the Wrist.—Splinting and massage in 
cases of lesser rigidity, in cases with tenderness or occasional recrudes- 
cence of more acute symptoms. Corrective manipulation in more 
resistant cases. The cast should reach from the palm to the elbow and 
be applied at intervals varying from a few days to a few weeks. Occa- 
sionally a forcible correction of the deformity may be undertaken under 
anesthesia. This, however, should be restricted to resistant contrac- 
ture in the chronic stage, not showing acute acerbations, and in which 
the carpus shows no tendency to subluxation. In exceptional cases the LEGEND FOR PLATE XXXIV 
Fig. i.—I. B. Infectious Arthritis, Wrist and Fingers. 
Fig. 2.—F. B. Ankylosis, Elbow and Wrist; Infectious Arthritis. 
Fig. 3.—A. P. Infectious Arthritis. Cast for Correction of Finger Deformities. 
Fig. 4.—F. S. Traumatic Arthritis; Bone Erosions. Adduction Contracture. 
Fig. 5.—F. S. Following Operative Treatment (Arthrolysis and Tenotomies). 
Fig. 6.—F. B. Infectious Arthritis; Fingers, Elbow, Wrist and Shoulder. 
Fig. 7.—J. N. Subluxation of Wrist; in Infectious Arthritis. 
Fig. 8.—A. P. Finger Contractures; Infectious Arthritis. PLATE XXXIV 208 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
correction may also be facilitated by plastic lengthening of the con- 
tracted flexor tendons of the wrist. 
Mueller (1894) reported 3 cases of arthritis deformans of the 
wrist joint treated with extirpation of the capsule, trimming of the 
articular surfaces, and resection of the scaphoid and lunare. For 
arthrotomy of the wrist one may employ with advantage Ollier’s pos- 
terior incision: from a point midway between the styloid processes, an 
incision is made on the dorsal surface and carried down through the 
posterior annular ligament to the middle of the second metacarpal, 
radially to the extensor indicis tendon. 
The Deformities of the Metacarpophalangeal Joints and Fingers.— 
The hyperextension of the metacarpophalangeal joint is best managed 
by splinting combined with massage and passive motions in cases which 
are not too resistant. In the latter type, correction could be obtained 
by manipulation with or without anesthesia, the result of correction 
being secured by a plaster cast which holds the fingers closed. Con- 
siderable difficulty is encountered in meeting the extension deformities 
of the fingers. One may gradually force the phalangeal joints into 
flexion by corrective splints, or may do so by manipulation in one sit- 
ting. The former procedure, if feasible, is preferable because the friable 
capsular tissues and the degenerated tendinous structures react severely 
to the application of force. 
Table of Cases.—Total deformities of hands and fingers 25 
Causes: 
Tonsillar and sinus infections 6 
Influenza 2 
Gonorrhea 2 
Cause not established 15 
25 
Deformities: 
Flexion contracture of wrist alone 8 
Flexion contracture of wrist and fingers 9 
Flexion contracture of fingers alone 2 
Extension of fingers and metacarpophalangeal joints. 2 
Subluxation of the wrist 1 
Ankylosis of wrist, no deformity 3 
25 . CHRONIC ARTHRITIC DEFORMITIES OF UPPER EXTREMITY 
209 
Treatment: 
Splints and massage 10 
Improved 7 
Not improved 3 
10 
Cast 3 
Improved 2 
Not improved 1 
3 
Forcible correction 3 
Improved 3 — 
Total treated 16 
(Plate XXXIV, 1-8). 
BIBLIOGRAPHY 
Barker, L. F. Differentiation of the diseases included in chronic arthritis, Am. 
Journ. Med. Sciences, 1914, 147:1. 
Bulkley, K. Pneumococcus arthritis, Ann. of Surg., 1914, 59:71. 
Dunn, C. H. Rheumatism in children, Am. Journ. Med. Sciences, 1908, 136:66. 
Hammond, R. Teeth and tonsils as causative factors in arthritis, Am. Journ. 
Med. Sciences, 1918, 156:541. 
Hirsch, K. Beitrag zur Kenntnis der ankylosierenden traumatischen Arthritis 
des Handgelenkes, Arch. f. Orthop., 1917, vol. 15. 
Nathan, P. W. Neurological conditions associated with polyarthritis and 
spondylitis, Am. Journ. Med. Sciences, 1916, 152-667. 
Osgood, R. B. The end results of attempts to mobilize stiffened joints, Surg. 
Gyn. Obstet., December, 1913. 
Pemberton, R. The metabolism and successful treatment of chronic joint dis- 
ease, Am. Journ. Med. Sciences, 1912, 1917, vols. 144, 146, 147, 151, 153. 
Resciike, K. Mobilisation versteifter Schultergelenke, Arch. f. klin. Chir., 1918, 
hi: 784. 
Schmerz, H. Bericht iiber Gelenkmobilisation, Beitr. z. klin. Chir., 1919, 
117:618. 
Skinner, C. E. Treatment of arthritis deformans, Am. Journ. Med. Sciences, 
1910, 140:684. 
Steedman, J. F. Treatment of ankylosis of the elbow joint, Brit. Med. Journ., 
1918, 2:433. CHAPTER IX 
CONGENITAL MALFORMATIONS AND DEFORMITIES 
The study of congenital malformations and deformities of hand and 
fingers leads into the darkest period of the emhryological and onto- 
logical development of man. In the first period of intra-uterine life, 
covering the first two months, the agencies which are capable of pro- 
ducing malformation seem to be most powerful. The activities of 
growth and development are so intense, at this time, that any disturb- 
ance of these must have grave morphological consequences. 
A number of theories have been brought forth in an effort to shed 
light upon the factors responsible for congenital deformities. Some of 
these views are necessarily speculative and cannot very well be sub- 
stantiated, especially as they reach back into the very early life of the 
embryo. Other theories consider mechanical factors and external forces: 
position, outside pressure, etc. The latter have in their favor greater 
plausibility in general, but when it comes to their application to the 
individual case, the field for mechanical theories becomes greatly limited. 
The former type is represented by the archipterygial or primitive ray 
theory of Gegenbaur. It is, according to him, the suppression of devel- 
opment of any of the primitive rays which is responsible for the occur- 
rence of certain deformities. If the first primitive ray of the upper 
extremity is involved, the bones affected are the radius, scaphoid, 
trapezium, the first metacarpal, and the thumb. This is a theory which 
is applicable to a limited number of congenital deformities only. On 
the other hand, a representative of those which point to external forces 
in explaining the origin of deformities is the amniotic theory of 
Schwalbe, Dareste, and others. Here it is amniotic pressure or 
mechanical constrictions from amniotic bands which are held respon- 
sible for such deformities as hemimelia, phocomelia, etc. 
In the course of the discussion of the different types and groups of 
congenital deformities of the upper extremity, it will become clear that 
it is a futile attempt to subjugate all the different deformities of so 
heterogenous a type and character, or even a great majority of them, 
to any one of the theories which have been advanced. So, for instance, 
the amniotic theory, very applicable to cases of external amniotic con- 
striction, furrows, and certain cases of syndactylia, fails in the explana- 
tion of a great many other deformities. Those theories which rely 
upon primary aberrations and variations have a wider applicability, 
especially in deformities of a bilateral and symmetrical character. There 
should also be mentioned the views which ascribe to certain malforma- 
210 CONGENITAL MALFORMATIONS AND DEFORMITIES 
211 
tions of the spinal cord and spinal column an essential role in the pro- 
duction of congenital deformities, such as claw-hand, congenital claw- 
foot, etc. Finally, it must not be overlooked that polyglandular dis- 
turbances, especially functional anomalies of the hypophysis, may be 
responsible for some of the congenital malformations of more general 
type- 
While as a whole the theory of embryonal aberration or primary 
aberration covers the greater part of the cases of congenital malforma- 
tions of the hand and fingers, it seems certain that other factors also 
come into play and that no one theory is capable of covering even the 
large majority of cases of congenital malformations. 
Classifications.—The most thorough and scientific classification of 
the congenital deformities we have found to be fhat of Potel, which 
we quote here, adapted to the conditions of the upper extremity. 
Congenital Deformities in Regard to Upper Extremity 
Classification of Potel: 
I. Embryonal evolutionary type 
A. Osteogenetic disturbances 
1. Systemic osseous dystrophy 
a. Enchondral ossification 
(achondroplasia, hyperchondroplasia, hereditary dystro- 
phy arachnodactylia) 
b. Periosteal dysplasia (osteopsathyrosis) 
c. Disturbance of ossification of membranous bone 
(congenital absence of clavicle) 
2. Localized osseous dystrophy 
a. Ectromelia (brachymelia, micromelia) 
aa. Transverse 
absence forearm and hand—E. vera 
absence of hand alone—ectrochiria 
absence of fingers—ectrodactylia 
brachydactylia—microdactylia 
(1) Hemimelia 
(2) Phocomelia 
absence of segments 
humerus, forearm bones 
bb. Longitudinal E 
absence of radius, partial or total 
congenital club-hand 
absence of ulna 
b. Skeletal hypertrophy 
gigantism, partial or total 
macrodactylia 
elbow, forearm bones 
carpal bones 
syndactylia: osseous 
fibrous, membranous 
acrodactylia 
c. Deficient segmentation and fusion 212 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY- 
d. Hypersegmentation 
aa. Transverse (polydactylia) 
bb. Longitudinal (hyperphalangism) 
e. Axial deviations (comptodactylia, clinodactylia) 
f. Heteroplastic aberrations 
osseous developmental aberra- 
tions osteogenetic exostoses 
B. Articular Malformations 
1. Relaxations (hyperextension elbow, wrist; congenital clown- 
ism) 
2. Subluxations (shoulder, thumb) 
3. Congenital dislocations (shoulder, elbow, radius, thumb) 
C. Muscular Malformations 
1. General muscular dystrophies (congenital contractures) 
2. Localized 
a. Congenital elevation of the scapula 
b. Congenital atrophy of deltoid 
c. Congenital contracted club-hand 
IT. Amniotic type 
A. Cicatricial 
1. Amniotic amputations 
2. Amniotic strands 
3. Amniotic furrows 
B. Compression 
1. Amniotic syndactylia 
A clinical classification less complex and applicable to most of the 
conditions of the upper extremity, but at variance in many respects 
with Potel’s classification, is the following: 
Clinical Classification 
A. Deformities by developmental suppression, agenesis 
1. Congenital defect of the forearm bones (congenital club-hand) 
2. The cleft hand (lobster claw-hand) 
3. Ectrodactylia (aphalangism) 
B. By developmental arrest 
1. Syndactylia 
2. Symphalangism 
C. By developmental aberrations 
1. Polydactylia (some cases) 
2. Hyperphalangism 
D. Dysplastic conditions 
1. Congenital synostoses 
2. Brachydactylia (some cases) 
3. Fusion of carpal bones CONGENITAL MALFORMATIONS AND DEFORMITIES 
213 
E. Polyglandular dystrophy 
1. Polydactylia (some cases) 
2. Macrodactylia (partial gigantism) 
3. Arachnodactylia 
F. Contractures (neurogenetic or amniotic) 
1. Contracted club-hand 
2. Contracted fingers 
3. Amniotic contractures (nonsymmetrical) 
Much of the difficulty in properly classifying a case is due to its 
complications. For instance, it is not unusual to find polydactylia, 
ectrodactylia and syndactylia together in one case. In fact, there 
seems to be a certain relationship between overdevelopment and sup- 
pression. It is to be hoped that further investigations both of embryo- 
logical and anatomical nature will bring more light on the questions of 
etiology. 
Embryology.—The embryology of the upper extremity can be 
found in W. H. Lewis’ excellent article, “American Journal of 
Anatomy” (1901), which is here quoted in part: 
The first indication of the arm bud appears during the 3rd week 
as a slight swelling of the lower cervical region on the anterior portion 
of the Wolffian ridge. This gradually enlarges, and, by the time the 
embryo is 4.5 mm. in length and 3 weeks old, the arm is of considerable 
size. The base now lies opposite the lower 4th cervical and the 1st 
thoracic vertebrae. The arm bud is at first filled with a homogenous 
mesenchyme. No nerves or myotomes have yet entered the arm. Dur- 
ing the 4th week, before the nerves enter, differentiation begins by in- 
creased condensation of the skeletal core. During the 5th week, the 
nerves from the first anlage of the cervicobrachial plexus push into the 
premuscle sheath which surrounds the skeletal core. 
By the end of the 5th week, the skeletal core can be differentiated 
into many of the skeletal elements, three of which contain cartilage, 
namely, humerus, ulna, and radius. The premuscle sheath also becomes 
more or less differentiated into several groups of muscles, but at first 
without sharp lines. Toward the distal end differentiation is less com- 
plete and, in the hand, premuscle tissue still represents the intrinsic 
muscles. The nerves have grown into the hand by this time and most 
of the branches of the brachial plexus found in the adult are now 
present. 
By the end of the 6th week, most of the muscles of the arm can 
easily be recognized. The intrinsic muscles of the hand are just begin- 
ning to show fibrillation. The tendons and ligaments are also becom- 
ing more sharply differentiated. Most of the skeletal elements consist 
of cartilage and the surrounding perichondrium. The distal row of 
phalanges are not yet differentiated. The nerves, both sensory and 
motor, are distributed much as in the adult. 
During the end of the 7th week, all skeletal elements are of cartil- 
age except the distal row of phalanges, from the second to the fifth 214 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
digits, which are of condensed tissue. All muscles are differentiated 
and muscle fibers are present. Tendons and ligaments, except in the 
distal parts of the digits, are well formed. 
One will note from these embryological facts that the development 
of the skeletal plant (anlage) occurs, practically entirely, between the 
third and seventh week. Another point of importance is that the de- 
velopment of the nerve system is ahead of the differentiation of the 
muscle system, a point with which the neurogenetic theory of malforma- 
tion has to reckon. 
During the development of the upper extremity, there occurs a 
certain migration of the arm which changes its topographical relation 
to the spine. The whole extremity migrates caudally. The scapula, 
for instance, which in the embryo of four weeks occupies a place oppo- 
site the fourth and fifth cervical vertebrae wanders downward, so that 
in the sixth week the greater portion of the scapula lies below the 
first rib and the lower angle reaches the fifth rib. This fact has already 
been mentioned in discussion of the congenital elevation of the scapula, 
a condition which really belongs in this chapter, but has, for reasons of 
expediency, been placed by the writer among the shoulder affections 
of the upper extremity. 
The brachial plexus also has a very marked caudal inclination indi- 
cating the migration of the extremity. There is also a migration of the 
pectoralis muscles and th'e latissimus dorsi from a more' anterior to a 
posterior plane of the thoracic wall, and, by the seventh week, the pec- 
toralis muscles have reached the adult position. The trapezius muscle 
also wanders caudally. In the embryo of four and one-half weeks, the 
posterior end of the trapezius premuscle mass lies no further down than 
the fourth cervical. At the end of six weeks, it already reaches the fifth 
thoracic vertebra. Such migration also occurs in the serratus magnus 
muscle, which wanders downward from the cervical region, and in the 
rhomboids, which migrate, between the fourth and seventh weeks, from 
the level of the fifth cervical to a definite position in the thoracic region. 
This embryological migration is a factor in several congenital deformi- 
ties about the shoulder and arm; not only in congenital elevation but 
also in certain anatomical variations of the thoracic muscles. 
A-i. Congenital Club-hand.—Suppression of the development of the 
first ray, which includes radius, scaphoid, trapezium, the first meta- 
carpal, and the thumb, is, according to Gegenbaur, responsible for the 
majority of cases of club-hand deformity. Developmentally, the radius 
is behind the ulna and it can therefore be understood why suppression 
setting in at a certain moment will find the ulna developed and the 
radius partially or totally undeveloped. The suppression of growth, 
however, is not confined to the radius alone nor to the first ray in 
general. There are cases in which the defect involves the ulna and 
the ulnar ray. The radial defects are, however, by far in the prepon- 
derance over the ulnar defects in the group of club-hands associated 
with bone involvement. CONGENITAL MALFORMATIONS AND DEFORMITIES 
215 
Up to 1904, Kirmisson reported 67 cases, 57 of which showed total 
and 10 partial bone defect. Antonelli (1912) reported 114 cases with 
total or partial defect of the radius and Whitmann in 1912 could col- 
lect more than 200 cases in the literature. 
The majority of all cases of this type are associated with defects of 
the radius. Among the congenital defects of the ulna, of which there 
is a small minority, a family of 9 is mentioned by Blencke in which 4 
members showed the deformity. Bilateral club-hands are about as fre- 
quent as unilateral. Complications with deformities and defects of 
other nature are very common, and among those complications there 
are mentioned club-foot, congenital deformities of the thorax, fusion 
of the ribs, and many others. 
Anatomical details concerning these deformities have been described 
by Kirmisson and Longet. Kirmisson dissected a case of total defect 
of the radius with absence of thumb. He found all the thumb muscles, 
as well as the muscles of the radial side of the forearm, entirely absent; 
and in addition to this, the long head of the biceps was also missing. 
The defect involved radius, scaphoid, semilunar, trapezium, as well as 
the skeleton of the thumb. The superficial and the deep flexors are 
often found united in one mass at the upper end of the forearm, and it 
is with difficulty only that they can be differentiated by their distal 
insertions. There is no flexor of the thumb nor index finger, if the 
latter is missing too, and there is no pronator quadratus. In the case 
described by Kirmisson both supinators were absent. There was one 
small muscle blending with the muscles of the posterior region of the 
forearm which probably represented all that was left of the extensors 
carpi radiales. Of the posterior group, the anconeus and the extensor 
of the fifth finger were missing. In the hand, small bundles from the 
pisiform bone represented the abductor of the fifth finger, and there 
were only three ulnar lumbricales. No muscles at the radial border of 
the hand or of the thenar were present. 
In cases of ulnar club-hand, the defect involves not only the ulna 
but also one or two of the metacarpals and phalanges. Cases are re- 
ported in which the ulna was entirely missing and only two radial digits 
existed. In the case reported by Neumann, for instance, the third, fourth 
and fifth fingers were absent and there was total defect of the ulna. 
The anatomical data are more meager in regard to the ulnar club- 
hand than they are in regard to the radial. Watts found a bilateral 
congenital absence of the ulna in a monodactylous fetus, an additional 
finger being attached at the elbow, where a web was binding the fore- 
arm to the humerus. In this case, the superficial extensors of the fore- 
arm were present and the deeper group was missing. The forearm flex- 
ors were represented but were badly disorganized and disarranged. In 
the remainder of the hand, there was only one muscle, a lumbricalis, aris- 
ing from the lateral side of the tendon of what was considered to be the 
flexor pollicis muscle. Dislocation of the head of the radius was found 
in connection with a defect of the lower end of the ulna in a case of 216 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
ulnar club-hand reported by Kirmisson. In this case, three fingers were 
and a third finger. 
fully developed: the thumb, a completely fused index and middle finger, 
A second group of cases of congenital club-hand deformity are those 
which are not associated with bone defects. As to the etiology of this 
deformity, we are entirely in the dark. It is certain that the amniotic 
theory cannot easily be called upon in explanation of this deformity if 
the bilaterality and symmetry of it is considered. Potel groups these 
cases under muscular malformation of localized character. They are 
truly contracted club-hands and by some considered as club-hands in 
the stricter sense of the word because of their analogy to the ordinary 
congenital club-foot. 
According to the type of contracture, one may distinguish ulnar, 
palmar, radiopalmar, ulnardorsal, and radiodorsal club-hands. 
The author’s series embraces 12 cases of congenital club-hand: 
A. Defects of forearm bones Cases 
Congenital defects of the radius 3 
Congenital defects of the ulna 2 
B. Contracted club-hand 7 
Club-Hand 
Case 
Age 
Deformity 
Bone Defects; Com- 
plications 
Treatment 
Result 
P. S. 
3 mos. 
bilateral sym- 
metrical con- 
genital club- 
hands 
congenital defects of 
radius 
splint treat- 
ment; oper- 
ative treat- 
ment defer- 
red 
K. Me. 
5 mos. 
congenital bi- 
lateral club- 
hand bilateral 
symmetrical 
total defect of right 
radius both thumbs 
missing 
operation os- 
teotomy of 
ulna 
fair 
M. W. 
8 wks. 
congenital club- 
hand, right 
partial defect of radius: 
only lower epiphysis 
and part of upper 
developed 
deferred 
operative 
treatment 
H. P. 
14 mos. 
ulnar club-hand 
total defect of ulna; 
syndactylia between 
2d and 3d finger 
osteotomy of 
radius 
poor, re- 
currence 
C. K. 
17 yrs. 
bilateral ulnar 
club-hand 
symmetrical rudimen- 
tary ulnar; lower 
3d missing; only 
7 carpal bones; func- 
tion of hand good 
not treated 
CONGENITAL CLUB-HAND CONGENITAL MALFORMATIONS AND DEFORMITIES 
217 
CONTRACTED CLUB-HAND: BILATERAL, SYMMETRICAL 
Case 
Age 
Deformity 
Bone Defects; Com- 
plications 
Treatment 
Result 
C. M. 
11 mos. 
contracted club- 
hands bilat- 
eral 
contraction elbows; 
adductor contrac- 
tion of the arms; 
flexion contracture 
hips and knees; con- 
genital club-foot; 
genital hypoplasia; 
high palate 
not treated 
F. T. 
7 yrs. 
flexion contrac- 
tracture of 
the left hand 
Atrophy of shoulder 
muscles; contracture 
of elbows; fragilitas 
ossium; callus of the 
humerus 
plastic length- 
ening of 
fingers; ar- 
throdesis of 
wrist 
good; both 
deformity 
and func- 
tion 
G. H. 
8 yrs. 
congenital con- 
tracted club- 
hands bilat- 
eral symmet- 
rical, ulnar 
deviation 
congenital flexion con- 
tracture of hips and 
knees; contractures 
of shoulders; bilat- 
eral congenital flat- 
foot ; high palate; 
genital hypoplasia; 
function good 
not treated 
A. B. 
io yrs. 
congenital con- 
tracted club- 
hands; ulnar 
deviation; bi- 
lateral; sym- 
metrical 
congenital contract- 
ures of the knees, 
congenital club-foot; 
cutaneous syndac- 
tylia between thumb 
and index fingers 
operative cor- 
rection of 
syndactylia 
muscle ed- 
ucation 
Good 
F. C. 
6 mos. 
congenital bi- 
lateral sym- 
metrical club- 
hands with 
ulnar devia- 
tion 
genua recurvatam bi- 
lateral ; total ab- 
sence of the patellae; 
function good 
club-hands 
not treated 
E. T. 
6 mos. 
congenital bi- 
lateral club- 
hands ulnar 
abduction 
adduction contract- 
uresof the shoulders; 
congenital club-feet; 
webbing of the bases 
of the fingers 
(:pterodactylism) 
splints and 
plasticlength- 
ening 
fair 
D. A. 
i| yrs. 
rachitic con- 
tracted club- 
hands since 
birth 
rachitic deformities of 
legsandhands; func- 
tion good 
not treated 
(Plates XXXV, XXXVI, XXXVII.) LEGEND FOR PLATE XXXV 
Fig. i.—D. C. Bilateral, Congenital, Radial Club-hands. Defect of Radius. 
Fig. 2.—K. McC. Bilateral,Congenital, Radial Club-hands; Absence of Radii; Thumbs 
Missing (X-Ray). 
Fig. 3.—K. McC. Bilateral, Congenital, Radial Club-hands. 
Fig. 4.—F. C. Contracted Club-hands. 
Fig. 5.—H. P. Congenital, Ulnar Club-hand, Left. Absence of Ulna. 
Fig. 6.—E. T. Contracted Club-hand, Syndactyl, Left. 
Fig. 7.—E. T. X-ray of Contracted Club-hand. 
Fig. 8.—A. B. Contracted Club-hands. PLATE XXXV LEGEND FOR PLATE XXXVI 
Fig. i.—A. D. Rachitic Contracted Club-hands. 
Fig. 2.—G. S. Congenital Contracted Club-hands. 
Figs. 3, 4.—X-rays of Contracted Club-hand. 
Fig. 5.—G. H. Congenital Contracted Club-hands. 
Fig. 6.—J. D. Rachitic Contracted Club-hands. PLATE XXXVI LEGEND FOR PLATE XXXVII 
Fig. i.—L. M. Acquired Club-hand (Osteomyelitis). 
Fig. 2.—L. S. Acquired Club-hand (Osteomyelitis). 
Fig. 3.—R. G. Neoplasty of Thumb. Italian Flap Method. 
Fig. 4.—R. G. End Result. 
Figs. 5, 6.—R. G. X-rays. PLATE XXXVII 224 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Treatment.—In the treatment of club-hand deformity without bone 
defects, that is, in cases of contracted club-hands, tenotomies or teno- 
plasties are usually found sufficient. These measures must be followed 
by prolonged fixation in corrected position. More advanced cases, 
with bowing of radius and ulna, need osteotomy or excision of a wedge- 
shaped piece of bone from the curve in the forearm. The maintenance 
of the corrected position is quite a problem and success will follow only 
persistent and painstaking after treatment. Splints must be worn for 
a long time and the muscle power of the extensors must be carefully 
developed by manipulation, massage, and passive motion. 
The treatment of the skeletal club-hand deformity usually involves 
operative interferences on the forearm bone. Bardenheuer split the 
ulna longitudinally and implanted the carpus between the two halves. 
McCurdy severed the ulna at a point near the proximal edge of the 
carpus and then implanted the proximal end of the ulna into the carpus. 
Vulpius used periosteum flaps from the ulna after he had corrected the 
deformity. Albee implants a tibial graft obliquely into the carpus at 
the distal end and into the ulna at the proximal end. 
In the writer’s series of 12 cases, 3 were operated upon: 1 by osteot- 
omy of the ulna, and 2 by osteotomy of the radius. The immediate 
results were good, but 2 of the cases later showed the recurrence of the 
deformity. In some of the cases not operated upon, the treatment 
applied was that of massage, splinting, and muscle educational exercises. 
The reason for the conservatism which was observed in the treat- 
ment in general was the astonishingly good function of hand and fingers 
seen, especially in cases of contracted club-hands; besides, complicat- 
ing deformities, such as club-feet, which called for early treatment, made 
it necessary to postpone for some time the treatment of the hands; this 
was the case in two patients of this series. How far one may go in 
correcting this deformity by splints is rather hard to determine. Mild 
and moderate degrees of contracted club-hands will yield to the use 
of corrective splints. In more advanced cases, operative procedures 
on the forearm bone must be carried out. The muscle contractures, 
and the shortening of the soft structures, vessels, nerves, etc., may put 
an early limit to splint correction and impose the necessity of opera- 
tive correction of the forearm, in a limited number of cases. However, 
early stretching or tenotomies followed by painstaking splint treatment 
will make most of the cases of contracted club-hands amenable to cor- 
rection without operations on the bone; this leaves, then, essentially the 
skeletal group of congenital club-hands for the osteoplastic methods. 
A-2. The Cleft Hand (Lobster claw-hand).—This is a very rare 
deformity, of which only a few cases so far have been reported in the 
literature. A. H. Tubby reports a case of cleft hand extending through 
five generations and associated with cleft feet. Cases of bilateral lobster 
claw-hand deformity associated with cleft foot have also been reported 
by McKnight and Brandenburg. Of 4 cases reported by Bircher, 2 
showed hereditary tendencies (mother and daughter). Combinations of CONGENITAL MALFORMATIONS AND DEFORMITIES 
225 
this condition with polydactylia, brachydactylia, hyperdactylia, spina 
bifida, and other deformities have been described. 
Case Reports.—R. B., 9 days. No family history was obtainable. The 
right hand showed a fully developed thumb and index finger on the 
radial side and a fully developed little finger on the ulnar side. Between 
these 2 fingers, there was a deep cleft reaching to the carpus. The 
left hand showed radially a thumb and index finger, both being united 
by a syndactylous web. On the ulnar side there was a fully developed 
little finger and between the latter and the index finger there was a 
deep cleft reaching to the carpus. 
The thenar muscles on both sides seemed to be fully developed and 
excellent motion of the fingers was observed, except for the lack of 
opposition of the thumb. The feet showed a similar cleft. On the right 
foot, there was a cleft between the 1st and 4th toes, the 2nd and 3rd 
toes being missing, the cleft reaching to the tarsus. On the left there 
was a cleft between the 1st and 5th toe, the 2nd, 3rd and 4th toes being 
missing, the cleft also reaching to the tarsus. A plastic operation for 
the improvement of the syndactylia on the right hand was performed. 
Aside from this, no radical operation was attempted to correct the cleft, 
as it was noticed that the patient was using his hand with increasing 
skill and that the forceps motion of the cleft hands was very useful. 
The patient was finally able to hold on to objects and developed a 
considerable amount of dexterity in the use of his hands, especially the 
adductor movement of the finger. However, there was no opposition 
movement of the fingers in the sense of the opposition of the thumb 
(Plate XXXVIII, 1). 
B. H., 8 months. Right lobster claw-hand. There is a deep cleft 
reaching to the carpus between what appears to be the thumb and the 
index finger. The latter, however, is abnormally large. There is a 
fully developed little finger. The others are missing. The X-ray 
picture shows that the large index finger is clearly a fused 3rd and 4th 
finger, all phalanges being completely united. The 3rd and 4th meta- 
carpals are normally developed. The 5th finger is normal. The 2d 
finger is totally missing, together with its metacarpal. The case is 
complicated by congenital absence of the tibiae and congenital absence 
of the patellae. In this case, also, no attempt was made to correct 
the claw-hand deformity, as the function of the hand promised to be 
good (Plate XXXVIII, 5, 6). 
A-3. Ectrodactylia.—Ectrodactylia is the congenital absence of one 
or more of the entire fingers including the metacarpals. The cleft 
hand which was described in the foregoing paragraph is a type of ectro- 
dactylia. In unilateral cases, amniotic amputations may be considered 
as the cause of this deformity, but other cases must necessarily have 
their explanation of their origin in theories of primary aberrations 
which interfere with the development of the hand. Tubby distinguishes 
a marginal and central group. In the marginal group, the fingers of 
the radial or ulnar border are suppressed (oligodactylia). In the LEGEND FOR PLATE XXXVIII 
Fig. i.—R. B. Congenital, Bilateral, Lobster Claw-hand. 
Fig. 2.—Ectromelia and Ectrodactylia. 
Fig. 3.—R. E. Ectromelia and Ectrodactylia. 
Fig. 4.—R. E. X-ray. 
Fig. 5.—M. H. Right, Lobster Claw-hand. 
Fig. 6.—M. H. X-ray, Showing Fused Third and Fourth Finger (Giant Finger). PLATE XXXVIII 228 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
central group, the defect of the fingers and metatarsals results in the 
cleft formation already described. Klippel and Rabaud, who report 4 
cases of total ectrodactylia, make a distinction between an ectrodactylie 
phalangicnne, where the fingers are represented by small stumps carry- 
ing osseous nodules which articulate with the metacarpals, and an 
ectrodactylie metacarpophalangiennc in which the metacarpals are miss- 
ing, as well as the fingers. In the case reported by Lewin, the 3rd and 
4th fingers were missing, and in Judet’s case there was a total 
defect of all fingers, three carpals alone being present. This latter case 
already presents a form of ectromelia or defect of all fingers. It is inter- 
esting to note that combinations have been described by Atwood of 
ectrodactylia with polydactylia combining a deformity by suppression 
with one by hyperformation. Luaces also reports a combination of ectro- 
dactylia with syndactylia. Often, however, it is difficult in alayzing the 
deformity to decide whether one deals with a proximal fusion of two 
fingers or a distal bifurcation of one. 
Case Report.—R. E., 3 years. Ectrodactylia of both hands. There are 
present on the left hand the thumb and 1 finger; on the right, 2 central 
fingers are present, both thumb and little finger being missing. The 
2 fingers on the right hand are syndactylic. There is total absence of 
the ulna and complete fusion between humerus and radius on the left 
extremity; and, on the right side, there is complete absence of the 
radius, with fusion of the ulna and humerus at right angle (Plate 
XXXVIII, 2, 3, 4). 
Aphalangism.—Aphalangism is the absence of single phalanges of the 
fingers. It may be considered as a mitigated type of ectrodactylia. 
The deformity has a pronounced hereditary tendency. Cragg and 
Drinkwater have reported a family of 5 generations, in which there 
were 25 abnormal and 17 normal members. The deformities were 
divided between brachydactylia (short fingers) and entire absence of 
phalanges. The absence concerns the terminal phalanges alone and 
farther reaching defects seem to be unknown, the types going on to 
complete ectrodactylism or total absence of fingers. It seems that in 
this group the theory of amniotic amputation finds its application, 
except that the bilaterality of the condition offers some difficulty of 
explanation. 
Case Report.—F. E., 10 years. Congenital lack of end phalanx of the 
index fingers. The deformity is bilateral and symmetrical, and was 
complicated by cleft palate and congenital club-foot- 
B-i. Syndactylia.—Dareste, an adherent of the amniotic theory, in 
his study of the anomalies and congenital deformities of the limbs, 
ascribes to amniotic influences certain forms of syndactylia as well as 
other deformities such as ectromelia and hemimelia. Central neuro- 
genetic influences and primary developmental variations or reversions 
to earlier type have likewise been mentioned in the etiology of syn- 
dactylia. The differences in the types of syndactylia, however, are such CONGENITAL MALFORMATIONS AND DEFORMITIES 
229 
that it does not seem possible that a single theory could cover the many 
clinical variations. Tubby divides syndactylia as follows: 
Finger web or cutaneous syndactylia. 
Skin and fibrous connective tissue webs. 
Bony fusion. 
Kirmisson speaks of the first type as syndactylie membraneuse. In 
cases apparently completely fused, in giant fingers, for instance, the 
bony fusion is not always as complete as the morphological fusion. 
Cases are reported of apparently totally fused giant fingers bearing but 
one nail in which the X-ray shows complete skeletal separation of two 
fingers (Nove-Josserand). 
Partial fusion of the fingers and metacarpals is not uncommon. In 
some cases the fusion involves only the proximal half of the phalanx, 
giving the distal part the appearance of bifurcation such as seen in 
polydactylia. It is at times difficult to decide whether one has to deal 
with a polydactylous finger attached to the distal half of the end 
phalanx or with a proximal fusion of the finger. In some cases one 
observes a type of fusion which involves the distal parts of the fingers 
mainly, causing them to be matted together closely, whereas the bases 
are found to be comparatively free (acrosyndactylia). Identification of 
the individual fingers in these cases is often quite difficult. 
Combinations with other deformities are quite frequent. Syn- 
dactylia is often associated with cleft hand, club-hand, or polydactylia. 
We have observed syndactylia in two cases of ectrodactylia and ectro- 
melia. In contracted club-hands, cutaneous syndactylia is especially 
frequent. Other deformities such as acrocephalia, cleft palate, etc., at 
times complicate the deformity (Ruh, Davis, Bertolotti). The ana- 
tomical observations of Klippel and Rabaud have furnished some data 
in regard to the circulatory conditions in syndactylie fingers. These 
authors have found in their cases that the superficial palmar arch de- 
scends as far distally as to reach the proximal phalanges. The bifurca- 
tion from this arch of collateral arteries was therefore much more 
peripheral than in the normal hand. 
Anomalies of the insertion and the course of the tendons have also 
been studied and reported. The findings naturally vary extensively 
almost with each individual case. 
Syndactylia is a deformity which shows a strong hereditary tend- 
ency and reports on syndactylie families are quite frequent in the litera- 
ture. Luaces mentions a syndactylie family of 39 with 14 syndactylous 
members, the deformity in some instances skipping one generation. 
Treatment.—A number of operative methods have been devised for the 
treatment of syndactylia in different forms and stages. The method of 
Zeller consists of the longitudinal splitting of the web with a triangular 
flap left to cover the base. Tubby tunnels the finger at the base and 
lines the tunnel by flaps raised from both sides of the finger. Later, 
after the canal has been established and properly lined, he deals with 
the distal end of the web. The most generally adopted method of 230 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
treating simple syndactylia is that of Didot, which consists of a sort of 
trap-door incision made both on volar and dorsal sides, by which flaps 
are raised having their bases laterally on opposite sides. When these 
flaps are liberated and the fingers pulled apart, the free skin can then 
be turned around the adjacent sides of the fingers, making the covering 
complete. The flaps are then sutured to the skin at the middle of the 
volar side on one finger and at the middle of the dorsal side on the 
other. This method avoids the placing of skin sutures at the opposing 
lateral surfaces of the fingers, a precaution which prevents the recur- 
rence of the fusion. Spitzy treated some of the cutaneous cases by 
small prisms which were pressed against the web, thinning the latter 
out by gradual compression. This thinned out web is later divided by 
clipping. 
No single method is applicable for all cases nor even for a majority 
of cases of syndactylia. The greatest difficulty is to obtain a sufficient 
amount of skin; especially the adjacent sides of the finger should be 
thoroughly covered to prevent a reappearance of fusion. It seems 
that, even with the plastic methods of Didot, one hardly ever obtains 
enough skin for covering in cases where fusion is more complete. 
In some cases the author has used to good advantage abdominal 
flaps which were so placed that they could be fastened in the inter- 
digital space of the separated fingers and were large enough to furnish 
ample material of skin. 
The writer has had under observation 12 cases of syndactylia, 8 of 
which were operated on. 
In the after treatment following operations for syndactylia, the post- 
operative dressing is a matter of greatest consequence. It is not in- 
frequent that a graft showing a considerable amount of vitality becomes 
later devitalized in its edges by profuse secretion and maceration of 
skin. The writer has been in the habit of dressing cases on which skin 
plasty had been performed as early as two or three days after opera- 
tion, taking good care that a proper spread of the fingers is always 
secured. When the wounds have healed definitely, constant attention 
must be paid to the scars, owing to the fact that they have a great 
tendency to contract. Wherever possible, a scar is placed on the dorsal 
surface, but when a volar scar is unavoidable, the finger is held in com- 
plete extension for a period of several months, with a dorsal finger 
splint applied. In the mechanical after treatment, active motion of the 
fingers is of the greatest usefulness. Not only should flexion and ex- 
tension movement be practiced, but abduction and adduction motion 
of the fingers should also be encouraged and when systematic drills 
and muscle educational exercises are planned and devised, this point 
should be kept in mind. This is especially true in cases of webs between 
the thumb and index fingers in which there is a great tendency for 
adduction and flexion of the thumb. By muscle exercises, especially by 
rotatory motion of the thumb carried out several times a day in regular 
sittings, together with a painstaking splint treatment, such postoper- CONGENITAL MALFORMATIONS AND DEFORMITIES 
231 
Name 
Age 
Deformity andComplications 
Treatment 
Results 
Remarks 
C. L. 
7 yrs. 
syndactylia 3rd and 4th fin- 
gers left; cutaneous syn- 
dactylia between 4th and 
5th fingers 
plasty method, 
Didot 
good 
similar deformity 
in uncle 
M. E. 
2 yrs. 
webbing of 3rd and 4th fin- 
gers of both hands with 
contracture of middle fin- 
ger 
not treated 
mother had webbed 
fingers on left 
hand; in mater- 
nal grandmother’s 
family two mem- 
bers affected; de- 
deformity handed 
down through fe- 
male members 
R.J. 
5 mos. 
cutaneous web between 
thumb and index fingers 
both hands, preventing 
abduction of thumb 
not operated 
no heredity 
T. L. 
16 yrs. 
syndactylia fingers left hand; 
2nd, 3rd, 4th fingers fused 
complete from tip to base; 
right hand, 3rd and 4th 
from tip to base; 2nd and 
3rd from base to end of 
proximal phalanx (Plate 
XXXIX, 1, 2) 
operation 3rd and 
4th right; Didot 
method; 3rd 
and 4th; left: 
abdominal flap 
good 
one brother with 
3 fingers missing 
C. A. 
4 mos. 
complete bony syndactylia; 
all fingers of both hands 
(acrosyndactylia) 
not operated 
no heredity 
M. J. 
2 yrs. 
syndactylia right hand; 
total fusion 3rd and 4th 
fingers 
operation; plasty, 
Didot 
good 
no heredity 
J. c. 
4 yrs. 
syndactylia both hands; 
webbing of all fingers with 
partial cleft between 
thumbs and index fingers 
not treated 
no heredity; cleft 
palate; brachy- 
dactylia 
M.W. 
25 yrs. 
syndactylia right, complete 
cutaneous syndactylia 3rd 
and 4th 
plasty of Didot 
fair 
treatment inter- 
rupted 
B. S. 
3 yrs. 
partial syndactylia both 
hands; symmetrical webs 
between 2nd, 3rd, 4th and 
5th; web between 4th and 
5th partial 
plasty of Didot 
good 
symphalangism in 
mid-phalangeal 
joint, bilateral 
symmetrical, 2nd 
and 3rd fingers; 
X-ray shows bone 
fusion in 4th 
F. S. 
8 yrs. 
bilateral acrosyndactylia; 
fusion of 3rd, 4th and 5th 
fingers both hands; fusion 
of nails; bones distinctly 
separated 
operation Didot 
good; 4 com- 
pletely sepa- 
rated fingers 
syndactylia both 
feet; webbing of 
3rd and 4th toes 
L. D. 
12 yrs. 
bilateral symmetrical syn- 
dactylia; cutaneous webs 
between 3rd and 4th fin- 
gers ; bones entirely sepa- 
rated 
Didot’s operation 
good 
similar defprmity 
in one cousin 
W. F. 
7 wks. 
bilateral syndactylia; acro- 
syndactylia right index 
and 3rd fingers; left—all 
fingers fused at tips 
■ 
operation plasty; 
steps: separat- 
ing 2nd and 3rd 
fingers right; 
isolating thumb 
and 5th fingers 
left; separating 
2nd and 4th fin- 
gers left; resec- 
tion of rudimen- 
tary 3rd finger 
left 
fair, 4 fingers 
obtained on 
on left hand 
no heredity 
(Plates XXXIX, XL.) 
Table of Cases of Syndactylia LEGEND FOR PLATE XXXIX 
Fig. i.—T. L. Syndactylia. 
Fig. 2.—T. L. Final Operative Result. 
Fig. 3.—L. T. Syndactylia, Left Hand, Complete. 
Fig. 4.—L. T. X-ray. Showing Skeleton Complete Except Basal Phalanx III and All 
End Phalanges. 
Fig. 5.—Baby F. Acrosyndactylia. 
Fig. 6.—Mrs. W. Syndactylia. PLATE XXXIX LEGEND FOR PLATE XL 
Fig. i.—L. D. Syndactylia before Operation. 
Fig. 2.—L. D. Syndactylia after Treatment. 
Fig. 3.—C. W. Syndactylia before Operation. 
Fig. 4.—C. W. Syndactylia after Operation. 
Fig. 5.—M. J. Syndactylia after Operation. 
Fig. 6.—C. L. Syndactylia after Operation. PLATE XL 236 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
ative contractures may be avoided. Of the 8 cases operated upon, 
Didot’s method of plasty was used in 6 cases, the flap method was used 
in i case and a simple plasty in another case. In this connection, there 
should be mentioned a technic of Pieri for the relief of the contracted 
thumb. This method consists in the formation of two triangular flaps 
in the web between thumb and index finger, which are obtained by an 
incision at the edge of the web, and two additional incisions at the 
opposite extremes on the web at right angle, one going down on the 
volar and one on the dorsal surface. When these flaps are liberated 
and the thumb and index fingers are pulled apart, the skin flaps are 
turned over the corresponding surfaces of the metacarpals of the 
thumb and index finger. In this way the natural web between the 
thumb and the index finger is deepened. This method has also been 
used by the writer on several occasions with satisfactory results 
(Plate XXI, i, 2, 3). 
B-2. Symphalangism.—Symphalangism is a very unusual and ex- 
tremely rare condition of the fingers, which essentially consists in a 
fusion of the interphalangeal joints. This fusion is not always a true 
bone fusion, but often represents extra-articular contractures only, 
especially of ligamentous and tendinous nature. In the latter instances, 
the X-ray picture shows a separation of the phalanges and a joint slit, 
although the latter is often very narrow and incomplete. True bone 
fusion is so uncommon that Rimbaud considered his case as absolutely 
unique. Instances of this kind, however, have been repeatedly men- 
tioned in the literature. The most extensive list is that of Goldflam, 
who cites 26 cases in 3 generations out of a total of 46 members of 
the family. The writer has observed 2 cases of symphalangism, both 
occurring in members of the same family. 
Case Reports.—W. S., 3 years. Bilateral cutaneous syndactylia be- 
tween 2d, 3d, 4th, and 5th fingers. The X-ray pictures show true fusion 
between the basal and end phalanx of the 4th finger and of the 5th 
finger on both hands. In the 5th finger, the line between basal and 
middle phalanx cannot be seen, while in the 4th finger the place of the 
1st interphalangeal joint is merely indicated by an indentation. In the 
2d and 3d finger, the joint is present but the joint slit is very narrow. 
Passive motion was possible to a limited extent in the 1st interphalan- 
geal joint of the index fingers and it was barely indicated in that of 
the middle finger, while the 4th and 5th fingers were entirely stiff. An 
attempt was made to force flexion and extension movement but, while 
it was partly successful for the index fingers, it completely failed for 
the middle finger. The deformity was entirely symmetrical on both 
hands. 
Baby S., 6 months, sister of W. S. The deformity is absolutely iden- 
tical with that of the brother of the child except that the fusion in the 
4th finger is even more complete than in the brother. In the 5th finger, 
however, there is an indication of a middle phalanx represented by a 
small round shadow. This case also showed fusion of the radius with CONGENITAL MALFORMATIONS AND DEFORMITIES 
237 
the humerus on the right side, whereas the brother’s elbow was normal 
in this respect (Plate XLI, i, 2, 3). 
C-i. Polydactylia.—In polydactylia again, a central and a marginal 
type may be distinguished. The condition may originate from a bifur- 
cation over the metacarpophalangeal joints, in which case there is a 
total duplication of fingers; or there may be a bifurcation of the meta- 
carpal bones or of the phalanges themselves. In the latter instance, 
there is then an approachment to syndactylic forms with complete 
fusion, a point which has been referred to before. The marginal form, 
that is, the duplication of the thumb and little fingers, is by far the more 
frequent type. 
Heredity is a distinct feature of this type of congenital deformity. 
Bernard mentioned an instance of polydactylia covering 5 generations; 
in the cases reported by Brandeis regarding a hexadactylous family and 
in the polydactylous family of Atwood, a good illustration is given of 
the influence of heredity. The largest report on familial deformities of 
this type is that of Moore who, in a family of 7 generations, found 20 
cases of polydactylia among 237 members. Amrein reports 7 sisters 
with hexadactylia. Many other instances of this kind are on record, 
too numerous to mention. 
Some anatomical data of the condition are at hand. In a description 
of Danforth it is noted that the supernumerary fingers contained a car- 
tilaginous core not attached to the other bones of the hand. The 
abductor digiti minimi was sending slips into a supernumerary digit 
attached to the 5th finger. On the volar side, he found that branches 
of the proper digital nerve supplied the extra finger. These fingers 
often present all the elements of a normal finger in a shortened and 
more or less abortive condition. Polydactylia is often found in com- 
bination with other deformities, not only of the hand itself, but also of 
other parts of the body. Darest described a case of retinitis pigmentosa 
and coloboma of the iris combined with polydactylia. There are many 
cases on record of polydactylia associated with polyglandular syndromes 
such as obesity, genital hypoplasia, etc. Such combinations seem to 
throw a new light upon the influences of endocrine glands in the for- 
mation of deformities. 
Case Reports.—J. C., 2 years. Polydactylia of the right hand. Dupli- 
cation of the end and basal phalanx of the thumb. Of the radial acces- 
sory phalanx, the end phalanx had been removed, but the basal phalanx 
had been left, and patient presented himself on account of deviation of 
the thumb to the ulnar side. The operation consisted in the re- 
moval of the accessory proximal phalanx of the thumb and in the 
correction of the deviated end phalanx of the thumb proper by oste- 
otomy. 
A. J., 1 year. The patient showed a very small rudimentary super- 
numerary little finger attached to the ulnar border of the hypothenar 
eminence. This supernumerary finger carried a distinct nail. It was 
removed and the examination showed that it had no cartilage core but LEGEND FOR PLATE XLI 
Fig. i.—W. S. Cutaneous Syndactylia and Symphalangism. 
Fig. 2.—W. S. X-ray. Fusion of Mid-phalangeal Joints 3, 4 and 5. 
Fig. 3.—M. S. Sister of W. S. X-ray. Symphalangism. Fusion of Mid-phalangeal 
Joints, 3, 4 and 5. 
Fig. 4.—PoLYDACTYLIA. RUDIMENTARY ACCESSORY, FIFTH FlNGER, BEARING NAIL. 
Fig. 5.—J. C. Polydactylia. Part of Polydactylous Thumb Removed. PLATE XLI 240 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
consisted mainly of fibrous tissue; it had a perfectly separated, tiny, 
individual flexor tendon (Plate XLI, 4, 5). 
C-2. Hyperphalangism.—This condition is characterized by the 
existence of four instead of the three phalanges of the fingers or of three 
instead of the two phalanges of the thumb. The mode of development 
of the phalanges throws some light upon this deformity. The pha- 
langes in the embryo are differentiated in serial order, the basal one 
appearing first and the terminal one last. According to Grafenberg, the 
terminal phalanges show evidence of two elements, a proximal and a 
distal one. When the distal one fails to unite with the proximal one, 
it may cause the appearance of a fourth phalanx. This deformity may 
he considered as a reversion to type, as the primitive digits are probably 
composed of many phalanges. Embryologically, it is a developmental 
arrest consisting in failure of fusion between the two halves of the 
terminal phalanx. It is an extremely rare deformity. Reynolds de- 
scribed a case in which the thumb had the appearance of the fifth 
finger with the terminal phalanx so shaped as to make the thumb like 
one of the digits. Curiously enough, there was no thenar eminence 
and the hand was flat. In 2 cases of Joachimsthal, the index fingers 
had four phalanges each, and in a third case reported by him, there 
was hyperphalangism of the third finger. The X-ray showed distinct 
deviation from the normal type of ossification. In the case of Joachims- 
thal, the distal end of the basal phalanx showed an abnormal epiphysis. 
Pfitzner reported 3 cases of three-jointed thumbs. He considered the 
middle phalanx as the supernumerary one, as it showed neither a dis- 
tinct epiphysis nor an articular surface. But a case of epiphysis of the 
middle phalanx on both hands is reported by Freund; on the other 
hand, in the instances described by Dubreuil-Chambardel, there was 
a distinct joint dividing the second metacarpal into two unequal parts 
so that the supernumerary link seemed to be given off by the meta- 
carpal instead of the phalanx. There is, in the literature on this de- 
formity, a good deal of discrepancy both in regard to the seat of the 
supernumerary link and in regard to the part the epiphysis plays in the 
formation of the deformity. 
D-i. Congenital Synostoses—a. Radio-ulnar Synostosis.—Congenital 
synostoses of both forearm hones is occasionally observed. The seat 
of the synostosis is usually the upper end of the forearm bone. The 
radio-ulnar synostosis constitutes a serious obstacle to the pronation 
and supination movement of the forearm. The forearm is usually held 
in extreme pronation and either passive or active supination is entirely 
impossible. 
Case Report.—B. D., 8 years. Congenital radio-ulnar synostosis of the 
right forearm. The forearm is held in extreme pronation, passive sup- 
ination being impossible; flexion and extension in the elbow is free. 
The X-ray shows a synostosis of the proximal radio-ulnar joint and 
operation is advised but refused. CONGENITAL MALFORMATIONS AND DEFORMITIES 
241 
The treatment of this condition is entirely operative. The most 
efficient method is the resection of the synostotic head of the radius 
with or without interposition of the flap of muscle between radius and 
ulna. In cases in which the synostosis reaches farther down, occupying 
the entire upper fourth of the forearm bone or more, the operative pro- 
cedure is fraught with considerable difficulty. The mere resection of 
the bone bridge and the interposition of muscle flap does not seem to 
give as good results, according to reports in the literature, as does the 
complete resection of the syndactylic part of the radius, which causes 
a new radio-ulnar joint to be formed more distally. 
b. Congenital Synostosis of the Humerus zvith the Forearm Bones.— 
The writer has observed 2 cases of this type. They were associated 
with other deformities and have accordingly been mentioned in pre- 
vious paragraphs. 
Case Reports.—W. E., 4 years. Ectrodactylia. This case shows a 
complete synostosis of the radius with the humerus at the left elbow 
and a complete synostosis of the ulna with the humerus at the right. 
The ulna is united with the humerus at almost right angle, whereas the 
radius is united in extended position. The musculature of the arm 
and forearm is very much underdeveloped and a differentiation of the 
flexors and extensors of the elbow or of the pronators and supinators 
cannot be made. 
Baby S., 6 months old. Case of cutaneous syndactylia and symphal- 
angism. This case shows a complete fusion of the radius with the 
humerus on the right side while the left elbow is entirely free. The 
fusion between radius and humerus is at an angle of 1350 (Plate XLII, 
1-6). 
E. Polyglandular Dystrophy.—In regard to the polyglandular dys- 
trophy, a short perfunctory mentioning of this condition as an under- 
lying cause of deformity of the hand is sufficient. It is doubtful, to say 
the least, whether or not the polyglandular condition of the body is 
the underlying cause or merely a coincident. Cases of polydactylia 
have been described with marked polyglandular defects. 
E-i. Polydactylia.—Polydactylia has been observed in connection 
with polyglandular dystrophy. The majority of cases of polydactylia, 
however, do not belong to this group, although, as mentioned before, 
it is in this deformity especially where hereditary influences are most 
marked. 
E-2. Macrodactylia.—The diagnosis of this condition must be made 
with caution. True macrodactylia or partial gigantism is extremely 
rare. Most cases of so-called giant fingers are associated with severe 
deformities, especially with cleft hand. A close study, supported by the 
X-ray picture, shows that most of these giant fingers are more or less 
complete fusions of the skeletal and soft parts of the digits. 
E-3. Arachnodactylia.—Arachnodactylia is a very rare condition. It 
is usually a degenerative stigma, the principal feature of which is the LEGEND FOR PLATE XLII 
Fig. i.—C. A. Congenital Partial Ankylosis Elbows. Contractures Shoulders and 
Wrist. 
Fig. 2.—C. A. X-ray. Right Elbow. Deformity of Joint. 
Fig. 3.—M. S. X-ray. Congenital Fusion of Radius and Humerus, Right. 
Fig. 4.—R. E. Fusion of Both Elbows. Ectrodactylia. 
Fig. 5.—R. E. X-ray. Left Elbow. Fusion of Radius and Humerus, Absence of Ulna. 
Fig. 6.—R. E. X-ray. Right Elbow. Fusion of Ulna and Humerus, Absence of 
Radius. PLATE XLII LEGEND FOR PLATE XLIII 
Fig. i.—O. W. Congenital Contracture of Thumb. 
Fig. 2.—O. W. After Operation. 
Fig. 3.—L. T. Amniotic Furrowing of Fingers. 
Fig. 4.—L. T. After Operation. PLATE XLIII 246 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
unusual length of the fingers especially the end phalanges which are 
tapered at the ends. We have observed only i case of this kind in 
a child with heavy hereditary taint. 
F. Congenital Contractures and Amniotic Furrows.—There is a 
distinct group of congenital deformities of hand and fingers, in which 
the action of amniotic strands and adhesions is so evident, that there 
is little room for doubting their importance in the formation of this 
deformity. Amniotic furrows are often seen encircling the fingers, the 
thumb, the hand and wrist, and the constriction leaves distinct and 
deep grooves which sometimes go on to complete amputation of the 
finger or even hand or forearm. 
F-2. A special type of deformities are congenital contractures of the 
fingers and thumb. The fingers are found drawn into flexion position 
by cutaneous webs which run from the volar surface of the fingers into 
the palm of the hand. These contractures seem to be different from 
what is seen in contracted club-hands; probably here, too, amniotic 
adhesions are at work in producing this deformity. The writer has 
observed 3 cases of this type. 
F-3. Case Report.—L. T., 2 years. This patient showed amniotic fur- 
rows and grooves at the index, 3rd and 4th fingers of the left hand. Motion 
was in no way restricted and there did not seem to be any damage to 
the deeper structures. This case was complicated, besides, by a spon- 
taneous amputation of the right leg in the lower third of the tibia and 
by absence of the end phalanx of the 2nd toe of the left foot. These 
deformities were also clearly caused by amniotic constriction. The 
grooves in the fingers were treated by excision and subsequent skin 
plasties (Plate XLIII, 3, 4). 
Case Reports.—J. P. Contracture of the little finger of the right hand 
since birth. The case resembles clinically that of Dupuytren’s con- 
tracture except that it is congenital and not progressing. The motion 
of the finger is intact. The contracture is caused by fascial bands run- 
ning from the base of the little finger to the palm of the hand. 
G. J., 12 years. Both 5th fingers of the patient here held in flexion 
position by a web extending from the middle phalanx to the bottom of 
the hand. This case was operated by a skin plasty and the deformity 
was cured (Plate XLIII, 1, 2). 
H. A., ip2 years. There was a congenital contracture of the 2nd, 
3rd and 4th fingers of the left hand, together with flexion contractures 
of the wrist. The deformity was remedied completely in the 3rd and 
4th fingers, while the correction of the 2nd finger was only partial. This 
case also showed a congenital elevation of the scapula and a multiple 
fusion of the ribs on both sides. There was also wedge formation of 
the 5th dorsal vertebra. The first two cases may be classified as am- 
niotic contractures. The third case, however, cannot be placed in this 
group, because af the concurrence of other deformities, that is, the in- 
volvement of the spinal column, the existence of an elevated scapula, 
and the anomalies of the ribs. These complications demonstrate the CONGENITAL MALFORMATIONS AND DEFORMITIES 
247 
more central origin of the deformity. The development of it must 
necessarily date back into a very early period of embryonal life. 
BIBLIOGRAPHY 
Abbe, T. Report of a case of congenital amputation of fingers, Am. Journ. 
Obstet., 1916, 73 : 1089. 
Ahreiner, G. Zwei seltene Falle von angeborener Gelenkankylose, Beitr. z. 
klin. Chir., 1909-1910, 65:462. • 
Albee, F. H. Orthopedic and Reconstruction Surgery. W. Id. Saunders, 1919. 
Atwood, E. S. A polydactylous family, Journ. of Heredity, February, 1917. 
Axhausen, G. Zur operativen Behandlung der Klumphand und des Klump- 
fusses, Arch. f. klin. Chir., 1919, vol. in. 
Bailleul. Malformation congenitale de la main, Rev. d’orthop., July, 1914. 
Ballantyne, J. W. Manual of antenatal pathology. Wm. Green and Sons, 
Edinburgh, 1902. 
Ballowitz, E. Uber einen Fall von symmetrischer Heptadaktylie, Miinchen. 
med. Wchnschr., 1915, 62:1605. 
Bennenberg, T. Luxatio capituli radii congenita, Ztschr. f. orthop. Chir., 1893, 
vol. '2. 
Bernard, R. Neuve cas de polydactylie hereditaire de cinq generations, Nouv. 
Iconogr. de la Salpetr., 1916-1918, vol. 28. 
Bertolotti, M. Etudes des influences morphogenetiques des glandes a secretion 
interne sur l’organogenese, Paris, 1915. 
Blencke, A. Beitrag zur sogenannten Klumphand, Ztschr. f. orthop. Chir., 
1904, 12:380. 
Blumenthal, M. Uber hereditare angeborene doppelseitige Supinations- 
storung, Ztschr. f. orthop. Chir., 1904, 12:181. 
Boorstein, S. W. Symmetrical congenital malformations of extremities, Ann. 
of Surg., February, 1916. 
Brandeis, J. W. Polydactylism as a hereditary character, Journ. Am. Med. 
Assoc., 1915, 64:1640. 
Brandenberg, F. Missbildungen und Ilereditat, Ztschr. f. orthop. Chir., 1908, 
vol. 21. 
Chesser, E. Congenital defects of the phalanges, Brit. Med. Journ., 1917, 2:215. 
Chrysospathes, J. Uber eine Supinations-Extensionsbehinderung des Vor- 
derarmes beim Neugeborenen, Beitr. z. klin. Chir.,' 1914, 92:690. 
Coudray, P. Deux cas de synostose radio-cubitale superieure d’origine con- 
genitale, Rev. d’orthop., 1918, 6:361. 
Cragg, E. and Drinkwater, H. Hereditary absence of phalanges through five 
generations, Brit. Med. Journ., 1917. 
Crawford, B. R. A case of congenital defect of hands and feet, Lancet, London, 
May 25, 1918. 
Cushing, H. Hereditary ankylosis of the proximal phalangeal joint, Proc. 
New York, Acad, of Med., 1915, 621. 
Danforth, C. FI. A comparison of the hands of a pair of polydactylous negro 
twins, Am. Journ. Physio-Anthrop., 1919, 2:147. 
Dareste, C. Memoires sur les anomalies des membres, Journ. de l’anatomie, 
1882, vol. 18. 248 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Davis, F. B. Case of acrocephalo-syndactylism, Journ. Nerv. and Ment. Dis., 
1915* 63:567. 
De Castro, A. Sur quelques cas de hemimelie, Nouv. Iconogr. de la Salpetr., 
1916-1918, vol. 28. 
Dietz, P. J. Die radioulnare Synostose, eine seltene angeborene Missbildung 
der Ellbogengegend, Fortschr. a.d. Geb.d. Rontgenstr., 1910-1911, 16:22. 
Drenkhahn. Ein Fall von seltener Missbildung der Vorderarme, Ztschr. f. 
orthop. Chir., 1903, 11:598. 
Dubreuil-Chambardel, L. Sur une variation anatomique du metacarpien II, 
Nouv. Iconogr. de la Salpetr., 1918. 
Fere and Perrin. Note sur les anomalies des doigts, Rev. de Chir., 1905, 31:66. 
Fontes, V. Uni caso de polisindactilia, Arch, de anat. de Lisbon, 1916, 2:297. 
Gassul, R. Eine durch Generationen prevalierende symmetrische Fingerkon- 
traktur, Deutsche med. Wchnschr., October 24, 1918. 
Gill, A. B. Deformities of the hand, New York Med. Journ., 1919, 105:1061. 
Greig, D. M. Two cases of congenital superior radio-ulnar synostosis, Edinb. 
Med. Journ., April, 1917. 
Hilgenreiner, H. Neues zur Hyperphalangie des Daumens, Beitr. z. klin. 
Chir., 1910, 67:196. 
Hollander, E. Familiare Fingermissbildung, Berl. klin. Wchnschr., 1918, 
55:472. 
Hornung, H. Eine neue unblutige Behandlung der Syndaktylie, Ztschr. f. or- 
thop. Chir., 1908, vol. 20. 
Joachimsthal, G. Angeborene seitliche Deviation der Fingerphalangen, Ztschr. 
f. orthop. Chir., 1893, 2 : 2^5- 
Jones, S. F. Congenital dislocation of the ulna, Am. Journ. orthop. Surg., 
November, 1911. 
Jurcic, F. Fall von Hyperphalangie beider Daumen, Arch. f. klin. Chir., 80: 562. 
Kaufmann, J. A case of bilateral congenital fusion of the radius and ulna, 
Journ. Am. Med. Assoc., 1919, 73:1842. 
Kirmisson, E. Un cas de syndactylie membraneuse associee a la brachydactylie, 
Rev. d’orthop., 1919, 3:309. 
Paralysie infantile associee a une malformation du membre superieur 
gauche, Rev. d’orthop., January, 1920. 
Kirmisson and Longuet. Nouveau cas de main bote congenitale, Rev. d’orthop., 
i893,4:59- 
Klippel, M. and Rabaud, E. Etude sur les malformations congenitales des 
membres, Nouv. Iconogr. de la Salpetr., 1914-1915, vol. 27. 
Lestache, G. Un caso de ausencia congenita bilateral y completa del radio 
y de todos los huesos del carpo, La Pediatr. espan., February 20, 1918. 
Leullier, M. Un cas de phalange supplementaire des deux pouces, Journ. de 
radiol. et d’electrol., 1916-1917, vol. 2. 
Lewin, P. Congenital absence or defects of bones of the extremities, Am. 
Journ. Roentgen., 1917, 4:431. 
Lewis, W. H. The development of the arm in man, Am. Journ. Anat., 1901- 
1902, 1:145. 
Ligabue, P. Mano torta congenita e suo tratamento, Arch, di ortop., 1913, 
30:712. 
Luaces, G. Sindactilia congenita en varias generaciones, La Pediatr. espan., 
March 15, 1917. CONGENITAL MALFORMATIONS AND DEFORMITIES 
249 
Magaliiaes, A. F. Um caso de mao radiopalmar dupla congenita, Brazil-medico, 
December 15, 1917- 
McCurdy, S. L. Congenital absence of radii with operation, Ann. of Surg., 
1896, 44. 
McKnight. Cleft hand and foot, Med. and Surg., 1917, 1 :30. 
Michelsohn, J. Ein Fall von totalem Defekt des Radius, Ztschr. f. orthop. 
Chir., 1904, 12:445. 
Milne, J. A. Congenital absence of radii, Brit. Med. Journ., 1915, 2:821. 
Muir, J. Seven generations of polydactylia, South African Med. Rec., June 12, 
1915- 
Neumann. Ein Fall von angeborenem Ulnadefekt, Berk klin. Wchnschr., 
1916, 53:1376. 
Nove-Josserand. Sur une variete anormale de syndactylie, Rev. d’orthop., 1918, 
6:405. 
Potel, G. Essai sur les malformations congenitales des membres. Classification 
pathologique, Rev. de Chir., 1914, vols. 49, 50. 
Redard, M. Contribution a l’etude des amputations congenitales du membre 
superieur, Rev. d’orthop., 1893, 4:50. 
Contribution a l’etude des amputations congenitales du membre supe- 
rieur, Rev. d’orthop, 1893, 4:50. 
Renvall, G. Zur Kenntniss der kongenitalen, familiar auftretenden Extrem- 
itatenmissbildungen, Arch. f. Anat. u. Entwcklngsgesch., 1909. 
Reynolds, L. R. Hyperphalangism accompanied by supernumerary epiphyses 
and muscular deficiencies, Anat. Rec., 1917, 13:113. 
Rietschel. Die Arachnodaktylie, Miinchen. med. Wchnschr., 1917, 64:781. 
Rimbaud, L. and Revault d’Alonnes, G. Ankylose osseuse des articulations 
phalango-phalanginette des deux mains, Nouv. Iconogr. de la Salpetr., 
1916- vol. 28. 
Rinciieval. Treatment of congenital bone deformities in forearm and leg, 
Verhandl. d. deutsch. Gesellsch. f. Chir., 1914, 23d congr. 
Roederer, K. Un cas de malformation symmetrique de la main accomp. d’un 
halux valgus, Rev. d’orthop., 1914, vol. 3. 
Rosenkranz, E. Uber kongenitale Kontrakturen der oberen Extremitaten, 
Ztschr. f. orthop. Chir., 1905, vol. 14. 
Rotii, P. B. Congenital club-hand, Proc. Royal Soc. Med., Sect. Dis. Children, 
vol. 9. 
Ruh, H. O. Acrocephalosyndactylism, Am. Journ. Dis. Children, April, 1916. 
Sicard, J. A., Nandin, L. and Cantaloube, P. Macrodactylie chez un blesse 
de guerre, Nouv. Iconogr. de la Salpetr., 1916-1918, vol. 28. 
Steindler, A. Congenital malformations and deformities of the hand, Journ. 
Orthop. Surg., 1920, No. 12, vol. 2. 
Still, W. F. A rare congenital malformation: bilateral absence of the radius 
and ulna with other abnormalities of the upper extremity, Lancet, 1916, 
2:1015. 
Tilanus, C. B. Uber einen seltenen Fall von Ectrodaktylie, Ztschr. f. orthop. 
Chir., 1896, 4: 186. 
Tubby, A. H. Deformities and diseases of bones and joints, vol. 1, Macmillan 
and Co., 1912. CHAPTER X 
TRAUMATIC DEFORMITIES 
Traumatic Deformities of the Hand and Fingers—Dislocations of 
the Hand—Total Radiocarpal Dislocations.—Complete posterior dis- 
locations are accompanied by laceration of the posterior capsule of the 
lateral ligaments; often, also, by fracture of the styloid process of the 
ulna. Complete anterior dislocations’ are accompanied by lacerations 
of the anterior carpal and lateral carpal ligaments. The hand is held 
in extension. 
Isolated Carpal Dislocations.—Dislocations of the semilunar, os 
magnum, scaphoid, pisiform. In isolated dislocations of the carpus, 
those of os magnum have not been reported, but cases are described 
of isolated dislocation of the head of the bone alone or together with 
uncinatum. Isolated dislocation of trapezium and trapezoid have not 
been observed. A fracture sprain of the pisiform bone occurs occasion- 
ally, caused by the pull of the flexor carpi ulnaris. 
The typical lesion is the dislocation of the os lunatum. It is caused 
by forcible hyperextension when both the lunare and scaphoid are 
pressed against the volar surface of the wrist. The dislocation is always 
volar, the lunare being squeezed out in the forcible hyperextension 
movement. All observers agree that dislocation occurs during dorsi- 
flexion, often by a violent push against the volar surface of the hand. 
According to Potel, dorsiflexion of the wrist causes volar dislocation. 
The mechanical factor is the pressure exerted against the os lunatum 
by the os magnum distally and the radius proximally; but it is hard to 
decide whether the pressure from the proximal or from the distal end 
is the main factor which forces the bone out of its position. 
The symptoms of the dislocation are pain, swelling and disturbance 
of function. It is the dorsiflexion more than abduction and adduction 
which is restricted. Pronation and supination are usually normal. In 
this dislocation, the fingers, especially the second, third, and fourth, 
cannot be closed. If the os lunatum is very prominent in the volar surface, 
flexion contracture of the finger may occur. Violent pain is caused by 
forcible movements, especially by gripping and closing the fist. The 
pain may radiate into the fingers and arm. Even paresis of the median 
nerve with sensory disturbances, atrophy of the thenar muscles and 
glossy skin have been observed in cases of dislocation of the semilunar 
bone. 
Chronic Cases.—In chronic cases, the symptoms are not caused by the 
dislocation alone, but also by the traumatic arthritis which follows the 
250 TRAUMATIC DEFORMITIES 
251 
injury. The arthritis is intimately connected with the displacement, 
and the removal of the dislocated bone usually gives considerable relief. 
The treatment of chronic cases is that of removal of the bone. It 
can be reached by volar incision, made between the palmaris longus 
and the flexor carpi ulnaris (Hessert and Lilienfeld). Some authors 
prefer an incision between the palmaris longus and the flexor carpi 
radialis (Poulsen). The results of the resections are, on the whole, 
good. They are better if there is little or no secondary traumatic 
arthritis complicating the dislocation. 
Case Report.—E. M. F., 20 years old. The patient fell a month ago 
upon the extended hand from a height of 5 feet, injuring his right wrist. 
The symptoms were swelling, pain, tenderness, and inability to flex the 
wrist. The X-ray showed a forward dislocation of the os lunatum. 
An attempt to reduce under ether failed. The patient gained so much 
under mechanical treatment that the plan of resection of the bone was 
abandoned. 
Isolated dislocation of the scaphoid is hardly ever observed. All 
old and unreducible dislocations of the carpal bones become orthopedic 
problems owing to the marked disturbance of function. • The only 
appropriate treatment for these lesions is the removal of the dislocated 
bone. Most of these cases become irreducible within a few weeks 
after the injury. 
Chronic Traumatic Dislocation of the Phalanges.—According to Web- 
ber’s statistics covering 198 dislocations in general, 20, or over 10 
per cent, were those of the phalanges. The usual dslocation of the 
phalanges is that of dorsal dislocation of the distal portion. The dis- 
location in the interphalangeal joint is less frequent than the dislocation 
in the metacarpophalangeal joint. Reports of Guibe on the metacarpo- 
phalangeal and interphalangeal dislocations show 84 in the metacarpo- 
phalangeal joints of the thumb, 27 in the metacarpophalangeal joints of 
the fingers, 26 in the first interphalangeal joints of the fingers, and 69 
in the second interphalangeal joints. 
Of great orthopedic interest are the dislocations of the thumb. A 
classification of Faraboeuf distinguishes in metacarpophalangeal dislo- 
cations between complete dislocations and incomplete dislocations on 
one side, and so-called complex dislocations on the other, according to 
the relation of the sesamoid to the dislocated joint. In the incomplete 
dislocations, the sesamoid still adheres to the joint surface of the meta- 
carpal. In the complete dislocations, the sesamoids are displaced dis- 
tally together with the distal portion. In the complex dislocations, 
they are wedged in between metacarpal and the basal phalanx. 
The most frequent form is the interphalangeal posterior dislocation 
caused by fall upon the extended thumb or by blow. There is a tear 
in the capsular ligament and often, also, laceration of the lateral liga- 
ments of the thumb. Piquard and Dubar published 2 cases, the one 
from operation, the other from autopsy, that showed the rupture occur- 
ring at the insertion of the capsule to the basal phalanx. The extensor 252 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
tendon of the thumb itself almost always remains intact (Malgaigne). 
Fracture of the base of the distal phalanx is a not infrequent compli- 
cation. 
Guibe distinguishes in these dislocations between a complete and 
an incomplete displacement. In the incomplete displacement, the distal 
phalanx rests with its articular surface upon the head of the basal pha- 
lanx at a more or less right angle. In the complete displacement, the 
distal phalanx is pushed entirely over the head of the basal phalanx, so 
that the axes of these two bones are parallel. 
Within a very short time, these dislocations become irreducible. This 
irreducibility is caused by two factors. One is the displacement of the 
extensor tendon; the other is the interposition between the articular 
ends of fibrous and tendinous tissue. It is, in fact, only in the first few 
days that a reduction of the dislocation by manipulation is possible with- 
out great difficulty. 
In reducing the dislocation, flexion suffices for the incomplete type. 
In complete dislocation, however, traction and pull forward is necessary, 
together with hyperextension. Pailaillon found 13 of his 55 cases irre- 
ducible. 
In the event that reduction is impossible, open operation is indicated. 
A flap incision is made over the dorsal side of the articulation, the con- 
vexity of the flap pointing distally. Then the extensor tendon is care- 
fully dissected and drawn aside. The resection of the interposed cap- 
sular tissue is now possible. It is often necessary to resect the head of 
the basal phalanx also, and this can be done without fear of a stiff or 
ankylosed joint. 
Forward dislocation of the thumb is much more infrequent than pos- 
terior dislocation. It may also be divided into two groups—complete 
and incomplete. In incomplete dislocation, the distal phalanx rests upon 
the head of the basal phalanx with its posterior border at more or less 
right angles. In the complete dislocation, the distal phalanx is dislo- 
cated upward as well as forward and the axes of the bones are parallel. 
Reductions of this dislocation have been reported by Poinsot and Cyrus 
Pirondi, the latter succeeding in reducing a dislocation on the sixth day; 
but ordinarily, dislocation here, also, becomes irreducible within a few 
days and open operation again must be resorted to. The technic is 
similar to that in posterior dislocation. 
Case Reports.—Sister M. B. Subluxation of the thumb. The thumb 
pulled out of joint 3 years ago while the patient was working. The ex- 
amination shows the subluxation of the thumb between the 1st meta- 
tarsal and the trapezium. The subluxation became reduced automat- 
ically in flexion of the finger. 
Mrs. C. N. Old dislocation of the finger. Injured finger 4 months 
ago by fall. Examination reveals a posterior dislocation in the 1st inter- 
phalangeal joint of the little finger, entirely irreducible. The patient is 
treated operatively. Resection of the head of the phalanx is carried out 
from a posterior flap incision. TRAUMATIC DEFORMITIES 
253 
N. R., i year. Posterior dislocation of the end phalanx of the right 
thumb. Irreducible. Treatment by operation: opening of the joint, 
resection of the capsule and reduction. 
Dislocations of the Fingers.—These usually occur as the result of a fall 
or blow upon the fingers forcing the joints into hyperextension and re- 
sulting in posterior displacement of the distal portion. Lateral dislo- 
cations of the fingers by direct violence, such as a blow, are not infre- 
quent and are usually accompanied by a fracture sprain of the bases of 
the distal phalanx. A rupture of the lateral ligaments is also present. 
The reduction of all dislocations of this type very soon becomes impos- 
sible and operative interference is necessary. 
Fracture Deformities of the Hand and Fingers. 
Carpus. Fractures of the individual carpal bones. 
Forearm fractures. Typical Codes’ fracture of the radius 
and ulna; fracture of styloid process of the ulna; fracture 
of styloid process of radius. 
Fracture deformities of fingers. 
Fracture, of Scaphoid.—The most common fracture among the carpal 
bones is that of the scaphoid. In fracture of the scaphoid, the tender- 
ness is located at the dorsum of the wrist at or about the snuffbox. 
There is, secondarily, a development of traumatic arthritis in the single 
joints of the wrist. The mechanism of the injury in fracture of the 
scaphoid is usually a fall upon the extended hand. Pain and inability 
to flex the wrist are the most prominent symptoms. All flexion move- 
ment of the wrist becomes painful. 
The fracture of the scaphoid should be differentiated from the wrist 
sprain caused by distortion. Most patients with wrist sprain complain of 
pain at the radial or radiodorsal region. Only exceptionally is the ulnar 
region involved. The pain is strictly localized to this region. There is 
tenderness upon pressure, especially in volar flexion of the wrist and in 
ulnar abduction. This pain is a distention pain due to the fact that the 
carpal reinforcing ligaments are strained at the radiodorsal or radial 
surface. Occasionally there is pain on dorsiflexion and on radial abduc- 
tion which may be explained as a compression pain, but the typical pain 
in wrist distortion is localized on the radial and radiodorsal side and be- 
comes more evident in flexion of the wrist. The anatomical basis is the 
injury to the lateral radial ligament and the radiodorsal ligament, al- 
though occasionally the lateral ulnar ligament may be involved. 
Case Report.—R. A. Old fracture of the scaphoid. Patient fell 8 
months ago upon extended hand. Since then he complained of pain and 
inability to move the wrist. Examination showed tenderness of the 
wrist below the tip of the radius; passive motion free; active extension 
painful. The X-ray showed fracture of the scaphoid. In this case, the 
symptoms of scaphoid fracture were indefinite and there was reason to 
construe the syndrome as strain of the dorsolateral structures, but the 
X-ray picture cleared up the diagnosis (Plate XLVI, 6), 254 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
The treatment of the fractured scaphoid involves the application of 
massage, heat, passive motion and splint and plaster immobilization, and 
there are cases of undoubted fracture of the scaphoid in which function 
returns to normal, even though the fragments never really unite except 
by fibrous union. 
In the majority of cases, however, operative interference is neces- 
sary. The operation consists in partial excision, the proximal fragment 
being usually the one more easy of access. 
Fracture Deformities of the Wrist—Colics’ Fracture.—The disability 
following Colies’ fracture of the wrist depends, as to degree and duration, 
upon several factors. The actual deformity of the bone is only one of 
these factors and not necessarily the determining one. There are cases 
which show considerable fracture deformity with silver-fork deviation 
and yet have acquired an astounding degree of utility, while others with 
little or no deformity are not infrequently gravely handicapped in mo- 
tion. One must remember that with a fracture of the lower end of the 
radius, there also occur, and to a considerable degree, injuries to the 
soft parts, especially tears of the muscle tissue and hemorrhage into 
the tendon sheaths lying anteriorly to the fractured bones. The organi- 
zation of such blood clots in tendon sheaths has a great deal to do with 
the later disability of the wrist. It ties up the flexor tendons and pre- 
vents their free action. There is further to be considered that Colles’ 
fracture, just as the injuries in the wrist itself, is often followed by sec- 
ondary traumatic arthritis. This latter factor, much more than the 
original injury itself, determines the degree of disability. The muscles of 
the forearm undergo shrinkage and degeneration, the tendons become ad- 
herent, and the circulation is usually very considerably disturbed. It is 
easy to see that the age of the patient will be of great influence upon the 
outcome of the fracture deformity. Old people are extremely prone 
to develop traumatic arthritic conditions in the wrist and degenerative 
changes in the muscles and tendons. For this reason, one need not be 
surprised to find a great deal of discrepancy between the deformity 
present and the amount of disability directly and indirectly resulting 
therefrom. 
The writer’s series covers 15 cases of Colles’ and forearm fractures 
ranging in age from 15 to 67 years, and, in duration of the deformity, 
from 3 weeks to a year following injury. 
Considering the cases of fracture deformity of the radius of more 
than two months’ duration, we have then 6 cases with considerable de- 
formity. Of these 6 cases, 3 had poor function, and 3 good function. 
There were also 5 cases, with moderate, slight, or no deformity, among 
which function was poor in 2 cases, fair in 1 case, and good in 2 cases. 
This shows that the degree of the deformity is not in keeping with the 
degree of disability. 
On the other hand, there were 6 cases over forty years of age; of 
these, function was poor in 5 cases, and fair in 1 case, in spite of the fact TRAUMATIC DEFORMITIES 
255 
that 5 of the cases had either only very slight deformity of the wrist or 
none at all. 
Table of Deformities from Colles’ and Forearm Fractures 
Name 
Age 
in 
Years 
Dura- 
tion 
Deformity 
Mode of 
Injury 
Degree of 
Deformity 
Function 
B. M. 
23 
1 yr. 
Colles’ fracture: backward dis- 
placement 
blow 
considerable 
good 
P. K. 
26 
6 mos. 
Colies’ fracture: posterior dis- 
placement 
fall 
considerable 
poor 
K. U. 
63 
3 mos. 
Colles’ fracture: anterior dis- 
placement 
hyperexten- 
sion 
considerable 
poor 
E. S. 
48 
3 mos. 
Colles’ fracture: posterior dis- 
placement 
hyperexten- 
sion 
moderate 
poor 
0. H. 
18 
10 mos. 
Colles’ fracture: posterior dis- 
placement 
blow 
slight 
fair 
A. M. 
19 
2 mos. 
Colles’ fracture: posterior dis- 
placement 
with sublux- 
ation of ulna 
hyperexten- 
sion 
considerable 
poor 
K. W. 
20 
5 mos. 
Colles’ fracture: posterior dis- 
placement 
with sublux- 
ation of ulna 
hyperexten- 
sion 
considerable 
good; al- 
most full 
motion 
F. W. 
5i 
1 yr. 
Colles’ fracture: None 
hyperexten- 
sion 
none 
poor; atro- 
phy scar- 
bound ten- 
dons 
E. B. 
67 
2 mos. 
Colles’ fracture: posterior dis- 
placement 
hyperexten- 
sion 
very slight 
poor; stiff- 
ness of fin- 
gers and 
wrist 
K. C. 
60 
5 wks. 
Colles’ fracture: posterior dis- 
placement 
hyperexten- 
sion 
slight 
poor 
J.K. 
20 
6 wks. 
Colles’ fracture: posterior dis- 
placement 
hyperexten- 
sion 
slight 
poor 
L. 0. 
45 
3 wks. 
fracture of the 
ulna 
blow 
slight 
fair 
A. K. 
30 
8 mos. 
fracture ulna; 
nonunion 
fall 
none 
poor 
E. P. 
15 
1 yr. 
fracture forearm posterior dis- 
bones: placement 
hyperexten- 
sion 
considerable 
good 
L. F. 
18 
8 mos. 
fracture of the 
radius 
blow 
none 
good 
In the treatment of fracture deformities of the forearm and wrist, the 
medicomechanical after treatment plays a most important part. This 
should begin at the earliest possible moment within eight or ten days 
after the injury and should be continued until motion has been restored 
to the fullest possible extent. 
Fracture Deformities of the Fingers.—Chronic deformities follow- 
ing fractures of the fingers often lead to disabilities because of the in- 
volvement of the neighboring joints. Traumatic arthritis also plays a 256 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
considerable part as complicating- the original deformity and interfering 
with the function of the joint. 
The treatment of the fracture deformity is principally medicome- 
chanical and consists in early and persistent active and passive motion 
of the joint involved and in massage of the muscles governing the action 
of this joint. In the phalangeal joints, stiffness can as a rule be over- 
come by continuing the mechanical after treatment for a period of from 
four weeks to three months. 
In several cases of fracture deformities of the fingers of the writer’s 
observation, the physiological motion was restored readily by means of 
massage and active and passive motion. One case of fracture deformity 
of the thumb had to be operated upon because of its complications. The 
case was one of the injury to the thumb eighteen months previously, 
which resulted in the fracture of the basal phalanx and also in backward 
and ulnar displacement of the end phalanx. In this case, the resection 
of the head of the basal phalanx had to be undertaken in order to reduce 
the dislocation. Good function of the phalangeal joint of the thumb 
was obtained and this persisted during one and one half years of obser- 
vation. 
Fracture Deformities of the Elbow—Cubitus Valgus.—A traumatic 
cubitus valgus is often observed as a result of fracture deformity of the 
elbow involving the external condyle. In the normal individual, the 
carrying angle of the elbow is io to 150 in men and 20° or more in 
women. A considerable increase in the carrying angle in women takes 
place during puberty owing to the increased width of the pelvis. The 
anatomical basis of the normal angulation is, according to Huebscher, 
not a slanting position of the articular end, but rather a lateral curving 
in of the lower end of the humerus. In the pathological cubitus valgus, 
this carrying angle is increased by the deformity, which is caused, most 
commonly, by the fracture of the external condyle of the humerus. 
Cases of cubitus valgus from occupational strain, such as exercise or 
lifting, have been reported by Schwartz, but it seems that a certain 
natural predisposition (laxity of the lateral ligaments) is necessary in 
order to bring about a cubitus valgus deformity following mild occu- 
pational strain. 
Bonnet reported 3 cases of cubitus valgus in paralysis of the median 
and ulnar nerves; the deformity in these cases was due to the disturb- 
ance of muscle equilibrium, incident to the loss of the flexor muscles 
arising from the inner condyle. In paralysis of the median alone, the 
flexor carpi ulnaris is the only one to persist, but it is sufficient to coun- 
terbalance the muscles coming from the outer condyle. In paralysis of 
both nerves, however, the action of the extensor group, coming from the 
outer condyle and the external edge of the humerus, brings about un- 
opposed abduction of the forearm. 
Traumatic Cubitus Varus.—The cubitus varus is a frequent deformity 
following fracture of the elbow joint. The most common single type of 
fracture leading to this deformity is the fracture of the internal condyle TRAUMATIC DEFORMITIES 
257 
or the intracondyloid fracture of the humerus. The factor determining' 
the disability is not so much the lateral deviation of the elbow joint as the 
displacement of the fragment in front or behind the line of the joint. 
Of 5 cases of cubitus varus observed, 2 were fractures of the internal 
condyles, 2 were fractures of the outer condyle, and 1 was on intra- 
condyloid fracture. The deformity was brought about by fall upon the 
elbow in extension in 3 cases and the function was good in 4 of the 5 
cases. In 1 case, the fracture had led to a partial ankylosis of the elbow 
with poor function; this was due to extra-articular adhesions rather than 
to displacement of the condyle, since the latter was displaced directly 
lateralwards. 
The treatment of the cubitus varus deformity, as such, is entirely 
surgical, and consists in the osteotomy of the humerus immediately above 
the elbow joint. In the one case in which such osteotomy was performed, 
the result was a restoration of the normal carrying angle. In the other 
cases there was not enough deformity to warrant the operation, since the 
function of the elbow was not impaired (Plate XLV, 1, 2, 3, 4). 
Elbow Strain.—This condition should be differentiated as a distinct 
clinical entity. It is caused by a sprain of the extensor muscles of the 
forearm which originate at the external condyle of the humerus. The 
lateral ligament of the elbow, spreading out fan-shape from the external 
epicondyle and serving as point of insertion for the extensor muscles, is 
sprained or torn. There is, therefore, direct pressure pain at the external 
epicondyle of the humerus. But the deep fascia of the. forearm which 
also becomes aponeurotic, serving as tendon of insertion to the anconeus 
quartus, the extensor carpi radialis and ulnaris, the extensor digitorum 
communis, and the extensors of the fifth finger, consequently partici- 
pates in the muscle strain; the result is tenderness of the extensor sur- 
face of the forearm distally from the external epicondyle. It is important 
to know that these sprains of the elbow may not only come about by 
direct or indirect trauma, but that they may also occur as occupational 
disturbances caused by continued and gradual strain upon the extensor 
muscles. They have received occasional attention under the name of 
joint neuralgias (epicondylalgia of Ramak and Bernhardt), while Oppen- 
heim regards them as occupational neuroses.2 The treatment of this 
condition is fixation in 'splint or cast followed by massage. 
Traumatic Ankylosis of the Elbozv.—Fracture deformities of the elbow 
resulting in ankylosis are frequent. It is usually the intracondyloid or 
supracondyloid fracture of the lower end of the humerus which leads 
to the deformity and ankylosis. A displaced fragment is very often 
found in front of the elbow joint and is then the cause of considerable 
restriction of the flexion range of motion. The bony obstacles are, how- 
ever, by no means the only, nor are they usually the principal, sources 
of the functional difficulties. Very extensive and very strong extra- 
2 Tennis elbow is a condition of elbow sprain recently described by Osgood. He be- 
lieves that the occasional strains of the external condyle cause the inflammation of bursae 
situated in this space, which produces some of the symptoms. LEGEND FOR PLATE XLIV 
Fig. i.—G. W. Fracture Deformity of Elbow. 
Fig. 2.—G. W. X-ray before Treatment. 
Fig. 3.—G. W. After Arthroplasty. 
Fig. 4.—G. W. X-ray after Operation. PLATE XLIV LEGEND FOR PLATE XLV 
Fig. i.—V. W. Cubitus Varus Traumaticus. 
Fig. 2.—V. W. X-ray before Operation. 
Fig. 3.—V. W. After Operation. 
Fig. 4.—V. W. X-ray after Operation. PLATE XLV 262 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
articular adhesions are quite regularly found in front of the elbow joint. 
They are the result of the organization of the considerable hematoma 
which follows the injury of the soft structures surrounding the joint. 
They determine as a rule much more the ultimate restriction of the range 
of motion than does the displacement and interposition of the fragments 
themselves. 
Where the ankylosis is due mainly to periarticular adhesions, the 
treatment must take into consideration the extent to which the fibrous 
strand may be overcome by mechanical means. There is a possibility of 
recovering by conservative treatment, both in children and in adults, a 
certain amount of motion, if there is no grave intra-articular destruction 
of the joint surface. The treatment must be carried out with the proper 
amount of judgment and caution, in view of the reaction of the soft tis- 
sues to forcible manipulation. The position of the elbow joint in cases 
in which the articular surfaces have remained intact is then dictated by 
muscular contracture and by the extra-articular adhesions; a relaxation 
of the contracted muscles of the elbow joint may be often obtained by 
fixation. When mobilizing procedures are in order, passive manipula- 
tions should keep pace with active motion. If a fragment is wedged in 
front of the elbow joint, it can be dissected out without materially inter- 
fering with the integrity of the joint itself, and postoperative mechanical 
treatment and mobilization of the elbow joint is to follow within a week 
or two after operation. 
Case Reports.—J. F., 16 years old. Fracture of the left elbow 5 years 
ago. Inability to extend the elbow. Examination shows the lateral 
condyle detached from the outer side of the humerus, to a point in front 
of the elbow joint where it can be felt under the skin. The extension 
of the arm is checked at 150°, the flexion at 8o°. The detached piece of 
the external condyle was resected and so were the adhesions in front of 
the elbow joint. The arm was placed in a plaster-of-Paris cast for two 
weeks and then the mechanical after treatment was started. The elbow 
obtained its full range of motion. 
A. K., 13 years. Fracture of the elbow y2 year ago. Examination 
shows flexion of the elbow checked at right angle. The X-ray shows 
fracture of the lower end of the humerus, the upper fragment being dis- 
placed forward. The lower end of the upper fragment was resected, 
and a series of casts applied, with the result that the range of motion 
reached from 145 extension to 45 flexion, or ioo°. 
M. W., 12 years. Fracture of the elbow 5 months ago. There was 
ankylosis of the elbow at the angle of 130°. No flexion or extension, but 
free pronation and supination. The X-ray showed intracondyloid frac- 
ture, the inner condyle being displaced forward and inward so as to form 
a bony prominence in front of the elbow joint, preventing flexion. The 
lower end of the humerus was resected as well as the adhesions in front 
of the joint. The range of motion was then from 450 to 160°, equaling 
113°. The arm was put up in flexion. In this case, most of the motion 
gained by operation was lost for a time by early interruption of plaster TRAUMATIC DEF'ORMITIES 
263 
fixation, and the premature and too vigorous beginning of the after 
treatment. But after application of the cast, the loss of the motion was 
made up to a large extent. 
B. G., 35 years. Fracture of the elbow 5 months ago. X-ray shows 
fracture of the external condyle of the humerus which is displaced for- 
ward in front of the elbow joint. At operation, the external condyle was 
resected and the numerous adhesions were freed. The motion of the 
elbow, which before the operation was limited to 20°, was then increased 
to range from 8o° to 160°, or 8o°. In this case, although the after treat- 
ment was instituted almost immediately after operation, progress was 
slow because of muscle contracture which considerably resisted the ap- 
plication of active and passive motion, so that in the end the gain in 
motion was rather limited. 
Experiences of only partial result after removal of existing mechani- 
cal obstacles in the elbow have taught us two things: first, that it is pos- 
sible by too vigorous and too early after treatment to lose some of the mo- 
tion regained at operation, due to the reformation of extra-articular adhe- 
sions. This would lead to the adoption of more conservative means and 
possibly to a prolongation of the fixation treatment after operation. On 
the other hand, in several cases, we could not escape the impression that 
the resection of bone at operation was not sufficient to insure free motion 
of the joint, and that, possibly, a more radical procedure would bring 
about more uniform results. Arthroplasty, we believe, should be done 
more often in the latter group of cases. 
Altogether, 19 cases of ankylosis of the elbow joint upon traumatic 
basis were observed. 
Arthroplasty of the Elbow Joint.—The first arthroplasty on any 
joint was performed by Helferich in 1893; the next by Miculicz in 1895; 
both on temporomaxillary joints, and in both cases temporal muscle flaps 
were used. Gluck (1892) used skin flaps and Schumski nonabsorable 
material of zinc, rubber, celluloid, and silver. 
The method of arthroplasty received the greatest impetus with the 
introduction of soft tissue interposition. Murphy in 1905 introduced the 
fascia flap in this country. 
In the upper extremity, the elbow is the most suitable joint for 
arthroplasty. Arthroplasty of the shoulder joint is seldom indicated 
because of the excellent function that can be obtained from a stiff shoul- 
der joint in suitable position. For the same reason, the arthroplasty in 
the wrist joint is rarely used, not only because a stiff wrist in proper 
position gives excellent service, but also because arthroplasty of the 
wrist itself is a rather uncertain operation. According to Henderson’s 
table covering 126 cases of arthroplasty of the elbow, the results were 
good in 97 or 76 per cent, fair in 21 or 16 per cent, and poor in 8 or 6 
per cent of the cases reported. 
Technic of Arthroplasty of the Elbow—Albee’s Method.—A vertical 
incision is made, six inches in length, on the posterior surface of the 
elbow, directly over the olecranon, from two inches below to four inches RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
264 
Table of Cases of Traumatic Ankylosis of Elbow 
Name 
Age 
Years 
Dura- 
tion 
Condition 
Deformity 
Func- 
tion 
Treat- 
ment 
Result 
M. W. 
12 
5 mos. 
intracondyloid frac- 
ture and dislocation 
of the ulna acquired 
by fall 
cubitus varus 
with extension 
ankylosis 
poor 
operative 
resection 
poor 
G. W. 
9 
3 mos. 
supracondyloid frac- 
ture with forward 
displacement and 
dislocation of ulna 
cubitus varus 
with ankylosis 
in extension 
very 
poor 
arthro- 
plasty 
fair 
W.M.L 
12 
1 yr. 
supracondyloid frac- 
ture with volar dis- 
placement acquired 
by fall in extension 
cubitus varus 
with extension 
ankylosis 200 of 
motion 
poor 
resection 
of fragm. 
poor; gain 
15° 
B. G. 
J.P. 
35 
20 
6 mos. 
8 wks. 
fracture of internal 
condyle with volar 
displacement by fall 
in extension 
fracture external con- 
dyle by fall in ex- 
tension 
extension anky- 
losis 
partial ankylosis 
700 motion 
poor 
resection 
of fragm. 
not 
treated 
poor; gain 
15° 
F. R. 
7 
2 mos. 
supracondyloid frac- 
ture with volar dis- 
placement acquired 
by fall in extension 
ankylosis with 
200 motion 
poor 
resection 
of fragm. 
fair; gain 300 
MC F. 
16 
5 yrs. 
fracture of external 
condyle; posterior 
displacement ac- 
quired by fall in 
flexion 
partial ankylo- 
sis; 11 o° motion 
resection 
of fragm. 
good; gain of 
full motion 
A. K. 
13 
6 mos. 
supracondyloid frac- 
ture with volar dis- 
placement; acquired 
by fall in extension 
ankylosis 20° 
motion 
poor 
resection 
of fragm. 
fair; gain 300 
H. D. 
11 
4 wks. 
supracondyloid frac- 
ture with volar dis- 
placement sustained 
by fall in extension 
partial ankylo- 
sis in flexion; 
range 0 f motion 
80 0 
fair 
conserv- 
ative 
fair; in- 
creased flex- 
ion 
M. B. 
9 
2 mos. 
supracondyloid frac- 
ture with volar dis- 
placement ; by fall 
in extension 
partial ankylo- 
sis ioo° motion 
good 
not 
treated 
L. Y. 
8 
1 yr. 
fracture int. condyle 
volar displacement; 
by fall in extension 
ankylosis in flex- 
ion 15 0 motion 
poor 
not 
treated 
J. M. 
35 
4 yrs. 
supracondyloid frac- 
ture ; by fall in ex- 
tension 
complete bony 
ankylosis 
poor 
not 
treated 
E. D. 
7 
1 yr. 
fracture int. condyle 
volar displacement 
by fall in extension 
complete anky- 
losis in exten- 
sion 
poor 
not 
treated 
M. L. 
38 
2 yrs. 
supracondyloid frac- 
ture ; volar displace- 
ment by fall in ex- 
tension 
flexion checked 
at 90 0 
conserv- 
ative 
fair; moder- 
ate gain of 
flexion 
D. O. 
30 
20 yrs. 
fracture int. condyle 
by fall 
extension anky- 
losis at 130°; 
range of motion 
100 
good 
not 
treated 
J.E. 
E. B. 
35 
15 
4 yrs. 
9yis. 
supracondyloid frac- 
ture by fall in ex- 
tension 
contracture biceps 
following strain 
extension anky- 
losis complete 
extension check- 
ed at 150° 
poor 
good 
not 
treated 
not 
treated 
P. S. 
21 
2 yrs. 
extra-articular lesion 
by fall in extension 
extension limit- 
ed at 1600 
good 
conserv- 
ative 
good; full 
motion 
A. G. 
25 
6 mos. 
extra-articular adhe- 
sions 
extension limit- 
ed at 150° 
good 
conserv- 
ative 
good; full range 
of motion 
(Plate XLIV, 1-4 
XLVI, 1-5.) TRAUMATIC DEFORMITIES 
265 
above (Langenbeck’s incision). The ulnar nerve is displaced and re- 
tracted. The olecranon is sawed through obliquely from within outward. 
The bone connections between olecranon and humerus are severed with 
a narrow sharp osteotome. Then the olecranon with the triceps attached 
to it is retracted backward and the interior of the joint is exposed. If 
bone bridges are present between the head of the radius and the ulna, 
they are separated with an osteotome and the coronoid process is freed 
from the trochlea in a similar way. Exostoses are cut away from the 
head of the radius and the head itself is shaped with the rongeur to nor- 
mal size. A free fascia flap is inserted and, carrying it up high to the 
anterior surface of the humerus, its margins are secured to the capsule 
on all sides. The ulnar nerve is replaced and the skin is closed. 
McAusland’s technic.—A U-shaped incision is made, beginning on the 
lateral aspect three inches above the elbow joint and passing over the 
middle of the olecranon and hence upward to a point corresponding to 
the beginning of the incision on the opposite side. The skin and super- 
ficial fascia are dissected and retracted upward. The ulnar nerve is dis- 
sected and retracted. A straight incision is made from the lateral aspect 
of the condyle to the opposite side crossing midway over the olecranon. 
The latter is sawed across and separated. In case of extensive bony 
ankylosis, one saws directly across the line of the joint, three-fourths 
through, and breaks the remainder. Capsule, fascia and ligaments are 
dissected back and the humerus is made to protrude through the wound. 
A new trochlea is rounded off with the rongeur. Then a piece corre- 
sponding to the olecranon fossa in the normal humerus is removed and 
the surface of the olecranon is curetted out so as to receive the new 
humeral extremity. The joint surfaces should fit accurately. 
A free fascia flap is then obtained from the outer side of the thigh. 
This is placed around the humeral condyle by attaching it first to the 
anterior capsule and then tying it around the condyles by a purse-string 
suture so as to cover all raw surfaces. Fascia, ligaments and capsule are 
then sutured and the olecranon is replaced with strong chromic catgut. 
The skin is closed. No splint is used, but arm and forearm are placed 
on pillows and passive motion begins on the fifth day. 
Ashhurst’s Technic.—This method gives an excellent approach to the 
joint. A skin incision is made beginning at the external supracondyloid 
ridge of the humerus, five cm. above the joint, and is continued down- 
ward to the joint level, from which point it is curved slightly backward 
on the forearm. The soft parts are cleared away from the humerus. 
The supinator longus and the extensors carpi radiales are placed for- 
ward, the triceps backward until the external condyle is thoroughly ex- 
posed, as well as the anterior capsule of the joint and the external lateral 
ligament. Then the external condyle is detached from the bone with an 
osteotome, the section entering the elbow joint on the capitellar surface 
of the humerus. In most cases, even if the ulnohumeral joint is thor- 
oughly ankylosed, the radiohumeral joint is found free. The external 
condyle is then turned down. The next step is the dislocation of the LEGEND FOR PLATE XLVI 
Fig. i.—E. R. X-ray. Fracture Ankylosis of Elbow. 
Fig. 2.—E. R. Motion of Elbow after Operation. 
Fig. 3.—E. R. X-ray after Operation, Spur Removed. 
Fig. 4.—B. G. Fracture Ankylosis of Elbow. 
Fig. 5.—B. G. X-ray. Showing Fragment. 
Fig. 6.—R. A. X-ray. Fracture of Scaphoid. PLATE XLVI 268 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
joint. Severing the synostoses between humerus and ulna by chisel, the 
joint is then dislocated by adducting the forearm around the internal 
lateral ligament as a hinge until the forearm is almost parallel with the 
upper arm and radius and ulna are coming into full view. Then the bone 
ends are shaped. As little as possible is done to the ulna, especially when 
the head of the radius is intact, reliance being placed mainly upon the 
resection of the humerus for the shaping of the new joint. But when 
ankylosis exists in the radio-ulnar joint also, then resection of the head 
of the radius rather than the insertion of the flap between radius and 
ulna is advisable. The shaping of the humerus is carried out with the 
Gigli wire-saw. Then the interposition of the flap is carried out. The 
bones are temporarily restored to normal relation, the skill incision is 
enlarged from the upper edge backward across the posterior surface of 
the arm. A flap of fat and fascia is obtained from the superficial surface 
of the triceps muscle with its base at the olecranon. The elbow joint is 
again dislocated and the flap is attached to the internal lateral ligament 
of the. elbow, as well as to the anterior and posterior capsules. 
The forearm is again restored to normal position, the external condyle 
is brought up in place and fixed to the humerus, the triceps is sutured to 
the supinator longus and the extensors carpi radiales, and the skin is 
closed. The method has been used by the writer to very good advantage 
in one case of severe fracture deformity of the elbow with ankylosis and 
cubitus varus deformity, and in one case of congenital ankylosis. 
General Remarks on Arthroplasty.—Certain biological facts regarding 
tissue reaction and tissue changes in the cases operated by arthroplasty 
must be taken into consideration in order to appreciate the conditions 
upon which operative success is based. 
According to Allison and Brooks, any inflammatory process of suffi- 
cient severity within a joint will result in the formation of granulation 
tis'sue, which destroys the joint cartilage and finally causes union of the 
denuded bone surfaces by fibrous bands. By a metaplastic process, this 
fibrous tissue will often be transformed into bone and then a bony union 
is established. It is the purpose of arthroplasty to prevent the occurrence 
of just such adhesions as generally take place in inflammatory and sup- 
purative joints. From the experiments of Allison and Brooks, it is 
known that denuded joint surfaces are at the end of five days covered 
with granulation tissue which pours out of the bone from the marrow 
spaces and gradually develops into fibrous tissue. This is the primary 
stage of the osseous union and it takes only a deposition of lime salts to 
bring about fusion between the bones constituting the joint. 
In the event of interposing fascia or other soft tissue between the 
bone ends, as is done in our present methods of arthroplasty, such ad- 
hesions can be prevented only if a cavity is formed between the two 
bone ends by the absorption of the transplanted tissue. In those instances 
where parts of the tissue persist, the persisting islets promote adhesions. 
From this point of view, then, there is no distinct advantage to be derived 
from the use of a pedicled flap. TRAUMATIC DEFORMITIES 
269 
Case Reports.—G. W., 12 years. Sustained a surpracondyloid fracture 
of the humerus 6 months ago; examination showed the elbow completely 
ankylotic in extension of about 150°; cubitus varus deformity. X-ray 
showed a fracture through the internal condyle and trochlea with dis- 
placement of the fragments upward. Dislocation of the ulna. Opera- 
tion : arthroplasty of the elbow following Ashhurst’s technic. An incision 
is made over the radial side of the lower end of humenus and upper end 
of forearm. The muscles are stripped off the bone, proceeding between 
the brachialis anticus and triceps above and the supinator longus and 
extensors of the wrist below. The radiohumeral joint is exposed. Then 
the olecranon is sawed across, and, with the triceps adherent to it, de- 
flected upward. The joint is then entirely dissected in its internal aspect 
and all adhesions are resected. Then the forearm is swung around the 
internal lateral ligament and the bones are made to protrude through 
the wound. The lower end of the humerus is resected and shaped. It is 
then covered by a flap taken from the fascia of the posterior surface of 
the upper arm. This flap is fastened over the lower end of the humerus 
by a purse-string suture. The bones are replaced and the wounds closed. 
The patient did not retain entirely the initial range of motion, but he got 
a fair mobility, which at the present is about 40°, and under persistent 
after treatment is constantly improving (Plate XLV, 1-4). 
Dr. C. W., 26 years. Ankylosis of both elbows following general 
sepsis 3 years ago. Position of the elbow is ankylosis in extension on both 
sides; pronation and supination free. Arthroplasties following identical 
technic on both elbows. A longitudinal incision was made over the inner 
aspect of the humerus and forearm, subperiosteal stripping of the elbow 
joint exposing the lower end of the humerus and upper end of the ulna; 
the bone bridge uniting humerus and ulna was chiseled away, so that a 
cavity of three-quarters of an inch long remained. Then the bone ends 
where shaped. A free fascia flap was interposed to cover the distal ends 
of the humerus and the wounds were closed. Following operation both 
elbows were placed in extension. Results: the right elbow has a range 
of motion from 108 extension to 55 flexion, or 53°, 3 months after opera- 
tion; the left elbow, 105 extension to 62 flexion or 430, after 2 months. 
While the range of motion is moderate, it is absolutely free and painless 
and shows no tendency to decrease. 
F. B., 30 years. Ankylosis of the right elbow following chronic 
arthritis existing for 5 years. Arthroplasty of the radiohumeral joint and 
radio-ulnar joints to relieve pronation ankylosis as a first step of the 
arthroplasty of the elbow. The radiohumeral joint is reached by a lateral 
incision. The head of the radius is exposed and resected; a flap is inter- 
posed. Then, the lower radio-ulnar joint is also exposed, and a flap in- 
serted between ulna and radius, after resecting a bone bridge uniting 
the two bones. The result of this operation was a gain in pronation and 
supination movement amounting to about 50° to 6o°.3 
3 In his later arthroplasties of the elbow, the writer is using, now regularly, the pos- 
terior U-shape incision. In shaping the bone ends, one does very well to follow the 
practice of Putti, who carefully smoothes off the ends with files of suitable shape. 270 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Of 4 arthroplasties of the elbow, the result was good (range of mo- 
tion 50° or over) in 2 cases; fair (range of motion 40° or over) in 2 cases. 
Tendon Ruptures.—The subcutaneous ruptures of tendons are rare. 
The tear usually occurs at or near the insertion or at the junction of the 
tendon of insertion with the muscle. The so-called spontaneous rup- 
tures of tendon are hardly ever purely traumatic. As investigations, es- 
pecially those covering the rupture to the biceps of the forearm, have 
shown, such ruptures usually involve already diseased tendons. The 
changes consist mainly in hyaline degeneration of the tendon, subse- 
quent to chronic changes in the joint, especially arthritis deformans. 
Ruptures of the Finger Tendons.—Of the tendons of the fingers, the 
one most often involved is the extensor tendon of the thumb. According 
to Schlatter’s observation, a comparatively slight trauma often suffices 
to cause rupture. Van Verth reports 3 cases of rupture of the long ex- 
tensor tendon of the thumb, 2 occurring in waiters and 1 in a wood- 
carver, both occupations involving continued and chronic strain upon 
these tendons. To this group, the so-called drummer’s palsy may also 
be added, which afifects the tendon of the long extensor of the thumb 
and is induced by the continuous strain upon this tendon. 
In rupture of the tendon, the ends appear frayed, and there is a round- 
cell and spindle-cell infiltration in the tendon surrounding areas of hyaline 
necrosis. That the rupture occurs in changed tendon tissue is further 
shown by numerous hemorrhages seen in the masses of the tendon tissue. 
Stern reports 11 cases of this deformity, which, according to him, was 
first described by Abbe in 1894. Such causes as buttoning tight buttons, 
pulling the fingers, wrestling, basket ball or baseball playing, bowling, 
a fall upon the fingers, are known to produce the injury. These injuries 
are really occupational in character. In the case of the thumb extensor, 
the rupture is usually found at the point where the tendon appears dis- 
tally to the ligamentum carpi dorsale and turns laterally to reach the 
first metacarpal of the thumb. In none of the cases of tendon ruptures 
of the extensor tendons of the fingers observed by Schlatter was there 
found an injury to the bone. His series embraces 9 cases of rupture of 
the tendon at the end phalanx or at the second interphalangeal joint. 
The typical symptom is inability actively to extend the end phalanx, 
although passive extension is entirely free. If left to itself, the end pha- 
lanx drops into a position of flexion (drop phalangette). 
In the majority of cases, immobilization restores ability of extension, 
although the prognosis of the conservative treatment is not always good. 
When operation is required, and this is the case in all instances which do 
not promptly yield to immobilization, the procedure is simple. The ten- 
don can easily be picked out and fastened to the distal phalanx of the 
finger. Only in old cases, the place of rupture may not easily be dis- 
tinguished and one may have to resort to the expedient of fastening the 
tendon to the capsule of the interphalangeal joint. 
Case Reports.—M. M., 35 years. Three weeks ago, when reaching 
behind a pillow, the patient injured the extensor tendon of the index TRAUMATIC DEFORMITIES 
271 
finger of the right hand. There was evidently no violent injury and no 
pain. The end phalanx of the index finger was noticed to drop into 
flexion position and there was no power of active extension, although the 
end phalanx could be straightened passively. Treatment consisted in 
volar splint and the disability disappeared within a few weeks. 
M. B., 48 years. Ruptured extensor tendons of the fingers, 6 months 
ago, by being caught in a wringer. Examination showed that active 
extension of all fingers was impaired in the end phalangeal joints. There 
was no fracture; the condition improved considerably after 2 weeks of 
massage and splinting. 
Dislocation of the Extensor Tendons of the Finger.—This is an injury 
of rare occurrence. The statistics of Schlatter show that up to 1909 there 
were only 10 cases reported of dislocation of the extensor tendons of 
the fingers. In Schlatter’s case, there was a rupture combined with dis- 
location of the extensor aponeurosis of the fifth finger, caused by a blow. 
In dislocation of the tendon, the two halves are displaced laterally. Con- 
sequently, active extension is impossible at the start; however, if the 
patient is helped somewhat at the beginning of extension, the remainder 
of the motion can be carried out actively. The treatment, in cases of 
dislocation of the tendon, consists in the suturing together of the two 
laterally displaced halves of the tendon. 
Of rupture of the extensor tendons in midphalangeal joints, only 2 
cases are reported, one by Maydl and the other by Schlatter. The de- 
termining factor in this injury is the state of the finger tendons at the 
moment the injury is received. A forcible, active extension of the joint, 
acting together with a violent force which tends to produce passive 
flexion at the same time, brings about a rupture of the tendon over the 
midphalangeal joints. The case reported by Schlatter was treated suc- 
cessfully by immediate operation and suture. 
The Rupture of the Biceps Tendon.—A complete analysis of this con- 
dition is to be found in Maydl’s report of 1882, as well as in later reports 
of Loos (1901) and of Ledderhose (1909). Observations on rupture of 
the larger tendons have been made as early as 1722, when J. L. Petit re- 
ported ruptures of the tendo achillis and of the quadriceps tendon. Rup- 
tures of the biceps have been reported by Ashhurst (1873), by Poncet, 
Hueter, Nelaton, Jarjavay, and many others. All these ruptures came 
about by active exertion of the muscle.4 The statistics of Loos show, up 
to 1901, 68 cases, in the literature of which 44 were muscle ruptures, 18 
tendon ruptures, and 6 incomplete tears of the tendon, giving the relation 
of muscle to tendon rupture as 5 to 2. The typical rupture was that of 
the long head of the biceps, and the upper part of the tendon was rup- 
tured in 19.5 per cent. The muscle was ruptured in 36.9 per cent and 
the tendon muscle line was ruptured in 43.6 per cent of the cases. In- 
vestigation into the condition of the shoulder joint in cases of rupture 
of the biceps almost always reveals the fact that an arthritis deformans 
4 There is also a classical rupture of the plantaris muscle of the leg, which occurs 
suddenly through traumatic influences. 272 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
of this joint is present. The biceps tendon is often displaced from its 
bed in the sulcus intertubercularis and in the majority of cases only a few 
strands are left of the. intra-articular portion of the tendon, since the 
rupture occurs very near to the place of origin at upper margin of the 
glenoid cavity. Often the upper extra-articular portion of the tendon is 
adherent to the sulcus intertubercularis, being caught at times under a 
bony bridge. 
In rupture of the tendon, there is, as a rule, considerable downward 
displacement of the peripheral end of the tendon. The gap amounted, 
in cases reported by Dreyzehner, to io cm. and more. With the rupture 
of the tendon, the belly of the biceps muscle also becomes displaced down- 
ward and this displacement becomes more distinct when the muscle goes 
into active contraction. There is above the contracted muscle belly of 
the biceps a space in which the anterior surface of the humerus can be 
easily palpated. The contractile power of the biceps is greatly reduced, 
and, naturally, its absolute strength is diminished accordingly. 
It is not always the proximal tendon of the biceps muscle which is 
ruptured. There are cases reported which involve the rupture of the 
tendon-of insertion of the biceps at the tuberosity of the radius. This, 
however, is the great exception. It has already been mentioned that the 
condition underlying spontaneous rupture of the biceps muscle is an 
arthritis deformans of the shoulder joint, the tendon taking part in the 
arthritic changes. In no case reported in the literature could the purely 
traumatic nature of the rupture of the tendon be demonstrated. Accord- 
ing to Ledderhose, the rupture of the tendon is based upon chronic de- 
generative changes in the tendon itself, following chronic arthritic 
changes in the shoulder joint, and the trauma is only a superinducing 
factor. Mueller, in his careful study of the literature up to 1912, con- 
curs in this view. He finds most conspicuous vascular changes in the 
tendon showing the typical picture of an endarteritis obliterans. In dif- 
ferentiation from muscle hernia it should be remembered that, in the rup- 
ture of the biceps tendon, contracture of the muscle increases the tumor. 
In true muscle hernia, on the other hand, contracture of the muscle will 
cause the tumor to disappear, while a relaxation of the muscle will cause 
the hernia to become more apparent. Nevertheless, many cases of rup- 
ture of the biceps tendon have been reported in the literature as herniae 
of this muscle. 
The treatment of this condition is almost entirely operative. Only 
in rare instances of incomplete rupture, immobilization of the muscle and 
bandaging may result in a union of the tendon. The great majority of 
the cases require operation. This consists of longitudinal incision in the 
interspace between the deltoid and pectoralis muscles, and the dissection 
of the peripheral end of the tendon. This procedure is not always an 
easy one, since the tendon is often pulled out of the sulcus intertubercu- 
laris and curled up or reflected backward. The securing of the central 
end of the tendon is always fraught with considerable difficulties and, 
since the rupture takes place near the origin, the finding of the central TRAUMATIC DEFORMITIES 
273 
end requires the opening of the shoulder joint. Most observers, however, 
do not consider the opening of the shoulder joint a proper procedure, and 
content themselves rather with fastening the peripheral end of the ten- 
don back to its sheath in the intertubercular sulcus. 
Case Report.—H. J. S., 21 years. Traumatic rupture of the biceps, 
seven weeks ago, the patient was caught in a log chain hook receiving an 
extensive lacerated wound of the left arm, a,nd a partial rupture of the 
biceps muscle. The wound healed kindly and there were no complica- 
tions. At the examination, the biceps could be palpated at the anterior 
aspect of the upper arm, but on contraction it did not have normal con- 
figuration and was considerably indurated. There was no interference 
with free contraction and all motion was normal, except for a moderate 
weakness of the elbow flexion in comparison with the other arm. This 
was a case of purely traumatic rupture of the biceps. No treatment was 
indicated. 
Of the muscles of the upper extremity, tendon ruptures have been 
observed in the trapezius, the deltoid, and the pectoralis major, in rare 
instances. Tears of the tendons of insertion of the latissimus dorsi and 
pectoralis muscles, however, are not uncommon. The symptoms caused 
by muscle tears of the inward rotators of the arm, especially of the 
pectoralis major and latissimus dorsi, can be differentiated from other 
periarticular lesions of the shoulder joint by the location of the tender- 
ness and the peculiar restriction in motion. These conditions have been 
considered in Chapter I. 
Contrary to the relative frequency of tendon ruptures of the extensors 
of the fingers, ruptures of the flexor muscles of the fingers are extremely 
rare. Haessler reports a case of rupture of the flexor profundus of the 
fourth finger and, in a case of Schlatter, a rupture occurred in the flexor 
profundus of the little finger. In the latter instance, the tendon was 
found curled up in its tendon sheath and could be sutured back into 
place. Another case of rupture of the flexor profundus tendon of the 
fourth finger cured by suture is reported by Lessing. 
Habitual Dislocation of the Shoulders.—Habitual dislocation of the 
shoulder often follows injuries producing relaxation of the capsule. The 
tears of the rotators are often held responsible for this condition, but of 
the greatest influence is the condition of the capsule, especially the an- 
terior and the inferior portion. Muscular conditions, such as muscle 
atrophy, have often been found responsible for the habitual dislocation 
(Burrel and Lovett, Clairmont, Ehrlich) ; but it seems that a relaxation 
of the inferior of axillary portion of the capsule is a most important 
element for the usual type of the subcoracoid habitual dislocation. 
The mechanics of this condition have been studied extensively by 
T. T. Turner, who believes that the extreme motions of the shoulder tend 
to force the humeral head out of the socket, but are checked by the tight- 
ening of the capsule on the opposite side of the joint. In his opinion, it 
is in abduction and outward rotation that the resistance of the capsule 
is broken in its axillary portion and the head escapes from the socket 274 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
into the axilla, forcing the torn capsule margins apart with each repeti- 
tion of the dislocation. These torn margins of the capsule are separated 
and, finally, they cicatrize together across the gap, forming in this axillary 
portion of the capsule a cicatricial piece which prevents the capsule from 
tightening up and makes the subsequent escape of the head from the 
socket more easy. 
Sever, while recognizing the relation of the capsule to the habitually 
dislocated head, points out that the ligamentous capsule of the shoulder 
joint is a rather feeble and very lax structure, and that the shoulder owes 
its stability to its muscular capsule, formed by the subscapularis, supra- 
spinatus, infraspinatus, and teres minor muscles. The only portion of 
the joint capsule which is not guarded by muscular origins or insertions 
is that between the origin of the triceps at the lower edge of the glenoid 
fossa and the insertion of the subscapularis above. It is indeed in this 
portion where the capsule is more frequently torn and, as a result of 
these primary tears, there exists a relaxation of this portion of the capsule 
which allows subsequent and recurring dislocations. Therefore, it is 
argued, when the muscular control of the capsule is diminished, relaxa- 
tion of the capsule will be enhanced and followed by subsequent recur- 
ring dislocation. The muscles which are mainly involved in the securing 
of the head in the socket are the subscapular muscle and the supra- 
spinatus. 
From this point of view, the newer methods of operation applied in 
this condition may be considered. 
Clairmont and Ehrlich form a small flap from the posterior portion 
of the deltoid with an upper basis. This muscle flap is carried midway 
around the neck of the humerus, then forward, and is there sutured to 
the capsule. The method used by Burrell and Lovett (1908) is very effi- 
cient. An incision is made over the coracoid process and extended down- 
ward following the line of the cephalic vein. The latter is drawn inward 
and the deltoid and pectoralis muscles are separated in their intermus- 
cular septum. Then the coracobrachialis and short head of the biceps 
come into view in the upper end of the wound and the insertion of the 
pectoralis major in the lower angle. Head and neck of the humerus can 
now be exposed by blunt dissection. 
The anterior and internal aspect of the capsule is now exposed; the 
latissimus dorsi and pectoralis muscles being drawn inward, the sub- 
scapularis tendon is divided and the muscle retracted upward. With the 
arm in abduction of 250, one obtains the best exposure of the relaxed 
capsule. Then the relaxed part of the anterior and inferior capsule is 
grasped with hemostats. Three sutures of No. 1 catgut are inserted 
through the fold and then an elliptical piece an inch long and one half inch 
wide is dissected between the sutures already placed. When the sutures 
are tied, the capsule is then distinctly shortened. 
T. T. Thomas gives three routes by which the capsule may be ex- 
posed: the deltopectoral or external to the short head of the biceps; the 
antero-axillary, between the coracobrachialis and the axillary vessels; TRAUMATIC DEFORMITIES 
275 
and, finally, the postero-axillary, or posterior to the axillary vessels. He 
objects to the deltopectoral exposure because it is too far lateral. The 
antero-axillary operation gives a freer exposure than the deltopectoral 
route. The best route, however, is the postero-axillary incision, which 
gives exposure just where the changes in the joint lesion are best de- 
tected; no muscles have to be divided, and perfect drainage is possible, 
which is important because of the uncontrollable oozing which practically 
always occurs during the first twenty-four to forty-two hours. It is only 
necessary in this method to refrain, carefully, from injuring the circum- 
flex nerve, which lies directly in the field of exposure. Sever considers 
as the essential point the suturing of the capsule. Such operations as 
devised by Loeffler (fascia plasty), and Schultz, as well as the bone 
transplants used by Eden, and especially also the muscle flap operations 
as devised by Ollerenshaw and by Clairmont and Ehrlich, he thinks are 
unnecessary; he also maintains that the success of many of the capsule 
plaiting operations is due to the fact that the subscapularis tendon is 
shortened in the process. 
In order to get a clear exposure of the joint capsule, it is necessary to 
divide a portion of the pectoralis major as well as the subscapularis ten- 
don. The latter is then sutured following the plaiting of the capsule. 
The suturing of the subscapular tendon and the dividing of the pectoralis 
major tendon are then, according to Sever, the two important factors and 
are all that is really necessary in order to control the situation. The 
deltoid and coracobrachialis will be able to hold the humerus in place 
if the pull of the stronger pectoralis major is removed and the slack in the 
subscapularis tendon is taken up by suture. It seems from observations 
made both by Sever and Thomas, that the capsular operations, either be- 
cause of the plasty of the capsule itself or because of the muscle suture 
incident to it, offer at present the best results in the operative treatment 
of the recurrent dislocation of the shoulder. 
In his latest report, T. T. Thomas gives the results of 42 operations. 
On the 24 shoulders operated in nonepileptics, only the capsule opera- 
tion was performed, and in 13 cases there was no dislocation since opera- 
tion, which had occurred between 3 months to 13 years prior to the 
report. In 18 cases of shoulder operations in epileptics, the capsule opera- 
tion was done in all but 1 in which a high excision of the neck of the 
humerus was performed to stop the recurrent dislocation. Taylor re- 
cords 11 cases of complete success after a period of from 4 years to n}4 
years. Only 2 cases were to be classed as failures, and 2 showed good 
results after a second capsular operation. 
Chronic Dislocation of the Radio-ulnar Joint.—Isolated dislocation of 
the radio-ulnar joint was first reported by Desault in 1777, and according 
to the statistics of M. Sterne (1919), 31 volar and 18 dorsal dislocations 
of the lower radio-ulnar joint have been described. It has been an old 
teaching of Malgaigne that the volar dislocation of the radio-ulnar joint 
is caused by forced supination, and the dorsal dislocation by forced pro- 
nation of the forearm. 276 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
In order to prevent confusion, it is necessary to exclude the disloca- 
tions of the lower radio-ulnar joint which occur in Madelung’s deformity 
as well as those which occur at times in arthritic wrists and which have 
been mentioned in Chapter VIII. Only those dislocations which are 
caused by direct violence are here considered. The mechanism produc- 
ing ulnar dislocations is, according to Sterne, as follows: 
Forced dorsiflexion of the wrist causes a volar dislocation of the ulna. 
Forced volar flexion of the wrist causes dorsal dislocation of the ulna. 
The latter statement is in keeping with the observation of dorsal disloca- 
tion of the ulna occurring in the forced volar flexion in arthritic wrist 
joints. 
Forced pronation causes dorsal dislocation of the ulna; forced supi- 
nation causes volar dislocation of the ulna. 
Pronation of the hand with the forearm fixed, or supination of the 
forearm with the hand fixed, causes volar dislocation. 
On the other hand, supination of the hand with the forearm fixed, 
or pronation of the forearm with the hand fixed, causes dorsal dislo- 
cation. 
The treatment of the condition consists in reduction of the disloca- 
tion and reefing of the capsule. A fascia strip may be used to reinforce 
the capsule and guard against recurrence. 
Dislocation of the Head of the Radius—Case Reports.—L. V. K., 
6 years. About 3 months ago, while playing, patient fell and hit his 
elbow. Another fall followed 10 days later. At this time, a disloca- 
tion of the head of the radius was found. The examination of the 
elbow showed that the flexion stopped at 75°, while extension in the 
elbow was almost complete, lacking only io° to 150. In supination 
it was easy to push the head of the radius into its place in contact 
with the capitellum of the humerus, but when the forearm was pro- 
nated, the head of the radius promptly circled around the ulnar half 
of the capitellum in front until it could be felt almost in the middle 
of the cubital fold. Jt appeared that, with the stretching of the biceps 
tendon, the head regularly pulled out of its connection with the humerus 
so that the only position in which it is safe is that of flexion of the 
elbow and supination of the forearm. 
L. T., 12 years. The patient was struck on the elbow, 6 or 7 years 
ago, by a bottle hitting the outer side of the elbow. The examination 
showed the forearm in pronation; no active supination was possible. 
The X-ray showed a dislocation of the radius forward. 
F. J., 6 years. Dislocation of the head of the radius following birth- 
palsy. Dislocation of the head of the radius was caused by the pull 
of the biceps tendon which forced the head of the radius out of its con- 
tact with the capitellum into the lateral aspect of the cubital fold where 
it could be felt readily under the extensor tendons. This case was 
operated, and the head of the radius resected, the neck being held in 
place by a fascial strip. During the short observation of the patient, 
no recurrence of the dislocation was observed. TRAUMATIC DEFORMITIES 
277 
The Snapping Shoulder.—This is a rare condition which must be 
separated distinctly from habitual dislocation or subluxation of the 
shoulder. The contributions of Kappis have done much to promote 
our knowledge of the underlying pathology. The principal point in the 
snapping shoulder is that the whole joint moves under the deltoid 
muscle or, one may say, the deltoid muscle glides over the whole joint 
much in the fashion in which the tensor fasciae glides over the greater 
trochanter of the hip joint in cases of so-called snapping hip. The 
symptom of snapping is elicited by the contraction of the scapulo- 
humeral muscles. The humerus is fixed against the scapula and the 
entire joint moves as a whole under the deltoid muscle. In habitual 
dislocation of the shoulder, on the other hand, there exists a true dis- 
location in which the humerus leaves the glenoid fossa either partially 
or totally. The typical snapping of the shoulder has been observed, 
according to Kappis, in 9 cases, some of which were classified as habit- 
ual dislocations. The snapping occurs regularly when the joint is 
moved under the lateral portion of the deltoid and only 1 case of 
snapping of the anterior fibers of this muscle has been observed. It is 
possible that a number of the cases reported were actually complicated 
with posterior subluxation. In 1 case reported by Reich, there 
existed a fissure between the short head of the biceps and the insertion 
of the coracobrachialis muscle. 
One case was observed by the writer, which might be classified as 
snapping shoulder. The patient, 21 years old, complained of pain in 
the left shoulder for 5 years after he had been hit by a baseball over 
the tip of the acromion. The pain originally lasted only 3 or 4 days. 
However, 7 months later the pain recurred on movement. It came on 
in attacks, which have repeated themselves at regular intervals. When 
examined, it was found that the head of the left humerus protruded 
in front slightly more under the deltoid muscle than did the right head. 
The patient was able to carry out abduction to 450 without discomfort. 
From then on, however, abduction was considerably impaired, the head 
coming distinctly into relief, and, when abduction reached about 90°, 
it was accompanied by a jarring of the head underneath the deltoid 
muscle. As soon as this was accomplished, further abduction became 
quite easy and painless. There was distinct tenderness of the deltoid 
muscle over the outer circumference of the humeral head. 
The distinct jarring of the head at a point of 90° abduction would 
seem to place this case in the group of the snapping shoulders and not 
in that of habitual dislocation or subluxation. There was at no time 
any change in the relation between the humerus and the glenoid fossa. 
From the history, it appeared that the injury produced certain changes 
in the fibers of the lateral portion of the deltoid, as well as a relaxation 
of the capsule, with the result that the shoulder joint sagged forward 
under the fibers of the deltoid and had to be manipulated back, so to 
speak, before the upper circumference of the head could submerge 
under the muscular cover of the deltoid muscle. 278 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Snapping Elbow.—Typical snapping phenomena of the elbow have 
been reported by Juengling in 2 cases of his observation. In these, 
the snapping sign was elicited by displacement of the radial head and 
the condition therefore should rank among the habitual dislocations of 
the head of the radius. Both cases were treated by operation. In one 
case, formation of the new socket of the radius was found in which 
the head moved as in a hinged joint. Two cases of habitual dislocation 
of the head of the radius are found described above. 
Snapping Finger (Trigger finger; Doigt a ressort).—The first report 
of snapping fingers dates back to Notta (1859). Schilling, in 1901, 
reports 34 cases in the literature, while Hiller, in 1908, found 161 cases. 
Of these, 41 concerned the thumb, 47 the middle finger, 12 the index 
finger, and 44 the ring finger. 
The anatomical causes underlying the condition of snapping finger 
might be divided into changes of the tendon, of the tendon sheath, 
and of the capsule and ligaments. 
Among the changes of the tendons are to be mentioned tendon 
duplications, tendon bulbs, fibroma of the tendon, tears of the flexor 
sublimis at the bifurcation, and tumors and hyperplasias of the tendon. 
Among the changes in the tendon sheath, there have been observed 
hypertrophic villi of the sheath, thickening of the tendons, fibrous 
strands and fibrous deposits, fibromas of the sheath, and foldings or 
duplications of the sheath. 
Capsular ligamentous changes were cartilage ridges, or joint ridges, 
and changes in the lateral ligaments. 
The principal symptom of the snapping finger is the snapping sign 
of the finger which occurs when the finger is flexed to a certain angle. 
At this point further flexion of the finger is carried out only with dis- 
tinct effort and with an appreciable jar or snap. At the moment of 
snapping, pain is felt in the palm of the hand. Often the help of the 
other hand is necessary to flex the finger over the critical point, but 
when this is once overcome flexion is concluded without great effort. 
In extension a similar difficulty arises again at the same point at 
which the flexion had been locked. In order to complete extension, a 
distinct effort is also necessary to overcome the apparent obstacle. 
Again the characteristic jerk appears, sometimes with an audible click, 
and extension is completed. 
If the obstacle is not great, motion is painless. Often, however, 
especially in the beginning, pain is considerable and is usually referred 
to the volar surface of the metacarpophalangeal joint. It is here where 
one often notices a sensitive tumor of the size of a millet or pea. 
Case Report.—Mrs. J. T. C. The patient complains for several months 
of pain in the palm of the right hand over the 3d metacarpophalangeal 
joint. There is difficulty in flexing this joint. At a certain angle, the 
fingers seem to be locked by an obstacle which can be overcome only 
with considerable effort. At this moment, a distinct snapping occurs, 
and it is repeated in extension movement as soon as this point is TRAUMATIC DEFORMITIES 
279 
reached. There is a spot in the palm over the joint which is tender to 
pressure, and here the snapping can be felt distinctly. 
The treatment of this condition consists in massage, manipulation 
and splinting in earlier cases. One of the cases observed was that of 
a baby a few months old in which the middle finger showed a distinct 
snapping over the midphalangeal joint when an angle of about 6o° 
flexion was reached. The phenomenon disappeared after a short 
period of splinting. In cases not yielding to massage and splinting, the 
operative procedure is indicated. This consists, essentially, of an in- 
cision opening of the tendon sheath, and the removal of the cause of 
constriction either in the tendon or tendon sheath or in the joint or 
capsule. Such operative procedures have been reported by Hilde- 
brandt, who removed the spindle-shape thickening of the tendons and 
cured his case. 
Poulsen compiled the following statistics in regard to the operative 
and necropsy findings of this deformity: 
Of 64 cases so examined, changes in the tendon itself were found 
in 26 cases. Changes in the tendon sheath with tendon normal were 
found in 13 cases. Changes of both tendon sheath and tendon were 
found in 16 cases. Joint changes were found in 6 cases and no changes 
were found in 3 cases. 
Writer’s Cramp—Case Report.—J. G., stenographer: complains of 
cramping of the muscles of the right hand after writing- for some time. 
This has been followed lately by weakness in the hand which is espe- 
cially noted in the grip between the thumb and index finger. Exami- 
nation showed distinct weakness in the adductor of the thumb and in 
the opponens muscle. The treatment consisted in rest, massage, and 
the use of appropriate penholders. 
According to Benedict, a spastic and a paralytic form of writer’s 
cramp may be distinguished. In the spastic form, clonic and tonic 
cramps appear most frequently in thumb and index finger, which, in 
the case of the thumb, causes it to be drawn forcibly against the palm 
in a position of flexion. 
The case described above is of the paralytic form which manifests 
itself in a sensation of fatigue of arm and hand, making it impossible 
to use the hand in writing. To this is added, by some authors, the 
tremor form of writer’s cramp characterized by tremor of the entire 
hand, which increases gradually and makes attempts at writing im- 
possible. All three forms are characterized by the fact that the trouble 
appears only when an attempt is made to write, or soon after the begin- 
ning of writing, and that there are no symptoms in the intervals of rest 
except a slight sensation of ache in the arm and forearm. 
Hoffa thinks that the prognosis is, in general, unfavorable and that 
even after several months of rest the trouble usually recurs. The treat- 
ment consists in massage of all the muscles of the extremity, beginning 
with the lumbricales and interossei and ending at the muscles of the 
shoulder girdle. When the writing is resumed, it is well to use spe- 280 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
dally constructed appliances which hold the pen. Of these, the appli- 
ances of Nussbaum, Buchheim, and Cazenave, are the best known. 
These contrive to eliminate the action between thumb and index finger 
altogether by the use of a bracelet encircling these fingers (Cazenave 
and Zabludowski), or they consist in a ring or ball for the palm of the 
hand, to which the pen is attached, the finger pressing against the ball. 
Neural atrophies of the hand have been described by Ramsey Hunt. 
The motor type of neural atrophy of the hand is characterized by an 
absence of sensory symptoms. Hunt distinguishes a hypothenar and 
a thenar type. The former is caused by compression neuritis of the 
deep palmar branch of the ulnar nerve. This branch supplies all of the 
hypothenar and palmar muscles as well as the dorsal interossei, also 
the third and fourth lumbricales and the adductor pollicis. Soon after 
its origin, the deep palmar branch passes between the tendinous origins 
of the abductor and flexor brevis of the fifth finger. Again, this nerve 
is compressed at the point where it winds its course beneath the hook 
of the unciform bone. This form of palsy develops without accom- 
panying pain, paresthesia or anesthesia in the ulnar nerve distribution. 
On holding out the affected hand, the fingers cannot be completely ex- 
tended (interossei), a slight flexion persisting in all fingers, but espe- 
cially in the fourth and fifth, where the lumbricales are also involved. 
The index and little fingers are held somewhat in abduction, while the 
third and fourth remain in close apposition. 
The second type is the thenar palsy, a compression neuritis of the 
thenar branch of the median nerve, entirely motor in character. This 
is also an occupation neuritis due to overstrain of those muscles which 
tend to the play of the thumb. It is easily recognized by the char- 
acteristic limitation of the atrophy to the abductor pollicis, flexor pollicis 
brevis (outer head), and opponens pollicis. The general usefulness of 
the hand is not greatly impaired except for finer movements, such as 
writing. It is to be considered whether or not some, if not all, of the 
cases of writer’s cramp are to be classed under the thenar type 
of atrophy of the hand. Hunt thinks that the prognosis is favorable 
if the causative factor, which is usually an occupational one, is discov- 
ered at an early stage and removed. The writer has observed i case 
of this type. 
Case Report.—J. S., 18 years, complained of weakness of the muscles 
of the hand for about half a year. The examination showed thenar palsy 
with no loss of sensation, but with distinct atrophy of the muscles of 
the thenar and weakness of the hand. According to the statement of 
the patient, the trouble was not progressing. No distinct occupational 
factor was found causing the palsy but directions were given to avoid 
strain. TRAUMATIC DEFORMITIES 
281 
BIBLIOGRAPHY 
Albee, F. H. Orthopedic and Reconstruction Surgery. W. H. Saunders, 1919, 
513- 
Allison and Brooks. Surg. Gyn. Obstet., December, 1913. 
Surg. Gyn. Obstet., November, 1914. 
Angelotti, E. Sulla spalla vara, La Chir. organi di movimento, 1919, 3:513. 
Ashhurst, A. P. C. Old fractures of the elbow, Ann. of Surg., 1912, 56:647. 
Arthroplasty of the elbow, Ann. of Surg., 1915, 62:302. 
Baer, W. S. Am. Journ. Orthop. Surg, 1909, 7:1. 
Baum, E. W. Uber die traumatischen Affectionen des Os Luilatum und Navicu- 
lare, Beitr. z. klin. Chir., 1913, 87:568. 
Bergeret. Sur un cas de cubitus varus traumatique, Bull, et mem. Soc. de 
Chir. de Paris, 1918, 44:993. 
Bertein, P. Les articulations a ressort, Rev. de Chir., 1914, 49:788. 
Beviers, L. Traitement des articulations ballantes par l’arthroplastie, Lyon 
chirurg., 1919, 16:325. 
Billet, H. Les voies d’acces anterieures a l’articulation du coude, Rev. de Chir., 
1914, 49:21. 
Bonnet, P. De la deviation en valgus de l’avantbras dans les paralysies as- 
sociees du median et cubital, Lyon chirurg., 1919, 16:631. 
Borchees, E. Ruptur der Sehne des langen Bicepskopfes, Beitr. z. klin. Chir., 
1914, 90:635. 
Burkiiardt, LI. Spontane Luxation und Subluxation im Handgelenk, Beitr. z. 
klin. Chir., 1913, 88:403. 
Burrell and Lovett. Am. Journ. Med. Sciences, August, 1897. 
Chlumsky. Wien. klin. Wchnschr., 1902. 
Clairmont, P. and Ehrlich, H. Eine neue Operation zur Behandlung der 
habituellen Schultergelenksluxation mittels Muskelplastik, Arch. f. klin. 
Chir., 1909, 89:798. 
Delorme. Die Hemmungsbander des Schultergelenkes und ihre Bedeutung 
fiir die Schulterluxation, Arch. f. klin. Chir., 1910, 92 79. 
Dozier, H. C. Preventable deformities of the upper extremity, Intern. Journ. 
Surg., October, 1909. 
Dreyzeiiner. Ein Fall von Zerreissung der zentralen Sehne des Musculus 
Biceps Brachii, Arch. f. klin. Chir., 1902, 62 :552. 
Eigenbrodt. Uber isolierte Luxationen der Karpalknochen, speziell des 
Mondbeines, Beitr. z. klin. Chir., 30:805. 
Ewald, P. Arthritis Deformans des Schultergelenkes, Ztschr. f. orthop. Chir., 
28:166. 
Fink, F. Blutige Reposition irreponibler Daumenluxationen, Arch. f. klin. 
Chir., 1910, 93 : 1041. 
Gross. Mechanismus der Luxatio ossis lunati nebst Bemerkungen iiber die 
Entstehung der Frakturen desselben Knochens, Arch. f. klin. Chir., 1903, 
vol. 70. 
Guibe. Rev. d’orthop., March 1920. 
Haglund, P. Zur Frage der Mobilisation der Gelenke, Ztschr. f. orthop. 
Chir., 1914-1915, vol. 35. 
Hahn. Zwei Falle von subkultaner Zerreissung des Musculus Biceps Brachii, 
Wien. klin. Wchnschr., 1904. 282 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Heusner, L. Uber einen Fall von habitueller Luxation des Oberarmkopfes nach 
Oben, Ztschr. f. orthop. Chir., 1898, 5:1. 
Hiller, A. Uber den schnellenden Finger, Ztschr. f. orthop. Chir., 1908, 20:48. 
Koenig, F. Die spaeteren Schicksale difform geheilter Knochenfrakturen, Arch. 
£. klin. Chir., 1908, 85:187. 
Ledderiiose, G. Zur Frage der Ruptur des Biceps Brachii, Deutsche Ztschr. 
f. Chir., 1909, 101:126. 
Leriche, M. R. Resultats anatomiques et fonctionels donnes par la resection 
de l’epaule en milieu aseftique pour traumatisme, Lyon chirurg., 1919, 
vol. 16. 
Lessing. Traumatische subkutane Ruptur einer Fingerbeugesehne, Beitr. z. klin. 
Chir., 1901, 30:202. 
Lilienfeld. Luxatio ossis lunati volaris, Arch. f. klin. Chir., 1905, 76:641. 
Loos. Uber subkutane Ruptur des Biceps, Beitr. z. klin. Chir., 1901, 29:410. 
Maydl, K. Subkutane Muskel und Sehnenzerreissung so wie Rissfraktur, 
Deutsche Ztschr. f. Chir., 1882, 17:306. 
McAusland, W. R. Ankylosis of the elbow with report of four cases treated 
with arthroplasty, Journ. Am. Med. Assoc., January 23, 1915. 
Murard, J. Double and symmetrical luxatio-erecta of the shoulder, Rev. 
d’orthop., September, 1920. 
Murphy, J. B. Journ. Am. Med. Assoc., May 20, 1905. 
Ann. of Surg., 1913, 57:634. 
Neff. Surg. Gyn. Obstet., November, 1912. 
Ollerenshaw. Journ. Orthop. Surg., May, 1920. 
Pam perl, R. Knopflochluxation der Streckaponeurose der Fingerstrecker, Beitr. 
z. klin. Chir., 1918, 111:762. 
Poulsen, K. Finger a ressort, Arch. f. klin. Chir., 1911, 94:657. 
Luxatio ossi lunati, Arch. f. klin. Chir., 1907, 83:801. 
Reich, A. Die schnellende Schulter, Beitr. z. klin. Chir., 1914, 90:631. 
Schilling, Tii. Uber den schnellenden Finger, Beitr. z. klin. Chir., 1901, 30: 547. 
Schlatter. Subkutane Sehnenzerreissung an den Fingers, Deutsche Ztschr. 
f. Chir., 1908, 91: 317. 
Schloffer. Ruptur und Luxation der Strecksehne eines Fingers, Arch. f. klin. 
Chir., 1909, 90: 543. 
Schwarz, F. A. Uber pathologischen Cubitus Valgus, Deutsche Ztschr. f. Chir., 
1909, 102: 178. 
Sencert, L. Resection du coude pour ankylose vicieuse; guerison avec fonction- 
nement integral de l’articulation, Bull, et mem. Soc. de Chir. de Paris, 
1918, 44: 1018. 
Sever, J. W. Recurrent dislocation of the shoulder joint, Journ. Am. Med. 
Assoc., April 2, 1921. 
Stern, K. Zum Entstehungsmechanismus der isolierten Luxation im unteren 
Radio-ulnargelenke, Beitr. z. klin. Chir., 1919, vol. 117. 
Stern, W. G. Drop phalangette, Am. Journ. Orthop. Surg., 1909-1910, 484. 
Taylor, R. T. Stereo-arthrolysis, Surg. Gyn. Obstet., 1912, 326. 
Thomas, T. T. A common mechanism for most injuries of the shoulder region, 
Journ. Am. Med. Assoc., September, 1914. 
Recurrent dislocation of the shoulder, Surg. Gyn. Obstet., April, 1921. 
Young, J. K. Recurrent dislocation of the shoulder, Ann. of Surg., 1916, 63 :375. 
Zur Verth. Spontane Zerr'eissung der Sehne des langen Daumenstreckers, 
Deutsche Ztschr. f. Chir., 1909, 102:569. CHAPTER XI 
PHYSIOTHERAPY OF THE UPPER EXTREMITY 
With the correction of deformities and the restoration of anatomical 
alignment, only part of the work of reconstruction is accomplished. As 
a living organ, the locomotor apparatus, once disturbed, requires more 
than anatomical repair to take up anew the function for which it was 
destined. And in the same measure as the repair of alignment and 
form are based upon anatomical facts, so must functional repair have 
its physiological and biological foundation. 
Out of this need for physiological methods of repair, physiotherapy 
has come into existence. It means the development and reeducation 
of impaired muscles, the increase of muscle tone, the stimulation of 
retarded muscle action, the toning down of irritative and hypertonic 
muscle action, the overcoming of muscular contractures. It further 
means the development of circulatory balance, the overcoming of con- 
tractures of all kinds of tissues, and many other problems. In the field 
of reconstructive surgery of the upper extremity, it has the widest pos- 
sible application, from which hardly any type of case is exempt. 
The principal object of physiotherapy is, then, to open up physio- 
logical channels of motions blocked temporarily by disability. This 
object it pursues by mechanical means, by massage and manipulations, 
as well as by active movements which utilize the progress made by 
mechanical means and further its development. This is the task for 
the mechanotherapeutic side of physiotherapy. 
Its further aim is the coordination of elementary movements, ad- 
vancing the primitive motions to more complicated ones and the 
latter to purposeful manipulations, and finally to crafts and handwork; 
Muscle education and occupational therapy. 
The analysis of the ordinary routine motions in life into their ele- 
mentary constituents (kinesiology), both physiological and anatomical, 
is based upon the development of a rational system of either mechano- 
therapy or muscle education of the upper extremity. 
KINESIOLOGY AND MECHANOTHERAPY 
Elementary motion must not be construed to mean the play of a 
single muscle or even a single muscle group, but a selection of primitive 
and simple movements which may serve as a starting point to develop 
the more complicated ones. We know that no motion is possible in 
283 284 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
any joint without the action of the antagonistic muscles which work 
in the opposite direction. For instance, in the elbow, flexion as a simple 
motion cannot be conceived of without the check of the extensors of 
the elbow, because this check alone is able to provide the timing of 
the motion and its uniform velocity, which is an essential part of any 
coordinated motion. In the same way, one could not conceive of the 
simple motion of abduction of the arm by the deltoid muscle without 
the action of other muscles which stabilize the humerus against the 
glenoid fossa. We have, in these instances, two apparently simple 
motions carried out by only one or two muscles actively, but in which, 
secondarily, a number of muscle groups are involved. An example of 
complicated motion is the rotatory motion of the shoulder joint in which 
a number of different muscle groups come into action in regular suc- 
cession. When the details of gymnastic technic are gone into, an at- 
tempt will be made to analyze these motions into their elementary parts, 
but it must be understood that even then the so-called elements are still 
things of considerable complexity. Upon the basis of the analysis of 
movements, then, the reconstruction of the normal motions will have 
to be undertaken. On the other hand, elementary analysis will also 
be of service for the development of sustitutionary motion, a type of 
motion not usually used in common life, but which is physiologically 
open to development and must be called upon to serve in the case of 
deficiencies of the muscles originally charged with the respective move- 
ments. It is erroneous to believe that such substitutionary motions 
should be left entirely to the instinctive faculties of the individual af- 
flicted. They can be developed systematically, and for this reason some 
space is given in this chapter to the technic of developing substitu- 
tionary motion. 
Shoulder—Scapular Muscle Exercises.—The starting point for the 
exercises in this direction is the so-called neck-firm position, the arms 
being held elevated to the horizontal, the elbows flexed, the hands 
resting against the back of the neck; from this position, rotatory motion 
of the shoulder may begin with the contracture of the trapezius muscle 
and the elevator anguli scapula. In this position, it is mainly the third 
and fourth part of the trapezius muscle which hold the shoulder back 
in correct position. The first and second lift the shoulder-blade and the 
lower part of this muscle anchors the scapula firmly against the spinal 
column. In the upright position, only the upper part of this muscle 
will be seen to contract, but when the body is bent forward, all four 
parts contract, lifting the shoulder, while the lower fibers of the muscle 
relax as the upright position is again assumed. In this position, the 
rhomboid muscles act as a check modifying the upward motion. When 
the shoulder-blade is brought forward in position of elevation, then 
the serratus magnus comes into play, together with the anterior fibers 
of the trapezius. Both these muscles tend to rotate the scapula, caus- 
ing the lower inferior angle to move outward. But in forward motion 
of the shoulder-blade, this action can be checked by the pull of the PHYSIOTHERAPY OF THE UPPER EXTREMITY 
285 
rhomboid muscles, which hold the vertical border of the scapula paral- 
lel to the line of the spinous processes. In downward movements of 
the shoulder-blade, the inward tendency of the scapula and the down- 
ward movement of its lower inferior angle can be checked by the pull of 
the serratus magnus and the trapezius. Also, in downward movements 
of the shoulder-blade, the depressors of the arm come into play, that is, 
the latissimus dorsi and pectoralis muscles. In forward bending of the 
scapula, the pectoralis minor is the principal agent. In muscular indi- 
viduals, the play of the different muscles of the scapula can be seen 
very distinctly on rotatary motion. 
Exercises of shoulder movements should be practiced systematically. 
They are of excellent value as preoperative and postoperative exercises 
in arthrodesis of the shoulder joint, and they are, of course, of great 
importance in developing other substitutionary motions for the arm. 
It is necessary to control the posture of the patients closely when ele- 
vatory and rotatory motions of the scapula are carried out. There is 
a tendency to incline the head toward the side of the elevated scapula 
when elevation of the arm exceeds 135° because of the pull which the 
trapezius exerts upon the head and the cervical spine. Equilibrium 
must be maintained strictly by preservation of the symmetrical posture 
and also by development of muscles antagonistic to the contracting 
muscles, in this case, the trapezius of the other side. 
Elevation Exercises of the Arm.—The patient stands in upright position 
and is made to elevate the arm slowly first in a frontal then in a 
forward diagonal, and, finally, in the backward diagonal plane. When 
these exercises are carried out against resistance, they will bring out 
the action of the respective muscles to good advantage. In the frontal 
plane, elevation of the arm is possible to 90°; in the forward diagonal 
planes, up to 120°; in the backward diagonal plane to 450, without 
rotating the scapula. The fibers of the anterior part of the deltoid 
having the most favorable angle of application also produce the highest 
amount of elevation. In both forward and sideward elevation, the 
motion is checked by the tendon of the supraspinatus muscle and by 
contact of the greater tuberosity of the arm with the acromion. In 
backward elevation, the tension of the coracohumeral ligament checks 
further elevation. As the arm is swung from forward position through 
the lateral plane backward, one can see the different portions of the 
deltoid muscles contract in succession. When resistance is placed upon 
active elevation of the arm, a wider strip of muscle fibers can be 
brought into action at one time. Such arrangement will also bring 
out the supplementary action of the supraspinatus muscle which assists 
in raising the arm outward. The action of this muscle is very important 
for the deltoid, as it causes the head of the humerus to be held firmly 
against the glenoid fossa, and so counteracts that component of the 
deltoid which lifts the humeral head upward out of the glenoid fossa. 
While the trapezius muscle is not actively engaged in elevating the 
arm in the frontal plane before the angle of 90° abduction is reached, 286 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
still it is already in action as a stabilizer of the shoulder, preventing the 
downward pull of the shoulder-blade by the weight of the arm when 
the deltoid is contracted; therefore, action of the trapezius really starts 
long before the level of 90° is reached. This is important in cases of 
arthrodesis of the shoulder; in these instances one has to depend upon 
the action of the trapezius from the very first, when side motion of 
the arm begins. For this reason, the preparatory treatment of cases 
to be operated upon is as important as the postoperative development 
of this muscle. 
Practical exercises to bring out motions of this type are the lifting 
of weights in the frontal plane, use of dumb-bells and chest weights. 
Forward Raising of the Arm.—When the arm is raised forward, the 
anterior fibers of the deltoid contract, assisted during the first part of 
the arc of motion by the upper half of the pectoralis major. It will 
be noted, when the arm is placed in forward position, that there is also 
a rotation of the shoulder-blade around the side of the chest so that 
the glenoid fosS'a will look forward instead of outward as it does when 
the arm is elevated in lateral positiou. The shoulder-blade always fol- 
lows closely the plane in which the arm is elevated. It is in the frontal 
plane in side elevation; it points diagonally outward and forward in 
forward elevation of the arm. The significance of this arrangement is 
apparent. The plane in which the shoulder-blade moves must always 
correspond to that of the arm in order to secure a free and unrestrained 
motion of the shoulder joint. In forward shifting of the shoulder-blade, 
the pectoralis minor is especially active. The forward swinging of the 
arm is therefore a good exercise for the pectoralis muscles, especially 
if held in abduction and against resistance in which case the pectoralis 
major also comes prominently into action. 
Adduction of the Arm.—Adduction of the arm is carried out by the 
latissimus dorsi, pectoralis major, and teres major muscles. In the 
arc from 450 adduction to complete adduction, the scapula does not 
rotate; but from the horizontal to 450 adduction the scapula does rotate, 
if adduction motion is carried out against resistance, that is, against 
the contracture of the abductors. The shoulder-blade now rotates in 
a direction opposite to that seen in abduction of the arm. Strong re- 
sistance against adduction brings out the power of the pectoralis major, 
latissimus dorsi and teres major, and also of the scapular muscles, 
that is, rhomboids and levator anguli. Useful exercises in abduction 
and adduction motion are chest weights and the use of the vertical 
ladder. In backward extension of the arm, the back pull of the arm is 
accomplished by the lower three-fourths of the trapezius, while the 
back pull of the humerus against the scapula is carried out mainly by 
the infraspinatus and teres minor. Such muscles are admirably devel- 
oped during the back stroke of rowing, by quarter circle exercises, 
Indian clubs, etc. 
Rotatory Motion.—It now remains to consider the rotatory motions of 
the arms together with those of the scapula. Inward rotation of the PHYSIOTHERAPY OF THE UPPER EXTREMITY 
287 
arm is accomplished by the subscapularis, teres major, latissimus dorsi, 
and pectoralis muscles. Inward rotation in any positioi of abducton 
will require a check upon the adductory tendencies of the latissimiqs 
dorsi and pectoralis major so that, in these positions, the action of del- 
toid and supraspinatus must be called upon. When developing sub- 
stitutionary motion for lost pronation and supination, these rotatory 
motions in shoulder joint are of the greatest value. They can be taught 
and one can attain a great amount of skill and proficiency in inward 
and outward rotation of the whole extremity in the shoulder joint. A 
good method of exercising these motions are exercises forcing extreme 
rotation of forearm together with fixation of the shoulder-blade. If 
pronation and supination are checked, these rotatory motions of the 
shoulder joint will soon appear. The mechanical situation is then this: 
the humerus is held well balanced in a certain position of abduction 
by combined action of deltoid, pectoralis, and latissimus dorsi. Then 
the inward rotation is developed by exercises of the latissimus dorsi, 
pectoralis, teres major, and subscapularis; and the outward rotation by 
action of the infraspinatus and teres minor. 
Massage and Passive Motion.—In massage of the shoulder, the patient 
is either in recumbent or in sitting position; if in the latter, the elbow 
is supported by the assistant and the massage of the deltoid is carried 
out with the arm in abduction to relax this muscle. 
Passive abduction and outward rotation are especially indicated in 
extra-articular conditions leading to adduction and inward rotation 
contractures such as subdeltoid bursitis, birth-palsy, and contractures 
following prolonged fixation. 
For afflictions of the joint and periarticular adhesions, friction and 
vibration are indicated. The shoulder joint can be reached easily by 
the finger in the pit of the axilla, especially if the arm is held in abduc- 
tion. In the line of exercise treatment, timed motion with Indian clubs 
and wands are especially useful to carry out all circumductory motions. 
These may be supported by exercises with chest weights, especially 
those combined with a quarter circle in which the spine is given a posi- 
tion of hyperextension and in which especially the backward reach of 
the arms may be worked out. 
Elbow—The Triceps Muscle.—The primary function of the triceps is 
the extension of the elbow joint, in which this muscle acts as a lever 
of the first order. It develops speed as well as power, both by virtue 
of the rather long leverage afforded to this muscle by the projection 
of the olecranon process and by virtue of the great number of short 
fibers which combine in the formation of power of this muscle. There 
are numerous practical ways in which this muscle may be devel- 
oped (resistance exercises, parallel bars, trapeze exercises, ladder, 
etc.). 
In the developing of this muscle, attention should be paid also to 
its function as a stabilizer of the shoulder joint. This stabilization is 
carried out by the long head of the triceps, which holds the humerus 288 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
against the glenoid fossa, and this is, in fact, the main function of this 
part of the muscle, according to Duchenne. In all cases of paralysis 
of the abductors, the stabilization of the head of the humerus becomes 
of great importance because it is the only factor which counteracts the 
pull of gravity tending to distract the head from its bed in the glenoid 
fossa. In the absence of the abductors of the shoulder, the triceps, 
supported by the biceps and coracobrachialis, protects the joint from 
a position of downward subluxation or dislocation. All forcible motion, 
carried out either in the shoulder, elbow, or wrist joints, calls for firm 
stabilization in the scapulohumeral joint. For this reason, the triceps 
plays an active part in almost all of the forcible motions of the upper 
extremity, such as throwing, lifting, grasping, and other motions of the 
forearms and hand as well. 
Biceps.—The biceps can be developed in a similar way by simple exer- 
cises on the horizontal and parallel bars and by gymnastic exercises 
with dumb-bells, Indian clubs, and wands. Development of the biceps 
also aids in stabilization of the shoulder joint. 
If one wishes to develop the supinatory power of the biceps, the 
elbow should be in a position of semiflexion of about 1200 to 135°. 
At a more acute angle, the muscle is too much relaxed to fully display 
its supinatory power. In an extended position, on the other hand, 
while the tension of the muscle is considerable, its angle of application 
becomes comparatively small and this mechanical disadvantage dimin- 
ishes its supinatory power. It has been mentioned that in this position 
the supinator brevis has to come to the aid of the biceps in the act 
of supination. It is easy to find movements in practical life which will 
serve the purpose of developing these muscles, and it is unnecessary 
to dwell upon a long list of suggestions 
Pronation of the Elbow.—The position of choice in starting develop- 
ment of pronation is slight flexion of the elbow and hyperextension of 
the wrist. In this position of the elbow, the round pronator works at 
a favorable angle and in its action is readily supported by the pronator 
quadratus. The hyperextension of the wrist gives opportunity to the 
secondary pronators to come to action, especially the flexor carpi 
radialis. Pronation and supination movements should be carried out 
alternately in flexion and extension because of the fact that different 
muscle action becomes prevalent in one or the other of these positions. 
Active pronatory and supinatory exercises can be carried out with ad- 
vantage by dumb-bells and wands. They should be carried out both 
with and without resistance. 
Massage.—The elbow joint is easily accessible to direct massage, espe- 
cially in its lateral and posterior aspects. The elbow is held in flexion 
with the forearm resting upon the table and the patient in sitting posi- 
tion. Friction and vibratory movements can be readily applied to 
either the lateral or posterior aspects of the joint or in front, at the 
inner or outer bicipital groove. 
Passive motion is of special importance in periarticular adhesions PHYSIOTHERAPY OF THE UPPER EXTREMITY 
289 
in front of the elbow joint, such as is seen after prolonged fixation, 
or following fractures, or in Volkmann’s contractures, or in contrac- 
tures of congenital nature. Club swinging, hanging, and carrying 
weights is a valuable support for the mechanical treatment. 
The Elementary Motions of the Hand.—The gripping power of the 
hand should be developed in hyperextension of the wrist. The use of 
a tool requiring a grip of some force, such as a screw driver, repre- 
sents an easy and practical application. In the development of circum- 
ductory motions of the hand, Indian clubs or moderately weighted iron 
dumb-bells are useful, care being taken that the forearm be properly 
immobilized. The writer is using to advantage a so-called wrist roll; 
a roll of varying diameter which in turning lifts a weight, and in the 
turning of which, according to the diameter chosen, more or less grip- 
ping power is required (Plate XLVII, 8). 
Massage.—Massage of the forearm muscles is carried out best with the 
patient in sitting position and the arm resting upon a board. The dif- 
ferent muscle groups of the forearm, as well as those of the thenar and 
hypothenar eminence, are taken up separately in the application of 
effleurage and petrissage. Friction, massage, and vibration are excel- 
lent means for mobilization of the wrist and finger joints. 
In carrying out passive stretching of the wrist joint, the hand of 
the operator grips that of the patient from below, gently forcing the 
palm in a dorsal direction. In this position, circumductory motion can 
be carried out also. 
In the treatment of flexion deformity of the fingers by passive 
motion, not only each finger but each finger joint must be taken up 
separately. When the result of this treatment is to be maintained by 
splinting, the splint should also have individual finger parts pliable 
enough to give each joint the proper position. 
Technic of the Medicomechanical Development of Substitutionary 
Motion, Following Operations—Arthrodesis of the Shoulder.—In cases 
of arthrodesis of the shoulder, the postoperative development of the 
trapezius muscle becomes an important factor. It can be carried out 
by active exercises, with or without resistance, elevating the arm and 
shoulder by contraction of trapezius muscle. The first attempts at 
motion should be carried out in the recumbent position, so that no 
gravital strain may interfere with the action of the muscle. When this 
is accomplished to a degree where the muscle is able to hold the entire 
extremity in abduction without too great an effort, exercises in upright 
position are added. It must be kept in mind that the forcible contrac- 
tion of the trapezius muscle is very prone to produce inclination of 
the head to its side. Postural exercises must then be provided for, 
which will secure a symmetrical position of the head. This is best 
done by developing the action of the trapezius and other shoulder 
muscles of the other side. 
Development of Pronators of the Forearm and Flexors of the Wrist 
into Flexors of the Elbozv.—Necessity for this arises in cases where a LEGEND FOR PLATE XLVII 
PHYSIOTHERAPY 
Fig. i.—Mobilization of Elbow. 
Fig. 2.—Mobilization and Massage of Shoulder. 
Fig. 3.—Abduction Exercises of Shoulder. 
Fig. 4.—Massage of Hand. 
Fig. 5.—Dumb-bell Exercises for Shoulder. 
Fig. 6.—Extension Exercises for Shoulder. 
Fig. 7.—Pronation and Supination Exercises. 
Fig. 8.—Exercises for Forearm and Finger Flexors (Wrist Roll). PLATE XLVII 292 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
muscle transposition has been carried out on the forearm flexors. In 
this operation, the flexors of the wrist are assuming the role of the 
lost biceps and brachialis anticus, for which they are better fitted after 
their point of origin has been transposed to a higher level at the hu- 
merus. It requires a great deal of careful after treatment to develop 
this substitutionary motion to a point where it becomes of real practical 
value. The first condition is that all attempts of flexion of the elbow 
must be carried out in the horizontal position, so that the antagonistic 
force of gravity is eliminated. The starting point is one of flexion in 
the elbow at less than right angle, so as to avoid overextension of the 
flexor muscles. The wrist is held in slight hyperextension to give the 
proper amount of tension and the exercises are given carefully in sev- 
eral daily sittings, each one covering only a very short period of time. 
During all the exercises, one must be on constant guard against undue 
stretching of the muscles by unsuitable positions of the elbow, and 
against exhaustion of these muscles by unduly prolonged sittings of 
muscular exercises. 
Development of Substitutionary Pronation and Supination.—Situations 
may arise in which active or passive pronation and supination is im- 
possible, either by reason of contractures or synostoses of the forearm 
bone, or by reason of paralytic conditions. Rotation can be developed 
in these cases in the shoulder joint and it will, to a large measure, take 
the place of pronation and supination movement. The muscle mechan- 
ics underlying this method have already been explained at length. By 
means of supination exercises, such as used in the development of the 
physiological supination, this substitutionary supination will be devel- 
oped also. Wand exercises, dumb-bells, and the use of certain tools, 
screw drivers, turning of door knobs, etc., are simple and effective 
means for this purpose (Plate XLVII). 
Records.—The keeping of records in the course of medicomechan- 
ical treatment is an essential factor in judging the results obtained. 
Graphic records should be made and carefully kept. They should show 
not only the deformity of the joint prevailing at the time the treatment 
is begun, but must also demonstrate graphically, from measurements 
taken at regular intervals, the improvement obtained by treatment. 
Considerable thought and attention has been given to the standardiza- 
tion of joint records and it was found to be a rather difficult matter, if 
both accuracy and simplicity of records are to be combined. In a 
hinged joint, the matter is rather simple because the results can be 
charted readily upon a planimetrical record based upon the two-coor- 
dinate system. But in the tridimensional motions of the shoulder or of 
the wrist, the matter becomes considerably complicated. An elaborate 
apparatus is the so-called joint perimeter, devised by Huebscher; an- 
other is the globe net perimeter of Ouervain and Ludloff. Other peri- 
meters are the globe magnet perimeter, and the so-called swimmer 
globe perimeter, consisting of a globe filled with oil and carrying a 
swimmer on top. The latter again is supplied with a compass needle PHYSIOTHERAPY OF THE UPPER EXTREMITY 
293 
so that declinations can be read in all three dimensions. In the so-called 
joint perigraph, a double hollow sphere is used, the inner one rotating 
freely in the outer, with a pencil fastened to the inner globe graphing 
the movement upon the paper which lines the hollow outer globe. One 
may also mention the projection joint perigraph, in which a mercury 
drop moves freely in a hollow globe studded with the ends of fine 
copper wire arranged in parallels and meridians at even distances. 
These copper wires transmit electric impulses as the current is closed 
over the wire ends by contact with the mercury drop. In the ordinary 
course of mechanotherapeutic treatment, such complicated apparatus 
are hardly necessary and one will be well able to get along with simple 
devices. Nutter records finger deformities by the tracing method, and 
simple graphic finger curves obtained by tracing are also used by Gott- 
lieb. Such an arrangement is entirely sufficient for ordinary use and 
it is only necessary to agree upon certain starting positions from which 
the angulation of a joint is measured. For instance, in the elbow, i8o° 
should mean full extension; in the shoulder i8o°, full abduction to the 
perpendicular. In pronation and supination, the starting or neutral 
position is the so-called thumb-up position, from which the degrees 
of pronation and supination are measured in either direction. The 
writer has used the simple graphic curves based upon the Cartesian 
coordinate system for the measurement of movements of the fingers 
and elbow joints. In the elbow joint for instance, the ordinata means 
the degrees of flexion and extension obtained, the base line being that 
of right angular flexion. Above, it is flexion up to full flexion and, 
below, extension up to full extension. The abscissa means the element 
of time in which the change in range of motion is obtained in units 
of days, weeks, months, etc. In the wrist and shoulder joint, the 
amphiarthrotic motions can be analyzed in two planes. For instance, 
in the shoulder: abduction and adduction, flexion and extension. Ab- 
duction and adduction is marked on the ordinata, and flexion and exten- 
sion on the abscissa. In this way, the range of motion is signified by 
a quadrangular figure similar to the periscopic measurement of the field 
of vision. In this instance, in and outward rotation has to be recorded 
separately. In the wrist joint, the two-coordinate system serves for 
the recording of flexion and extension in the ordinata, and abduction 
and adduction in the abscissa, of the system. 
MUSCLE EDUCATION AND OCCUPATIONAL THERAPY1 
Muscle Education.—This is based upon the analysis of everyday 
motion into its physiological elements, thereby arriving at elementary 
motions which are simple and yet serve an intelligent purpose. It links 
up closely with the medicomechanical treatment in that it takes over 
1With the cooperation of Miss M. Prosser, in charge of the work of muscle education 
and occupational Therapy. 294 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
the elementary motion developed by physiological methods and makes 
it subservient to the will and purpose of the patient. It is connected 
on the other side with occupational therapy by furnishing, as it were, 
the building stones upon which the edifice of the more complicated 
motions, underlying crafts, and accomplishments, is erected. 
Occupational Therapy.—This is based upon the principle that the best 
type of remedial exercises is that which calls into play a series of speci- 
fied voluntary movements involved in the ordinary trades and occupa- 
tions in life (Baldwin). 
Muscle education is based upon the principle that in order to attain 
the degree whereby such specified voluntary motions will be obtained, 
an intermediate stage must be passed through, in which the elementary 
motions developed by mechanotherapy are made subservient, not only 
to will and purpose, but* especially, also, to coordination and to the 
element of time. The fundamental reason for the necessity of muscle 
education as an intermediate step between mechanotherapy and occu- 
pational therapy in the ordinary sense is, then, the fact that it serves 
as a link bridging physiological motion and handcraft. The funda- 
mental reason why attempts at developing occupational therapy often 
fail in given cases is because the complicated motion involved will be 
beyond the patient’s ability to time and to coordinate them, unless their 
elementary constituents have first been developed in subserviency to 
coordination and time. 
In the development of muscle education, the writer has been careful 
to base the whole system upon four fundamental conditions: 
1. A clear recognition of what the elementary motions are in the dif- 
ferent joints of the extremity (standardization of motions). 
2. A uniformity of the working tools and instruments; and of the 
choice of practical objects to be used in developing such elementary 
motions (standardization of work). 
3. A system of developing elementary motion based upon the close 
relationship of the elementary act of motion to the unit of time. In 
other words, the methods and progress are judged as a product of 
both time and motion (coordination of movement and time). 
4. An accurate system of records by which progress can be measured 
with a degree of accuracy and reliability compatible with an easy ap- 
plication (standardization of records, based upon principles 1-3). 
Technic of Muscle Educational Treatment—Shoulder.—Elevation 
exercises of the shoulder on the blackboard. 
a. Push and pull exercise (up and down strokes). 
b. Continuous oval exercise (progressive circling). 
c. Compact oval exercise (shading of ovals by up and down stroke; 
combinations a and b). 
These exercises are timed, the elementary movements being done 
either upon count or at certain rate per minute. The exercises combine PHYSIOTHERAPY OF THE UPPER EXTREMITY 
295 
both the elevation of the shoulder and flexion and extension move- 
ment of the .elbow. 
Exercises for the Hand—Cube and Peg Drill.—The Cube and Peg Drill 
consists in the gripping of cubes of special size and placing them one 
upon top of the other at a certain rate per minute. These exercises 
involve the following elementary motions: the closing of the fingers, 
the release of the fingers, opposition of the thumb, slight pronation 
and supination motion. 
To a lesser degree: flexion and extension in the elbow, elevation 
of the shoulder. 
The following material is used for the exercises: 2 inch cubes; 1 
inch cubes; y2 inch cubes; *4 inch pegs and Y& inch pegs. The latter 
are inserted into peg holes arranged in the manner of a cribbage board 
(Plate XLVIII, 1-4). 
Records.—In order to keep accurate records, it is necessary first 
of all to have a standard by which the functional ability of the hand 
or arm can be measured. One may have the choice of developing 
either an absolute or a relative standard upon which to base the 
records. An absolute standard for a given occupation, such as the set- 
ting of cubes or pegs, could be obtained, only by ascertaining the 
normal values for similar occupations, from examinations of a large 
number of patients of the same age. But it is a matter of great difficulty 
to arrive at an absolute standard, not only because of the long series 
of tests on different groups of normal individuals, but also because 
there are other variables entering into the calculations, which make the 
results of tests rather inaccurate. One of these sources of error may 
be the mental attitude of the patient at the time the test is given; an- 
other, his natural dexterity; his state of concentration, etc. Therefore, 
when confronted with this task, we found it nearly impossible to estab- 
lish absolute standards of accuracy which would be of binding value in 
comparing therapeutic results. 
The relative standard means the comparison of the afflicted extrem- 
ity with the normal. It may not be as accurate or scientific as the ab- 
solute standard, but it excludes largely the sources of error, caused by 
variation of concentration and mental attitude, for instance, or by dif- 
ferences in individual dexterity, etc. For the ordinary routine work, it 
has proved adequate and the tables given are all based upon this 
method of comparison. 
The second point of importance is the advisability of reducing the 
curves obtained to a percentage basis. By this is meant that, the work- 
ing capacity of the normal extremity being 100, the work of the afflicted 
extremity is compared in terms of percentage and is so expressed by a 
graph. The following examples of graphic records on patients made 
will give a conception of the manner in which the system of percentage 
records has been carried out. The total of patients with disabilities 
of the upper extremity, treated in the last two years by muscle edu- 
cational methods, were 97, distributed as follows: LEGEND FOR PLATE XLVIII 
MUSCLE EDUCATION 
Fig. i.—Equipment for Cube and Peg Drill (2", 1", Cubes, and §" Pegs). 
Fig. 2.—Exercises with 2-inch Cubes. 
Fig. 3.—Peg Exercises. 
Fig. 4.—Arm-raising Exercises: Push and Pull, Ascending Oval, Horizontal Oval, 
Compact Oval. 
Fig. 5.—Jig Saw and File. 
Fig. 6.—Drill, Awl, Plane and File. 
Fig. 7.—Weaving, Basketry and Caning. 
Fig. 8.—Class in Occupational Therapy. PLATE XLVIII 298 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
Cases 
Infantile paralysis , . .. 36 
Spastic paralysis 27 
Fracture deformities 5 
Arthritis of the upper extremity 6 
Birth-palsies 4 
Congenital fractures and deformities 6 
Volkmann’s contractures 2 
Inflammatory and cicatricial contractures 6 
Traumatic paralysis 5 
Total 97 
Case Reports.—T. G., infantile paralysis. Flail shoulder. Operative 
treatment: arthrodesis of the shoulder. The curves express the per- 
centage of arm reach in elevation of the arm with the elbow extended 
and the progress of this reach after different numbers of trials. As 
a rule, not more than 1 or 2 trials are made a day, because the patient 
easily becomes tired and exhausted and loses interest in the work. The 
graphic curve in this case shows that the range had increased from 
41.6 per cent to 72.3 per cent, or from 1234 inches of elevation to 21 
inches in ordinary push and pull exercises. 
In the rhythmic drill of the compact oval, this progress was from 
44 to 69 per cent or from to 2034 inches of eleveation; and, in 
the ascending oval, the progress was from 22 to 68 per cent. In full 
extension exercises on the wall, the percentage increased from 21 per 
cent to 78 per cent. The starting point of the shoulder exercises is 
given by the condition of the patient after the cast had been removed 
following arthrodesis, and after a sufficient time of medicomechanical 
treatment had been allowed for free elevation of the arm up to about 
the horizontal. The full reach of the upper extremity in vertical abduc- 
tion is taken as the base line or 100 per cent (Plate XLIX, 1-4). 
H. S., paralysis of the fingers and thumb following severe burn 
injury from live wire destroying the tendons at the wrist. Percentage 
record: Cube and Peg Drill. With the 2-inch cubes, the normal left 
hand reached frequency of 120 to 160 per minute; the defective right 
hand 72 to 132 per minute, the percentage progressing then from 60 
per cent to 94 per cent. With the i-inch cubes, the percentage of the 
defective hand progressed from 61 per cent to 93 per cent. With the 
Yz-inch cubes, the percentage progressed from 58 to 92 per cent. In 
using the cubes, no work could be done until the 4th trial, 
from which time on, the efficiency improved from o to 40 per cent. 
With the 34-inch peg, no work was possible until the 14th trial. From 
this time on, the efficiency improved from o to 43 per cent (Plate XLIX, 
5, 6; L, 1, 2, 3). 
O. K., 15 years. Volkmann’s contracture. Preceding operative 
treatment: plastic lengthening of the tendons. PHYSIOTHERAPY OF THE UPPER EXTREMITY 
299 
Percentage curve: i inch cubes: range of percentage increased from 
78.6 to 98.8 per cent; with the ]/\ inch pegs from 28 to 50 per cent 
(Plate L, 4, 5). 
F. N., 35 years. Live wire burn of both wrists. Preceding opera- 
tion: tenoplasty and flexor plasties of the thumbs. The progress of the 
work done by the thumb and index finger with 2 inch cubes, 1 inch 
cubes, and *4 inch cubes, is seen in the accompanying chart. The abso- 
lute efficiency reaching 105 to no movements in the 2 inch, 105 in the 
1 inch, and 75 in the *4 inch cube. In the use of the thumb and middle 
finger, the accompanying curve shows that the dexterity of this move- 
ment increased from 7 movements at the first trial to 80 at the last 
(Plate L, 6, 7). 
A study of these charts will reveal several factors which otherwise 
would not be so distinctly apparent. In the first place, one may learn 
exactly where function is bound by physiological limits. It may be, 
for instance, that in a case no difficulty of handling objects is seen in 
the percentage curve and that the lines go steadily up in the graphs. 
Then an object is reached, *4 inch peg for instance, where no amount 
of drill will produce progress and the percentage curve remains per- 
sistently low. At this point, then, we have an insurmountable obstacle, 
from the muscle educational point at least, and it may or may not be 
possible to overcome it by operation. In many cases this leads to dis- 
tinct operative indications. For instance, the approximation of thumb 
and index finger, or of thumb and middle finger, may prove sufficient 
up to a certain point, whereas no amount of further exercise and prac- 
tice will bring about material improvement. It is then necessary to 
consider whether the obstacle can be removed by operative procedure. 
In a number of instances, it could. For example, in cases of deficient 
opposition of the thumb, an additional thumb plasty subsequently raises 
the efficiency, so that all simple objects can be handled with compara- 
tive ease. In this fashion, many operative indications grew out of the 
progress of the muscle educational treatment and continuous contact 
between the surgeon and the teacher was necessary in order to ap- 
praise the possibilities of reconstruction. In the cases in which the 
smaller objects, such as *4 and % inch pegs, were handled with fair 
percentage (50 per cent or over), the patient was usually deemed cap- 
able of entering into occupational instruction, since 50 per cent efficiency 
in y2 inch cubes enables the patient to run scroll saw, drill, and larger 
tools in general. 
The timed exercises, we believe, have proved of greatest value in 
this work. They stimulate the patient in his effort and are an incentive 
to him to beat his own records with each subsequent trial. They are 
a great factor in forcing an issue with the will and coordination power 
of the patient. As far as possible, the patients are encouraged to keep 
their own records. 
In establishing this system of muscle education, stress was laid espe- 
cially upon the simplicity of the objects to be used for the training. The LEGEND FOR PLATE XLIX 
i. Arm-raising Rhythmic Drill. 
Percentage of Defective Right Arm. 
2. Arm-raising Rhythmic Drill. 
PUSH-AND-PULL EXERCISE. 
Range of Defective Right Arm. 
3. Arm-raising Rhythmic Drill. 
Ascending Oval. 
Range of Defective Right Arm. 
4. Arm-raising Rhythmic Drill. 
Compact Oval. 
Range of Defective Arm. 
5. Cube and Peg Drill (Two Inch Cubes). 
Percentage Improvement of Defective Right Hand. 
6. Cube and Peg Drill (One Inch Cubes). 
Percentage Improvement of Defective Right Hand. PLATE XLIX LEGEND FOR PLATE L 
1. Cube and Peg Drill (Half Inch Cubes). 
Percentage Improvement of Defective Right Hand. 
2. Cube and Peg Drill (Quarter Inch Pegs). 
Percentage Improvement of Defective Right Hand. 
3. Cube and Peg Drill (Eighth Inch Pegs). 
Percentage Improvement of Defective Right Hand. 
4. Cube and Peg Drill (One Inch Cubes). 
Percentage Improvement of Defective Right Hand. 
5. Cube and Peg Drill (Quarter Inch Pegs). 
Percentage Improvement of Defective Right Hand. 
6. Cube and Peg Drill. 
Defective Right Thumb, Index and Middle Fingers. 
Improvement in Frequency per Minute. 
7. Cube and Peg Drill (Two Inch, One Inch and Half Inch Cubes) 
Defective Right Thumb, Index and Middle Fingers. 
Improvement in Frequency per Minute. PLATE L 304 
RECONSTRUCTIVE SURGERY OF THE UPPER EXTREMITY 
cube and pegs are obtainable everywhere and they do not entail any 
great expense. No expensive apparatus is used. Older patients soon 
learn the technic of this simple drill and attain a certain proficiency in 
making records; they also require less supervision as time goes on. 
How far this type of muscle educational drill will go toward perfecting 
the efficiency of the hand, the writer is not able to say, but there seems 
to be no doubt of the fact that his sysem of elementary muscle drill 
by means of timed exercises with standardized and simple objects fills 
in a breach between the physiotherapy and the occupational therapy 
proper, and will enable many a patient to enter the field of vocational 
training. 
Occupational Therapy.—Occupational exercises, in the stricter 
sense, are started when the patient attains a certain degree of profi- 
ciency in the timed muscle educational drill. 
In general, one may estimate that a 50 per cent efficiency in y2 inch 
cubes qualifies the hand for the handling of larger tools, such as drill 
handle, screw driver, saw or plane; the same efficiency in inch cubes 
or y inch pegs qualifies it for caning, reedwork, etc. 
Molding in clay is used as the first step, as it is an excellent means 
to develop the strength of fingers and thumb. 
Crafts Presented and Material Used 
Modeling.—Plasticine, wax, papier-mache, plasterwork, cement work, 
pottery. 
Weaving.—Hand and cardboard loom weaving, beadwork, simple rug 
and mort weaving. 
Basketry.—Pine needle, raffia, reedwork, chair caning. 
Woodwork.—Simple bench work and toy making; use and care of tools; 
scroll saw. 
Wood Carving.—Whittling, chip carving, use of knives, chisels, gauges. 
Bookbinding.—Cardboard and paper construction. 
Metal Work.—Copper, brass, tin. 
Leather Work.—Flat modeling, embossing, lacing, cutwork, stenciling 
and dyeing of leather. 
Sewing and Textiles.—Simple stitching, embroidery, cross-stitching, 
applique work, crochet knitting, cord knitting, rake and spool knitting; 
braided and hooked rug making. 
Design and Color.—Principles introduced and applied to subjects taught. 
In most cases, muscle educational drill and occupational instruction 
run parallel; the patient, as he masters the various steps of the drill, 
takes up more and more of the occupational work also, in the measure 
in which his physical ability improves. 
This breaks the monotony of drill work and gives the patients new 
incentive and interest. One period of drill and one (longer) period of 
occupational work is given daily. PHYSIOTHERAPY OL THE UPPER EXTREMITY 
305 
The occupational work is carried out mainly in groups, under the 
supervision of the teachers; in many cases, however, individual and bed- 
side work must be given. Not only for the sake of physical improve- 
ment, but also in the interest of the mental attitude of the patient, bed- 
side instruction is carried out as early and as extensively as conditions 
will permit. 
BIBLIOGRAPHY 
Baldwin, B. T. The function of psychology in the rehabilitation of disabled 
soldiers, Walter Reed Monograph, Psychological Bull., August, 1919. 
Bowen and McKenzie. Applied anatomy and kinesiology. Lea and Febiger, 
1919. 
Brandeis, A. Uber die Ursachen der Muskelermudung, Ztschr. f. orthop. 
Chir., 1894, 3:366. 
Bucholz, H. On the exercise treatment of paralysis, Am. Journ. Orthop. Surg., 
May, 1912. 
A manual of therapeutic exercises and massage. Lea and Febiger, 1917. 
Dann, W. Gymnastic treatment for joint and muscle disabilities. Oxford, 
1918. 
Freiberg, A. H. The bristow coil and the treatment by graduated muscle 
contraction, Journ. Orthop. Surg., 1919, 148. 
Frey, v. M. and Mayer, O. B. Versuche iiber die Wahrnehmung gefiihrter 
Bewegungen, Ztschr. f. Biol., 1917-1918, vol. 68. 
Frey, v. M. Uber Bewegungswahrnehmungen und Bewegungen in resezierten 
und anaesthetischen Gelenken, Ztschr. f. Biol., 1917-1918, vol. 68. 
Georrig, M. A. Uber den Einfluss der Zeitdauer auf die Grossenschatzung 
von Armbewegungen, Arch, f. d. ges. Physiol., 1916, vol. 36. 
Gottlieb, A. Graphic presentation of finger deformities, Surg. Gyn. Obstet., 
1919, 29:420. 
Lovett, R. W. Treatment of infantile paralysis. Blakiston’s Sons and Co., 
Philadelphia, 1916. 
Mackenzie, W. C. The action of muscles including muscle rest and muscle 
reeducation. Hoeber, New York, 1918. 
Nutter, J. A. The standardization of joint records, Journ. Orthop. Surg., 1919, 
1 =423. INDEX 
Aberle’s technic in ischemic contracture, 130 
Acrosyndactylia, 229 
Albee’s technic of thumb plasty, 122 
Amniotic furrows, 246 
Amniotic theory of congenital deformities, 
210 
Ankylosis, traumatic—of elbow, 237 
Aphalangism, 228 
Archipterygial theory of Gegenbaur, 210 
Arthritic deformities, 200 
— chronic, 200 
— classification, 200 
— 204 
— hands and fingers, 205 
— shoulder, 202 
Arthrodesis of shoulder, 44 
Arthrodesis of wrist, 77 
Arthroplasty of elbow, 263 
— Albee’s method, 263 
— Ashhurst’s method, 265 
— elbow, 263 
— McAusland’s method, 265 
Bartow’s and Plummer’s silk ligament fixa- 
tion, 43 
Biceps, rupture of, 271 
Biesalski and Mayer’s thumb check opera- 
tion, 105 
Brachial plexus paralysis, 93 
Birth-palsy, 12 
— clinical pathology of, 14 
— complications of, 16 
— congenital dislocation of shoulder, 16 
— dislocation of shoulder in, 15 
— forearm (Klumpke’s) type, 15 
— joint theory of, 13 
— neurogenetic theory of, 12 
— operation for dislocation, 18 
— plexus operation in, 18 
— prognosis of, 17 
— Sever’s operation in, 18 
— treatment of, 17 
Brickner’s operation for subdeltoid bursitis, 6 
Brickner’s treatment of subdeltoid bursitis, 6 
Burrell and Lovett’s operation for habitual 
shoulder dislocation, 274 
Cinematization, 125 
Clairmont and Ehrlich’s operation for habit- 
ual shoulder dislocation, 274 
Claw-hand, inflammatory, 107 
Codman’s sign in subacromial bursitis, 3 , 
Colles’ fracture, 254 
Club-hand, 214 
— Albee’s operation, 224 
— Bardenheuer’s operation, 224 
— congenital, 2x4 
— McCurdy’s operation, 224 
— operative treatment, 224 
Congenital contractures, 246 
Congenital elevation of scapula, 22, 23 
— bony articulations in, 23, 28 
— clinical symptoms of, 28 
— muscle anomalies in, 23, 28 
— operations for, 32 
— reports of cases of, 32 
— skeletal anomalies in, 23, 28, 29 
— treatment of, 32 
Congenital embryology, 213 
— malformations and deformities, 210 
— Pot el’s classification, 211 
Congenital synostosis of, elbow, 241 
— forearm bones, 240 
Contractures, 103 
— chronic inflammatory, 103 
conservative treatment, 105 
operative treatment, 107 
— claw-hand, osteotomy in, 108 
— wrist and fingers, 103 
Cubitus valgus, traumatic, 256 
Cubitus varus, traumatic, 256 
Dawburn’s sign in subacromial bursitis, 3 
Deformities, chronic arthritic, 200 
— congenital, 210 
— Madelung’s, -145 
— Sprengel’s, 22 
Delitala’s technic of forearm forcipization, 
\25 
Deltoid muscle, dynamics of, 39 
Deltoid paralysis. See Paralysis 
Dermogenetic scar contractures, 109 
Didot’s operation for syndactylia, 230 
307 308 
INDEX 
Dislocation of, extensor tendons, 271 
— shoulder, habitual, 273 
■— hand, 250 
— head of radius, 276 
— os lunatum, 250 
— phalanges, 251 
— radio-ulnar joint, 275 
— thumb, 251 
Doigt a ressort, 278 
Duchenne-Erbs type of birth-palsy, 12 
Dupuytren’s contracture, 149 
— Gill’s method, 151 
— Hutchinson’s operative method, 151 
— pathology of, 149 
— treatment of, 150 
— Tubby’s method of resection of palmar 
fascia, 151 
Ectrodactylia, 225 
— metacarpo-phalangienne, 228 
— phalangienne, 228 
Elbow, arthroplasty of, 263 
— fracture deformity of, 256 
— paralysis of, 56 
— scar contractures of, 117 
— strain of, 257 
— traumatic ankylosis of, 257 
— tuberculosis of, 191 
Elevation of scapula. See Congenital eleva- 
tion 
Finger tendons, rupture of, 270 
Foerster’s operation, 170 
Forcipization of the forearm, 125 
Fracture deformities of wrist, 254 
Fracture deformity of elbow, 256 
Fracture of scaphoid, 253 
Gegenbaur’s Archipterygial theory, 210 
Hand, paralysis of, 70 
— primitive motions of, 289 
Humero-ulnar synostosis, congenital, 241 
Hyperphalangism, 240 
Ischemic contracture, 126 
— after treatment of, 144 
— Jones’ method of treatment, 130 
— operative methods, 130 
— pathology of, 127 
— resection of forearm bones in, 134 
— table of cases, 135 
— treatment of, 129 
Italian flap method in scar contractures, 116 
Joint perimeter, 292 
Jones’ operation for drop wrist, 93 
Jones’ treatment of ischemic contracture, 
130 
Kiliani’s operation for shoulder paralysis, 47 
Kinesiology, 283 
— shoulder of, 284 
Kinoplasty of forearm, 125 
Klumpke’s type of birth-palsy, 15 
Kocher’s incision for resection of elbow, 192 
Kocher’s posterior route of resection of 
shoulder, 190 
Krukenberg’s method of forcipization of 
forearm, 125 
Langenbeck’s incision for resection of elbow, 
i93 
Lange’s pathognomonic position of shoulder 
joint, 3 
Lime deposits in muscles, 3 
Lobster claw-hand, 224 
Lunare, dislocation of, 250 
Lyle’s method of phalangizatidn, 124 
Madelung’s deformity of wrist, 145 
Malformations. See Congenital 
Mechanotherapy, 283 
Muscle dynamics of deltoid, 39 
— elbow, 57 
—- fingers, 72 
— interossei, 72 
— scapula, 36 
— thumb, 73 
— wrist, 70 
Muscle education, 41, 283, 293 
Musclospiral paralysis, 90 
— dissociative diagnosis of, 91 
Neoplasty of thumb and fingers, 122 
Nerve lesion, splint treatment, 92 
Nerve, reaction of degeneration in periph- 
eral lesion, 89 
Nerve suture, 89 
Neural atrophy of hand, 279 
Nicoladoni’s finger exchange method, 123 
Obstetrical paralysis. See Birth-palsy 
Occupational therapy, 293 
Oligodactylia, 225 
Ollier’s incision for resection wrist, 196 
Osteotomy of metacarpals in claw-hand 
contracture, 108 
Paralysis of brachial plexus, 93 
— of deltoid muscle, 39 
— arthrodesis of shoulder, 44 
— conservative treatment, 40 
— Kiliani’s method, 47 INDEX 
309 
Scar contractures, dermogenetic of wrist 
and fingers, 109 
Scar contractures, pedunculated flap in, 116 
Scar contractures of elbow, 117 
Scapula, bony articulations of, 23, 28 
— congenital elevation, 22 
— embryological development of, 23 
Scapular grating, 7 
Schepelmann’s technic of thumb plasty, 123 
Sever’s operation in birth-palsy, 18 
Sever’s operation for habitual dislocation 
of shoulder, 274 
Shoulder, habitual dislocation of, 273 
Shoulder joint, Tuberculosis of, 187 
Shoulder muscles, paralysis of, 36, 39 
Silk ligament, fixation of shoulder, 43 
— suspension of elbow, 60 
Snapping, elbow, 278 
— fingers, 278 
— shoulder, 277 
Spastic paralysis, 159 
— after treatment, 183 
— arthrodesis of wrist in, 165 
— clinical symptoms, 160 
— conservative treatment, 162 
— decompression operation, 170 
— Foerster’s operation, 170 
— operation for, contracture of wrist, 163 
pronation contracture, 164 
— operative treatment, 163 
— Stoffel’s operation, 171 
— thumb check plasty of Biesalski and 
Mayer, 165 
— Tubby’s operation for pronation con- 
tracture, 164 
— types of, 159 
Spina ventosa, 197 
Spitzy’s treatment of syndactylia, 230 
Sprengel’s deformity, 22 
Stabilization of wrist, 77 
Stiles’ operation for drop-wrist, 93 
Stoffel’s operation in spastic paralysis, 171 
Subacromial bursa, 1 
— differential diagnosis, 3, 5 
— pathology of, 2 
— report of cases, 7 
— treatment of, 5 
— X-ray findings, 2, 4 
Subdeltoid bursitis, 1 
Subscapular bursae, 10 
Substitutionary motion, 289 
— abduction of shoulder, 41 
— flexion and extension of fingers, 74, 183 
— flexion of thumb, 73 
— motion of interossei, 74 
— musculospiral paralysis, 91 
— opposition of thumb, 73, 85 
Paralysis, operative treatment, 42 
— silk ligament fixation, 43 
— substitutionary motion, 41 
— transplantation methods, 42 
Paralysis of elbow, 56 
— author’s method of muscle plasty, 60 
— muscle dynamics, 57 
— Robert Jones’ skin plasty, 60 
— silk ligament suspension, 60 
— treatment, 60 
Paralysis of hand, 70 
— claw-hand formation, 72 
— distribution, 75 
— Jones’ cockup splint in, 76 
— paralytic drop-hand, 76 
— stabilization of wrist in, 77 
— technic of interosseous tendon trans- 
plantation in paralytic drop-hand, 84 
— thenar palsy, 73 
— thenar substitutionary motion in, 73 
— thumb, 85 
— treatment of , 76 
by arthrodesis, 77 
by tendon transplantation, 77, 79 
Paralysis musculospiral, 90 
— conservative treatment, 92 
— dissociative diagnosis, 91 
— Robert Jones’ operation, 93 
— Stiles’ operation, 93 
Paralysis of serratus magnus, 37 
— case reports, 38 
— Duval’s operation, 37 
— Eiselsberg’s operation, 37 
— Skillem’s operation, 38 
Paralysis of shoulder muscles, 36, 39 
Paralysis of thenar muscles, 85, 100 
Pedunculated flap in scar contractures, 116 
Periarthritis humero scapularis, 1 
Phalanges, dislocation of, 251 
Phalangization method in neoplasty of 
thumb, 124 
Physiotherapy of upper extremity of shoul- 
der, 283 
Pieri’s method of phalangization, 124 
Pieri’s operation for webbed thumb, 119, 236 
Pocket flap, 116 
Polydactylia, 237, 241 
Pseudo-Sprengel’s deformity, 29 
Radio-ulnar synostosis, congential, 240 
Radius curvus, 148 
Reaction of degeneration, 89 
Records of muscle education, 295 
Records of joint movement, 292 
Sauerbruch’s method of cinematization, 125 310 
INDEX 
Substitutionary pronation of forearm, 58, 
183 
— supination of forearm, 58, 183 
Suprascapular bursae, 10 
Syndactylia, 228 
— operative treatment, 229 
— table of cases, 231 
Symphalangism, 236 
Taylor’s technic of plexus operation in birth- 
palsy, 18 
Tendon bridging, 109 
Tendon plasties in inflammatory contrac- 
tures, 107 
Tendon ruptures, 270 
Tendon sheath, chronic inflammation of, 103 
Tendon transplantation in deltoid paralysis, 
42 
— paralytic wrist, 93 
Tenosynovitis, tuberculous, 198 
Thumb, dislocation of, 251 
Thumb plasty, 122 
Traumatic deformities, 250 
Traumatic paralysis of hand. See Paralysis 
— thenar muscles, 100 
Trigger finger, 278 
Tubby’s operation for, pronation contrac- 
ture, 164 
— syndactylia, 229 
Tuberculosis, 187 
— elbow joint, 191 
resection of elbow, 192 
Kocher’s method, 192 
treatment, 192 
— shoulder joint, 187 
Kocher’s posterior route, 190 
technic of resection of head, 189 
— wrist joint, 194 
Ely’s operation for, 195 
Lister’s operation for, 196 
treatment of, 195 
Tuberculous dactylitis, 197 
— Albee’s operation, 198 
— Bardenheuer’s operation, 198 
— tenosynovitis, 198 
Ulnar palsy, delayed, 127 
Vanghetti’s method of cinematization, 125 
Volkmann’s contracture, 126 
Winged shoulder, 37 
Wrist, fracture deformities of, 254 
Wrist joint, sprain of, 253 
— tuberculosis of, 194 
Writers’ cramp, 279 
Zeller’s operation for syndactylia, 229