[Reprinted from the Boston Medical and Surgical Journal 
of February 6, 1896.] 
A CASE OF FRACTURE OF THE UPPER END 
OF THE HUMERUS JUST BELOW THE TU- 
BEROSITIES, WITH DISLOCATION OF THE 
HEAD OF THE BONE INTO THE AXILLA.1 
GEORGE H. MONKS, M.D. 
A man of about fifty fell down stairs, striking 
heavily on his left shoulder. He had evidently sus- 
tained considerable injury to his shoulder, and was 
taken to the City Hospital at once. The external ap- 
pearances about the shoulder were those of dislocation 
of the humerus. Ether was therefore administered 
by the house-officer, and an examination made. It 
then became evident that the head of the bone was 
broken off from the shaft, and displaced into the 
axilla, where it could easily be felt and moved about. 
Its fractured surface rested against the thorax. While 
the patient was still under ether 1 was sent for, and 
reaching the hospital soon after, I tried by manipula- 
tion to return the fragment to its proper place again, 
but without avail. It was therefore decided, after 
consultation with Dr. I). W. Cheever, to allow the 
man to come out of ether, in order to explain to him 
the exact condition of the shoulder, the necessity for 
operation, etc., and, after having obtained his consent, 
to cut down upon the head of the bone, and again 
attempt reduction. 
1 Specimen shown and ease reported at the meeting of the Surgical 
Section of the Suffolk District Medical Society, December 4, 1895. 2 
The next day, therefore, the man’s consent having 
been obtained, ether was again given and an incision 
made into the axilla down to the displaced head of the 
bone. The fragment was freely movable, but by com- 
bined manipulation it could not be returned to the 
glenoid cavity. The fragment was therefore drawn 
out through the wound; and a tendon, which was 
apparently the only structure to which it was attached, 
was divided and the fragment removed. [This ten- 
don, as was proved later, was that of the subscapularis 
muscle, a fact which explains why the head was drawn 
inwards into the axilla, and could not be returned to 
the glenoid cavity.] The forefinger was then inserted 
through the rent in the capsular ligament into the 
shoulder-joint, but no other fragment could be found 
only the roughened end of the shaft. The axillary 
wound was then stitched with silkworm-gut. All did 
well for two days, when abdominal distention ap- 
peared, as well as other serious symptoms; and the 
man died four days after the operation. 
An autopsy was made by Dr. Councilman, but the 
cause of death could not be determined with certainty. 
There was nothing about the seat of fracture to sug- 
gest a cause, and the wound in the axilla was ap- 
parently healing by first intention. 
The shaft of the humerus was removed and cleaned, 
and also one small fragment (the greater tuberosity). 
The head of the bone, which had been excised at the 
operation five days previously, was then fitted to the 
fragments removed at the autopsy, and the specimen as 
a whole carefully examined. There were two main 
fragments in addition to the shaft. The larger frag- 
ment consisted of the rounded head of the bone and 
the lesser tuberosity, while the smaller fragment com- 
prised only the greater tuberosity. 
It is, of course, impossible to explain with any 3 
certainty the way in which this combined fracture and 
dislocation occurred. The most probable explanation 
is, however, that the man’s shoulder struck the ground 
in such a way that the bone was first fractured, and 
then dislocated. The head of the bone (fragment A) 
was probably driven out, through the rent in the cap- 
sule, by the shaft, after which the shaft returned to its 
normal position leaving the head of the bone in the 
axilla. The head, as already stated, could not return 
to the joint because of the contraction of the subscap- 
ularis muscle which was attached to it. [The arrow 4 
indicates the direction in which this fragment was 
drawn by the contraction of the subscapularis.] 
The greater tuberosity (fragment B) presumably 
did not follow the rest of the bone in its excursion 
into the axilla, but was probably pulled upwards and 
backwards by the supraspinatus, infraspinatus, etc.— 
a fact which perhaps explains why this fragment was 
not discovered at the time of the operation when the 
joint cavity was explored. 
Whatever the mechanism may have been, however, 
the case seems to be a sufficiently rare one to justify 
its publication.