Neuritis Complicating Dislo- 
cation of the Shoulder 
and Elbow. 
BY 
M. A. VEEDER, M.D., 
Lyons; °Ht y. 
REPRINTED FROM TRANSACTIONS. 
1896. NEURITIS COMPLICATING DISLOCATIONS 
OF THE SHOULDER AND ELBOW. 
By M. A. VEEDEK, M.D., 
LYONS. 
A knowledge of the precise nature of the injury to surround- 
ing softer tissues that may attend dislocations is especially im- 
portant in the case of the shoulder- and elbow-joints. For example, 
in dislocation of the humerus the head of the bone is very liable 
to be crowded forcibly against the nerves of the brachial plexus, 
and of the posterior cord of the plexus especially, originating 
symptoms that may appear widely in the parts supplied by the 
musculo-spiral, circumflex, and subscapsular nerves which arise from 
this cord. In like manner the ulnar and median nerves may be- 
come involved in dislocations at the elbow. The symptoms attend- 
ing this accident may be slight or severe, according to the extent 
of the lesion, and may present varying characteristics according as 
the trophic, motor, or sensory filaments of the nerve are involved. 
There may be transient or complete paralysis of one or more 
muscles, as shown by the inability to execute certain movements. 
At the shoulder this impairment of the muscles may have the 
very important consequence of permitting recurrence of the dislo- 
cation almost spontaneously when the arm is placed in certain 
positions. The writer has seen a case in which there had been 
such recurrences nine times, and in which the deltoid and teres 
muscles were plainly atrophied and partly paralyzed. Such patients 
are very apt to imagine that the dislocation has not been completely 
or properly reduced, but it will be found that there is no impedi- 
ment to motion in or about the joint, but, on the contrary, perhaps 
there may be too free motion because of muscular relaxation and 
loss of control. Putting the arm in particular positions will show 
which muscles fail to act, and they also may be found flabby and 
atrophied. In the case of injury of this sort to the ulnar and 2 
M. A . VEEDEE, 
median nerves at the elbow, muscular contractures may appear 
in the hand and arm. The symptoms thus tar enumerated are 
the final outcome of the inflammatory condition. In the more 
acute stages, in addition to muscular spasm or loss of power, the 
tissues throughout the region supplied by the nerves affected may 
become cedematous, the skin reddened and glossy, and there may 
be loss of sensation on the one hand, or burning pains such as 
characterize gunshot-wounds of nerve-trunks, on the other. Re- 
cently the writer has seen two cases in which the symptoms men- 
tioned were of the most decided character throughout the entire 
area supplied by the musculo-spiral nerve. In one case the hand 
became so painful immediately on receipt of the injury that the 
patient did not notice at first that the shoulder had been dislo- 
cated. The subsequent history showed that these pains were due 
to a very serious lesion of the musculo-spiral nerve, and not to any 
direct injury of the hand, all the characteristic symptoms of neu- 
ritis appearing throughout the track of the nerve. Slight and 
transient symptoms betokening injuries of this character are present 
in many cases of dislocation. It is only occasionally that they 
become so serious as to attract attention, and even then they may 
be overlooked at the outset, and being first noticed at a later stage 
may be supposed to be of rheumatic origin, or to have arisen 
from the pressure of bandages, disuse of the arm, or even failure 
to reduce the dislocation ; whereas they are involved in the very 
nature of the injury. 
If complications due to nerve injury are at all severe, recovery 
is so tedious compared with ordinary dislocations that it is not 
strange that patients, not understanding the source of the diffi- 
culty, become impatient and inclined to find fault. Hence it is 
specially desirable that the physician should be able to give a 
clear 'account of the injury and its prognosis. Sometimes the full 
effect of the damage done to the nerve may not appear until after 
several months, or until the arm is used in some employment that 
is too laborious and exacting. A very instructive case of this sort 
came under the observation of the writer in which the elbow was 
much bruised in the process of dislocation, but in which it did not 
become apparent how serious the injury to the ulnar nerve had been 
until the patient resumed his occupation, which involved more or 
less use of the shovel. The result was that cedema reappeared in 
the track of the nerve, followed by very rapid atrophy and con- NEURITIS COMPLICATING DISLOCATIONS. 
3 
tractures, the ring and little fingers shrivelling up and becoming 
claw-shaped. This condition disappeared in great measure, how- 
ever, on avoidance of the particular kind of labor that had brought 
it on. At the end of three or four years the atrophy and con- 
tractures were scarcely noticeable, although the arm remained 
weak, being in all probability permanently slightly paralyzed. 
In dealing with such cases the first question that arises is as to 
the precautions to be taken at the time of the reduction of the dis- 
location. It is essential that the anatomical relations of the parts 
should be understood and kept in mind so as to avoid every manip- 
ulation that would tend to increase the injury to nerve-trunks that 
may have been caught and pressed upon by the dislocated bone. 
There is no case in which this is more likely to be necessary than 
that of dislocations of the humerus. Here the upper margin of 
the dislocated head of the bone rests against the neck of the scapula, 
or against the clavicle with the axillary structures put upon the 
stretch beneath it. If in this condition the elbow be pulled directly 
outward from the side of the body the entire bone will act as a 
powerful lever, the fulcrum being at the point of contact with the 
scapula or clavicle, as the case may be, and increased tension being 
exerted in the very direction in which the axillary nerves arc 
already stretched. The hand making traction at the elbow has 
the advantage of the long arm of the lever, so that but little re- 
sistance will be felt even when the axillary structures are being 
subjected to very great pressure and stretching. Moreover, it is 
in the very cases in which the nerves are most injured that the 
muscles also offer the least resistance to such manipulations, on 
account of their becoming paralyzed, increasing the possibility of 
doing harm unconsciously. 
In reducing the form of dislocation of the humerus to which 
reference has just been made, it is wise to keep one hand in the 
axilla so that the amount of pressure brought to bear in that loca- 
tion may be estimated by the tension felt in the tissues, and for 
the purpose also of pulling the head of the bone outward in the 
direction of its socket, so as to relieve the pressure on the underly- 
ing parts. If it is proposed to carry the arm directly upward so 
that traction may be made in that direction, which is a very 
effectual way of reducing the dislocation, the elbow should be 
swept forward and inward rather than outward, so as to relax the 
tension upon the parts in the axilla rather than increase it. In 4 
M. A. VEEDER, 
reducing dislocations other than those at the shoulder the ques- 
tion of injury to nerves during the requisite manipulations does 
not become so prominent. In eases of dislocation complicated by 
fracture with large displacement and much distortion of the parts, 
however, it is a point that it is well to keep in mind. Otherwise 
than in the cases just described, but little can be done for the pre- 
vention of injuries of tins class. 
Subsequent to reduction, however, there are questions in regard 
to treatment that demand consideration. Fortunately, in the great 
majority of cases the injuries to nerves attendant upon dislocations 
are not serious, resulting in nothing more than transient soreness, 
stiffness, or muscular relaxation, as the case may be, and requiring 
little or no treatment. On the other hand, cases may be met with 
at any time that will tax the resources even of the most skilful. 
Sucli cases may promise equally well with those of ordinary char- 
acter at the outset. The dislocation is very easily reduced, it may 
be, and yet strength does not return to the arm, and pain and swell- 
ing do not cease. The patient becomes discouraged, and goes from 
surgeon to surgeon, receiving all sorts of suggestions in regard to 
the nature of the injury and its treatment, but no immediate relief. 
The symptoms being such as have been indicated throughout the 
course of the discussion, the question is as to what is best to be 
done to prevent inflammation, and to promote repair in the nerve- 
trunks that have been damaged. Practically this resolves itself, 
for the most part, into a question as to the effect of use or disuse 
of the arm at different stages in the process of healing. As in the 
ease of the patient using the shovel, already mentioned, too severe 
usage even at a late stage, after all active symptoms had apparently 
subsided, may be attended by the appearance of consequences as 
untoward as contracture and atrophy. At an earlier period, during 
more active inflammation, even moderate use of the arm may pro- 
duce such pain, swelling, muscular spasm, and loss of control that 
it may be difficult to induce the patient to submit even to passive 
motion, if this be thought desirable or necessary at this stage. A 
section of nerve and the tissues surrounding it being bruised and 
perhaps reduced to pulp, and it being impossible to adjust and retain 
the parts in apposition directly by the aid of sutures, it is evident 
that repair must be difficult and liable to interruption. There must 
be a filling in of tissue and more or less cicatricial formation. If 
during this process the nerve be pulled about by active or passive NEURITIS COMPLICATING DISLOCATIONS. 
5 
movements of the limb, and acute inflammatory symptoms at once 
appear, the danger of permanent impairment of function would 
seem to be increased. If, on the other hand, the bruised tissues 
be allowed to heal with as little disturbance as possible, the resto- 
ration of the integrity of the nerve being the main point kept in 
view in the treatment, there may ensue considerable stiffening of 
the arm due to its disuse and to trophic changes causing adhesions 
among the muscles and their aponeuroses. As a rule, stiffening of 
this sort, unlike deprivation of nerve-supply, does not result in 
permanent impairment. It is the lesser of two evils, and will dis- 
appear gradually as the arm comes to be used, or an anaesthetic 
may be given and the adhesions broken up whenever the process 
of repair has reached a point that it is thought will justify such 
interference. In case the adhesions are forcibly broken up at an 
early stage, it may be found that they will recur because of the 
inability of the patient to endure even passive motion because of 
pain and spasm. Such recurrence indicates the existence of a 
troublesome pathological condition, essentially of an irritative 
nature, at the seat of the primary lesion in the case. Neverthe- 
less, the tendency is toward recovery even in cases as bad as this, 
although it may be slow. At the end of a year or two the motion 
of the arm will be found, as a rule, to have become perfectly free, 
atrophic and paralytic symptoms due to deprivation of the nerve- 
supply alone remaining. In all cases of this kind massage and 
electrical stimulation are of service, improving the nutrition, pre- 
venting adhesions, and tending to restore the nerve-supply in so 
far as it has not been absolutely destroyed. Still there are cases 
in which every resource that cau be imagined will require to be 
supplemented by patience. 
Most of the points that have been mentioned are based upon 
observations made by the writer in the course of ordinary general 
practice, and verified by references to the somewhat scanty litera- 
ture of the subject. It would seem that neuritis complicating dis- 
locations, particularly at the shoulder and elbow, is much more 
frequent than is.generally supposed, it usually occurring in such 
a mild form as not to attract attention even when the char- 
acteristic symptoms are quite well defined. The purpose of the 
present paper will have been served if renewed attention shall have 
been drawn to a subject that should interest the general practi- 
tioner especially, who is liable to meet with these cases at any 6 
NEURITIS COMPLICATING DISLOCATIONS. 
moment, and who must deal with them on the spot no matter what 
their character or degree of severity. 
DISCUSSION. 
Dr. H. S. Drayton, of New York: I would add simply a word 
commendatory of the suggestions made by the author with reference 
to treatment. A few cases have come under my observation showing 
sequelae of injury, chiefly of the shoulder, and, like the author, I 
have noticed that frequently the patients are unable to give a very 
good history of the trouble. There seemed to be a chronic rheumatoid 
condition, and where there was also wasting and irritation I found 
massage one of the best remedies, associated with mild galvanism. In 
one case in particular, affecting the left shoulder, with uselessness of 
the hand, after three or four months’ treatment writh massage and 
galvanism there was considerable redevelopment of the deltoid, disap- 
pearance of contractures in the hand, and power to use this member.