The shoulder : rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa / E.A. Codman.

  • Codman, E. A. (Ernest Amory), 1869-1940.
Date:
1934
Catalogue details

Licence: In copyright

Credit: The shoulder : rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa / E.A. Codman. Source: Wellcome Collection.

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    position is strengthened by reference to the age table, which shows that I have never operated on a young man and demonstrated a rupture of the tendon. In those eases in which the tendon is actually evulsed from the facet, a complete circle with a falciform edge is not formed as heal¬ ing progresses, for the bone forms a defect in the circle. The base of the former triangle is the bone of the tuberositv. It mav be bare and as a rule has no granulations; sometimes there is a little velvety tissue on it. On microscopic section of the bare facet, one finds a little shim of fibrous tissue over the spongiosa, and that is all. As a rule there is a little plaque of dense bone beneath this, and at the pe¬ riphery of the defect some raised *4productive” bone. These bony changes are shown in the X-ray. Healing in these cases would appear to he at >till more of a disadvantage than when a stub of tendon is left on the tuberosity. It is not unusual to find both, some stub and some bony defect. From the operator's point of view a stub of tendon is a great advantage, for where evulsion has occurred he must drill the tuberosity in order to suture the tendon. A knowledge that a falci¬ form edge is present is also important for the operator, for in most cases he must remove it and pare down to the real tendon tissue be¬ fore he sutures. The new tissue in this falciform edge is seldom strong enough to hold a suture, and would be in the way of the sound tissue. (Fig. 12.) Referring to Fig. (5 will help the reader to understand the points at which rupture or evulsion is likely to take place. The figure shows that the insertion of the tendon into the bone is very super¬ ficial. and the shell of the surface of the bone is very thin. Under high magnification very many minute prolongations of the tendon are inserted into this thin shell of bone. (The structure suggests to my mind a room full of people hanging to the ceiling by having all their fingers deeply thrust into the plaster as into finger holes in a bowl¬ ing ball.) As a practical matter this network of attachment to the tuberositv does hold against excessive pull except in elderly people when the attachment is pulled out. In most, of the cases I have seen at operation it was apparently evulsed at the line of junction, but soon after the injure a stub of tendon would probably have been found. Such stubs probably slowly disappear. Referring again to Fig. 0, it will be seen that stress on the supra- spinatus tendon in the direction of its normal pull may result m four different forms of break in continuity: a. The tuberosity, facet and all may be pulled away. This may occur without making a communication between the base of the