Postgrad Med J: first published as 10.1136/pgmj.43.502.541 on 1 August 1967. Downloaded from

Case reports 541

A rare DAVID J. FULLER M.B., B.S. Senior House Officer, Rowley Bristow Orthopaedic Hospital, Pyrford, Surrey

RUPTURE of the supraspinatus component of the In October, 3 months later, he presented to this is not an uncommon occurrence. The unit complaining of disabling loss of voluntary diagnosis and treatment of this event is well movement at the left . Pain was not a accounted for in surgical texts. An entirely symptom. unrelated condition which is also thoroughly des- Examination revealed a right shoulder of nor- cribed in the literature is traumatic paralysis of mal contours with full active range of movement the . The performance of abduction and full power. On the left side the deltoid muscle at the shoulder joint is normally achieved by was completely wasted. There was no anaesthesia supraspinatus and deltoid working in harmony in the area supplied by the superficial branch of and should either of the above two events occur, the circumflex . The left shoulder could be such abduction that remains possible is very much moved passively without pain through the entire a function of the other intact mechanism. normal range. The active movements, however, Isolated deltoid paralysis, in fact, results in very of flexion, extension and abduction were reduced little disability whereas a complete tear of the to some 150 each. When the left was passively supraspinatus tendon usually represents a severe guided to a point 20° or more from the trunk and handicap. then the supporting was removed, the arm copyright. collapsed to the side. Case report A diagnosis of complete rupture of the supra- The patient is a 58-year-old business man. He is spinatus tendon in a shoulder previously afflicted right-handed. with traumatic paralysis of the deltoid muscle was 1924 made. The patient was offered surgery; the alter- At the age of 15 he was involved in a road natives being attempted repair of the ruptured accident with a horse and cart, and he suffered a tendon or arthrodesis of the shoulder. A pause of dislocation of the left shoulder which was reduced 8 weeks convinced the patient that the disability at a nearby hospital. The injury resulted in per- was severe and he elected to have the tendon http://pmj.bmj.com/ manent damage to the left circumflex humeral repaired operatively. nerve with total paralysis of the deltoid muscle. Operation. The repair was performed on 12 This incident in no way prevented the patient from January 1967. The exposure was effected by the leading an active sporting life-as a young man he posterior approach described by Debeyre, Patte & was a serious oarsman and competed in several Elmelik (1965). Through an incision which runs major rowing events. above and parallel with the scapular spine and

19651 out across the , the was divided, on September 29, 2021 by guest. Protected In October of this year he developed a classical the acromion osteotomized and reflected forwards right-sided supraspinatus tendinitis and was there- on the acromio-clavicular ligament and the fore seen by an orthopaedic surgeon who atrophied remnant of the deltoid was identified. confirmed that the left deltoid was still paralysed. This exposure reveals the whole length of the For the next 8 months this painful right shoulder supraspinatus and its tendon and in this case the resulted in greater use of the left arm than normal. latter was found to be completely ruptured leaving 1966 a triangular defect in the cuff through which the In July, at the same time as the symptoms in the sub-acromial bursa and the shoulder joint com- right shoulder were finally subsiding, he first municated. The defect was repaired by simple became aware of weakness in the left arm. He apposition and suture of healthy tissue plus two was, in fact, on a motoring holiday at this time stout silk U-sutures transfixing the greater and his progressive difficulty in controlling the tuberosity. Advancement of the supraspinatus in steering wheel of the car with his left arm revealed its fossa, as performed in twelve out of thirty- to him that all was not well. three cases by Debeyre et al. (1965), to relieve Postgrad Med J: first published as 10.1136/pgmj.43.502.541 on 1 August 1967. Downloaded from

542 C:ase reports tension on the suture line was not necessary in concurrently bilateral and this unlucky man, by this case. Post-operatively the arm was supported suffering pain on the right and tendon rupture on in 900 abduction in a thoraco-brachial plaster the left, escaped neither of the unpleasant clinical spica. manifestations of this condition. Six weeks after the operation the plaster was (c) The abduction disability removed and the patient was able to actively For many years it was taught that supraspinatus abduct the left arm to 1000. initiates and deltoid completes abduction at the shoulder joint. This was demonstrated to be clearly Discussion untrue by the studies of Inman, Saunders & This case has been put on record essentially Abbott in 1944. They showed that the two muscles because of its rarity and the following brief dis- contract more synchronously than was thought, cussion will indicate a few brief points of interest whilst the short rotators do their very important that it demonstrates. work of supplying the coupling force that holds in the humeral head. (a) The paralysed deltoid This case illustrates that the supraspinatus The patient was exceedingly unfortunate to receive muscle can play perhaps a greater role in abduc- a permanently paralysed deltoid muscle as a com- tion than is generally appreciated. Without his plication of his . A transient deltoid muscle the patient experienced practically paresis is not uncommon but an anatomical in- no disability for a period of over 40 years. When teruption of the nerve very rarely follows shoulder he lost the use of his supraspinatus he was com- dislocation. The absence of any demonstrable pletely incapable of holding any abductive force anaesthetic patch of skin over the shoulder at all above 150. Clearly, he had been relying upon suggests that the nerve injury occurred distal to his intact supraspinatus for elevating his arm in the circumflex humeral nerve's division into deep the coronal plane. We know that when the roles and superficial branches, although the phenomenon are reversed, and the power of supraspinatus is of overlap could account for this finding. lost whilst the deltoid muscle remains intact, the (b) The rotator cuff rupture power of abduction is grossly diminished-a factcopyright. The essential pathology of 'degenerative/ that is normally made use of when diagnosing a inflammatory' tendon lesions is not yet fully complete supraspinatus tendon tear. understood although it is known that all thick The conclusion is that perhaps appearances are tendons have a tendency to become avascular in deceptive and that the comparative size of the the middle. At the present time, however, surgical deltoid and the supraspinatus is no index of their treatment depends more upon an understanding actual roles in shoulder abduction. Providing that of the natural history of the condition rather than all other factors are normal, the deltoid muscle its essential pathology. This knowledge of natural might well be very much the understudy of supra- http://pmj.bmj.com/ history informs us that degeneration and inflam- spinatus in normal abduction. mation often occur in the rotator cuff in an other- wise healthy body, but the processes are self- Summary limiting and spontaneous recovery is the rule. The The first documented case of supraspinatus degenerative area can be very painful. It can also tendon rupture and paralysed deltoid co-existing be the site of a mechanical breach. Probably, the in a shoulder is recorded. greater the vascular reaction of attempted repair The surgical treatment selected and the early the more intense is the pain that the patient results of the operation are described. on September 29, 2021 by guest. Protected experiences. The significance of the parts played by each of It appears probable in the case under discussion the two muscles in the performance of abduction that during 1965 and 1966 degenerative processes of the arm is emphasized. were active in both right and left . The right side was painful, the left side was not. Per- Acknowledgment haps the excess load of activity borne by the left I should like to thank Mr A. G. Apley, F.R.C.S., not only shoulder compensating for its painful fellow on for his permission to publish this case, but also for his help the other side was a factor in the subsequent in its presentation. rupture. Certainly the left supraspinatus tendon References would have been degenerate at this time because DEBEYRE, J., PATTE, D. & ELMELIK, E. (1965) Repair of tendon rupture occurs as an event in the chronic ruptures of the rotator cuff of the shoulder. J. Bone Jt process of degeneration, not suddenly in a healthy Surg. 47-B, 36. INMAN, V.T., SAUNDERS, J.B. DE C.M., & ABBOTT, L.C. tendon. (1944) Observations on the function of the shoulder joint. It is unusual for supraspinatus tendinitis to be J. Bone Jt Surg. 26, 1.