THE ANTERIOR CAPSULAR MECHANISM

IN RECURRENT ANTERIOR DISLOCATION OF THE SHOULDER

Morphological and Clinical Studies with Special Reference to the

Glenoid Labrum and the Gleno-humeral Ligaments

H. F. MOSELEY, MONTREAL, CANADA

and
B. OVERGAARD*, KARLSTAD, SWEDEN

From the Accident Service, Royal Victoria Hospital, Montreal

INTRODUCIION AND SURVEY OF THE LITERATURE

The concept of the capsular mechanism in the shoulder joint has been described by
Townley (1950) and Moseley (1959, 1961). Townley defined it as the function of the normal
capsule which allows this usually lax structure to become an effective barrier against anterior
projection of the humeral head in external rotation.
The anatomical structures which constitute these anterior and posterior capsular or
soft-tissue mechanisms respectively can be defined as follows (Fig. 1).
The anterior capsular mechanism comprises 1) the synovial membrane, capsule including the
gleno-humeral ligaments, glenoid labrum and scapular periosteum, and the related recesses
and subscapular bursa ; and 2) the subscapularis muscle and tendon with the connective
tissue arrangements to the structures listed above.

PO3TET

3u.pCcLsp1

tzZ-tl3 tt

.5-ubd-Q.1-tJ

ot:

FIG. 1
The anterior and posterior capsular mechanisms.

The posterior capsular mechanism consists of 1) the posterior capsule, synovial membrane,
labrum, periosteum, and recesses; and 2) the postero-superior cuff and the associated muscles,
which are the supraspinatus, infraspinatus and teres minor.
The anterior and posterior capsular mechanisms are separated superiorly by the coraco-
humeral ligament and the long tendon of the biceps, and demarcated inferiorly by the long
tendon of the triceps.
McLaughlin and Cavallaro (1950) referred in their study of anterior dislocations of the
shoulder to the anterior and posterior pillars. Other authors have used the terms anterior
and posterior supports of the shoulder.
* Merck, Sharp and Dohme Research Fellow.

VOL. 44 B, NO. 4, NOVEMBER 1962 913

914 H. F. MOSELEY AND B. OVERGAARD

The gleno-humeral ligaments-These three ligaments are merely slightly firmer portions of
the capsular ligaments (Codman 1934). We have found their first description in the writings
of Schlemm (1853).
The superior gleno-humeral ligament originates from the supraglenoid tubercle and the adjacent
labrum, in front of and together with the tendon of the long head of the biceps, which it
accompanies laterally to its insertion in the fovea capitis of the humerus near the tip of the
lesser tuberosity, together with a portion of the coraco-humeral ligament. As the superior
gleno-humeral ligament is accompanied by a small artery, Welcker (1876, 1877) considered it
to be a nutrition ligament of the humeral head and compared it with the round ligament
of the hip joint. Bland Sutton (1884) believed that the superior gleno-humeral ligament was
the divorced tendon ofthe subclavius, but this postulate has never been confirmed (Gardner
and Gray 1953). Delorme (1910) carried out careful anatomical dissections of these ligaments
and produced shoulder dislocations in cadavers in order to demonstrate the significance of
these check ligaments in relation to Kochers (1870) method ofreducing shoulder dislocations.
He did not attribute to the superior gleno-humeral ligament any capacity to prevent dislocation,
because this tiny ligament is, within the physiological range of movement at the gleno-humeral
joint, protected from excessive tension by the other ligaments. Furthermore, because of its
weakness, it would not be expected to be capable of checking a forcible abduction in the
gleno-humeral joint, but rather would tear immediately. DePalma, Callery and Bennett (1949)
and DePalma (1950), in their anatomical study of ninety-six shoulder specimens, found the
superior gleno-humeral ligament to be the most constant of the three ligaments.
The middle gleno-humeral ligament was described by Delorme as a very dense ligament, usually
one to two centimetres in width and up to four millimetres in thickness. DePalma et al. found
it to be a structure of considerable variability ; it was poorly defined or absent in nearly one-
third of their specimens. When the ligament is present it originates from the supraglenoid
tubercle, from the labrumjust below the superior gleno-humeral ligament, or from the scapular
neck. It extends laterally and distally towards its insertion on the lesser tuberosity, and it is
fused with the posterior aspect of the subscapularis tendon in its distal half.
The inferior gleno-humeral ligament reinforces the capsular area between the subscapularis and
the origin of the long head of the triceps. It is triangular in shape, arising from the antero-
inferior labrum and continuing distally to the surgical neck and to the medial border of the
lesser tuberosity of the humerus. Fick (1910) frequently found it to be merely a diffuse

thickening of the antero-inferior

part of the capsule. Delorme was of the opinion that this
ligament, though variable in thickness, was always well developed and up to four millimetres
thick. De Palma et a!., however, only found it to be a well defined ligament in a little
more than half of their series ; in the remaining specimens it was poorly defined or absent.
In addition to
above-mentioned the ligaments, Delorme described a system of fibres
passing between that part of the posterior surface of the subscapularis tendon which joins the
middle gleno-humeral ligament, and the origin of the long head of the triceps. Thus the fibres,
the fasciculus obliquus, pass downwards over the anterior aspect of the capsule. Strasser
(1917) called these fibres ascending fibres. Recently they have been recognised by Landsmeer
and Meyers (1959) who could trace this longitudinal-oblique system down to the glenoid
labrum and to the fascial envelope of the subscapularis tendon.
The function of the gleno-humeral ligaments is usually described as the limitation of
lateral rotation at the gleno-humeral joint ; and so they act as checkreins. From his experiments
on cadavers, however, Delorme made a closer analysis of the function of each individual
ligament. He found that the middle gleno-humeral ligament goes into action when the arm
is externally [laterally] rotated or dorsally flexed and is in a dependent or slightly abducted
position, as, for instance, when holding out the arm in order to execute a flinging movement.
If the abduction is increased coincidentally with external rotation the check of the inferior
gleno-humeral ligament will start, and thus its upper fibres will tighten more at slight abduction,

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 RECURRENT ANTERIOR DISLOCATION OF THE SHOULDER 915

while the check will be performed by the whole ligament in the mid-way position. When the
externally rotated arm is elevated in anterior flexion (ventropulsion), this movement will soon
be checked by the fasciculus obliquus.
The clinical importance of these ligaments has recently been stressed by McLaughlin
(1960), who wrote: The sole inelastic defence against forward displacement of the humerus
from the glenoid is the triangular sling formed by the gleno-humeral ligaments. He reported
three cases with unsuccessful Bankart-type repairs for damaged glenoid labra, where at the
time of re-operation these repairs were intact despite further dislocations. Careful inspection
of the anterior capsular mechanism, however, revealed in one case an avulsion of the gleno-
humeral ligaments from the humerus, and in the other two cases the middle gleno-humeral
ligament was disrupted. After repair of these lesions no further dislocations occurred.
The synovial recesses-Recesses or diverticula formed by the synovial membrane of the
anterior capsular mechanism, which are significant in the etiology of recurrent dislocation,
are the subscapularis bursa (superior subscapularis recess) and the inferior (subscapularis)
recess. These have been studied by, among others, DePalma et a!., Gardner and Gray, and
Olsson (1953). The subscapularis bursa is present in most cases (80 to 89 per cent); its
opening into the joint is usually situated between the superior and the middle gleno-humeral
ligaments. The bursa extends along the superior tendinous border of the subscapularis muscle
medially towards the inferior surface of the coracoid process. Its base is also attached to the
anterior surface of the subscapularis tendon for a variable extent, on the average four
centimetres by two centimetres in the young athlete operated upon for recurrent dislocation.
The bursa extends over a similar area between the capsule and the posterior surface of the
tendon. It is in this latter synovial space that the communication with the joint is found.
Thus the bursal arrangement acts as a gliding mechanism for the upper border of the
subscapularis and the coracoid process. In one of Olssons specimens the subscapularis
bursa extended as far as eight centimetres, the mean depth being approximately four
centimetres, measured along the upper margin of the tendon from the upper corner of the
lesser tuberosity.
The opening of the inferior recess is situated between the middle and the inferior gleno-
humeral ligaments. Occasionally, when the middle gleno-humeral ligament is absent, a large
synovial recess may be found above the inferior gleno-humeral ligament. In other cases there
is a complete absence of synovial recesses.
Thus it is evident that a considerable variation in the arrangement of the gleno-humeral
ligaments and the synovial recesses exists. In this connection it must be stressed that the
anterior part of the gleno-humeral fibrous joint capsule is not continuous with the glenoid
labrum in those cases where the above-mentioned synovial recesses are present. In the cases
with a large superior recess the capsule continues in the medial direction as far as the
subcoracoid region and is then reflected back on to the scapular neck and continues to the
glenoid rim. This was the arrangement in 8&6 per cent of the specimens studied by DePalma
et a!. ; in their remaining specimens the capsule was continuous with the labrum around the
entire circumference, and in those cases there were no subscapularis recesses.
The glenoid labrum*_In current text-books of anatomy this formation is invariably described
as a fibrocartilaginous structure (Gray 1958, Lanz and Wachsmuth 1959), and this definition
is also reflected in the surgical literature (Bost and Inman 1942). Its structure and function
have been compared with those of the semilunar cartilages in the knee joint, which are flexible
but constant in general form and which do not heal after tearing.
Bankart (1923, 1938) claimed that the detachment of the labrum was the essential lesion
underlying the recurrent state; this was also later accepted by Perkins (1953). Clinical
experience has shown, however, that the labrum is not invariably damaged in recurrent
Dr C. 0. Townley has been studying the histological structure of the glenoid labrum since 1950 and has found
it to consist of fibrous tissue. His unpublished information has been available to us by personal communication.

VOL. 44 B, NO. 4, NOVEMBER 1962

916 H. F. MOSELEY AND B. OVERGAARD

dislocations, although it is in the majority of cases. Further, as shown by DePalma

et a!. (1949) and by Olsson (1953), in those decades of life in which labral detachments are
more common and severe, recurrent dislocations seldom occur. Townley (1950) removed the
anterior labrum in a dissected specimen by a posterior approach. He demonstrated that the
anterior capsular mechanism remained a functional unit and that no anterior dislocation could
be produced unless further damage was inflicted on the capsular mechanism.
Scougall (1957) showed that avulsion of the postero-inferior part of the glenoid labrum
produced experimentally in a monkey (Macaca mulatta) was capable of sound repair without
operation. Arthrography of the shoulders before the animal was killed at eight weeks showed
no leakage of the contrast medium beyond the joint confines. Histological examination of
the previously injured area showed perfect healing. He claimed that his findings should also
apply to humans.
In an attempt to elucidate some aspects of the anatomical basis for recurrent shoulder
dislocation we have carried out an anatomical, including an embryological, investigation of
the anterior capsular mechanism of the gleno-humeral joint and correlated the results with the
operative findings in a consecutive series of twenty-five cases of recurrent anterior dislocation
of the shoulder studied in detail with stereoscopic photography.

MATERIALS AND METHODS

Our embryological and foetal series

consists of shoulder joints from forty-
five human embryos and foetuses,
ranging in crown-rump (CR) length
from twenty-seven millimetres to term.
From the earliest embryos the upper
half of the trunk was removed in its
entirety; in the remaining foetuses the
shoulder girdles were removed and the
humeri were divided in their proximal
parts. After fixation in 10 per cent
formalin and decalcification in a mix-
ture of equal volumes of 45 per cent
formic acid and 68 per cent sodium
7
.,

formate or 50 per cent formic acid and

20 per cent sodium citrate respectively,
. FIG. 2 . the specimens were embedded in paraffin
Diagram to show levels of transverse (horizontal) sections .
through gleno-humeral joint (Figs. 3 to 6). and sectioned transversely (horizon-
tally). Sections were selected for micro-
scopical study according to Figure 2 (1, 11). Most ofthe sections were stained with haematoxylin
and eosin ; some were stained by a modified Massons method, and one by a modified
Papanicolaous stain.
In addition, seventy-five shoulder joints from cadavers were dissected in order to study
the arrangement of the gleno-humeral ligaments and the synovial recesses. Sixty-three of
these specimens came from anatomical cadavers ; the remaining twelve were fresh necropsy
specimens. Sixty-four cadavers were from subjects over fifty years of age ; the youngest was a
still-born infant, the oldest eighty-seven years. The dissections were carried out in the way
described by Schlemm (1853): the shoulder joint was opened from behind and the humeral
head resected. The anterior capsular mechanism was then studied in detail macroscopically.
In eight of the necropsy specimens the anterior glenoid labrum was removed, fixed, sectioned,
and stained with haematoxylin and eosin for microscopical study. Representative joints were
recorded in colour stereoscopic photography for repeated viewing.

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 RECURRENT ANTERIOR DISLOCATION OF THE SHOULDER 917

Our clinical series consists of twenty-five consecutive cases of recurrent anterior shoulder
dislocation operated upon by a modification of Bankarts procedure, including the application
of a Vitallium prosthesis on the anterior scapular neck, as described by Moseley (1947).
An anterior approach through the delto-pectoral interval is used, and the tip of the coracoid
with the coracobrachialis and the short head ofthe biceps attached to it is divided and reflected
downwards. After the abnormal laxity in the anterior capsular mechanism has been
demonstrated by forward and medial traction by a towel forceps in the tendinous tissue and
two guide sutures in the muscle belly of the subscapularis, arthrotomy is performed by dividing
the subscapularis together with the capsule at about the level of the musculo-tendinous
junction. The lesions ofthe anterior capsular mechanism which can be exposed by this approach
are then examined and recorded by colour stereoscopic photography. The postero-lateral

.-.. -. I - -

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C-orc.co\.d---, -
FIG. 3
- -
---- ---1.* h.l.L:t\.
to8G The earliest specimen showing a well formed
(__.__p / }-.Q(..ci gleno-humeral joint. Embryo, 27 millimetres
3L.: 5cc..puA.ct 1.3
CR-length. Note the clearly defined anterior and
posterior labrum, giving a more fibrous im-
-- pression than does the hyaline cartilage. Note
b p trdor- I also the joint space, the biceps tendon in its
groove, thecoracoid and the subscapularis tendon.
Qko\-3 .2 Section I. (Modified Papanicolaous stain, - 28.)

notch of the humeral head, which was proved by Hermodsson (1934) to be a compression
fracture, is also examined by digital palpation and occasionally by stereoscopic photography.
The anterior glenoid labrum or its remains were excised at operation and sections were
prepared for microscopical studies in twenty-five cases, sixteen of which belonged to the present
clinical series.
Two cases of arthrodesis of the shoulder for traumatic paralysis of the brachial plexus
also provided material for this study. In one of these cases the entire glenoid labral ring was
removed and sectioned serially; in the other the anterior portion of the labrum was excised.
All the operation specimens were fixed in 10 per cent formalin, and stained in a variety of ways
with haematoxylin and eosin, Masson trichrome, phospho-tungstic-acid-haematoxylin, and
haematoxylin-phloxin-saffran.
RESULTS
THE GLENOID LABRUM

This structure was studied on the sections made from the embryological and foetal
material, from the necropsy material and from the specimens removed at operation. Attention

VOL. 44 B, NO. 4, NOVEMBER 1962

918 H. F. MOSELEY AND B. OVERGAARD

was paid to the following characteristics : the appearance of the so-called labrum in different
states of rotation of the gleno-humeral joint ; its relationship to the osseous glenoid rim, to
the capsule and to the periosteum of the scapular neck, and to the hyaline cartilage of the
glenoid fossa. Further, the type of tissue constituting the labrum, the relative amount of
fibrocartilage present and its distribution, were noted.
The earliest specimen in the series that showed a clearly defined gleno-humeral joint with
a joint space was an embryo measuring twenty-seven millimetres in CR-length (Fig. 3). The
labrum seemed to be more fibrous than the hyaline cartilage, but no statement concerning the
presence of fibrocartilage could be made at this early stage. At thirty-nine millimetres
CR-length the labral tissue was still too immature to allow any definite statement of this kind,
but the histological picture resembled that of fibrous tissue with a small transition zone

: --
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.-

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t(.bt t r-\ t2. .- I . AN .

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FIG. 4
Oblique section II of a shoulder joint
at 39 millimetres CR-length. The
posterior joint space shows well, and
the anterior joint space has just started
to develop. The labrum resembles
fibrous tissue with a small transition
zone, although the development of the
tissues has not yet reached the stage
where a definite statement could be
made. (Haematoxylin and eosin, - 30.)

towards the hyaline cartilage of the glenoid fossa. (See Figure 4, which shows a joint space
posteriorly; the anterior joint space has just started to develop.)
From our next specimen, with a CR-length of sixty-six millimetres, and on up to term,
the capsular mechanisms had a fairly consistent pattern; so one common description of the
different stages will be sufficient for our purpose.
The microscopical studies of the glenoid labrum
showed it to consist of dense fibrous
connective tissue. On the transverse sections it had
a wedge- or washer-like appearance, and
it was continuous with the capsular tissue on one side and with the periosteum ofthe scapular neck
on the other (Figs. 5 and 6). Fibrocartilage was found in all cases, but it was confined to only a
small and narrow transition zone, grading from the hyaline cartilage of the glenoid fossa into the
fibrous tissue of the capsule. The fibrocartilage was situated where the capsule, the periosteum
of the scapular neck, and the hyaline articular cartilage of the glenoid fossa meet (Fig. 6).

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 RECURRENT ANTERIOR DISLOCATION OF THE SHOULDER 919

Our studies also showed that the labrum was a structure which varied in its shape in
relation to the state of rotation of the humeral head. This is illustrated in Figures 5 and 6,
which show a transverse section through the anterior and the posterior capsular mechanisms
in a foetus at term, taken just below the coracoid process (Section II). The humeral head is in
medial rotation. The attachment of the capsule to the bony glenoid rim is made up of fibrous
connective tissue of the same kind as in the capsule itself, with a narrow transitional zone of
fibrocartilage at the point of the glenoid rim. Anteriorly (Fig. 5) this capsular tissue is seen
to fold up when the humeral head is in medial rotation, thus forming a washer-shaped,
functional labrum, which will straighten out and disappear if the head is rotated laterally.

- ro#{149}st)eutr\o{

-- - 5cc.pulcLr r*ciob

! --

p5l.:;:1(.. 01-1.5 )1-(

t53ti - t}Q #{149} --0d -

FIG. 5 ub5ccip / I 3
Section 11 of a gleno-humeral in a foetus joint
at term. The humeral is in medialhead
h
rotation. Shows well the typical functional
fibrous labrum, made up of folds of capsular ) I -
I
- .- *Ct*
Q-L
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-
-
#{149}
- - .
- . - -
.
-
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tissue, which is heavier in this region of II , L
attachment. The labrum will straighten out
if the humeral head is laterally rotated. jout. i / -? (old5 oti ccpdc
(Modified Masson, - 15.)
5 c ti ue wEch. -w ill
- /5tL oL.* eL

Posteriorly (Fig. 6) no labrum could be seen when the posterior part of the capsule was
tight in medial rotation of the humeral head. We found the same arrangement in adult
shoulder joints.
Those labra which had been removed from necropsy specimens and those excised at
operation were also shown to consist of dense fibrous connective tissue, covered by synovial
membrane and continuous with the capsule. Fibrocartilage was also present here in the shape
of a small, narrow transition zone, as described before. In one case of arthrodesis of the
shoulder, however, the transition zone of fibrocartilage was larger, so that in some cross-
sections of the labrum up to approximately 50 per cent of the labral tissue consisted of
fibrocartilage; the rest was, as usual, made up of dense fibrous connective tissue.

VOL. 44 B, NO. 4, NOVEMBER 1962

920 H. F. MOSELEY AND B. VERGAARD

THE GLENO-HUMERAL LIGAMENTS AND TIlE SYNOVIAL RECESSES

These were studied on the dissected anatomical and necropsy specimens.

The superior gleno-humeral ligament was found in all but two of the seventy-five specimens.
Its size was rather variable.
The middle gleno-humeral ligament was found to be a variable structure. It could be identified
in all specimens, but was poorly defined in four. It originated from the scapular neck and

?ro5 - -

t.O -owt-. - -

- -

- -- , -.

- 4
- C#{231}
FIG. 6
----

Same section
as Figure 5. It shows the 7 -
region theof posterior labrum. _*/_ crt-
Apparently there exists no labrum at all
when the posterior capsule is stretched
by the medially rotated humeral head. - {*
The fibrocartilaginous transition zone is
well shown. (Modified Masson, - 12.)

5.tOt\- zOt\cz

from the labrum, just below the origin of the superior gleno-humeral ligament. The origins
of the ligament showed all variations from being completely labral to partly labral and partly
arising from the scapular neck; and finally, arising only from the scapular neck with no
attachment to the labrum (Figs. 7 to 10). The ligament was inserted together with the
subscapularis tendon on the lesser tuberosity. The length, width and thickness of the ligament
all showed considerable variability. The ligament became tense when the arm of the cadaver
was rotated laterally and dorsally flexed when in a dependent or slightly abducted position.
This agrees with the observations of Delorme.
The inferior gleno-humeral ligatnent in our series could be identified in all cases : it was a well
formed distinct structure in sixty-nine joints; in six it was merely a diffuse thickening of the
capsule. In all cases it arose from the antero-inferior part of the labrum and blended
with the capsule between the subscapularis and the triceps. Figure 9 shows a well defined
inferior gleno-humeral ligament, a poorly defined middle gleno-humeral ligament and a large
subscapularis recess. The inferior gleno-humeral ligament was found to tighten with increasing
abduction and lateral rotation in the gleno-humeral joint; the upper fibres of the ligament
were more tense in slight abduction, the lower more tense in pronounced abduction, while
the entire ligament was active in the intermediate position.

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 RECURRENT ANTERIOR DISLOCATION OF THE SHOULDER 921

THE SYNOVIAL RECESSES

The size of the subscapularis bursa and the subscapularis recess showed great variability,
although the topographical arrangement of the recesses could be divided into four types (the
classification of DePalma ci a!. has been used): in Type I there is one synovial recess above
the middle gleno-humeral ligament; this was the case in five (67 per cent) of our specimens.
Type II is characterised by one synovial recess below the middle gleno-humeral ligament:

qLzt\o-hutt\.
Lq3: -

-. )

(5p FIG. 7
The anterior capsular
mechanism viewed from
within the shoulder joint
in a dissected specimen
from a woman aged eighty-
seven. The humeral head
has been removed. All
three gleno-humeral liga-
ments are well seen and
arise from the glenoid
labrum. (Type I, Fig. 10.)
-2
O3-3(L -

two (27 per cent) of our specimens were arranged in this way. In Type III there are two
synovial recesses, one above the middle gleno-humeral ligament and one below; this
arrangement was present in sixty-seven (893 per cent) of our specimens. Finally, Type IV is
characterised by one large synovial recess above the inferior gleno-humeral ligament and by
the absence of the middle gleno-humeral ligament. In one of our cases we found a large
recess of this type; the middle gleno-humeral ligament was present, however, but poorly
developed (Fig. 9).
THE CLINICAL SERIES
As previously mentioned, our clinical material consists of twenty-five consecutive cases
of recurrent anterior dislocation of the shoulder, repaired by a modification of Bankarts

VOL. 44 B, NO. 4, NOVEMBER 1962

L
922 H. F. MOSELEY AND B. VERGAARD

procedure, using a Vitallium rim. The basic lesions in the anterior capsular mechanism,
which could be seen in our standard anterior approach to the shoulder, were recorded in
colour stereoscopic photography, which provided an excellent medium for further study of
these lesions. In addition, the laxity of the subscapularis muscle was demonstrated, and the
postero-lateral notch on the humeral head was palpated. The following points were noted.

.p_,.4_.. 11

- -
.-\

FIG. 8
Same view as in Figure 7. In this specimen
the middle gleno-humeral ligament is
attached partly to the labruin and partly to
the scapular neck (Type II, Fig. 10). Note
also the opening into the subscapularis bursa
and the inferior (subscapularis) recess. The
lower photograph is another view of same
specimen.

Laxity of the subscapularis muscle and tendon was demonstrable in all cases : in some
cases the tendon was also greatly attenuated and deficient inferiorly at its attachment to the
lesser tuberosity.
A postero-lateral notch of variable size in the humeral head was palpable in all cases;
it could also be demonstrated in all cases on pre-operative radiography in suitable projections.
The basic lesions of the anterior capsular mechanism, as observed after arthrotomy had
been performed, could be grouped into the following types.
The Bankart lesion-This type of lesion was present in twenty-one cases. The soft tissues-
that is, the labrum and capsule-were detached to a variable extent from the antero-inferior
bony glenoid rim. The extent of the detachment varied from one centimetre up to the entire

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 RECURRENT ANTERIOR DISLOCATION OF THE SHOULDER 923

anterior half of the soft-tissue attachment. The labrum was also split longitudinally in a few
cases. Fragmentation of the labrum was a common finding.
In
ten cases showing this type of lesion the periosteum of the scapular neck was also
raised as a sleeve, as described by Broca and Hartmann (1890), so that when the humeral
head dislocated into the subscapular space it pushed the capsular, labral and periosteal sleeve

tbaz 3t1Z-r-*d5 -uc3c1 c5t

Dt5QtO#{248} OG Pootli d\*cl.-

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0a -aai
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FIG. 9
This specimen (same view as in the
previous two figures) shows a poorly
defined middle gleno-humeral ligament,
arising only from the scapular neck, thus
taking part in creating a large anterior
pouch (Type III, Fig. 10).

in front of it. It could also be demonstrated that the joint capsule and the periosteum of the
scapular neck were directly continuous with each other.
In four cases of long duration showing these lesions calcification had occurred, usually
localised at the periphery of the avulsed periosteum.
Anterior pouch with intact glenoid labrum-This arrangement was observed in four cases.
In these the soft-tissue attachment to the glenoid rim was found to be intact. There was a
large anterior pouch with synovial lining, extending up under the coracoid process. In three
of these cases the middle gleno-humeral ligament was identified, and it was found to be
attached far medially on the scapular neck, with no connection at all to the labrum; the
ligament itself including its scapular attachment also appeared intact. In this way the ligament
took part in creating the large anterior pouch which could readily accommodate the humeral
head. In the third case the middle gleno-humeral ligament was not discernible.
It should be stressed that in these four cases, as well as in all the other cases, there was
also demonstrated a postero-lateral notch in the humeral head.

VOL. 44 B, NO. 4, NOVEMBER 1962

924 H. F. MOSELEY AND B. VERGAARD

r%.,t0ct

FIG. 10
The upper drawing shows the anterior pouch present in
Type Ill arrangement of the middle
gleno-humeral ligament. Types I, II and Ill below are diagrammatic cross-sections of the
middle gleno-humeral ligament as seen in specimens in Figures 7, 8 and 9.

DISCUSSION

Our examinations of embryological and foetal labra and of those obtained from necropsy
specimens and removed at operation revealed that the so-called labrum glenoidale was
practically devoid of fibrocartilage and was essentially made up of fibrous tissue. in only one
of eighty specimens examined was there a considerable proportion of fibrocartilage (up to
50 per cent). In all the other cases, including all the cases ofrecurrent dislocation, fibrocartilage,
as mentioned before, was confined to a small transition zone at the soft-tissue attachment on
the osseous glenoid rim : the rest of the labrum was made up of dense fibrous connective
tissue, the histological appearance of which resembled that of dense fibrous connective tissue
in general and did not resemble the appearance of the semilunar cartilage of the knee (McMillan
1961). In current text-books of histology (Greep 1954, Ham 1957, Bailey 1958, Finerty and
Cowdry 1960) fibrocartilage is defined as a combination of dense collagenous fibrous tissue
and cartilage cells, chondrocytes. The latter are enclosed in capsules and are often arranged

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 RECURRENT ANTERIOR DISLOCATION OF THE SHOULDER 925

in rows between which are dense bundles of collagenous fibres. This definition has been used
by us when distinguishing between hyaline cartilage, fibrocartilage and fibrous connective
tissue in order to define the fibrocartilaginous transition zone. The question concerning the
presence of fibrocartilage in the glenoid labrum during the foetal period has been a matter of
dispute. Haines (1947), for instance, reported a conspicuous fibrocartilaginous labrum at
twenty-three millimetres CR-length, and he also found the glenoid surface of the scapula to be
covered with a layer of fibrocartilage at sixty-six millimetres. Gardner and Gray (1953), in
their comprehensive study of the pre-natal development of the shoulder, could not confirm
these findings of Haines ; they were not able to find definite fibrocartilage in any shoulder
joint. However, they believed that the appearance of the area of the labrum next to the
scapula in a foetus at term suggested the appearance of fibrocartilage, the rest of the labrum
being densely fibrous.
It is also worth mentioning that Gegenbaur (quoted by Fick 1910) considered the labrum
to be part of the capsule, and Fick also pointed out that the chondrocytes were confined mainly
to the area of attachment of the labrum to the bony rim.
In conclusion, then, our studies did not show the glenoid labrum to be a consistent
structure comparable to a semilunar cartilage as is the current belief. Instead, it is evidently
a redundant fold of the capsular tissue as it attaches to the osseous glenoid rim, and it changes
its shape with different states of rotation of the humeral head, acting like a washer at the
synovial reflection at the periphery of the joint cavity in full rotation of the humeral head.
This concept is in complete agreement with that of Townley (1950, 1959), but we have not
been able to find a similar interpretation elsewhere in the literature studied.
Our dissections of necropsy specimens demonstrated the great variability in the
arrangement of the gleno-humeral ligaments and the synovial recesses of the anterior capsular
mechanism. We recognised four of the six different types of arrangement of these ligaments
and recesses described by DePalma our series was smaller
et a!. ; than theirs. In those cases
where the middle gleno-humeral ligament was poorly developed or attached a considerable
distance medially on the scapular neck with no connection at all with the labrum, an anterior
synovial pouch of variable, often considerable, size, allowing admittance of the humeral head,
was present.
It was most interesting to correlate these with the operative findings. As already
mentioned, we had in our clinical series four cases showing a completely intact soft-tissue
attachment to the anterior glenoid rim. In three of these cases the middle gleno-humeral
ligament arose well back on the scapular neck without attachment to the labrum, thus taking
part in the formation of a large anterior pouch ; in the fourth case no middle ligament could
be seen. One of these patients was a young man of pronounced asthenic habitus. His first
three displacements were spontaneously reduced subluxations which occurred without
antecedent trauma, but the last three were complete and required reduction in hospital.
There was no significant difference in the number of dislocations between the patients in this
group and those with Bankart lesions. However, we formed a definite impression that the
injuries leading to dislocation in the former group of patients were uniformly less severe
than those leading to dislocation in the other group. In addition, the dislocations in the former
group were also as a rule self-reduced, and only in rare instances was the help of a doctor
required. In this group ofcases the soft-tissue attachment to the anterior osseous rim, including
the labrum, was found intact. This pattern of post-traumatic anatomy was also noted by
McLaughlin (1960), who called it pseudo-sleeve avulsion when the subscapularis bursa

and recess are opened widely by rupture of the middle gleno-humeral ligament but the anterior
labrum and the scapular periosteum remain intact. Our investigation shows, however, how
the normal variation in the arrangement of the anatomical components of the anterior capsular
mechanism can provide the basis for such a pattern of morbid anatomy.
As mentioned before, a postero-lateral notch on the humeral head was found also in all

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926 H. F. MOSELEY AND B. VERGAARD

those cases which showed an intact soft-tissue attachment to the glenoid rim ; this has not to
our knowledge been previously reported in the literature.
Laxity of the subscapularis of varying degree could easily be demonstrated in all our
cases. We are, therefore, in complete disagreement with the opinion of Dickson, Humphries
and ODell (1953), who stated that laxity
of the subscapularis must remain a clinical
impression, for it is not accurately demonstrable.

SUMMARY
1 . The concept of the capsular mechanism of the shoulder joint with regard to recurrent
anterior dislocation of the shoulder has been defined and a survey of the literature presented.
2. An anatomical, including an embryological, investigation of shoulder joints with special
reference to the structure and function of the glenoid labrum and to the variations in the
arrangement of the gleno-humeral ligaments and the synovial recesses of the anterior capsular
mechanism is reported. The labrum, which is generally believed to be a consistent,
fibrocartilaginous structure, is shown to be a redundant portion of capsular tissue and a
continuation of the capsule as it attaches to the osseous glenoid rim. The fibrocartilaginous
element is confined to a small transition zone at the capsular attachment in the great majority
of cases. The great variability in the arrangement of the gleno-humeral ligaments and synovial
recesses is stressed, and it is shown that an anterior pouch of variable size is present when
the middle gleno-humeral ligament is attached to the scapular neck and not to the labrum.
3. The basic lesions of the anterior capsular mechanism found at operation for recurrent
anterior dislocation of the shoulder in twenty-five consecutive cases using a modified Bankart
procedure with a standard anterior approach to the joint are reported, and the findings are
correlated with the results of the anatomical investigation. In most cases the lesions were
found to be of the Bankart type with or without avulsion of the periosteum of the scapular
neck. In four cases, however, the soft-tissue attachment to the anterior glenoid rim was intact;
in those cases a large synovial pouch was present and the middle gleno-humeral ligament
was either not discernible or it arose from the scapular neck. In all cases a postero-lateral
notch on the humeral head was palpable and laxity ofthe subscapularis could be demonstrated.
When measured, the joint capacity was always greatly augmented.
4. The present work shows, from a basic standpoint, that Bankarts original idea that the
recurrent state was due to the failure of healing of the fractured fibrocartilaginous glenoid
labrum is no longer tenable.
5. Finally, the anomalous attachment or the insufficient development of the middle gleno-
humeral ligament in certain cases of recurrent anterior shoulder dislocation is shown to
provide the anatomical basis for the recurrent state in these cases ; this is the weak area in
the antero-inferior part of the capsule which has been described in the literature for the past
hundred years. Thus we have returned to the original view of Hippocrates.

We wish to express our gratitude to

Gardner Professor
of the Department E. of Anatomy, Wayne State
University, Detroit, for allowing us to
of his foetal use
shoulder part
material. Dr J. Langman and
Dr S. M. Banfill of the Department of Anatomy, McGill University, have kindly placed anatomical and foetal
material at our disposal. Professor G. C. McMillan, Chairman of the Department of Pathology, McGill
University, has Spent considerable time in assisting us with the microscopical studies for which we are greatly
indebted to him.

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