On November 3, 1936, the same day Franklin Roosevelt was reelected president of the United States, a laborer in his early twenties fell and was seen for a shoulder dislocation at New York’s Hospital for Joint Diseases. Dr. Henry Milch, a 41 year old orthopedic surgeon, attended the case and under general anesthesia, applied Kocher’s maneuver. He encountered resistance, as often occurs with reductions, and he pressed forward. A loud snapping sound was heard as the arm gave way to a spiral humeral fracture.
Now Dr. Milch had no choice but to operate. The long head of the biceps bound one of the fracture fragments. Cutting it was not enough to free the fragment. He had to cut the “pectoralis major, the coracobrachialis, the short head of the biceps, the latissmus dorsi, the subscapularis, and finally the medial portion of the capsule. Only then could reposition be accomplished.” Milch commented drily: “Ultimate return of moderate function rewarded these efforts.”
The case clearly bothered him and he began to question the use of the Kocher technique. “The spice of science was friendly controversy” as was said of him. Kocher’s method was the paradigm and Milch began to explore alternatives. “The chance application of any of the other methods is often greeted with complete astonishment,” he said at the time. But Milch wanted something safer [it is not known whether Milch read German, as Kocher’s original article excluded force against resistance].
Milch’s interests included music and mathematics. He was a founding member of the Doctor’s Orchestra of New York. He probably went home and played the viola while he thought about the case.
“It seemed…the head, fixed in internal rotation by the biceps or the internal rotators had been split in a spiral manner…” He thought of a recent article he had read, which attributed the obstruction in reduction to the long head of the biceps. That fit his case. But Stimson thought the obstruction was from the capsule and Speed thought it was the subscapularis and pectoralis major. Which was right?
For that he turned to his other interest, mathematics. “In different manner and degree all the shoulder muscles must exert their forces on the dislocated as well as the normally placed humeral head. Indeed, even allowing for their natural elasticity, it is hardly conceivable that muscles, adapted to a normal position, should not exert incalculable abnormal stresses in the suddenly altered relationship between the humeral head and the glenoid cavity.”
In the anatomic position the muscle alignment appears at first to be haphazard “some of the muscles run upward and outward, some downward and outward, others up and down, and still others simply outward.” How could any technique be safe? In any direction there is a muscle to oppose the movement.
Ever the mathematician, Milch drew lines of forces on a radiograph of an arm in the overhead position. In this position “the cross-stresses due to the oblique course of the different muscles are absent or are reduced to a minimum.”
So why were reductions not done in the overhead position? Milch noted that the technique of upward traction is as old as Celsus (though I could not locate that in De Medicina. – JN) The technique was thought to risk injury from stretching the arteries and nerves of the axilla. Though skeptical of such claims, Milch nonetheless devised a way around them.
Step 1 is bracing the humeral head against the glenoid rim, using your hand (Milch originally said to use the thumb). Milch, like Kocher, is a leverage technique.
Step 2 is abduction of the arm. “As the arm is abducted, it is gently externally rotated to release the twisted capsule… Once the arm has been brought into complete abduction in this overhead position, all cross-stresses exerted by all the muscles have been eliminated….”
Step 3 is “pulsion” or pushing the head over the rim. [In this position] “…the head can be gently pushed over the rim of the glenoid…”
He states that it can be done without sedation if the physician “has the patient’s confidence and does not abuse it by causing excessive or unnecessary pain.” He proposed the name for this procedure as “abduction, external rotation, and pulsion.” Descriptive names are more helpful but potentially more tedious, as one must rehearse the procedure in speaking its name. That and his introduction of the name in the penultimate paragraph of his article prevented its adoption. The procedure became known simply as “Milch.”
Modern modifications to Milch are often employed, such as adding a small amount of traction to assist the last part of reduction.
Lessons for today:
-Milch is a leverage technique, so brace the humeral head against the glenoid using your hand
-Milch was not originally a traction technique.
-It can be done without sedation.
-Milch is also a pulsion technique where the humeral head is pushed in manually.
-Kocher’s original article opposed forceful reduction.
Milch H. Treatment of Dislocation of the Shoulder. Surgery. 1938;3:732-740