While the prognosis is favourable on the whole, recovery is usually attended with fibrous ankylosis and incapacity to raise the arm above the level of the shoulder. The disease often progresses slowly, and may last for years.

Treatment.—The limb should be immobilised in the position of abduction with the forearm and hand directed forwards; the most efficient apparatus is a plaster spica embracing the thorax and the upper limb down as far as the wrist. If the articular surfaces are affected and the disease is likely to lead to ankylosis, the arm should be abducted to a right angle. The severe pain of caries sicca may be relieved by blistering or by the application of the cautery. To inject iodoform, the needle is introduced either immediately outside the coracoid process, or just below the junction of the acromion process and spine of the scapula. When the disease does not yield to conservative measures, or the X-rays show a gross lesion in the bone, excision of the joint should be performed; a close fibrous ankylosis usually results, and the arm is quite a useful one provided the abducted position has been maintained throughout.

Pyogenic Diseases.—The shoulder-joint may be infected by extension of suppurative osteomyelitis from the upper end of the humerus, or from suppuration in the axilla, or through the blood stream by ordinary pus organisms, pneumococci, typhoid bacilli, or gonococci. Extension should be applied to the arm abducted at a right angle. When it is necessary to open the joint, the incision should be placed anteriorly in the line of the inter-tubercular groove; if a counter-opening is required it is made on the posterior aspect by cutting on the point of a dressing forceps introduced through the anterior incision.

Arthritis Deformans.—The shoulder is seldom affected alone, except when the arthritis is a sequel to injury, such as a fracture of the neck of the humerus. The common type of lesion is a dry arthritis with fibrillation and eburnation of the articular surfaces. The long tendon of the biceps is usually destroyed, the head of the bone is drawn upwards, and, after wearing through the capsule, rubs on the under surface of the acromion, which also becomes eburnated. The clinical features are pain, stiffness, and cracking on movement, and as these symptoms may also be caused by loose bodies in the joint, an X-ray picture should be taken to differentiate between them.

Neuro-arthropathies of the shoulder are met with chiefly in syringomyelia. In some cases there is a large fluctuating and painless swelling; in others marked and rapid wasting of the deltoid and scapular muscles with flail-like movements of the joint associated with disappearance of the upper end of the humerus (Fig. 104).



Loose bodies are rare in the shoulder; we have met with a case in which the joint-cavity was distended with loose bodies of synovial origin, and as most of these had undergone ossification, the X-ray appearances were highly characteristic. They were removed through an anterior incision.

Ankylosis is not so disabling at the shoulder as at other joints, as the mobility of the scapula on the chest wall largely compensates for the fixation of the joint.

THE ELBOW-JOINT

In disease of the elbow, the usual attitude is that of flexion with pronation of the hand. Swelling of the joint, whether from effusion of fluid or from thickening of the synovial membrane, is observed chiefly on the posterior aspect, above and on either side of the olecranon, because the synovial sac is here nearest the surface. The free communication between the elbow and the superior radio-ulnar joint should be borne in mind.



Tuberculous disease is the most common and important affection (Fig. 106). It usually occurs in patients under twenty, but may be met with at any age; in children the age-incidence is earlier than in the other large joints, a considerable proportion being met with in the first two years of life (Stiles). When the disease is confined to the synovial membrane, its onset is insidious, there is little or no pain, and no interference with any movement except complete extension. The chief evidence of disease is a white swelling on either side of and above the olecranon, obscuring the bony landmarks. The further progress is attended with wasting of the triceps, symptoms of involvement of the articular surfaces, and with abscess formation.



The occurrence of articular caries without swelling of the synovial membrane is exceptional, and is associated with a good deal of pain and considerable restriction of movement. Rigidity from muscular contraction occurs late, and is rarely complete. Tuberculous foci in the bones are met with chiefly in the lower end of the diaphysis of the humerus; in children, the epiphyses are so small that the ossifying junction is intra-articular. Foci are also met with in the upper end of the ulna. The grosser osseous lesions cause enlargement of the bone, and are readily demonstrated by skiagraphy. Abscess formation most commonly occurs beneath the triceps, and the abscess points at one or other edge of that muscle. A subcutaneous abscess may form over the upper end of the ulna or over the radio-humeral joint. Tuberculous hydrops with melon-seed bodies is rare.



Treatment.—Conservative measures are persevered with so long as there is a prospect of securing a movable joint. The limb is placed in a light form of splint reaching from the axilla to the wrist, flexed to rather less than a right angle and with the hand semi-pronated and dorsiflexed. To inject iodoform or other anti-tuberculous agent, the needle of the syringe is easily introduced between the lateral condyle and the head of the radius. A localised focus of disease in one or other of the bones may be eradicated without opening into the synovial cavity.

If the articular surfaces are so involved that recovery is likely to be attended with ankylosis, the disease should be removed by operation, and cure with a useful and movable joint may then be reasonably anticipated within two or three months. When the patient's occupation is such that a strong stiff joint is preferable to a weaker movable one, bony ankylosis at rather less than a right angle should be aimed at.

Arthritis deformans occurs as a hydrops with hypertrophy of the synovial fringes and loose bodies, or as a dry arthritis with eburnation and lipping of the articular margins.

Neuro-arthropathies are met with chiefly in syringomyelia, and are attended with striking alterations in the shape of the bones and with abnormal mobility.

Pyogenic diseases result from staphylococcal osteomyelitis—chiefly of the humerus or ulna—and from gonorrhoea.

The remaining diseases at the elbow include syphilitic disease in young children, bleeder's joint, hysterical affections, and loose bodies, and do not call for special description.

Ankylosis of the elbow-joint, if interfering with the livelihood of the patient, may be got rid of by resecting the articular ends of the bones, or by inserting between them a flap of fascia and subcutaneous fat derived from the posterior aspect of the upper arm—arthroplasty.

THE WRIST-JOINT

The close proximity of the flexor sheaths to the carpal articulations permits of infective processes spreading readily from one to the other. The arrangement of the synovial membranes also favours the extension of disease throughout the numerous articulations in the region of the wrist.

Tuberculous disease is met with chiefly in young adults, but may occur at any age. It usually originates in the synovial membrane, but foci are frequently present in the carpal bones, and less commonly in the lower ends of the radius and ulna, or in the bases of the metacarpals. The clinical features are almost invariably those of white swelling, which is most marked on the dorsum where it obscures the bony prominences and the outlines of the extensor tendons. Wasting of the thenar and hypothenar eminences, and filling up of the hollows above and below the anterior annular ligament, render the appearance on the palmar aspect characteristic.

The attitude is one of slight flexion with drooping of the hand and fingers. The fingers become stiff as a result of adhesions in the tendon sheaths, and the power of opposing the thumb and fingers may be lost. Pain is usually absent until the articular surfaces become carious. Softening of the ligaments may permit of lateral mobility, and sometimes partial dislocation occurs. Abscess may be followed by sinuses and infection of the tendon sheaths, especially those in the palm.

The localisation of disease in individual bones or joints can be determined by the use of the X-rays.

Treatment.—Conservative measures may be persevered with over a longer period than in most other joints. The forearm, wrist, and metacarpus are immobilised in the attitude of dorsal flexion, while the fingers and thumb are left free to allow of passive movements. It may be necessary to give an anaesthetic to obtain the necessary degree of dorsiflexion. To inject iodoform, the needle is inserted immediately below the radial or the ulnar styloid process. Sometimes the carpal bones are so soft that the needle can be made to penetrate them in different directions. Operative treatment is indicated in cases which resist conservative measures, or when the general health calls for speedy removal of the disease.

Other diseases of the wrist are comparatively rare. They include pyogenic affections, such as those resulting from infective conditions in the palm of the hand, different types of gonorrhoeal, rheumatic, and gouty affections, and arthritis deformans. An interesting feature, sometimes met with in arthritis deformans, consists in eburnation of the articular surfaces of the carpal bones, although the range of movement is almost nil.

THE HIP-JOINT

Owing to the depth of this joint from the surface, it is not possible to detect the presence of effusion or of synovial thickening as readily as in other joints, hence in the recognition of hip disease we have to rely largely upon indirect evidence, such as a limp in walking, an alteration in the attitude of the limb, or restriction of its movements.

The whole of the anterior and fully one-half of the posterior aspect of the neck of the femur is covered by synovial membrane, so that lesions not only of the epiphysis and epiphysial junction, but also of the neck of the bone, are capable of spreading directly to the synovial membrane and to the cavity of the joint. Conversely, disease in the synovial membrane may spread to the bone in relation to it. Infective material may escape from the joint into the surrounding tissues through any weak point in the capsule, particularly through the bursa which intervenes between the capsule and the ilio-psoas, and which in one out of every ten subjects communicates with the joint.

TUBERCULOUS DISEASE

Tuberculous disease of the hip, morbus coxae, or "hip-joint disease," is especially common in the poorer classes. It is a frequent cause of prolonged invalidism, and of permanent deformity, and is attended with a considerable mortality. It is essentially a disease of early life, rarely commencing after puberty, and almost never after maturity.

Pathological Anatomy.—Bone lesions bulk more largely in hip disease than they do in disease of other joints—five cases originating in bone to one in synovial membrane being the usual estimate. The upper end of the femur and the acetabulum are affected with about equal frequency.

In addition to primary tuberculous lesions, secondary changes result from the inflamed and softened bones pressing against one another subsequent to the destruction of their articular cartilages. The head of the femur undergoes absorption from above downwards, becoming flattened and truncated, or disappearing altogether. In the acetabulum the absorption takes place in an upward and backward direction, whereby the socket becomes enlarged and elongated towards the dorsum ilii. To this progressive enlargement of the socket Volkmann gave the suggestive name of "wandering acetabulum" (Fig. 108). The displacement of the femur resulting from these secondary changes is one of the causes of real shortening of the limb.



Clinical Features.—It is customary to describe three stages in the progress of hip disease, but this is arbitrary and only adopted for convenience of description.

Initial Stage.—At this stage the disease is confined to a focus in the bone which has not yet opened into the joint or to the synovial membrane. The onset is insidious, and if injury is alleged as an exciting cause, some weeks have usually elapsed between the receipt of the injury and the onset of symptoms. The child is brought for advice because he has begun to limp and to complain of pain. There is a history that he has become pale and has ceased to take food well, that his sleep has been disturbed, and that the pain and the limp, after coming and going for a time, have become more pronounced. On walking, the affected limb is dragged in such a way as to avoid movement at the hip, and to substitute for it movement at the lumbo-sacral junction. The child throws the weight of the trunk as little as possible on to the affected limb, and inclines to rest on the balls of the toes rather than on the sole. There is usually some wasting of the muscles of the thigh and flattening of the buttock. Diminution or loss of the gluteal fold indicates flexion at the hip which might otherwise escape notice. Pain is complained of in the hip, or is referred to the medial side of the knee, in the distribution of the obturator nerve. Sometimes the pain is confined to the knee, and if the examination is restricted to that joint the disease at the hip may be overlooked. At this stage the attitude of the limb is not constant; at one time it may be natural, and at another slightly flexed and abducted. Tenderness of the joint may be elicited by pressing either in front or behind the head of the bone, but is of little diagnostic importance. Pain elicited on driving the head against the acetabulum may occasionally assist in the recognition of hip disease, but the diagnostic value of this sign has been overrated and, in our opinion, this test should be omitted.

Most information is gained by testing the functions of the joint, and if this is done gently and without jerking, it does not cause pain. The child should lie on his back, either on his nurse's knee or on a table; and to reassure him the movements should be first practised on the sound limb. On slowly flexing the thigh of the affected limb, it will be found that the range of flexion at the hip is soon exhausted, and that any further movement in this direction takes place at the lumbo-sacral junction. The child is next made to lie on his face with the knees flexed in order that the movements of rotation may be tested. The thigh is rotated in both directions, and on comparing the two sides it will be found that rotation is restricted or abolished on the side affected, any apparent rotation taking place at the lumbo-sacral junction. These tests reveal the presence of rigidity resulting from the involuntary contraction of muscles, which is the most reliable sign of hip disease during the initial stage, and they possess the advantage of being universally applicable, even in the case of young children.

Second Stage.—This probably corresponds with commencing disease of the articular surfaces, and progressive involvement of all the structures of the joint. The child complains more, and usually exhibits the attitude of abduction, eversion, and flexion (Fig. 109).



At first the attitude is maintained entirely by the action of muscles; but when it is prolonged, the muscles, fasciae, and ligaments undergo shortening, so that it becomes fixed.

On looking at the patient, the abnormal attitude may not be at once evident, as he usually restores the parallelism of the limbs by lowering the pelvis on the affected side and adducting the sound limb. This obliquity or tilting of the pelvis causes apparent lengthening of the diseased limb, and is best demonstrated by drawing one straight line between the anterior iliac spines, and another to meet it from the xiphoid cartilage through the umbilicus; if the pelvis is in its normal position, the two lines intersect at right angles; if it is tilted, the angles at the point of intersection are unequal. The flexion may be largely compensated for by increasing the forward curve of the lumbar spine (lordosis), and by flexing the leg at the knee. There may also be an attempt to compensate for the eversion of the limb by rotating the pelvis forwards on the affected side.



To demonstrate the lordosis, the patient should be laid on a flat table; in the resting position the lordosis is moderate, when the hip is flexed it disappears, when it is extended the lordosis is exaggerated, and the hand or closed fist may be inserted between the spine and the table (Fig. 112).



When the functions of the joint are tested, it will be found that there is rigidity, and that both active and passive movements take place at the lumbo-sacral junction instead of at the hip. While rigidity is usually absolute as regards rotation, it may sometimes be possible with care and gentleness to obtain some increase of flexion. For diagnostic purposes most stress should therefore be laid on the presence or absence of rotation.

If the sound limb is flexed at the hip and knee until the lumbar spine is in contact with the table, the real flexion of the diseased hip becomes manifest, and may be roughly measured by observing the angle between the thigh and the table (Fig. 113). This is known as "Thomas' flexion test," and is founded upon the inability to extend the diseased hip without producing lordosis.



Swelling is seen on the anterior aspect of the joint; it may fill up the fold of the groin and push forward the femoral vessels. It is doughy and elastic, but may at any time liquefy and form a cold abscess. Swelling about the trochanter and neck of the bone may be estimated by measuring the antero-posterior diameter with callipers, and comparing with the sound side. Swelling on the pelvic aspect of the acetabulum can sometimes be discovered on rectal examination.

Third Stage.—This probably corresponds with caries of the articular surfaces, since pain is now a prominent feature, and there are usually startings at night. The attitude is one of adduction, inversion, flexion, and apparent or real shortening of the limb (Fig. 114). The flexion is usually so pronounced that it can no longer be concealed by lordosis, so that when the patient is recumbent, although the spine is arched forwards, the limb is still flexed both at the hip and at the knee; with the spine flat on the table, the flexion of the thigh may amount to as much as a right angle. The adduction varies greatly in degree; when it is slight, as is most often the case, the toes of the affected limb rest on the dorsum of the sound foot. When moderate, it is compensated for by raising the pelvis on the affected side, with apparent shortening of the limb, this being the result of an effort on the part of the patient to restore the normal parallelism of the limbs, the sound limb being abducted to the same extent as the affected limb is adducted. It is important to recognise the cause of this shortening, as it can be corrected by treatment. As a result of the obliquity of the pelvis, the patient, when erect, exhibits a lateral curvature of the spine with the dorso-lumbar convexity to the sound side.



When adduction is pronounced, the patient is unable to restore the normal parallelism of the limbs, and the knee on the affected side may cross the sound limb. There is a deep groove at the junction of the perineum and thigh, great prominence of the trochanter, and the pelvis may be tilted to such an extent that the iliac crest comes into contact with the lower ribs.

As a result of the pressure of the carious articular surfaces against one another, the acetabulum is enlarged and the upper end of the femur is drawn gradually upwards and backwards within the socket. Examination will then reveal the existence of a variable amount of actual shortening; it will also be found that the trochanter is displaced above Nelaton's line, while above and behind the trochanter there is a prominent hard swelling corresponding to the enlarged acetabulum.

There may, therefore, be a combination of real and apparent shortening together amounting to several inches (Fig. 115).



In cases of long standing, beginning in childhood, the shortening is still further added to by deficient growth in length of the femur, and it may be of all the bones of the limb; even the foot is smaller on the affected side.

The most reasonable explanation of the attitudes assumed in hip disease is that given by Koenig. If the patient walks without crutches, as he is usually able to do at an early stage of the disease, the attitude of abduction, eversion, and slight flexion enables him to save the limb to the utmost extent; on the other hand, if he uses a crutch, as he is obliged to do at a more advanced stage, he no longer uses the limb for support, and therefore draws it upwards and medially into the position of adduction, inversion, and greater flexion. Similarly, if he is confined to bed, he lies on the sound side, and the affected limb sinks by gravity so as to lie over the normal one in the position of adduction, inversion, and flexion. Koenig's explanation accords with the fact that in the exceptional cases which begin with adduction and inversion we have usually to deal with a severe type of the disease, associated with grave osseous lesions—precisely those cases in which the patient is compelled from the outset to lie up or to adopt the use of crutches. Further, the transition from the abducted to the adducted position usually follows upon such an aggravation of the symptoms that the patient is no longer able to walk without the assistance of a crutch.

During the third stage the other signs and symptoms become more pronounced; the patient looks ill and thin, he is usually unable to leave his bed, his sleep is disturbed by startings of the limb, and the rigidity of the joint and the wasting of the muscles are well marked. The temperature may rise slightly after examination of the limb, or after a railway journey.

Abscess Formation in Hip Disease.—The formation of abscess is not related to any stage of the disease; it may occur before there is deformity, and it may be deferred until the disease is apparently cured. Its importance lies in the fact that if a mixed infection with pyogenic organisms occurs, the gravity of the condition is greatly increased.

An abscess may appear in the thigh in front or behind the joint. The anterior abscess emerges on one or other side of the psoas muscle; from the resistance offered by the fascia lata, the pus may gravitate down the thigh before perforating the fascia. It has occasionally happened that when such an abscess has been opened and become infected with pyogenic organisms, the femoral vessels have been eroded, and serious or even fatal haemorrhage has resulted. The posterior abscess appears in the buttock and may make its way to the surface through the gluteus maximus; more often it points at the lower border of this muscle in the region of the great trochanter, or it may gravitate down the thigh.

Abscesses which form within the pelvis originate either in connection with the acetabulum or in relation to the psoas muscle where it passes in front of the joint. Those that are directly connected with disease of the acetabulum may remain localised to the lateral wall of the pelvis, or may spread backwards towards the hollow of the sacrum. They may open into the bladder or rectum, or may ascend into the iliac fossa and point above Poupart's ligament (Fig. 115), or descend towards the ischio-rectal fossa. The abscess which develops in relation to the psoas muscle may be shaped like an hour-glass, one sac occupying the iliac fossa, the other filling up Scarpa's triangle, the two sacs communicating with each other through a narrow neck beneath Poupart's ligament.

So long as the skin is intact, the abscess is unattended with symptoms, and may escape notice. If it bursts externally, pyogenic infection is almost inevitable, and the patient gradually passes into the condition of hectic fever or chronic toxaemia; he loses ground from day to day, may become the subject of waxy disease in the viscera, or may die of exhaustion, tuberculous meningitis, or general tuberculosis.

Dislocation is a rare complication of hip disease, and is most likely to occur during the stage of adduction with inversion. It has been known to take place during sleep, apparently from spasmodic contraction of muscles. In the dorsal dislocation, which is the most common form, adduction and inversion are exaggerated, the trochanter projects above and behind Nelaton's line, and the head of the bone may be felt on the dorsum ilii. It is a striking fact that after dislocation has occurred there is less complaint of pain or of startings than before, and passive movements may be carried out which were previously impossible.

Diagnosis of Hip Disease.—The diagnosis is to be made not only from other affections of the joint, but also from morbid conditions in the vicinity of the hip, as in any of these the patient may seek advice on account of pain and a limp in walking. The patient should be stripped, and if able to walk, his gait should be observed. He is then examined lying on his back, and attention is directed to the comparative length of the limbs, to the attitude of the limbs and pelvis, and to the movements at the hip-joint, especially those of rotation. When there is any doubt as to the diagnosis, the examination should be repeated at intervals of a few days. In children, there are three non-febrile conditions attended with a limp and with shortening of the limb, which may be mistaken for hip disease,—congenital dislocation, coxa vara, and paralysis following poliomyelitis—but in all of these the movements are not nearly so restricted as they are in disease of the joint.

In tuberculous disease of the sacro-iliac joint, while the pelvis may be tilted, and the limb apparently lengthened, the movements at the hip are retained. In tuberculous disease of the great trochanter, or of either of the bursae over it, while there may be abduction, eversion, impairment of mobility, and swelling in the region of the trochanter followed by abscess formation, the movements are less restricted than in disease of the joint.

In psoas abscess associated with spinal disease, or in disease of the bursa underneath the psoas, the limb is flexed and everted, there may be lordosis, and the patient may limp in walking, but the movements at the hip are restricted only in the directions of extension and inversion, while in hip disease they are restricted in all directions.

New-growths in the vicinity of the hip—especially central sarcoma of the upper end of the femur—are difficult to differentiate from hip disease without the help of the X-rays.

Among other conditions which by interfering with the free mobility of the hip may simulate hip disease, are appendicitis, inflammation of the glands in the groin, staphylococcal disease of the upper end of the femur, and sciatica.

The diagnosis from other diseases of the hip-joint is made by careful consideration of the history, symptoms, and X-ray appearances.

Prognosis.—The prognosis in hip disease is more serious than in tuberculosis of other joints, excepting only those of the spine, and it is most unfavourable when there are gross lesions of the bones and infected sinuses.

Whatever the stage of the disease, recovery is a slow process, and even in early and mild cases it seldom takes place in less than one or two years, and is liable to be attended with some impairment of function. During the process of cure, complications are liable to occur, and after apparent recovery relapses are not uncommon. When arrested during the initial stage, recovery may be complete; but when there has been destruction of the articular surfaces, there is apt to be ankylosis of the joint and shortening of the limb.

In cases which terminate fatally, death usually results from meningeal, pulmonary, or general tuberculosis, or from pyogenic complications and waxy degeneration.

Treatment.—A large proportion of cases recover under conservative treatment, and the functional results are so much better than those following operative interference that unless there are special indications to the contrary, conservative measures should always be adopted in the first instance.

Conservative Treatment.—The first essential is to take the weight off the limb and secure its fixation in the attitude of almost complete extension and moderate abduction. When the symptoms are well marked, the child is kept in bed and the limb is extended with a weight and pulley.

Extension by Weight and Pulley (Fig. 116).—The weight employed varies from one to four pounds in children, to ten or more pounds in adolescents and adults, and must be adjusted to meet the requirements of each case. If pain returns after having been relieved, it is due to stretching of the ligaments, and the weight should be diminished or removed for a time. If there is deformity, the line of traction should be in the axis of the displaced limb until the deformity is got rid of. The extension should be continued until pain, tenderness, and muscular contraction have disappeared, and the limb has been brought into the desired attitude.



In restless children, in addition to the extension, a long splint is applied on the sound side and a sand-bag on the affected one; or, better still, a double long splint and cross-bar, the long splint on the affected side being furnished with a hinge opposite the hip to permit of varying the degree of abduction (Fig. 117).



When the deformed attitude does not yield rapidly to extension, it should be corrected under an anaesthetic, and if the adductor tendons and fasciae are so contracted that this is difficult, they should be forcibly stretched or divided.

The immediate correction of deformed attitudes under anaesthesia has largely replaced the more gradual method by extension with weight and pulley; and in hospital practice it is usually followed by the application of a plaster case. The plaster bandages are applied over a pair of knitted drawers; the pelvis and both thighs, the diseased one in the abducted position, are included. The case may be strengthened by strips of aluminium, and should be renewed every six weeks or two months.

Ambulant Treatment.—When the patient is able to use crutches, the affected limb is prevented from touching the ground by fixing a patten on the sole of the boot on the sound side. This may suffice, or, in addition, the hip-joint is kept rigid by a Thomas' (Fig. 118) or a Taylor's splint. The Thomas' splint must be fitted to the patient under the supervision of the surgeon, who must make himself familiar with the construction of the splint, and its alteration by means of wrenches.



In children who are unable to use crutches, a double Thomas' splint is employed; the child thereby is converted into a rigid object, capable of being carried from one room to another and into the open air. Personally we have obtained satisfaction from the double Thomas' splint employed for spinal disease, which extends from the occiput to the soles of the feet.

The fixation of the hip-joint and the taking of the weight off the limb by one or other of the above methods, should, as a general rule, be continued for at least a year.

Should an abscess develop, it is treated on the usual lines.

Operative Interference.—Widely diverse opinions are held on the question as to whether or not recourse should be had to operative interference.

Some surgeons are opposed to operative interference, on the grounds that however advanced the disease may be it will yield to conservative measures if judiciously and perseveringly carried out. Other surgeons advocate operative treatment in all cases which do not speedily show improvement under conservative treatment. An intermediate attitude may be adopted which recommends operation in cases in which the disease progresses in spite of conservative treatment, and in which periodic examination with the X-rays shows that there are progressive lesions in the upper end of the femur or in the acetabulum.

It is claimed by those who advocate operation under these conditions that pain and suffering are at once got rid of, sleep is restored, appetite returns, and there is a marked improvement in the general health, and that this result is obtained in months instead of years, and that the cure is more likely to be permanent. It is certainly unwise to delay operation until sinuses have formed, as such a course is largely responsible for the bad results which formerly followed excision of the joint.

Amputation for tuberculous disease of the hip has become one of the rarest of operations, but is still required in cases which have continued to progress after excision, and when there is disease of the pelvis or of the shaft of the femur, with sinuses, albuminuria, and hectic fever.

The Correction of Deformity resulting from Antecedent Disease of the Hip.—From neglect or from improper treatment, deformity may have been allowed to persist, while the disease has undergone cure. It is associated with ankylosis of the joint, or contracture of the soft parts or both. The contracture of the soft parts involves specially the tendons, fasciae, and ligaments on the anterior and medial aspects of the joint, and is usually present to such a degree that, even if the joint were rendered mobile, these shortened structures would prevent correction of the deformity. The usual deformity is a combination of shortening, flexion, and adduction.

Bilateral Hip Disease.—Both hip-joints may become affected with tuberculous disease, either simultaneously or successively, and abscesses may form on both sides. The patient is necessarily confined to bed, and if the disease is recovered from, his capacity for walking may be seriously impaired, especially if the joints become fixed in an undesirable attitude. The most striking deformity occurs when both limbs are adducted so that they cross each other—one variety of the "scissor-leg" or "crossed-leg" deformity—in which the patient, if able to walk at all, does so by forward movements from the knees. An attempt should be made by arthroplasty to secure a movable joint at least on one side.

OTHER DISEASES OF THE HIP-JOINT

Pyogenic Diseases are met with in childhood and youth as a result of infection with the common pyogenic organisms, gonococci, pneumococci, or typhoid bacilli. While the organisms usually gain access to the tissues of the joint through the blood stream, a direct infection is occasionally observed from suppuration in the femoral lymph glands or in the bursa under the ilio-psoas.

The clinical features are sometimes remarkably latent and are much less striking than might be expected, especially when the hip affection occurs as a complication of an acute illness such as scarlet fever. It may even be entirely overlooked during the active stage, and only noticed when the head of the femur is found dislocated, or the joint ankylosed. In the acute arthritis of infants also, the clinical features may be comparatively mild, but as a rule they assume a type in which the suppurative element predominates. The limb usually becomes flexed and adducted, and a swelling forms in front of the joint at the upper part of Scarpa's triangle; the upper femoral epiphysis may be separated and furnish a sequestrum.

The flexion and adduction of the limb favour the occurrence of dislocation. A child who has recovered with dislocation on to the dorsum ilii is usually able to walk and run about, but with a limp or waddle which becomes more pronounced as he grows up. The condition closely resembles a congenital dislocation, but the history, and the presence of gross alterations in the upper end of the femur as seen with the X-rays, should usually suffice to differentiate them.

Treatment.—In the acute stage the limb is extended by means of the weight and pulley, and kept at rest with the single or double long splint, or by sand-bags. If there is suppuration, the joint should be aspirated or opened by an anterior incision, and Murphy's plan of filling the joint with formalin-glycerine may be adopted. In children, it is remarkable how completely the joint may recover.

If there is dislocation, the head of the femur should be reduced by manipulation with or without preliminary extension; it has been successful in about one-half of the cases in which it has been attempted. Preliminary tenotomy of the shortened tendons is required in some cases. When reduction by manipulation is impossible, the joint structures should be exposed by operation and the head of the bone replaced in the acetabulum. When the upper end of the femur has disappeared, the neck should be implanted in the acetabulum, and the limb placed in the abducted position.

Arthritis Deformans.—This disease is comparatively common at the hip, either as a mon-articular affection or simultaneously with other joints.



The changes in the joint are characteristic of the dry form of the disease, and affect chiefly the cartilage and bone. The atrophy and wearing away of the articular surfaces are accompanied by new formation of cartilage and bone around their margins. The head of the femur may acquire the shape of a helmet, a mushroom, or a limpet shell, and from absorption of the neck the head may come to be sessile at the base of the neck, and to occupy a level considerably below that of the great trochanter (Fig. 120). These changes sometimes extend to the upper part of the shaft, and result in curving of the shaft and neck, suggesting a resemblance to a point of interrogation (Fig. 121). The acetabulum may "wander" backwards and upwards, as in tuberculous disease. It is usually deepened, and its floor projects on the pelvic aspect; its margins may form a projecting collar which overhangs the neck of the femur, or grasps it, so that even in the macerated condition the head is imprisoned in the socket and the joint locked. There is eburnation of the articular surfaces in those areas most exposed to friction and pressure.



These changes are necessarily associated with restriction of movement, and in advanced cases with striking deformity, which consists in shortening of the limb, usually with eversion and displacement of the trochanter upwards and backwards in relation to Nelaton's line.

The clinical features are usually so characteristic that there is little difficulty in diagnosis. Restriction of the movements of abduction and adduction, the presence of cracking and of grating of the articular surfaces, and the aggravation of the pain and stiffness after resting the limb, are characteristic of arthritis deformans. The prominence of sciatic pain may lead to the disease being regarded as sciatica.

The greatest difficulty is met with in cases in which the disease occurs as mon-articular affection in adolescents, for the resemblance to tuberculous disease of the hip and to coxa vara may be close. Skiagrams do not always enable one to differentiate between them.

Treatment is conducted on the same lines as in other joints. The normal movements are maintained by suitable exercises, and an effort is made to diminish the pressure on the articular surfaces in walking by the use of sticks or crutches.

Shortening of the limb may be compensated by raising the sole of the boot. When the X-rays show that the disability is mainly due to new bone locking the head of the femur, such new bone may be removed by operation, cheilotomy (Sampson Handley). Excision of the joint has in some cases yielded satisfactory results; it is indicated in young patients who are otherwise healthy, and who are unable to walk on account of pain and deformity.

Osteo-chondritis Deformans Juvenilis.—Under this term Perthes describes an affection of the hip in children which differs in many respects from the juvenile form of arthritis deformans. Islands of cartilage appear in the epiphysis of the head of the femur, and the epiphysis itself becomes flattened without involvement of the articular surface or of the acetabulum.

The disease is met with in children between five and ten; there is a limp in walking without pain or sensitiveness, so that the child continues to take part in games. Abduction is markedly restricted and the trochanter is elevated and prominent. There is no crepitation on movement or other signs of involvement of the articular surfaces. The X-rays show the deformity of the head and clear areas in the interior of the upper epiphysis corresponding to the islands of cartilage; these clear areas resemble those due to caseous foci in tuberculous coxitis.

The disease runs a chronic course, and in the course of a year or two the limp and the restriction of abduction disappear, so that no active treatment is called for.

Neuro-Arthropathies.—Charcot's disease is usually met with in men over thirty who suffer from tabes dorsalis. One or both hip-joints may be affected. Sometimes the first manifestation is a hydrops and a fluctuating swelling in the upper part of Scarpa's triangle. In many of the recorded cases, however, attention has first been directed to the disease by the deformity and limp associated with disappearance of the head of the femur, or by the occurrence of pathological dislocation. The absence of pain and tenderness is characteristic. When dislocation has occurred, the limb is short, and the upper end of the femur is freely movable on the dorsum ilii. When both hips are dislocated, the attitude and gait are similar to those observed in bilateral congenital dislocation. The rotation arc of the great trochanter may be much reduced as a result of the disappearance of the head of the femur. There may be considerable formation of new bone, giving rise to large tumour-like masses in relation to the capsular ligament and the muscles surrounding the joint.

The treatment consists in protecting and supporting the joint. When the affection is unilateral, advantage may be derived from a Thomas' or other form of splint, along with a patten and crutches; in bilateral cases, from the use of crutches alone.

Loose bodies in the hip are mostly the result of hypertrophy of synovial fringes in arthritis deformans and in Charcot's disease, and do not figure in the clinical features of these affections; Caird has observed a case in which the cavity of the joint and the bursa beneath the psoas were filled with loose bodies, many of which had undergone ossification and gave a characteristic picture with the X-rays.

Hysterical affections of the hip resemble those in other joints.

THE KNEE-JOINT

The knee is more often the seat of disease than any other joint in the body.

The synovial membrane extends beneath the quadriceps extensor as a cul-de-sac, which either communicates with the sub-crural bursa, or forms with it one continuous cavity. When the joint is distended with fluid, this upper pouch bulges above and on either side of the patella, and this bone is "floated" off the condyles of the femur. When there is only a small amount of fluid, it is most easily recognised while the patient stands with his feet together and the trunk bent forwards at the hip-joints, and the quadriceps completely relaxed; the fluid then bulges above and on each side of the patella, and its presence is readily detected, especially on comparison with the joint of the other side.

On account of the great extent of the synovial membrane, a large quantity of serous effusion may accumulate in the joint in a comparatively short time, as a result either of injury or disease. The villous processes and fringes may take on an exaggerated growth, and give rise to pedunculated and other forms of loose body.

The bursae in the popliteal space, especially that between the semi-membranosus and the medial head of the gastrocnemius, as well as the sub-crural bursa, frequently communicate with the synovial cavity of the knee and may share in its diseases.

As the epiphyses at the knee are mainly responsible for the growth in length of the lower extremity, and are late in uniting with their respective shafts—twenty-one to twenty-five years—serious shortening of the limb may result if their functions are interfered with, whether by disease or injury. The epiphysial cartilages lie beyond the limits of the synovial cavity, so that infective lesions at the ossifying junctions are less likely to spread to the joint than is the case at the hip or shoulder, where the upper epiphysis lies partly or wholly within the joint; disease in the lower end of the femur is more likely to implicate the knee-joint than disease in the upper end of the tibia.

One of the commonest causes of prolonged disability and feeling of insecurity in the knee, is to be found in the wasting and loss of tone in the quadriceps extensor muscle; the feeling of insecurity is most marked in coming down stairs. The instability of the joint is often added to by stretching of the ligaments and lateral mobility. As a result of both of these factors the joint is liable to repeated slight strains or jars which irritate the synovial membrane and tend to keep up the effusion and excite the overgrowth of its tissue elements.

TUBERCULOUS DISEASE

While tuberculous disease of the knee is specially common in childhood and youth, it may occur at any period of life, and is not uncommon in patients over fifty. The disease originates in the synovial membrane and in the bones respectively with about equal frequency.

When the synovial membrane is diseased, it tends to grow inwards over the articular surfaces (Fig. 122), shutting off the supra-patellar pouch and fixing the knee-cap to the femur, and diminishing the area of the articular surfaces. The ingrowth of synovial membrane may fill up the cavity of the joint, or may divide it up into compartments. Ulceration of the cartilage and caries of the articular surfaces are common accompaniments.



The femur and tibia are affected with about equal frequency, and the nature and seat of the bone lesions are subject to wide variations. Multiple small foci may be found beneath the articular cartilage of the tibia, or along the margins of the femoral condyles—especially the medial. Caseating foci are comparatively rare, but they sometimes attain a considerable size—especially in the head of the tibia, where they may take the form of a caseous abscess. Sclerosed foci, which form sequestra, are comparatively common (Fig. 123).



Clinical Types.—(1) Hydrops usually arises from a purely synovial lesion, but the joint may suddenly become distended with fluid when an osseous focus ruptures into the synovial cavity.

It is met with chiefly in young adults. As the fluid accumulates it gradually stretches the capsule, and pushes the patella forwards, so that it floats. There is little pain or interference with function; the patient is usually able to walk, but is easily tired. The amount of fluid diminishes under rest, and increases after use of the limb. In a certain number of cases it may be possible to recognise localised thickening of the synovial membrane, or the presence of floating masses of fibrin or melon-seed bodies. This is best appreciated if the knee is alternately flexed and extended by the patient while the surgeon grasps and compresses it with both hands. If the joint is opened, fibrinous material, often in the form of melon-seed bodies, may be found lining the synovial membrane.

Tuberculous hydrops is to be diagnosed from the effusion that results from repeated sprain, from the hydrops of loose body, gonorrhoea, arthritis deformans, Charcot's disease, and Brodie's abscess in the adjacent bone, and from the haemarthrosis met with in bleeders.

(2) Papillary or Nodular Tubercle of the Synovial Membrane.—This is a condition in which there is a fringy, papillary, or polypoidal growth from the synovial membrane. It is most often met with in adult males. The onset and progress are gradual, and the chief complaint is of stiffness and swelling which are worse after exertion. Sometimes there are symptoms of loose body, such as occasional locking of the joint, with pain and inability to extend the limb; but the locking is easily disengaged, and the movements are at once free again. The patient may give a history of several years' partial and intermittent disability, with lameness and occasional locking, although he may have been able to go about or even to continue his occupation.

There is a moderate degree of effusion into the joint, and when this has subsided under rest it may be possible to feel ill-defined cords, or tufts, or nodular masses, and to grasp between the fingers those in the supra-patellar pouch. There is little wasting of muscles, and it is exceptional to have signs of disease of the articular surfaces or of cold abscess.

On opening the joint, there may escape fluid and loose bodies similar to those described under hydrops, and if the finger is introduced into the cavity, the upper pouch is felt to be occupied by fringes or polypoidal processes derived from the synovial membrane.

The diagnosis is to be made from arthritis deformans, and in some cases from loose body of other than tuberculous origin.

(3) Cold abscess or empyema of the knee is a rare condition, in which the joint becomes filled with pus. It usually results from a primary tuberculosis of the synovial membrane occurring in children reduced in health and the subject of tuberculosis elsewhere.

(4) Diffuse Thickening of the Synovial Membrane—White Swelling.—So long as this form of the disease remains confined to the synovial membrane, the chief feature is that of an indolent elastic swelling in the area of the joint. The swelling tapers off above and below, so that it acquires a fusiform shape, and from the wasting of the muscles it appears greater than it really is. The range of movement is moderately restricted.

At first the patient limps, keeps the knee slightly flexed, and complains of tiredness and stiffness after exertion. As the articular surfaces become affected, there is pain, which is readily excited by jarring of the limb, or by any attempt at movement; the joint is held rigid, and there may be startings at night. If untreated, flexion becomes more pronounced—it may be to a right angle—the leg and foot are everted, and, in children, the tibia may be displaced backwards (Fig. 124). The wasting of muscles continues, the part becomes hot to the touch, the swelling increases, and may show areas of softening or fluctuation from abscess formation.



White swelling is to be differentiated from peri-synovial gummata, from myeloma and sarcoma of the lower end of the femur, and from bleeder's knee. In the first of these the swelling is nodular and less uniform, and there may be tertiary ulcers or depressed scars in the neighbourhood of the patella. In tumours the swelling is more marked on one side of the joint, it is uneven or nodular, it does not correspond to the shape of the synovial membrane, and may extend beyond the limits of the joint, and it involves the bone to a greater extent than is usual in disease of the joint. Skiagrams show expansion of the bone in central tumours, or abundant new bone in ossifying sarcoma. The diagnosis of bleeder's knee is to be made from the history.

(5) Primary Tuberculous Disease in the Bones of the Knee.—So long as the foci are confined to the interior of the bone, it is impossible to recognise their existence, unless they are of sufficient size to cause enlargement of the bone or to be discernible in a skiagram.

The formation of peri-articular abscess takes place in rather more than fifty per cent. of cases. When left to themselves, such abscesses tend to spread up the thigh, or down the back of the leg between the superficial and deep layers of calf muscles, and numerous sinuses may result from their rupture through the skin.

Attitudes of the Limb in Knee-Joint Disease.—The attitude most often assumed is that of flexion, with or without eversion of the leg and foot. The flexion is explained by its being the resting attitude of the joint, and that which affords most ease and comfort to the patient. Once the joint is flexed, the involuntary contraction of the flexor muscles maintains the attitude, and if the patient is able to use the limb in walking, the weight of the body is a powerful factor in increasing it. The eversion of the leg is probably associated with contraction of the biceps muscle. Backward displacement of the tibia is met with chiefly in neglected cases of chronic disease of the knee when the child has walked on the limb after it has become flexed.

In certain cases, genu valgum or abduction of the leg is present along with a slight degree of flexion. The valgus attitude is associated with slight lateral displacement of the patella, with prominence and apparent enlargement of the medial condyle, with depression of the pelvis on the diseased side and apparent lengthening of the limb.

Treatment of Tuberculous Disease of the Knee.—Conservative measures are always indicated in the first instance, and are persevered with so long as there is a prospect of obtaining a movable joint.

Conservative Treatment.—If the joint is sensitive and tends to be flexed, the patient is confined to bed, the limb is secured to a posterior splint, and extension with weight and pulley persevered with until these symptoms have disappeared; during this time, from three to six weeks, methods of inducing hyperaemia and other anti-tuberculous procedures are employed. If it is proposed to inject iodoform or other drug, the needle is inserted into the interval between the bones on the medial side of the ligamentum patellae or into the upper pouch when this is distended with fluid.

If there is no pain or tendency to flexion, or when these have been overcome, the limb is put up in a Thomas' splint (Fig. 125) and the patient allowed to go about. The splint is worn for a period varying from six to twelve months; before being discarded it may be left off at night; it is ultimately replaced by a bandage.



The indications for operative treatment are: (1) marked symptoms of destruction of the articular cartilages; (2) a deformed attitude incapable of being rectified without operation; (3) a condition of the general health which requires that the disease should be got rid of as speedily as possible; (4) progress or persistence of the disease in spite of conservative treatment. When there is no prospect of recovery with a movable joint it is a waste of time and a possible source of danger to persevere with conservative measures. Operation permits of the disease being eradicated and the restoration of a useful limb within a reasonable time, averaging from three to six months.

In adults, the operation consists in excising the joint; in children the aim is to remove the diseased tissues without damaging the epiphysial cartilages.

Amputation is performed when the disease has relapsed after excision and there is persistent suppuration, and when life is threatened by the occurrence of tuberculosis in the lungs or elsewhere.

Treatment of Deformities resulting from Antecedent Diseases of the Knee.—Flexion is the commonest of these; when due to contracture of the soft parts, these are either stretched by degrees, the limb being encased in plaster after each sitting, or they are divided by open dissection in the popliteal space. If there is fibrous or osseous ankylosis, the choice lies between arthroplasty, the removal of a wedge of bone which includes the joint, or, in patients who are still growing, of a wedge from the femur above the level of the epiphysial cartilage. Backward displacement of the tibia, genu recurvatum, and genu valgum also require operative treatment.

OTHER DISEASES OF THE KNEE-JOINT

Pyogenic diseases result from infection through the blood stream, from one of the adjacent bones, or from a penetrating wound of the joint. The commoner types include the synovitis associated with disease in the adjacent bone, acute arthritis of infants, joint suppuration in pyaemia, pyogenic arthritis following upon penetrating wounds, and the affections which result from gonorrhoeal or pneumococcal infection.

Treatment.—The limb is immobilised on a posterior splint so padded as to allow slight flexion at the knee, and extension applied with sufficient weight to relieve the pain; it is also of benefit to induce hyperaemia by one or other of the methods devised by Bier. To tap the joint, the needle is introduced obliquely into the supra-patellar pouch, and if it is necessary to open the joint, the incision is made on one or on both sides of the patella, and Murphy's plan of inserting formalin-glycerine may be employed. If the infection progresses and threatens the life of the patient, it may be necessary to lay the joint freely open from side to side, sawing across the patella, and, the limb being flexed, the whole wound is left open and packed with gauze. As the infection subsides, the limb is gradually straightened. If these methods fail, amputation through the thigh may be the only means of saving life.

Arthritis deformans affects the knee more frequently than any of the other large joints. The changes related to the synovial membrane here attain their maximum development, and may assume the form of hydrops with or without fibrinous bodies, or of overgrowth of the synovial fringes and the formation of pedunculated loose bodies. It is suggested that these synovial changes follow upon repeated sprains or upon a previous pyogenic infection of the joint. The effusion and stretching of the ligaments that follow upon a sprain are incompletely recovered from; the synovial membrane becomes puckered, the quadriceps atrophies and no longer puts the ligamentum mucosum on the stretch; and the infra-patellar pad of fat, not undergoing the normal compression during extension, is readily nipped between the femur and tibia. Each nipping implies a fresh sprain, with return of the effusion, and so a vicious circle is set up which terminates in what has been called a villous arthritis, with fringes and loose bodies; in time, the articular cartilage at the line of the synovial reflection undergoes fibrillation and conversion into connective tissue, and the process spreading to the articular surfaces, the picture of a rheumatoid arthritis is complete. Fibrillation of the cartilage imparts a feeling of roughness when the joint is grasped during flexion and extension, and lipping of the margins of the trochlear surface of the femur may be felt when the joint is flexed; it is also readily seen in skiagrams. When a portion of the "lipping" is broken off, it may give rise to a loose body. In advanced cases with destruction of the cartilages, there may be movement from side to side, with grating of the articular surfaces.

In the early stages, treatment consists in limiting the movements of extension by means of a splint provided with a hinge that locks at thirty degrees from full extension and vigorous massage of the quadriceps. In the dry, creaking forms of arthritis, the symptoms are relieved by introducing liquid vaseline into the joint. When the symptoms are due to the presence of fringes and loose bodies, these may be removed by operation. When the disease is of a severe type, and is confined to one knee, the question of excising the joint may be considered.

Bleeder's knee, Charcot's disease, hysterical knee, and loose bodies in the joint have already been described.

THE ANKLE-JOINT

There is a common synovial cavity for the ankle and the inferior tibio-fibular joints. The epiphysial cartilage of the tibia lies above the level of this synovial cavity, but that of the fibula is included within its limits (Fig. 93). The talus is related to three articulations—the ankle above, the talo-navicular joint in front, and the calcaneo-taloid joint below. The tendon sheaths, especially those of the peronei and of the tibialis posterior, are liable to be infected by the spread of infective disease from the joint.

Tuberculous Disease.—Tuberculous disease at the ankle is met with at all ages. In the majority of cases the disease affects both bone and synovial membrane. Gross lesions in the bones are comparatively rare, and are chiefly met with in the head or neck of the talus.

Primary synovial disease usually exhibits the features of white swelling, projecting beneath the extensor tendons on the dorsum, and, posteriorly, filling up the hollows on either side of the tendo Achillis and below the malleoli (Fig. 126). The foot may retain its normal attitude, or the toes may be pointed and adducted. The calf muscles are wasted, there is little complaint of pain, and the movements of the joint may be so little interfered with that the patient can walk without a limp. When the disease involves the articular surfaces, there is pain and sensitiveness, the movements are restricted or abolished, and the patient is unable to put the foot on the ground.



A primary focus in the bone causes localised pain and tenderness, and a limp in walking, but the first sign may be the formation of abscess or the rapid development of articular symptoms. In such cases skiagrams afford valuable information.

Abscess formation is an early and prominent feature, whether the disease is of osseous or synovial origin, and sinuses are liable to form around the joint. Outlying abscesses and sinuses are usually the result of infection of the tendon sheaths in the neighbourhood.

Diagnosis.—When teno-synovitis occurs independently of disease of the ankle, the swelling is confined to one aspect of the joint. In sarcoma of the lower end of the tibia, the swelling lacks the uniform distribution of that met with in joint disease. In Brodie's abscess of the lower end of the tibia there may be swelling of the ankle, but there is an area of special tenderness on percussion over the bone.

Treatment.—The foot is immobilised at a right angle to the leg by splints or plaster of Paris; if articular symptoms are absent or have subsided, a Thomas' knee splint should be applied to enable the patient to move about without bearing his weight on the affected foot (Fig. 125). To inject iodoform, the point of the needle is inserted below either malleolus, and is then pushed upwards alongside of the talus. If localised disease in one of the bones is recognised before the joint is infected, it should be eradicated by operation.

When the disease is diffuse and resists conservative treatment, excision should be performed, the articular surfaces of the constituent bones being removed, and if necessary the whole of the talus.

Amputation is only called for in adults with rapidly progressing disease and diffuse suppuration, and in cases which have relapsed after excision.

The other diseases of the ankle include pyogenic, gonorrhoeal, rheumatic, gouty, and hysterical affections, arthritis deformans, and Charcot's disease. The last-named is generally associated with a rapid and painless disintegration of the bones of the ankle and tarsus, resulting in great deformity and loss of the arch of the foot—sometimes associated with perforating ulcer of the sole.

Tuberculous disease in the tarsus, metatarsus, and phalanges has been considered in the chapter on Diseases of Bone.



CHAPTER X

DEFORMITIES OF THE EXTREMITIES

The origin of deformities: (1) Those arising before birth; (2) those produced during birth; and (3) those acquired after birth.

Palsies of children: Anterior Poliomyelitis. Cerebral palsies: Spastic paralysis.

THE LOWER EXTREMITY: Congenital dislocation of hip—Snapping hip—Paralytic deformities—Contracture and ankylosis of hip—Coxa vara and coxa valga—Congenital dislocation of knee and patella—Genu recurvatum—Paralytic deformities—Contracture and ankylosis of knee—Genu valgum and genu varum—Congenital deformities of leg—Bow-leg—Club-foot: Talipes equino-varus; Pes equinus; Pes calcaneus; Pes calcaneo-valgus and varus; Pes cavus; Flat-foot and pes valgus—Painful affections of heel—Metatarsalgia—Hallux valgus and bunion—Hallux varus—Hallux rigidus and flexus—Hammer-toe—Hypertrophy of toes—Supernumerary toes—Webbed toes.

THE UPPER EXTREMITY: Congenital absence of clavicle—Elevation of scapula—Winged scapula—Congenital paralytic deformities of shoulder—Deformities of elbow—Club-hand—Deformities of wrist—Madelung's deformity—Deformities of fingers—Dupuytren's contraction—Polydactylism.

The surgery of the extremities is so largely concerned with the correction of deformities that it is necessary at the outset to refer briefly to some points relating to the time and mode of origin of these.

1. Congenital deformities—that is, those which originate in utero and are present at birth—are comparatively common and may be due to a variety of causes. Some result from errors of development—for example, supernumerary fingers or toes, and deficiencies in the bones of the leg or forearm. A larger number are to be attributed to a persistent abnormal attitude of the foetus, usually associated with want of room in the uterus—for example, the common form of club-foot and congenital dislocation of the hip. Less frequently amniotic bands so constrict the digits or the limbs as to produce distortion, or even to sever the distal part—intra-uterine amputation. Lastly, certain diseases of the foetus, and particularly such as affect the skeleton—for example, achondroplasia—cause congenital deformities.

2. Deformities originating during birth are all traceable to the effects of injuries sustained in the course of a difficult labour. Examples of these are: wry-neck resulting from rupture of the sterno-mastoid; lesions of the shoulder-joint and brachial plexus due to hyper-extension of the arm; a spastic condition of the lower limbs—Little's disease—resulting from tearing of blood vessels on the surface of the brain with haemorrhage and interference with the function of the cortical motor area.

3. Deformities acquired after birth arise from widely different causes, of which diseases of bone, including rickets, diseases of joints, and affections of the nervous system attended with paralysis, are amongst the commonest. Other deformities are produced by unsuitable clothing, such as a tight corset, or ill-fitting shoes distorting the toes, prolonged standing in growing subjects overstraining the mechanism of the foot and giving rise to the common form of flat-foot.

The part played by the palsies of children in the surgical affections of the extremities necessitates a short description of their more important features.

Anterior poliomyelitis is the lesion underlying what was formerly known as infantile paralysis—a name to be avoided, because the condition is not confined to infants and it is not the only form of paralysis met with in young children. Anterior poliomyelitis is characterised by an illness attended with fever, in which the child is found to have lost the power of one, less frequently of both lower extremities; or, it may be, of one or both arms. After a period, varying from six weeks to three months, the paralysis tends to diminish both in extent and degree, and in the majority of cases it ultimately persists only in certain muscles or groups of muscles. At the onset of the paralysis the affected limb is helpless and relaxed, the reflexes are lost, the muscles waste, and those that are paralysed exhibit the reaction of degeneration. In severe cases, and especially if proper treatment is neglected, the nutrition of the limb is profoundly affected; its temperature is subnormal, the skin is bluish in cold weather and readily becomes the seat of pressure sores. In course of time the limb lags behind its fellow in growth, and tends to assume a deformed attitude, which at first can easily be corrected, but later becomes permanent.



When the acute stage of the illness is past, the chief question is to what extent recovery of function can be looked for in the paralysed muscles.

It would appear to be established that if a muscle reacts to faradism it will recover, but the contrary proposition does not follow. It was formerly accepted that a muscle which exhibits the reaction of degeneration is incapable of recovery, but observation has shown that this is not the case. Complete destruction of the motor cells in the anterior horn of grey matter as a result of poliomyelitis is now known to be exceptional; as a matter of fact, damage to the nerve cells is usually capable of being repaired. The muscles governed by these cells may appear to be completely paralysed, but with appropriate treatment their functional activity can be restored. As functional disability is frequently due to the affected muscle being over-stretched, it is of the first importance, when the acute symptoms are on the wane, that every care should be taken to prevent the weak muscular groups being put upon the stretch, and the greatest attention should be paid to the posture of the limb during convalescence. For example, if the child is allowed to lie with the wrist flexed, the flexor muscles undergo shortening, and the extensors are over-stretched and are therefore placed at a mechanical disadvantage. As the inflammatory changes in the anterior horn of the cord subside, the flexor tendons, from their position of advantage, are in a condition to respond to the first stimuli that come from their recovering motor cells, while the extensors are not in a position to do so. If, on the other hand, the wrist and fingers are maintained in the attitude of extreme dorsiflexion, the extensors become shortened, and, relieved of strain, they soon begin to respond to the stimuli sent them from the recovering nerve cells. Similarly in the lower extremity, when, for example, the muscles innervated through the peroneal (external popliteal) nerve are paralysed, if the foot is allowed to remain in the attitude of inversion with the heel drawn up—paralytic equino-varus—an attitude which is rendered more pronounced by the pressure of the bedclothes, the chance of the muscles recovering their function is seriously diminished. Another potent factor in preventing recovery, especially in the lower limbs, is erroneous deflection of the body weight. If, for example, there is weakness in the tibial group of muscles, and the child is allowed to walk, the eversion of the foot will steadily increase, the tibial muscles will be more and more stretched, the opposing peroneal muscles will shorten, and, in time, the bones of the tarsus will undergo structural alterations which will perpetuate the deformity. If, on the other hand, by some alteration of the boot, the foot is maintained in the attitude of inversion, the weakened or paralysed tibial muscles are placed in a much more favourable condition for recovery.

It must be emphasised that no operation should be performed in these cases until the question whether it be possible or not to restore the apparently paralysed muscle is settled. The clinical test of the recoverability of a muscle is to keep it for a long period—six or even twelve months—in a condition of relaxation. This test should be made, no matter how many months or years the muscle may have been paralysed.

The first stage in the treatment, therefore, is the correction of existing deformity, after which the limb should be kept immovable until the ligaments, muscles, and even the bones have regained their normal length and shape. The slightest stretching of a muscle which is in process of recovery disables it again.

The age of the patient influences the method of treatment. In young children in whom the structures are soft and yielding, gradual correction of the deformity is to be preferred to the more rapid methods employed in older children. The proper sequence consists in correcting the deformity, providing the simplest apparatus to keep the limb in good position, preventing erroneous deflection of body weight during walking, and then allowing the child to grow and develop until he has reached the age of five before considering such an operation as transplanting tendons, and the age of ten before deciding to ankylose a flail-like joint.

Reposition, Manipulations, Supports.—An attempt is made to correct the deformity by manipulation, and the proper attitude is maintained by a mechanical support. If the foot has become rotated so that the sole looks laterally, the medial side of the boot must be raised, and an iron worn which extends from the knee down the lateral side of the leg, to end, without a joint, in the heel of the boot. In pes equinus, the iron is let into the back of the heel and extends forwards into the waist of the boot, to keep the foot at right angles to the leg and to relax the weak extensor muscles.

Division of Contractions.—Bands of fascia and contracted tendons which prevent correction of deformity may have to be divided or lengthened. This is best done by the open method.

Removal of Skin.—To assist in maintaining the desired attitude, Jones recommends the plan of excising an area of the redundant skin on the weaker aspect of the limb; in equinus, the skin is taken from the dorsum; in equino-varus, from the front and lateral aspect of the foot. When the edges of the gap have united, the foot is maintained in the desired attitude for some months, even if parents carelessly remove the iron support to let the child run about.

Tendon transplantation, a procedure introduced by Nicoladoni, is to be considered in children of five and upwards. It may be employed for different purposes: (1) To reinforce a weak muscle by a healthy one—for example, by transplanting a hamstring tendon into the patella to reinforce a weak quadriceps, or reinforcing the weak invertors of the foot by a transplanted extensor hallucis longus. (2) Transplantation may also be performed to replace a muscle which is quite inactive and does not show any sign of recovery—for example, the tibiales being paralysed, the peroneus longus may be implanted into the navicular or first metatarsal to act as an invertor of the foot.

Wherever possible a tendon should be transplanted directly into bone, as, if it is attached to soft parts it rarely holds firmly enough. The bone should if possible be tunnelled, and the tendon passed through the tunnel and securely fixed. When bringing a tendon to its new point of attachment, it should pass in as straight a line as possible, avoiding any bend or angle which might impair its action. Fat is the best medium for the transplanted tendon to traverse, as it acts as a sheath and prevents the formation of adhesions which would interfere with the function of the new tendon. All deformity must be corrected before transferring the tendon; if the tendon is too short to admit of this, it can be lengthened by means of silk threads (Lange).

According to Jones, the most successful transplantations are the following, in order: (1) The tibialis anterior into the lateral tarsus in paralysis of the peronei; (2) the peroneus longus into the navicular in paralysis of the tibial group; (3) the extensor hallucis longus into any part of the foot where it may be wanted; (4) the hamstrings into the patella, to reinforce the quadriceps, provided the strictest after-treatment can be secured; (5) deflection of part of the tendo Achillis to one or other side of the foot.

Arthrodesis.—This operation, first performed by Albert in 1877, consists in removing the cartilage covering the articular surfaces of bones with the object of producing a firm ankylosis. The procedure is most successful in the ankle and mid-tarsal joints, and as a result of it there is obtained a secure and firm base of support in walking. Before performing arthrodesis, the surgeon must decide whether the patient will be better off with a stiff joint or with a weak and movable ankle supported by apparatus. This is often a matter of social position; in the poor, an ankylosed joint is more useful and less expensive. An arthrodesis should seldom be performed at the ankle until the child has passed his eighth year, or at the knee until he has reached his twentieth year. There is plenty to be done during the period of waiting, and if this is done well, it is possible that the operation may not be required. The existing deformities, for example, will have to be corrected, areas of skin removed to relieve functionless muscles of strain, the body weight appropriately deflected, and the child must be taught to walk with the aid of a support, swinging his limb about, and using it effectively in a correct position. Such exercise is a powerful agent in promoting physiological and functional development.

Nerve anastomosis, which seeks to provide a new channel for the transmission of motor impulses to the paralysed muscles, has as yet a restricted field of application—for example, the tibial and peroneal nerves may be anastomosed when the muscles supplied by one of them are paralysed. Stoffel of Heidelberg lays stress on regard being paid to the anatomical arrangement of the nerve bundles within the nerve-trunk so that motor fibres may be joined to motor ones and not to sensory. It is necessary also to cut across some of the fibres of the healthy nerve in order that they may grow into the nerve which is degenerated.

In extreme cases in which the limb is hopelessly paralysed and useless, it may be amputated to admit of an artificial limb being worn; it must be borne in mind, however, that such limbs furnish poor stumps, usually quite unable to bear pressure.

Cerebral Palsies of Childhood—Spastic Paralysis.—These may be due to arrest of development of the brain, to injuries of the head at birth, to meningeal haemorrhage, or to other lesions of the brain, with secondary degenerative changes in the spinal cord. The commonest cause is haemorrhage occurring during child-birth from the veins which ascend from the middle part of the convexity of the hemisphere to open into the superior sagittal (superior longitudinal) sinus. The blood is poured out beneath the dura on one or on both sides of the falx cerebri, and as it accumulates near the vertex, the damage to the motor centres for the legs is usually more extensive than that to the centres for the arms. The paralysis may affect one side of the body—hemiplegia, or both sides—diplegia; less commonly one extremity alone is involved—monoplegia. In diplegia, in which both arms and both legs are affected in the first instance, the arms may recover while the lower extremities remain in a spastic state, a condition known as Little's disease. The mental functions may be normal but more frequently they are imperfectly developed, the impairment in some cases amounting to idiocy. The affected limbs exhibit muscular rigidity or spasm, which is aggravated on movement but disappears under an anaesthetic; the reflexes are exaggerated, and sometimes there are perverted involuntary movements (athetosis). The growth of the limb is impaired, and contracture deformities may supervene (Fig. 131). The amount of power in the limb is often astonishing, in marked contrast to what is observed to follow upon anterior poliomyelitis. The degree of natural improvement is by no means great, and normal function is almost never regained.

The treatment is concerned in the first place with improving the condition of the muscles by methodical exercises and massage. When reflex irritability of the muscles with consequent spasm is a prominent feature, the reflex arc may be interrupted by resection of the posterior nerve roots corresponding to the part affected. This operation, first suggested by Spiller but chiefly popularised by Foerster, has yielded the best results in cases of Little's disease, in which there still remains a considerable amount of voluntary movement, and yet there is inability to walk on account of involuntary spasm. In the case of the lower extremities, three or more of the lumbar and one or more of the sacral nerve roots are resected within the vertebral canal. Sensation is diminished but not abolished in the area of skin involved. Massage and exercises and, it may be, splints or apparatus are essential factors in promoting the recovery of function. It has not yet been decided whether the results of the resection of nerve roots justify the risk.

Apart from Foerster's operation, or when it has failed, the spasm of any individual muscle or group of muscles may be got rid of by diminishing the nerve supply to the muscle or by lengthening the tendon. Diminishing the nerve supply was suggested by Stoffel; it consists in exposing the motor nerve as it enters the muscle and resecting one-third or one-half of the fibres so as to reduce the innervation to the required degree. The method is still on its trial.

Lengthening the Tendons.—In spastic paraplegia, for example, Jones resects the origins of the adductors longus and brevis, lengthens the tendo Achillis, divides the popliteal fascia and hamstrings, and transplants the biceps into the quadriceps; after which the limbs are put up in the attitude of wide abduction for six weeks. It is important that the patient should begin to walk with the legs wide apart and learn to balance himself without any feeling of insecurity; he should be taught to look at an object straight in front of him rather than on the ground.

THE LOWER EXTREMITY

CONGENITAL DISLOCATION OF THE HIP

This is the commonest of all congenital dislocations. Its frequency varies in different countries, being greater on the continent of Europe than in this country. It is more often unilateral than bilateral (about 4 to 1), and is about three times more common in girls than in boys.

The dislocation takes place in the early months of intra-uterine life, and may be associated with deficiency of the liquor amnii.

Pathological Anatomy.—In the infant, the anatomical changes in the joint are less marked than they are after the child has borne its weight on the limb. The acetabulum, never having been occupied by the head of the femur, is imperfectly developed; it remains flat and shallow, is partly filled with fibro-fatty tissue derived from the synovial membrane, and is always too small for the head of the femur. The cotyloid ligament being broader and thicker than usual, makes the osseous portion of the socket appear deeper than it really is. In unilateral cases the affected half of the pelvis is contracted, so that the pelvic basin is narrowed and oblique. The head of the femur is small, flattened, and, in some cases, conical; and the angle formed by the neck with the shaft is altered, sometimes diminished, it may be to a right angle—coxa vara (Fig. 129); sometimes increased—coxa valga. There is also a variable degree of torsion of the neck, ante-torsion being of practical importance as it increases the difficulty of retaining the head in the socket. The capsule is lax and admits of the head passing upwards for a variable distance on to the dorsum ilii. In unilateral cases the ligamentum teres is elongated and thickened; in bilateral cases it is frequently absent.



In children who have walked, the head of the femur is pushed farther upwards on the dorsum ilii; the capsule becomes lengthened by supporting the weight of the body. That part of the capsule which arises from the lower margin of the acetabulum stretches across the socket and partly shuts it off from the rest of the joint cavity. In course of time the capsule becomes greatly thickened, and may present an hour-glass constriction about its middle, which may prove a serious obstacle to reduction. The socket becomes small and triangular, and there is almost no ledge against which the head of the femur can rest. A superficial depression may form on the ilium where it is pressed upon by the head of the femur, covered by the capsule; and in the course of years, as the head changes its position, several secondary sockets may be formed. No proper new bony socket forms like that in traumatic dislocations that remain unreduced because in the congenital variety the thickened capsule intervenes between the head of the bone and the dorsum ilii. The displacement of the head is most frequently backwards (dorsal luxation), and as the point of support thus falls behind the acetabulum the pelvis tilts forwards, and the lumbar spine becomes unduly concave (lordosis). The muscles of the hip and thigh alter in consequence of the changed relations; the gemelli, obturators, and piriformis are lengthened, the adductors, hamstrings, and ilio-psoas are shortened, while the glutei and quadriceps are but little altered. In rare cases the head is displaced upwards and lies immediately above the acetabulum.



Clinical Features.—The condition rarely attracts attention until the child begins to walk, but sometimes the unusual breadth of the pelvis, the presence of a lump in the buttock, snapping about the hip, or a peculiar way of holding the limb, leads the parents to seek advice early. In unilateral cases, when the child has learned to walk at the late age of two, three, or it may even be four years, it is noticed that the back is hollow and the buttocks unduly prominent, and that there is a peculiar and characteristic limp; each time the weight of the body is put upon the affected limb, the trunk makes a sudden dip towards that side. There is no pain on walking. The affected limb is shortened, as is shown by the projection of the great trochanter above Nelaton's line; the shortening gradually increases, and in time may amount to several inches. It is partly compensated for by resting the affected limb on the balls of the toes and flexing the knee on the sound side. The gluteal fold is shorter, deeper, and higher than on the healthy side, and on account of the obliquity of the pelvis the spine shows a lateral curvature, with its concavity to the affected side. The movements at the hip-joint are free in all directions except abduction; on practising external rotation it is often found to be abnormally free; lastly, in young children, if the pelvis is fixed, the head of the bone may be made to glide up and down on the ilium.

In bilateral cases the trunk appears well grown in contrast to the short lower limbs, the hollow of the back is exaggerated, the abdomen protrudes, the perineum is broadened, and the buttocks are unduly prominent. The gait is waddling like that of a duck, the trunk lurching from one side to the other with each step. In untreated cases the deformity and disability become more pronounced as the capsular and round ligaments are further stretched, the shortening and limp become more marked, the patient is easily fatigued by walking or standing, and is usually unfitted for earning a living. We have had under observation, however, an adult male with bilateral dislocation and extroversion of the bladder, who efficiently performed the duties of a carrier for many years.

Except in fat infants, the diagnosis is not difficult; the absence of pain and tenderness, the freedom of motion and the absence of the head of the femur from its normal position, differentiate the condition from tuberculous disease of the joint, and from coxa vara and other deformities in the region of the hip. Trendelenburg's test consists in noting the relative level of the buttocks when the patient stands on the affected leg. Normally the buttocks remain on the same level when the patient stands on one leg; in congenital dislocation the buttock of the limb raised from the ground drops to a lower level; in coxa vara it rises higher.

In paralytic conditions at the hip there may be considerable resemblance to dislocation, but the muscles are slack and wasted, and the normal attitude can easily be restored by pulling on the limb. The most certain means of diagnosis is by the X-rays, which show the position of the head of the bone in relation to the acetabulum, and any torsion of the neck of the femur that may be present. This last point is determined by taking a series of skiagrams in different positions of the limb; these are also useful in correcting erroneous impressions as to the angle of the neck of the femur.

Treatment.—We are indebted to Paci, Schede, Calot, Lorenz, and Hoffa for the rational treatment which seeks to reduce the dislocation by manipulation.

Reduction by Manipulation (Method of Lorenz).—The child is anaesthetised and placed on its back with the legs over the end of the table. While an assistant steadies the pelvis, the surgeon pulls on the limb so as to bring the trochanter down to Nelaton's line; this is followed by forced rotation outwards and inwards and forcible abduction to a right angle, and by kneading the adductors till they are stretched and torn. The next step is to stretch the hamstrings, and this is done by raising the foot, without bending the knee, until the front of the thigh meets the abdomen, and the toes the face. To stretch the anterior muscles, the patient is turned on the side or face, and the hip is hyper-extended both in the straight and in the abducted position. The stage is now reached at which attempts at reduction may be made; the child is again laid on its back, the surgeon grasps the knee, flexes the thigh to a right angle, rotates laterally, and slowly flexes and abducts, while the thumb pushes from behind on the trochanter, trying to guide and lift it over the rim of the socket as the hip reaches the over-abducted position. Lorenz uses a wedge of wood padded with leather about 3 inches high to rest the trochanter upon while attempting to lift it forward. When reduction takes place, there is generally a sound and a sudden jump, as in reducing a traumatic dislocation.

To keep the head in the socket, the limb must be maintained in the position of right-angled abduction and external rotation (90 deg.) by a plaster case, which includes the lower part of the trunk and both limbs down to the knee. Under the plaster, stockinette drawers are worn, and the bony prominences are padded with cotton wool. The plaster should overlap the costal margin. The first case is worn for two months or more, and is then renewed at shorter intervals, the degree of abduction being diminished at each renewal until the limbs are nearly parallel. The child is only kept in bed for a week or two, and is then allowed up, being provided with a boot and high sole on the affected side, but should not use crutches. At the end of six months, by which time the capsule has become tightened up round the head of the femur, the plaster is given up and massage and exercises are employed.

In bilateral cases both dislocations are reduced at one sitting if possible, and a plaster case applied with both thighs abducted and flexed to a right angle, the so-called "frog position."

In the event of failure to reduce a dislocation at the first attempt, the limb should be fixed in plaster in the abducted attitude for ten days or a fortnight, and then another attempt made. The greatest number of successes in bilateral cases is met with under five years of age, and in unilateral cases under seven. Reduction may sometimes be accomplished, however, in older children.

If it is found impossible to restore the head of the femur to the acetabulum, an attempt should be made by similar manipulations to wedge it under the long head of the rectus femoris, or, failing this, below the anterior iliac spine under the sartorius and tensor fasciae femoris. By thus converting a posterior into an anterior dislocation, the tilting of the pelvis and the lordosis are greatly diminished. This procedure, named by Lorenz anterior transposition of the head of the femur, is specially applicable to cases in which relapse has taken place after reduction, and to those above the age when reduction should be attempted.

Reduction by open operation may be had recourse to in cases in which, after several attempts, reduction has failed, or in which re-dislocation has occurred; it is, however, a serious operation. Attempts have also been made by means of pegs and other contrivances to fix the head of the bone and prevent it sliding upwards on the ilium. When reduction is impossible by any means, a stiff leather jacket with prolongations around the thighs may diminish the deformity and improve the walking.