6. Test the function of the groin. Always begin on the sound side
for comparison in order that the patient may become accustomed to
the manipulation before the limb suspected of disease is tested.
Tuberculosis in a joint is always accompanied by muscular spasms that
positively limit motion in every direction, while in other affections
only one or more limitations are observed, but never in all directions.
Compare closely the motions of the sound and affected limbs while the
patient is on the back. Turn patient on face and test for extension by
holding pelvis flat on table with one hand and gently elevating thigh
with the other. The normal range in a child is about twenty degrees
backward from the line of the body and limitation of this range is
perhaps the earliest indication of hip-joint disease. It is due to
psoas contraction. If this range of motion is unrestricted hip disease
can be practically excluded.
The X-ray completes the diagnosis when used with a thorough knowledge
of the physical signs. It must be remembered that in early life a
larger part of the extremity of the femur is cartilaginous and does
not show well in a radiograph. The X-ray picture shows clearly the
destructive effect of the disease on the femur and acetabulum and gives
a clear conception of the actual condition of the joint.
=Treatment.=—The object of treatment of this condition is threefold:
first, to relieve the pain that depresses the vitality of the patient;
second, to relieve the muscular spasms that induce distortion of the
limb and which stimulates the destructive process by increasing
pressure and friction of the diseased surfaces of the opposing bones;
third, to correct and prevent deformity by lessening pressure and by
restraining motion, thereby keeping the femur from upward displacement.
Rest and protection are the two cardinal features of treatment of
this condition. Sunshine, fresh air and good nutritious diet are very
important.
Complete rest of the joint offers the most favorable opportunity for
nature to repair this disease. The recumbent period of the treatment
necessitates rest in bed for the reduction of the deformity and
subsidence of acute symptoms. By the aid of traction, which is applied
to the length of the legs by means of a Buck’s extension. As much
weight should be applied as can be borne without discomfort to the
patient.
As soon as the deformity and acute symptoms have subsided, the
ambulatory treatment should be substituted to keep up the general
health of the patient. This merely consists of the application of a
long plaster of Paris spica of the hip which should reach well up to
the thorax and extend down and include the foot. All bony prominences
should be well padded, and a moderate amount of traction with about
twenty degrees abduction should be used while applying the plaster
bandage. Though various forms of apparatus have been devised for
fixation and traction, I believe that the plaster of Paris spica is
far the most effective and should always be used, changing the cast
as often as it becomes soiled. Locomotion is possible with crutches
providing the shoe on the well side is stilted by an iron patten which
is high enough to allow the casted limb to clear the floor.
The earlier treatment is begun, the better the outlook. Recovery with
perfect motion occurs in about twenty-five percent of hospital cases;
fifty per cent will obtain useful motion and the other twenty-five per
cent will obtain practical fixation, but it must be remembered that
results will range entirely according to the thoroughness of treatment,
the severity of the disease in the individual case, and the natural
resistance of the child. In general, the hip should be fixed as long as
it is sensitive, it should be protected and distracted as long as there
is muscular spasm, and protected until the congested and inflamed bone
of the epiphysis is replaced by firm healthy bone.