THE MUSCLES, TENDONS, AND TENDON SHEATHS
INJURIES: _Contusion_; _Sprain_; _Rupture_--Hernia of
muscle--Dislocation of tendons--Wounds--Avulsion of tendon.
DISEASES OF MUSCLE AND OF TENDONS: _Atrophy_; _"Muscular
rheumatism"_--_Fibrositis_; _Contracture_; _Myositis_;
_Calcification and Ossification_; _Tumours_. DISEASES OF TENDON
SHEATHS: _Teno-synovitis_.
INJURIES
#Contusion of Muscle.#--Contusion of muscle, which consists in bruising
of its fibres and blood vessels, may be due to violence acting from
without, as in a blow, a kick, or a fall; or from within, as by the
displacement of bone in a fracture or dislocation.
The symptoms are those common to all contusions, and the patient
complains of severe pain on attempting to use the muscle, and maintains
an attitude which relaxes it. If the sheath of the muscle also is torn,
there is subcutaneous ecchymosis, and the accumulation of blood may
result in the formation of a hæmatoma.
Restoration of function is usually complete; but when the nerve
supplying the muscle is bruised at the same time, as may occur in the
deltoid, wasting and loss of function may be persistent. In exceptional
cases the process of repair may be attended with the formation of bone
in the substance of the muscle, and this may likewise impair its
function.
A contused muscle should be placed at rest and supported by cotton wool
and a bandage; after an interval, massage and appropriate exercises are
employed.
#Sprain and Partial Rupture of Muscle.#--This lesion consists in
overstretching and partial rupture of the fibres of a muscle or its
aponeurosis. It is of common occurrence in athletes and in those who
follow laborious occupations. It may follow upon a single or repeated
effort--especially in those who are out of training. Familiar examples
of muscular sprain are the "labourer's" or "golfer's back," affecting
the latissimus dorsi or the sacrospinalis (erector spinæ); the
"tennis-player's elbow," and the "sculler's sprain," affecting the
muscles and ligaments about the elbow; the "angler's elbow," affecting
the common origin of the extensors and supinators; the "sprinter's
sprain," affecting the flexors of the hip; and the "jumper's and
dancer's sprain," affecting the muscles of the calf. The patient
complains of pain, often sudden in onset, of tenderness on pressure, and
of inability to carry out the particular movement by which the sprain
was produced. The disability varies in different cases, and it may
incapacitate the patient from following his occupation or sport for
weeks or, if imperfectly treated, even for months.
The _treatment_ consists in resting the muscle from the particular
effort concerned in the production of the sprain, in gently exercising
it in other directions, in the use of massage, and the induction of
hyperæmia by means of heat. In neglected cases, that is, where the
muscle has not been exercised, the patient shrinks from using it and the
disablement threatens to be permanent; it is sometimes said that
adhesions have formed and that these interfere with the recovery of
function. The condition may be overcome by graduated movements or by a
sudden forcible movement under an anæsthetic. These cases afford a
fruitful field for the bone-setter.
#Rupture of Muscle or Tendon.#--A muscle or a tendon may be ruptured in
its continuity or torn from its attachment to bone. The site of rupture
in individual muscles is remarkably constant, and is usually at the
junction of the muscular and tendinous portions. When rupture takes
place through the belly of a muscle, the ends retract, the amount of
retraction depending on the length of the muscle, and the extent of its
attachment to adjacent aponeurosis or bone. The biceps in the arm, and
the sartorius in the thigh, furnish examples of muscles in which the
separation between the ends may be considerable.
The gap in the muscle becomes filled with blood, and this in time is
replaced by connective tissue, which forms a bond of union between the
ends. When the space is considerable the connecting medium consists of
fibrous tissue, but when the ends are in contact it contains a number of
newly formed muscle fibres. In the process of repair, one or both ends
of the muscle or tendon may become fixed by adhesions to adjacent
structures, and if the distal portion of a muscle is deprived of its
nerve supply it may undergo degeneration and so have its function
impaired.
Rupture of a muscle or tendon is usually the result of a sudden, and
often involuntary, movement. As examples may be cited the rupture of
the quadriceps extensor in attempting to regain the balance when falling
backwards; of the gastrocnemius, plantaris, or tendo-calcaneus in
jumping or dancing; of the adductors of the thigh in gripping a horse
when it swerves--"rider's sprain"; of the abdominal muscles in vomiting,
and of the biceps in sudden movements of the arm. Sometimes the effort
is one that would scarcely be thought likely to rupture a muscle, as in
the case recorded by Pagenstecher, where a professional athlete, while
sitting at table, ruptured his biceps in a sudden effort to catch a
falling glass. It would appear that the rupture is brought about not so
much by the contraction of the muscle concerned, as by the contraction
of the antagonistic muscles taking place before that of the muscle which
undergoes rupture is completed. The violent muscular contractions of
epilepsy, tetanus, or delirium rarely cause rupture.
The _clinical features_ are usually characteristic. The patient
experiences a sudden pain, with the sensation of being struck with a
whip, and of something giving way; sometimes a distant snap is heard.
The limb becomes powerless. At the seat of rupture there is tenderness
and swelling, and there may be ecchymosis. As the swelling subsides, a
gap may be felt between the retracted ends, and this becomes wider when
the muscle is thrown into contraction. If untreated, a hard, fibrous
cord remains at the seat of rupture.
_Treatment._--The ends are approximated by placing the limb in an
attitude which relaxes the muscle, and the position is maintained by
bandages, splints, or special apparatus. When it is impossible thus to
approximate the ends satisfactorily, the muscle or tendon is exposed by
incision, and the ends brought into accurate contact by catgut sutures.
This operation of primary suture yields the most satisfactory results,
and is most successful when it is done within five or six days of the
accident. Secondary suture after an interval of months is rendered
difficult by the retraction of the ends and by their adhesion to
adjacent structures.
_Rupture of the biceps of the arm_ may involve the long or the short
head, or the belly of the muscle. Most interest attaches to rupture of
the long tendon of origin. There is pain and tenderness in front of the
upper end of the humerus, the patient is unable to abduct or to elevate
the arm, and he may be unable to flex the elbow when the forearm is
supinated. The long axis of the muscle, instead of being parallel with
the humerus, inclines downwards and outwards. When the patient is asked
to contract the muscle, its belly is seen to be drawn towards the
elbow.
The _adductor longus_ may be ruptured, or torn from the pubes, by a
violent effort to adduct the limb. A swelling forms in the upper and
medial part of the thigh, which becomes smaller and harder when the
muscle is thrown into contraction.
The _quadriceps femoris_ is usually ruptured close to its insertion into
the patella, in the attempt to avoid falling backwards. The injury is
sometimes bilateral. The injured limb is rendered useless for
progression, as it suddenly gives way whenever the knee is flexed.
Treatment is conducted on the same lines as in transverse fracture of
the patella; in the majority of cases the continuity of the quadriceps
should be re-established by suture within five or six days of the
accident.
The _tendo calcaneus_ (Achillis) is comparatively easily ruptured, and
the symptoms are sometimes so slight that the nature of the injury may
be overlooked. The limb should be put up with the knee flexed and the
toes pointed. This may be effected by attaching one end of an elastic
band to the heel of a slipper, and securing the other to the lower third
of the thigh. If this is not sufficient to bring the ends into
apposition they should be approximated by an open operation.
The _plantaris_ is not infrequently ruptured from trivial causes, such
as a sudden movement in boxing, tennis, or hockey. A sharp stinging pain
like the stroke of a whip is felt in the calf; there is marked
tenderness at the seat of rupture, and the patient is unable to raise
the heel without pain. The injury is of little importance, and if the
patient does not raise the heel from the ground in walking, it is
recovered from in a couple of weeks or so, without it being necessary to
lay him up.
#Hernia of Muscle.#--This is a rare condition, in which, owing to the
fascia covering a muscle becoming stretched or torn, the muscular
substance is protruded through the rent. It has been observed chiefly in
the adductor longus. An oval swelling forms in the upper part of the
thigh, is soft and prominent when the muscle is relaxed, less prominent
when it is passively extended, and disappears when the muscle is thrown
into contraction. It is liable to be mistaken, according to its
situation, for a tumour, a cyst, a pouched vein, or a femoral or
obturator hernia. Treatment is only called for when it is causing
inconvenience, the muscle being exposed by a suitable incision, the
herniated portion excised, and the rent in the sheath closed by sutures.
#Dislocation of Tendons.#--Tendons which run in grooves may be displaced
as a result of rupture of the confining sheath. This injury is met with
chiefly in the tendons at the ankle and in the long tendon of the
biceps.
Dislocation of the _peronei tendons_ may occur, for example, from a
violent twist of the foot. There is severe pain and considerable
swelling on the lateral aspect of the ankle; the peroneus longus by
itself, or together with the brevis, can be felt on the lateral aspect
or in front of the lateral malleolus; the patient is unable to move the
foot. By a little manipulation the tendons are replaced in their
grooves, and are retained there by a series of strips of plaster. At the
end of three weeks massage and exercises are employed.
In other cases there is no history of injury, but whenever the foot is
everted the tendon of the peroneus longus is liable to be jerked
forwards out of its groove, sometimes with an audible snap. The patient
suffers pain and is disabled until the tendon is replaced. Reduction is
easy, but as the displacement tends to recur, an operation is required
to fix the tendon in its place. An incision is made over the tendon; if
the sheath is slack or torn, it is tightened up or closed with catgut
sutures; or an artificial sheath is made by raising up a quadrilateral
flap of periosteum from the lateral aspect of the fibula, and stitching
it over the tendon.
Similarly the _tibialis posterior_ may be displaced over the medial
malleolus as a result of inversion of the foot.
The _long tendon of the biceps_ may be dislocated laterally--or more
frequently medially--as a result of violent or repeated rotation
movements of the arm, such as are performed in wringing clothes. The
patient is aware of the displacement taking place, and is unable to
extend the forearm until the displaced tendon has been reduced by
abducting the arm. In recurrent cases the patient may be able to
dislocate the tendon at will, but the disability is so inconsiderable
that there is rarely any occasion for interference.
#Wounds of Muscles and Tendons.#--When a muscle is cut across in a
wound, its ends should be brought together with sutures. If the ends are
allowed to retract, and especially if the wound suppurates, they become
united by scar tissue and fixed to bone or other adjacent structure. In
a limb this interferes with the functions of the muscle; in the
abdominal wall the scar tissue may stretch, and so favour the
development of a ventral hernia.
Tendons may be cut across accidentally, especially in those wounds so
commonly met with above the wrist as a result, for example, of the hand
being thrust through a pane of glass. It is essential that the ends
should be sutured to each other, and as the proximal end is retracted
the original wound may require to be enlarged in an upward direction.
When primary suture has been omitted, or has failed in consequence of
suppuration, the separated ends of the tendon become adherent to
adjacent structures, and the function of the associated muscle is
impaired or lost. Under these conditions the operation of secondary
suture is indicated.
A free incision is necessary to discover and isolate the ends of the
tendon; if the interval is too wide to admit of their being approximated
by sutures, means must be taken to lengthen the tendon, or one from some
other part may be inserted in the gap. A new sheath may be provided for
the tendon by resecting a portion of the great saphenous vein.
_Injuries of the tendons of the fingers_ are comparatively common. One
of the best known is the partial or complete rupture of the aponeurosis
of the extensor tendon close to its insertion into the terminal
phalanx--_drop-_ or _mallet-finger_. This may result from comparatively
slight violence, such as striking the tip of the extended finger against
an object, or the violence may be more severe, as in attempting to catch
a cricket ball or in falling. The terminal phalanx is flexed towards the
palm and the patient is unable to extend it. The treatment consists in
putting up the finger with the middle joint strongly flexed. In
neglected cases, a perfect functional result can only be obtained by
operation; under a local anæsthetic, the ruptured tendon is exposed and
is sutured to the base of the phalanx, which may be drilled for the
passage of the sutures.
_Subcutaneous rupture_ of one or other _of the digital tendons_ in the
hand or at the wrist can be remedied only by operation. When some time
has elapsed since the accident, the proximal end may be so retracted
that it cannot be brought down into contact with the distal end, in
which case a slip may be taken from an adjacent tendon; in the case of
one of the extensors of the thumb, the extensor carpi radialis longus
may be detached from its insertion and stitched to the distal end of the
tendon of the thumb.
Subcutaneous _rupture of the tendon of the extensor pollicis longus_ at
the wrist takes place just after its emergence from beneath the annular
ligament; the actual rupture may occur painlessly, more frequently a
sharp pain is felt over the back of the wrist. The prominence of the
tendon, which normally forms the ulnar border of the snuff-box,
disappears. This lesion is chiefly met with in drummer-boys and is the
cause of drummer's palsy. The only chance of restoring function is in
uniting the ruptured tendon by open operation.
[Illustration: FIG. 108.--Avulsion of Tendon with Terminal Phalanx of
Thumb.
(Surgical Museum, University of Edinburgh.)]
_Avulsion of Tendons._--This is a rare injury, in which the tendons of a
finger or toe are torn from their attachments along with a portion of
the digit concerned. In the hand, it is usually brought about by the
fingers being caught in the reins of a runaway horse, or being seized in
a horse's teeth, or in machinery. It is usually the terminal phalanx
that is separated, and with it the tendon of the deep flexor, which
ruptures at its junction with the belly of the muscle (Fig. 108). The
treatment consists in disinfecting the wound, closing the tendon-sheath,
and trimming the mutilated finger so as to provide a useful stump.
DISEASES OF MUSCLES AND TENDONS
_Congenital absence_ of muscles is sometimes met with, usually in
association with other deformities. The pectoralis major, for example,
may be absent on one or on both sides, without, however, causing any
disability, as other muscles enlarge and take on its functions.
_Atrophy of Muscle._--Simple atrophy, in which the muscle elements are
merely diminished in size without undergoing any structural alteration,
is commonly met with as a result of disuse, as when a patient is
confined to bed for a long period.
In cases of joint disease, the muscles acting on the joint become
atrophied more rapidly than is accounted for by disuse alone, and this
is attributed to an interference with the trophic innervation of the
muscles reflected from centres in the spinal medulla. It is more marked
in the extensor than in the flexor groups of muscles. Those affected
become soft and flaccid, exhibit tremors on attempted movement, and
their excitability to the faradic current is diminished.
_Neuropathic atrophy_ is associated with lesions of the nervous system.
It is most pronounced in lesions of the motor nerve-trunks, probably
because vaso-motor and trophic fibres are involved as well as those that
are purely motor in function. It is attended with definite structural
alterations, the muscle elements first undergoing fatty degeneration,
and then being absorbed, and replaced to a large extent by ordinary
connective tissue and fat. At a certain stage the muscles exhibit the
reaction of degeneration. In the common form of paralysis resulting from
poliomyelitis, many fibres undergo fatty degeneration and are replaced
by fat, while at the same time there is a regeneration of muscle fibres.
#Fibrositis# or "#Muscular Rheumatism#."--This clinical term is applied
to a group of affections of which lumbago is the best-known example. The
group includes lumbago, stiff-neck, and pleurodynia--conditions which
have this in common, that sudden and severe pain is excited by movement
of the affected part. The lesion consists in inflammatory hyperplasia of
the connective tissue; the new tissue differs from normal fibrous tissue
in its tendency to contract, in being swollen, painful and tender on
pressure, and in the fact that it can be massaged away (Stockman). It
would appear to involve mainly the fibrous tissue of muscles, although
it may extend from this to aponeuroses, ligaments, periosteum, and the
sheaths of nerves. The term _fibrositis_ was applied to it by Gowers in
1904.
In _lumbago_--_lumbo-sacral fibrositis_--the pain is usually located
over the sacrum, the sacro-iliac joint, or the aponeurosis of the lumbar
muscles on one or both sides. The amount of tenderness varies, and so
long as the patient is still he is free from pain. The slightest
attempt to alter his position, however, is attended by pain, which may
be so severe as to render him helpless for the moment. The pain is most
marked on rising from the stooping or sitting posture, and may extend
down the back of the hip, especially if, as is commonly the case,
lumbago and gluteal fibrosis coexist. Once a patient has suffered from
lumbago, it is liable to recur, and an attack may be determined by
errors of diet, changes of weather, exposure to cold or unwonted
exertion. It is met with chiefly in male adults, and is most apt to
occur in those who are gouty or are the subjects of oxaluric dyspepsia.
_Gluteal fibrositis_ usually follows exposure to wet, and affects the
gluteal muscles, particularly the medius, and their aponeurotic
coverings. When the condition has lasted for some time, indurated
strands or nodules can be detected on palpating the relaxed muscles. The
patient complains of persistent aching and stiffness over the buttock,
and sometimes extending down the lateral aspect of the thigh. The pain
is aggravated by such movements as bring the affected muscles into
action. It is not referred to the line of the sciatic nerve, nor is
there tenderness on pressing over the nerve, or sensations of tingling
or numbness in the leg or foot.
If untreated, the morbid process may implicate the sheath of the sciatic
nerve and cause genuine sciatic neuralgia (Llewellyn and Jones). A
similar condition may implicate the fascia lata of the thigh, or the
calf muscles and their aponeuroses--_crural fibrositis_.
In _painful stiff-neck_, or "rheumatic torticollis," the pain is located
in one side of the neck, and is excited by some inadvertent movement.
The head is held stiffly on one side as in wry-neck, the patient
contracting the sterno-mastoid. There may be tenderness over the
vertebral spines or in the lines of the cervical nerves, and the
sterno-mastoid may undergo atrophy. This affection is more often met
with in children.
In _pleurodynia_--_intercostal fibrositis_--the pain is in the line of
the intercostal nerves, and is excited by movement of the chest, as in
coughing, or by any bodily exertion. There is often marked tenderness.
A similar affection is met with in the _shoulder and arm_--_brachial
fibrositis_--especially on waking from sleep. There is acute pain on
attempting to abduct the arm, and there may be localised tenderness in
the region of the axillary nerve.
_Treatment._--The general treatment is concerned with the diet,
attention to the stomach, bowels, and kidneys and with the correction
of any gouty tendencies that may be present. Remedies such as
salicylates are given for the relief of pain, and for this purpose drugs
of the aspirin type are to be preferred, and these may be followed by
large doses of iodide of potassium. Great benefit is derived from
massage, and from the induction of hyperæmia by means of heat. Cupping
or needling, or, in exceptional cases, hypodermic injections of
antipyrin or morphin, may be called for. To prevent relapses of lumbago,
the patient must take systematic exercises of all kinds, especially such
as bring out the movements of the vertebral column and hip-joints.
[Illustration: FIG. 109.--Volkmann's Ischæmic Contracture. When the
wrist is flexed to a right angle it is possible to extend the fingers.
(Photographs lent by Mr. Lawford Knaggs)]
#Contracture of Muscles.#--Permanent shortening of muscles results from
the prolonged approximation of their points of attachment, or from
structural changes in their substance produced by injury or by disease.
It is a frequent accompaniment and sometimes a cause of deformities, in
the treatment of which lengthening of the shortened muscles or their
tendons may be an essential step.
#Myositis.#--_Ischæmic Myositis._--Volkmann was the first to describe a
form of myositis followed by contracture, resulting from interference
with the arterial blood supply. It is most frequently observed in the
flexor muscles of the forearm in children and young persons under
treatment for fractures in the region of the elbow, the splints and
bandages causing compression of the blood vessels. There is considerable
effusion of blood, the skin is tense, and the muscles, vessels, and
nerves are compressed; this is further increased if the elbow is flexed
and splints and tight bandages are applied. The muscles acquire a
board-like hardness and no longer contract under the will, and passive
motion is painful and restricted. Slight contracture of the fingers is
usually the first sign of the malady; in time the muscles undergo
further contraction, and this brings about a claw-like deformity of the
hand. The affected muscles usually show the reaction of degeneration. In
severe cases the median and ulnar nerves are also the seat of
cicatricial changes (ischæmic neuritis).
By means of splints, the interphalangeal, metacarpo-phalangeal, and
wrist joints should be gradually extended until the deformity is
over-corrected (R. Jones). Murphy advises resection of the radius and
ulna sufficient to admit of dorsiflexion of the joints and lengthening
of the flexor tendons.
Various forms of _pyogenic_ infection are met with in muscle, most
frequently in relation to pyæmia and to typhoid fever. These may result
in overgrowth of the connective-tissue framework of the muscle and
degeneration of its fibres, or in suppuration and the formation of one
or more abscesses in the muscle substance. Repair may be associated with
contracture.
A _gonorrhœal_ form of myositis is sometimes met with; it is painful,
but rarely goes on to suppuration.
In the early secondary period of _syphilis_, the muscles may be the seat
of dull, aching, nocturnal pains, especially in the neck and back.
_Syphilitic contracture_ is a condition which has been observed chiefly
in the later secondary period; the biceps of the arm and the hamstrings
in the thigh are the muscles more commonly affected. The striking
feature is a gradually increasing difficulty of extending the limb at
the elbow or knee, and progressive flexion of the joint. The affected
muscle is larger and firmer than normal, and its electric excitability
is diminished. In tertiary syphilis, individual muscles may become the
seat of interstitial myositis or of gummata, and these affections
readily yield to anti-syphilitic remedies.
_Tuberculous disease_ in muscle, while usually due to extension from
adjacent tissues, is sometimes the result of a primary infection through
the blood-stream. Tuberculous nodules are found disseminated throughout
the muscle; the surrounding tissues are indurated, and central caseation
may take place and lead to abscess formation and sinuses. We have
observed this form of tuberculous disease in the gastrocnemius and in
the psoas--in the latter muscle apart from tuberculous disease in the
vertebræ.
#Tendinitis.#--German authors describe an inflammation of tendon as
distinguished from inflammation of its sheath, and give it the name
tendinitis. It is met with most frequently in the tendo-calcaneus in
gouty and rheumatic subjects who have overstrained the tendon,
especially during cold and damp weather. There is localised pain which
is aggravated by walking, and the tendon is sensitive and swollen from a
little above its insertion to its junction with the muscle. Gouty
nodules may form in its substance. Constitutional measures, massage, and
douching should be employed, and the tendon should be protected from
strain.
#Calcification and Ossification in Muscles, Tendons, and
Fasciæ.#--_Myositis ossificans._--Ossifications in muscles, tendons,
fasciæ, and ligaments, in those who are the subjects of arthritis
deformans, are seldom recognised clinically, but are frequently met with
in dissecting-rooms and museums. Similar localised ossifications are met
with in Charcot's disease of joints, and in fractures which have
repaired with exuberant callus. The new bone may be in the form of
spicules, plates, or irregular masses, which, when connected with a
bone, are called _false exostoses_ (Fig. 110).
[Illustration: FIG. 110.--Ossification in Tendon of Ilio-psoas Muscle.]
_Traumatic Ossification in Relation to Muscle._--Various forms of
ossification are met with in muscle as the result of a single or of
repeated injury. Ossification in the crureus or vastus lateralis muscle
has been frequently observed as a result of a kick from a horse. Within
a week or two a swelling appears at the site of injury, and becomes
progressively harder until its consistence is that of bone. If the mass
of new bone moves with the affected muscle, it causes little
inconvenience. If, as is commonly the case, it is fixed to the femur,
the action of the muscle is impaired, and the patient complains of pain
and difficulty in flexing the knee. A skiagram shows the extent of the
mass and its relationship to the femur. The treatment consists in
excising the bony mass.
Difficulty may arise in differentiating such a mass of bone from
sarcoma; the ossification in muscle is uniformly hard, while the sarcoma
varies in consistence at different parts, and the X-ray picture shows a
clear outline of the bone in the vicinity of the ossification in
muscle, whereas in sarcoma the involvement of the bone is shown by
indentations and irregularity in its contour.
A similar ossification has been observed in relation to the insertion of
the brachialis muscle as a sequel of dislocation of the elbow. After
reduction of the dislocation, the range of movement gradually diminishes
and a hard swelling appears in front of the lower end of the humerus.
The lump continues to increase in size and in three to four weeks the
disability becomes complete. A radiogram shows a shadow in the muscle,
attached at one part as a rule to the coronoid process. During the next
three or four months, the lump in front of the elbow remains stationary
in size; a gradual decrease then ensues, but the swelling persists, as a
rule, for several years.
[Illustration: FIG. 111.--Calcification and Ossification in Biceps and
Triceps.
(From a radiogram lent by Dr. C. A. Adair Dighton.)]
Ossification in the adductor longus was first described by Billroth
under the name of "rider's bone." It follows bruising and partial
rupture of the muscle, and has been observed chiefly in cavalry
soldiers. If it causes inconvenience the bone may be removed by
operation.
Ossification in the deltoid and pectoral muscles has been observed in
foot-soldiers in the German army, and has received the name of
"drill-bone"; it is due to bruising of the muscle by the recoil of the
rifle.
_Progressive Ossifying Myositis._--This is a rare and interesting
disease, in which the muscles, tendons, and fasciæ throughout the body
become the seat of ossification. It affects almost exclusively the male
sex, and usually begins in childhood or youth, sometimes after an
injury, sometimes without apparent cause. The muscles of the back,
especially the trapezius and latissimus, are the first to be affected,
and the initial complaint is limitation of movement.
[Illustration: FIG. 112.--Ossification in Muscles of Trunk in a case of
generalised Ossifying Myositis.
(Photograph lent by Dr. Rustomjee.)]
The affected muscles show swellings which are rounded or oval, firm and
elastic, sharply defined, without tenderness and without discoloration
of the overlying skin. Skiagrams show that a considerable deposit of
lime salts may precede the formation of bone, as is seen in Fig. 111. In
course of time the vertebral column becomes rigid, the head is bent
forward, the hips are flexed, and abduction and other movements of the
arms are limited. The disease progresses by fits and starts, until all
the striped muscles of the body are replaced by bone, and all movements,
even those of the jaws, are abolished. The subjects of this disease
usually succumb to pulmonary tuberculosis.
There is no means of arresting the disease, and surgical treatment is
restricted to the removal or division of any mass of bone that
interferes with an important movement.
A remarkable feature of this disease is the frequent presence of a
deformity of the great toe, which usually takes the form of hallux
valgus, the great toe coming to lie beneath the second one; the
shortening is usually ascribed to absence of the first phalanx, but it
has been shown to depend also on a synostosis and imperfect development
of the phalanges. A similar deformity of the thumb is sometimes met
with.
Microscopical examination of the muscles shows that, prior to the
deposition of lime salts and the formation of bone, there occurs a
proliferation of the intra-muscular connective tissue and a gradual
replacement and absorption of the muscle fibres. The bone is spongy in
character, and its development takes place along similar lines to those
observed in ossification from the periosteum.
#Tumours of Muscle.#--With the exception of congenital varieties, such
as the rhabdomyoma, tumours of muscle grow from the connective-tissue
framework and not from the muscle fibres. Innocent tumours, such as the
fibroma, lipoma, angioma, and neuro-fibroma, are rare. Malignant tumours
may be primary in the muscle, or may result from extension from adjacent
growths--for example, implication of the pectoral muscle in cancer of
the breast--or they may be derived from tumours situated elsewhere. The
diagnosis of an intra-muscular tumour is made by observing that the
swelling is situated beneath the deep fascia, that it becomes firm and
fixed when the muscle contracts, and that, when the muscle is relaxed,
it becomes softer, and can be moved in the transverse axis of the
muscle, but not in its long axis.
Clinical interest attaches to that form of slowly growing
fibro-sarcoma--_the recurrent fibroid of Paget_--which is most
frequently met with in the muscles of the abdominal wall. A rarer
variety is the ossifying chondro-sarcoma, which undergoes ossification
to such an extent as to be visible in skiagrams.
In primary sarcoma the treatment consists in removing the muscle. In the
limbs, the function of the muscle that is removed may be retained by
transplanting an adjacent muscle in its place.
_Hydatid cysts_ of muscle resemble those developing in other tissues.
DISEASES OF TENDON SHEATHS
Tendon sheaths have the same structure and function as the synovial
membranes of joints, and are liable to the same diseases. Apart from the
tendon sheaths displayed in anatomical dissections, there is a loose
peritendinous and perimuscular cellular tissue which is subject to the
same pathological conditions as the tendon sheaths proper.
#Teno-synovitis.#--The toxic or infective agent is conveyed to the
tendon sheaths through the blood-stream, as in the gouty, gonorrhœal,
and tuberculous varieties, or is introduced directly through a wound, as
in the common pyogenic form of teno-synovitis.
_Teno-synovitis Crepitans._--In the simple or traumatic form of
teno-synovitis, although the most prominent etiological factor is a
strain or over-use of the tendon, there would appear to be some other,
probably a toxic, factor in its production, otherwise the affection
would be much more common than it is: only a small proportion of those
who strain or over-use their tendons become the subjects of
teno-synovitis. The opposed surfaces of the tendon and its sheath are
covered with fibrinous lymph, so that there is friction when they move
on one another.
The _clinical features_ are pain on movement, tenderness on pressure
over the affected tendon, and a sensation of crepitation or friction
when the tendon is moved in its sheath. The crepitation may be soft like
the friction of snow, or may resemble the creaking of new
leather--"saddle-back creaking." There may be swelling in the long axis
of the tendon, and redness and œdema of the skin. If there is an
effusion of fluid into the sheath, the swelling is more marked and
crepitation is absent. There is little tendency to the formation of
adhesions.
In the upper extremity, the sheath of the long tendon of the biceps may
be affected, but the condition is most common in the tendons about the
wrist, particularly in the extensors of the thumb, and it is most
frequently met with in those who follow occupations which involve
prolonged use or excessive straining of these tendons--for example,
washerwomen or riveters. It also occurs as a result of excessive
piano-playing, fencing, or rowing.
At the ankle it affects the peronei, the extensor digitorum longus, or
the tibialis anterior. It is most often met with in relation to the
tendo-calcaneus--_Achillo-dynia_--and results from the pressure of
ill-fitting boots or from the excessive use and strain of the tendon in
cycling, walking, or dancing. There is pain in raising the heel from the
ground, and creaking can be felt on palpation.
The _treatment_ consists in putting the affected tendon at rest, and
with this object a splint may be helpful; the usual remedies for
inflammation are indicated: Bier's hyperæmia, lead and opium
fomentations, and ichthyol and glycerine. The affection readily subsides
under treatment, but is liable to relapse on a repetition of the
exciting cause.
_Gouty Teno-synovitis._--A deposit of urate of soda beneath the
endothelial covering of tendons or of that lining their sheaths is
commonly met with in gouty subjects. The accumulation of urates may
result in the formation of visible nodular swellings, varying in size
from a pea to a cherry, attached to the tendon and moving with it. They
may be merely unsightly, or they may interfere with the use of the
tendon. Recurrent attacks of inflammation are prone to occur. We have
removed such gouty masses with satisfactory results.
_Suppurative Teno-synovitis._--This form usually follows upon infected
wounds of the fingers--especially of the thumb or little finger--and is
a frequent sequel to whitlow; it may also follow amputation of a finger.
Once the infection has gained access to the sheath, it tends to spread,
and may reach the palm or even the forearm, being then associated with
cellulitis. In moderately acute cases the tendon and its sheath become
covered with granulations, which subsequently lead to the formation of
adhesions; while in more acute cases the tendon sloughs. The pus may
burst into the cellular tissue outside the sheath, and the suppuration
is liable to spread to neighbouring sheaths or to adjacent bones or
joints--for example, those of the wrist.
The _treatment_ consists in inducing hyperæmia and making small
incisions for the escape of pus. The site of incision is determined by
the point of greatest tenderness on pressure. After the inflammation has
subsided, active and passive movements are employed to prevent the
formation of adhesions between the tendon and its sheath. If the tendon
sloughs, the dead portion should be cut away, as its separation is
extremely slow and is attended with prolonged suppuration.
_Gonorrhœal Teno-synovitis._--This is met with especially in the tendon
sheaths about the wrist and ankle. It may occur in a mild form, with
pain, impairment of movement, and œdema, and sometimes an elongated,
fluctuating swelling, the result of serous effusion into the sheath.
This condition may alternate with a gonorrhœal affection of one of the
larger joints. It may subside under rest and soothing applications, but
is liable to relapse. In the more severe variety the skin is red, and
the swelling partakes of the characters of a phlegmon with threatening
suppuration; it may result in crippling from adhesions. Even if pus
forms in the sheath, the tendon rarely sloughs. The treatment consists
in inducing hyperæmia by Bier's method; and a vaccine may be employed
with satisfactory results.
#Tuberculous Disease of Tendon Sheaths.#--This is a comparatively common
affection, and is analogous to tuberculous disease of the synovial
membrane of joints. It may originate in the sheath, or may spread to it
from an adjacent bone.
The commonest form--hydrops--is that in which the synovial sheath is
distended with a viscous fluid, and the fibrinous material on the free
surface becomes detached and is moulded into melon-seed bodies by the
movement of the tendon. The sheath itself is thickened by the growth of
tuberculous granulation tissue. The bodies are smooth and of a
dull-white colour, and vary greatly in size and shape. There may be an
overgrowth of the fatty fringes of the synovial sheath, a condition
described as "arborescent lipoma."
The _clinical features_ vary with the tendon sheath affected. In the
common flexor sheath of the hand an hour-glass-shaped swelling is
formed, bulging above and below the transverse carpal (anterior annular)
ligament--formerly known as _compound palmar ganglion_. There is little
or no pain, but the fingers tend to be stiff and weak, and to become
flexed. On palpation, it is usually possible to displace the contents of
the sheath from one compartment to the other, and this may yield
fluctuation, and, what is more characteristic, a peculiar soft crepitant
sensation from the movement of the melon-seed bodies. In the sheath of
the peronei or other tendons about the ankle, the swelling is
sausage-shaped, and is constricted opposite the annular ligament.
The onset and progress of the affection are most insidious, and the
condition may remain stationary for long periods. It is aggravated by
use or strain of the tendons involved. In exceptional cases the skin is
thinned and gives way, resulting in the formation of a sinus.
_Treatment._--In the common flexor sheath of the palm, an attempt may be
made to cure the condition by removing the contents through a small
incision and filling the cavity with iodoform glycerine, followed by the
use of Bier's bandage. If this fails, the distended sheath is laid open,
the contents removed, the wall scraped, and the wound closed.
A less common form of tuberculous disease is that in which the sheath
becomes the seat of _a diffuse tuberculous thickening_, not unlike the
white swelling met with in joints, and with a similar tendency to
caseation. A painless swelling of an elastic character forms in relation
to the tendon sheath. It is hour-glass-shaped in the common flexor
sheath of the palm, elongated or sausage-shaped in the extensors of the
wrist and in the tendons at the ankle. The tuberculous granulation
tissue is liable to break down and lead to the formation of a cold
abscess and sinuses, and in our experience is often associated with
disease in an adjacent bone or joint. In the peronei tendons, for
example, it may result from disease of the fibula or of the ankle-joint.
When conservative measures fail, excision of the affected sheath should
be performed; the whole of the diseased area being exposed by free
incision of the overlying soft parts, the sheath is carefully isolated
from the surrounding tissues and is cut across above and below. Any
tuberculous tissue on the tendon itself is removed with a sharp spoon.
Associated bone or joint lesions are dealt with at the same time. In the
after-treatment the functions of the tendons must be preserved by
voluntary and passive movements.
#Syphilitic Affections of Tendon Sheaths.#--These closely resemble the
syphilitic affections of the synovial membrane of joints. During the
secondary period the lesion usually consists in effusion into the
sheath; gummata are met with during the tertiary period.
Arborescent lipoma has been found in the sheaths of tendons about the
wrist and ankle, sometimes in a multiple and symmetrical form,
unattended by symptoms and disappearing under anti-syphilitic treatment.
#Tumours of Tendon Sheaths.#--Innocent tumours, such as _lipoma_,
_fibroma_, and _myxoma_, are rare. Special mention should be made of the
_myeloma_ which is met with at the wrist or ankle as an elongated
swelling of slow development, or over the phalanx of a finger as a small
rounded swelling. The tumour tissue, when exposed by dissection, is of a
chocolate or chamois-yellow colour, and consists almost entirely of
giant cells. The treatment consists in dissecting the tumour tissue off
the tendons, and this is usually successful in bringing about a
permanent cure.
All varieties of _sarcoma_ are met with, but their origin from tendon
sheaths is not associated with special features.