DISEASES OF INDIVIDUAL JOINTS
THE SHOULDER-JOINT
The shoulder is seldom the seat of disease, and most affections of the
joint are met with in adults. In young subjects, infective processes
result chiefly from extension of disease from the upper epiphysial
junction of the humerus, which is partly included within the limits of
the synovial cavity. The synovial membrane, in addition to lining the
capsular ligament, is prolonged down the inter-tubercular (bicipital)
groove around the long tendon of the biceps, and pus may escape from
the joint by this diverticulum and gravitate down the arm; we have
also observed loose bodies of synovial origin in this diverticulum.
There is frequently a communication between the joint and the
sub-deltoid bursa. There is no attitude characteristic of disease of
the shoulder-joint, but the girdle is usually elevated, the upper arm
held close to the side and rotated medially, while the elbow is
carried a little backwards. In the later stages, the head of the
humerus may be drawn upwards and medially towards the coracoid
process. Fixation of the shoulder-joint is largely compensated for by
movement of the scapula on the thorax, so that when testing for
rigidity the scapula should be fixed with one hand while passive
movements of the arm are carried out with the other. The deltoid is
usually atrophied, allowing the acromion, coracoid, and great
tuberosity of the humerus to stand out prominently beneath the skin.
Swelling is rarely a prominent feature, except when there is a
collection of synovial fluid or of pus in the bursa beneath the
deltoid.
#Tuberculous Disease# is usually met with in young adults, and is more
common in the right shoulder. The prominent features are pain,
rigidity, and wasting of the deltoid and scapular muscles. The pain is
sometimes severe, shooting down the arm and interfering with sleep,
and it may be associated with tenderness on pressure over the upper
end of the humerus. In cases with carious destruction of the
articular surfaces there are starting pains, and the arm is shortened.
If a cold abscess forms in the bursa underneath the deltoid, the pus
may burrow and appear at the anterior or posterior boundary of the
axilla or in the axillary space. Pus formed in the joint tends to
gravitate along the inter-tubercular groove. The axillary glands may
be infected.
The primary lesion is either a caseating focus in one of the
bones--most often in the upper end of the humerus--or it is of the
nature of caries sicca. The greater part of the head may disappear,
and the upper end of the shaft be drawn against the socket. In
exceptional cases, portions of the glenoid or humerus are found
separated as sequestra, or the disease involves parts outside the
joint, such as the acromion or coracoid process. Hydrops with
melon-seed bodies is rare. In young subjects, destruction of the
tissues at the ossifying junction may result in considerable
shortening of the arm.
The _diagnosis_ is to be made from (1) arthritis deformans, in which
the movements are less restricted, and are attended with grating and
cracking; (2) paralysis involving the deltoid and scapular muscles--by
the absence of pain, and the flail-like character of the movements;
(3) disease in the sub-deltoid bursa--by the absence of rigidity and
other evidence of implication of the articular surfaces; and (4)
sarcoma of the upper end of the humerus--by the history of the case,
the use of the X-rays or an exploratory incision. Injuries in the
region of the upper epiphysis resulting in loss of movement, may, in
the absence of a reliable history, be mistaken for tuberculous
disease.
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).
[Illustration: FIG. 103.--Arthropathy of Shoulder in Syringomyelia.
The upper end of the humerus has disappeared and the movements are
flail-like (cf. Fig. 104).]
[Illustration: FIG. 104.--Radiogram of specimen of Arthropathy of
Shoulder in Syringomyelia. The head of the humerus has disappeared and
masses of new bone have formed in the surrounding muscles (cf. Fig.
103).]
#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.
[Illustration: FIG. 105.--Radiogram showing Multiple partially
ossified Cartilaginous Loose Bodies in Shoulder-joint. The lowest one
is in the synovial prolongation along the tendon of the biceps.]
#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.
[Illustration: FIG. 106.--Diffuse Tuberculous Thickening of Synovial
Membrane of Elbow (white swelling) in a boy aet. 12.]
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.
[Illustration: FIG. 107.--Contracture of Elbow and Wrist following a
burn in childhood. Treated by resection of both joints, and the
insertion, on the palmar aspect of each, of a flap from the abdominal
wall.]
_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.
[Illustration: FIG. 108.--Advanced Tuberculous Disease of Acetabulum
with caries and perforation into pelvis.
(Anatomical Museum, University of Edinburgh.)]
#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).
[Illustration: FIG. 109.--Early Tuberculous Disease of Right Hip-joint
in a boy aet. 14, showing flexion, abduction, and apparent lengthening
of the limb.]
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.
[Illustration: FIG. 110.--Disease of Left Hip: position of ease
assumed by patient, showing moderate flexion and lordosis.]
[Illustration: FIG. 111.--Disease of Left Hip: disappearance of
lordosis on further flexion of the hip.]
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).
[Illustration: FIG. 112.--Disease of Left Hip: exaggeration of
lordosis produced by extending the limb.]
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.
[Illustration: FIG. 113.--Thomas' Flexion Test, showing angle of
flexion at diseased (left) hip.]
_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.
[Illustration: FIG. 114.--Tuberculous Disease of Left Hip: third
stage, showing adduction and shortening.]
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).
[Illustration: FIG. 115.--Advanced Tuberculous Disease of Left
Hip-joint in a girl aet. 14, showing flexion, adduction, shortening,
and iliac abscess.]
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.
[Illustration: FIG. 116.--Extension by adhesive plaster and Weight and
Pulley.]
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).
[Illustration: FIG. 117.--Stiles' Double Long Splint to admit of
abduction of diseased limb.]
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.
[Illustration: FIG. 118.--Thomas' Hip Splint applied for disease of
Right Hip. Note patten under sound foot. The foot on the affected side
is too near the ground.]
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.
[Illustration: FIG. 119.--Arthritis Deformans, showing erosion of
cartilage and lipping of articular edge of head of femur.]
_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.
[Illustration: FIG. 120.--Upper End of Femur in advanced Arthritis
Deformans of Hip. The shaft is curved and the head of the bone is at a
lower level than the great trochanter.]
[Illustration: FIG. 121.--Femur in advanced Arthritis Deformans of Hip
and Knee Joints. The upper end of the bone shows the condition of coxa
vara; the lower end shows enlargement of the medial condyle and
alteration in the axis of the articular surface.]
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.
[Illustration: FIG. 122.--Tuberculous Synovial Membrane of Knee,
spreading over articular surface of femur.]
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).
[Illustration: FIG. 123.--Lower End of Femur from an advanced case of
Tuberculous Arthritis of the Knee. Towards the posterior aspect of the
medial condyle there is a wedge-shaped sequestrum, of which the
surface exposed to the joint is polished like porcelain.
(Anatomical Museum, University of Edinburgh.)]
#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.
[Illustration: FIG. 124.--Advanced Tuberculous Disease of Knee, with
backward displacement of Tibia.]
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.
[Illustration: FIG. 125.--Thomas' Knee Splint applied. Note extension
strapping applied to affected leg, and patten under sound foot.]
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.
[Illustration: FIG. 126.--Tuberculous Disease in a man aet. 35, of six
weeks' duration.]
_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.