Manual of Surgery Volume II Part 21

When the talus pa.s.ses upwards between the tibia and fibula, it is sometimes impossible to effect reduction by manipulation, and the best results are then obtained by operation.

The after-treatment consists in keeping the leg on a pillow between sand-bags, and carrying out the usual ma.s.sage and movement.

In compound dislocations which have become infected, primary amputation may be indicated, but in young and healthy subjects an attempt may be made to save the foot.

#Dislocation of the talus# from its articulations with the bones of the leg above and the calcaneus and navicular below, is a comparatively common injury, and results from a violent wrench of the foot. It may be incomplete or complete. When the foot is plantar flexed at the moment of injury, the displacement is generally _forward_ with a tendency outward. The talus comes to rest on the third cuneiform and cuboid bones, the foot being abducted, inverted, and displaced medially. In a large proportion of cases the dislocation is compound, more or less of the talus being forced through the skin (Fig. 100).

[Ill.u.s.tration: FIG. 100.--Compound Dislocation of the Talus.]

When the foot is dorsiflexed at the moment of injury the displacement is _backward_, but this is rare, as is also _dislocation to one or other side_, and _dislocation by rotation_, in which the talus is rotated in its socket. In all these injuries the body of the talus loses its normal relationship with the malleoli.

An attempt should be made to reduce the dislocation under anaesthesia, the limb being placed in the same position as for reduction of dislocation of the ankle. While traction is made upon the foot, an a.s.sistant presses directly on the displaced bone and endeavours to manipulate it into position. In incomplete dislocations this usually succeeds, but it not infrequently fails in those which are complete, and under these circ.u.mstances it may be necessary to chisel through the lateral malleolus to admit of reduction, or to excise the talus.

In most cases of compound dislocation also, this bone should be removed.

#Sub-taloid Dislocation.#--In this dislocation, which results from the same kinds of violence as the last, the talus retains its position in the tibio-fibular socket, and the calcaneus and navicular, with the rest of the foot, are carried away from it. The body of the talus, therefore, maintains its normal relationship with the malleoli--a point of importance in the differential diagnosis between this injury and dislocation of the talus. The displacement is usually incomplete, and the foot may either pa.s.s backward and medially, or backward and laterally. When the foot pa.s.ses _backward and medially_, the head of the talus projects on the outer part of the dorsum, resting on the cuboid. The dorsum of the foot is shortened, the heel lengthened, the toes adducted, and the medial border of the foot raised. The lateral malleolus is unduly prominent, and reaches nearly to the sole.

[Ill.u.s.tration: FIG. 101.--Radiogram of Fracture-Dislocation of Talus.]

In the _backward and lateral_ variety, the medial malleolus and head of the talus project unduly towards the medial side of the foot, which is abducted and everted.

In neither variety is there any mechanical obstacle to movement at the ankle-joint.

The _treatment_ is carried out on the same lines as for dislocation of the talus, reduction being effected without difficulty in most cases.

If this fails, as it occasionally does, it may be necessary to excise the talus.

#Mid-tarsal or transverse tarsal dislocation#--that is, at the talo-navicular and calcaneo-cuboid articulations--is extremely rare.

The distal segment of the foot is usually displaced towards the sole; the foot is foreshortened, the malleoli raised from the sole, the arch of the foot is lost, and the first row of tarsal bones projects on the dorsum. The treatment consists in reducing the displacement by manipulation, after which ma.s.sage and movement are employed.

#Tarso-metatarsal Dislocations.#--One, several, or all of the metatarsals may be separated from the distal row of tarsal bones--the usual cause being a fall from a horse, the foot being fixed in the stirrup. The bases of the metatarsal bones are displaced laterally and towards the dorsum. The base of the second metatarsal and the first cuneiform are sometimes fractured. Reduction by manipulation is generally easy in dorsal dislocations, but may be difficult when the bones are displaced laterally. This may be due to fragments of bone or soft parts getting between the bones, and may necessitate operative interference. In old-standing dislocations, operation is to be advised only when locomotion is seriously interfered with.

#Dislocation of the Toes.#--The great toe may be dislocated at its metatarso-phalangeal joint, the base of the proximal phalanx pa.s.sing towards the dorsum (Fig. 102). Diagnosis and reduction are alike easy.

[Ill.u.s.tration: FIG. 102.--Radiogram of Dislocation of Toes.

(Sir Montagu Cotterill's case.)]

#Inter-phalangeal# dislocations are rare and are easily reduced.

CHAPTER IX

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 att.i.tude 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 pa.s.sive 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 a.s.sociated 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 s.p.a.ce. 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 a.s.sociated with disappearance of the upper end of the humerus (Fig. 104).

[Ill.u.s.tration: FIG. 103.--Arthropathy of Shoulder in Syringomyelia.

The upper end of the humerus has disappeared and the movements are flail-like (cf. Fig. 104).]

[Ill.u.s.tration: FIG. 104.--Radiogram of specimen of Arthropathy of Shoulder in Syringomyelia. The head of the humerus has disappeared and ma.s.ses 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 att.i.tude is that of flexion with p.r.o.nation 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.

[Ill.u.s.tration: 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.

[Ill.u.s.tration: 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 a.s.sociated 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.

[Ill.u.s.tration: 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-p.r.o.nated 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 antic.i.p.ated 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.