Manual of Surgery Volume II Part 26

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

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

_Arthrodesis._--This operation, first performed by Albert in 1877, consists in removing the cartilage covering the articular surfaces of bones with the object of producing a firm ankylosis. The procedure is most successful in the ankle and mid-tarsal joints, and as a result of it there is obtained a secure and firm base of support in walking.

Before performing arthrodesis, the surgeon must decide whether the patient will be better off with a stiff joint or with a weak and movable ankle supported by apparatus. This is often a matter of social position; in the poor, an ankylosed joint is more useful and less expensive. An arthrodesis should seldom be performed at the ankle until the child has pa.s.sed his eighth year, or at the knee until he has reached his twentieth year. There is plenty to be done during the period of waiting, and if this is done well, it is possible that the operation may not be required. The existing deformities, for example, will have to be corrected, areas of skin removed to relieve functionless muscles of strain, the body weight appropriately deflected, and the child must be taught to walk with the aid of a support, swinging his limb about, and using it effectively in a correct position. Such exercise is a powerful agent in promoting physiological and functional development.

_Nerve anastomosis_, which seeks to provide a new channel for the transmission of motor impulses to the paralysed muscles, has as yet a restricted field of application--for example, the tibial and peroneal nerves may be anastomosed when the muscles supplied by one of them are paralysed. Stoffel of Heidelberg lays stress on regard being paid to the anatomical arrangement of the nerve bundles within the nerve-trunk so that motor fibres may be joined to motor ones and not to sensory.

It is necessary also to cut across some of the fibres of the healthy nerve in order that they may grow into the nerve which is degenerated.

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

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

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

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

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

THE LOWER EXTREMITY

CONGENITAL DISLOCATION OF THE HIP

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

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

#Pathological Anatomy.#--_In the infant_, the anatomical changes in the joint are less marked than they are after the child has borne its weight on the limb. The acetabulum, never having been occupied by the head of the femur, is imperfectly developed; it remains flat and shallow, is partly filled with fibro-fatty tissue derived from the synovial membrane, and is always too small for the head of the femur.

The cotyloid ligament being broader and thicker than usual, makes the osseous portion of the socket appear deeper than it really is. In unilateral cases the affected half of the pelvis is contracted, so that the pelvic basin is narrowed and oblique. The head of the femur is small, flattened, and, in some cases, conical; and the angle formed by the neck with the shaft is altered, sometimes diminished, it may be to a right angle--_c.o.xa vara_ (Fig. 129); sometimes increased--_c.o.xa valga_. There is also a variable degree of torsion of the neck, ante-torsion being of practical importance as it increases the difficulty of retaining the head in the socket. The capsule is lax and admits of the head pa.s.sing upwards for a variable distance on to the dorsum ilii. In unilateral cases the ligamentum teres is elongated and thickened; in bilateral cases it is frequently absent.

[Ill.u.s.tration: FIG. 128.--Radiogram of Double Congenital Dislocation of Hip in a girl aet. 4.]

[Ill.u.s.tration: FIG. 129.--Innominate Bone and upper end of Femur from a case of Congenital Dislocation of Hip.]

In _children who have walked_, the head of the femur is pushed farther upwards on the dorsum ilii; the capsule becomes lengthened by supporting the weight of the body. That part of the capsule which arises from the lower margin of the acetabulum stretches across the socket and partly shuts it off from the rest of the joint cavity. In course of time the capsule becomes greatly thickened, and may present an hour-gla.s.s constriction about its middle, which may prove a serious obstacle to reduction. The socket becomes small and triangular, and there is almost no ledge against which the head of the femur can rest.

A superficial depression may form on the ilium where it is pressed upon by the head of the femur, covered by the capsule; and in the course of years, as the head changes its position, several secondary sockets may be formed. No proper new bony socket forms like that in traumatic dislocations that remain unreduced because in the congenital variety the thickened capsule intervenes between the head of the bone and the dorsum ilii. The displacement of the head is most frequently backwards (dorsal luxation), and as the point of support thus falls behind the acetabulum the pelvis tilts forwards, and the lumbar spine becomes unduly concave (lordosis). The muscles of the hip and thigh alter in consequence of the changed relations; the gemelli, obturators, and piriformis are lengthened, the adductors, hamstrings, and ilio-psoas are shortened, while the glutei and quadriceps are but little altered. In rare cases the head is displaced upwards and lies immediately above the acetabulum.

[Ill.u.s.tration: FIG. 130.--Congenital Dislocation of Left Hip in a girl aet. 8. The patient is putting the whole weight on the dislocated limb.]

_Clinical Features._--The condition rarely attracts attention until the child begins to walk, but sometimes the unusual breadth of the pelvis, the presence of a lump in the b.u.t.tock, snapping about the hip, or a peculiar way of holding the limb, leads the parents to seek advice early. In _unilateral cases_, when the child has learned to walk at the late age of two, three, or it may even be four years, it is noticed that the back is hollow and the b.u.t.tocks unduly prominent, and that there is a peculiar and characteristic limp; each time the weight of the body is put upon the affected limb, the trunk makes a sudden dip towards that side. There is no pain on walking. The affected limb is shortened, as is shown by the projection of the great trochanter above Nelaton's line; the shortening gradually increases, and in time may amount to several inches. It is partly compensated for by resting the affected limb on the b.a.l.l.s of the toes and flexing the knee on the sound side. The gluteal fold is shorter, deeper, and higher than on the healthy side, and on account of the obliquity of the pelvis the spine shows a lateral curvature, with its concavity to the affected side. The movements at the hip-joint are free in all directions except abduction; on practising external rotation it is often found to be abnormally free; lastly, in young children, if the pelvis is fixed, the head of the bone may be made to glide up and down on the ilium.

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

Except in fat infants, the _diagnosis_ is not difficult; the absence of pain and tenderness, the freedom of motion and the absence of the head of the femur from its normal position, differentiate the condition from tuberculous disease of the joint, and from c.o.xa vara and other deformities in the region of the hip. _Trendelenburg's test_ consists in noting the relative level of the b.u.t.tocks when the patient stands on the affected leg. Normally the b.u.t.tocks remain on the same level when the patient stands on one leg; in congenital dislocation the b.u.t.tock of the limb raised from the ground drops to a lower level; in c.o.xa vara it rises higher.

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

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

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

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

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

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

If it is found impossible to restore the head of the femur to the acetabulum, an attempt should be made by similar manipulations to wedge it under the long head of the rectus femoris, or, failing this, below the anterior iliac spine under the sartorius and tensor fasciae femoris. By thus converting a posterior into an anterior dislocation, the tilting of the pelvis and the lordosis are greatly diminished.

This procedure, named by Lorenz _anterior transposition of the head of the femur_, is specially applicable to cases in which relapse has taken place after reduction, and to those above the age when reduction should be attempted.

_Reduction by open operation_ may be had recourse to in cases in which, after several attempts, reduction has failed, or in which re-dislocation has occurred; it is, however, a serious operation.

Attempts have also been made by means of pegs and other contrivances to fix the head of the bone and prevent it sliding upwards on the ilium. When reduction is impossible by any means, a stiff leather jacket with prolongations around the thighs may diminish the deformity and improve the walking.

#Snapping Hip# (_Hanche a ressort_).--This is a rare affection, met with in children and young adults, and characterised by the occurrence of a sudden, snapping sound, sometimes attended with pain in the region of the great trochanter. This usually occurs when the limb is slightly flexed or adducted, and rotated either inwards or outwards.

On palpation a cord-like structure may be felt, which slips forwards and backwards over the trochanter when the position of the limb is altered.

The condition was formerly described as a voluntary dislocation of the hip; it is now believed to be due to a cord-like band of tissue slipping backwards and forwards over the trochanter. The band is usually derived from the fascia lata, sometimes reinforced by the anterior fibres of the gluteus maximus, sometimes by the tensor fasciae femoris. The condition seldom gives rise to any appreciable disability and surgical treatment is rarely called for. In a number of cases the muscle has been fixed by sutures with satisfactory results. In a recent case, an extensive open dissection proved negative, but the st.i.tching of the gluteus to the trochanter was followed by the disappearance of the snapping.

#Paralytic Deformities of the Hip.#--In anterior poliomyelitis the paralysis of muscles may be so widespread that the limb is unable to support the weight of the body, or certain groups of muscles only are paralysed and the child may be able to walk with the help of apparatus. Even if the ilio-psoas is paralysed, flexion is still possible by the anterior fibres of the gluteus medius, the anterior adductors, and when the leg is rotated out by the tensor fasciae and sartorius, the dislocation differs from the traumatic variety in that the head, although it leaves the socket, remains within the capsule.

Dislocation tends to occur from the disturbance of muscular balance, anterior dislocation being commoner than posterior in about the proportion of two to one; the nature of the dislocation is best demonstrated by means of the X-rays. Reduction is rarely possible without an open operation. Tendon and nerve-transplantation are scarcely possible, and arthrodesis is rarely to be recommended; contracture deformities, however, are often benefited by tenotomy in young children, and in older children by osteotomy through the trochanter, and putting the limb up in the abducted position.

In _spastic paralysis_ of cerebral origin, the tendency is towards contracture, usually in the att.i.tude of flexion, with adduction and inversion. This may result in dislocation backwards on to the dorsum ilii, and may occur in patients confined to bed (Fig. 131).

[Ill.u.s.tration: FIG. 131.--Contracture Deformities of Upper and Lower Limbs resulting from Spastic Cerebral Palsy in infancy.

(Photograph taken after death by Dr. Thomson of Norwich.)]

#Contractures and Ankyloses of the Hip.#--Various forms of contracture are met with as a result of cicatricial contraction, or from shortening of the fasciae, muscles, and ligaments when the hip has been maintained in the flexed position for long periods--for example, in psoas abscess, chronic rheumatism, or hysteria. The majority, however, result from tuberculous disease of the hip-joint. In osseous ankylosis, an attempt may be made to restore movement by the operation of Murphy, which consists in chiselling through the osseous junction between the bones, deepening the acetabulum if necessary, and then interposing between the bony surfaces a portion of fat-bearing fascia derived from the fascia lata over the great trochanter. The operation of Jones consists in detaching the great trochanter (the insertions of the glutei into it being left intact), dividing the neck of the femur, and then securing the separated portion of the trochanter to the proximal end of the neck to prevent union of the fragments.

c.o.xA VARA AND c.o.xA VALGA

These deformities depend on abnormalities of the angle of the neck of the femur; the average or normal elevation is 125 for the adult and 135 for the child; variations between 120 and 140 are considered normal. If the angle is less than 120 the condition is one of c.o.xa vara; if greater than 140, c.o.xa valga. The angle of inclination of the neck of the femur is dependent upon the adjustment of certain forces, namely, the weight of the body, the action of muscles, and the resistance of the bone. The most obvious cause of deviation of the neck from the normal angle is some condition which causes softening of the bone so that it yields under weight-pressure, the most common being partial fractures, rickets, and other diseases of the bone.

#c.o.xa Vara--Incurvation of the Neck of the Femur.#--There may be a simple adduction bend of the neck, the head sinking to, or even below, the level of the great trochanter (Fig. 132); or this may be combined with a curve of the neck, of which the convexity is upwards and forwards, so that the lower border of the neck is greatly shortened and the head approximated to the lesser trochanter. At the same time the shaft of the femur is adducted and rotated outwards.

[Ill.u.s.tration: FIG. 132.--Rachitic c.o.xa Vara.

(Sir Robert Jones' case. Radiogram by Dr. Morgan.)]

_Adolescent c.o.xa Vara._--This, the most common clinical type, is met with in boys between the ages of twelve and eighteen. The _unilateral_ form is nearly always the result of injury to the neck of the femur or to the epiphysial junction, although the deformity may not show itself for months or a year or two after the injury. The deformity may be the first indication, or it is preceded by pain and stiffness; the patient complains of being easily tired, of difficulty in kneeling and sitting, difficulty in riding, and of an increasing limp in walking.

On examination, the limb is found to be shortened, the great trochanter is displaced upwards and backwards and is unduly prominent, and the muscles of the b.u.t.tock and thigh are a little smaller and softer than on the normal side. The limb is adducted, its normal range of abduction, and sometimes also of flexion, is restricted, and there is, as a rule, some degree of lateral rotation, so that the toes point outwards. It should be noted that the same picture--shortening with eversion and stiffness at the hip--results from the common fracture of the neck of the bone in old people. The adduction element of the deformity is partly compensated for by upward tilting of the pelvis on the affected side and curvature of the spine with its concavity towards the affected limb.

_When the condition is bilateral_ it is usually the result of disease in the bone, rickets most frequently in this country. The att.i.tude and gait are highly characteristic, as the adducted and everted legs tend to cross each other at the knee, the deformity being of the scissors-like type (Fig. 134), and in extreme cases the patient is only able to walk with the aid of crutches.

_Diagnosis._--Pain in the hip and a limp in walking suggest _hip-joint disease_, but while in c.o.xa vara the movements are chiefly restricted in the direction of abduction, in hip disease they are restricted or absent in all directions. From _congenital dislocation of the hip_ the diagnosis can usually be made by the history, the examination of the joint and of its movements; and by the Trendelenburg test (p.

252). In _sacro-iliac disease_, the pain and tenderness are over the sacro-iliac joint and the movements at the hip are free in all directions. Valuable evidence is obtained from skiagrams.