59 there was no motion. Out of 227 cases analyzed so as to bring out
the position of the limli, 1 5 got well with deformity at an angle under
135°, and 141 presented an angle of deformity of not less than 165°.
They were enabled, therefore, to walk with limbs practically straight
and witii scarcely an apprecialjle deformity: 71 of these could extend
their limbs to an angle lictween 175° and 180°. These results, under-
stand, are from cases treated by all methods except extensive operative
356 ORTHOPEDIC SURGERY.
l)rocediires. By comparing the different ini-tliods, however, the protective
treatment, which included rest as well, gave tlie Inraest percentage of
good results, while tlie fixation came next, ami the expectant gave the
siuallest percentage.
Minor or Non-tubercular Diseases of the Knee.
1. Acute Arthritis of Ixfaxcv.
The most important of these diseases is the acute artliritis of infancy.
This has also been styled acnte epiphysitis and acute osteomyelitis. It
occurs in very early life, sometimes in a few weeks after birth, more
frequently within the first year of life. It begins as an acute process,
attended by marked constitutional disturbance, and soon resulting in
extensive suppuration with great deformity. The diagnosis can he easily
made by comparing these rapid changes with the ciianges which take
place in a chronic tubercular ostitis. Again, the age of the ])atient is
against a tubercular lesion. The treatment is surgical from the begin-
ning. If hot fomentations and rest fail to give relief Avithin the first
week, then the abscess should be freely incised, its depth noted, any
broken-down bone removed, and all the parts thoroughly drained. At
the same time, the limb should be l)roug]it into normal position and
retained by a firm dressing, and nothing has appeared ipiite so satisfactory
to me as the plaster of Paris. Where such prompt measures are not
adopted the case usually j)roceeds from bad to Avorse, and the end is
either a fatal result or a flail joint which troubles the patient throughout
life. I do want to emphasize, again and again, the necessitv for prompt
surgical measures.
2. Periarthritis.
Periarthritis is phlegmonous in childliood, while in adult life it is
simjilv a subacute or chronic inflammation <if tlie deeper structures sur-
rounding the joint, and is associated frecpiently witii rheumatism. The
diagnostic points have been mentioned already in discussing the differ-
ential diagnosis of tubercular ostitis, so that a repetition is unnecessary.
The treatment, however, calls for rest when it is jihlegmonous, with
resort to the knife if resolution does not follow pronqitly ; while in
adults, especially if it lie rheumatic, motion should be enjoined. If
adhesions have formed and a stiff joint results, then attempts should be
made to correct under an anaesthetic, at the same time preserving \\hat-
ever motion is gained. This brings one to the discussion of ankylosis
in general. Suffice it to say, that a joint that is very firmly ankylosed
from periarticular adhesions is exceedingly rare. There are also intra-
articidar adhesions, which make a restoration of fmiction exceedingly
difficult. Where osseous union between the patella and intercondyloid
space is believed to exist I favor open incision and a separation of this
union. The subsequent treatment is massage, the douche, and active
and passive movements.
3. Eheujiatic Arthritis of Knee.
Rheumatic arthritis is one of the most common affections of the knee
in adult life. It frequently depends upon a trauma of some kind, and it
MINOR OR XOy-TUBEBCULAR DISEASES OF THE KNEE. 357
is only after the disease is developed that a rheumatic element is dis-
covered. The diagnosis has already been under discussion. The treat-
ment may be outlined in the tbllowing (juotation, which I take from a
paper recently ]iul)lishi'd in the Dciircr Medical TiiiK'.s for January,
1895: "In sunnning up, therefore, the treatment of a chronic or sub-
acute rlieumatic knee, I would say that use in the early stage is good,
but let the patient understand that the motion is not to be forced — that
if he finds flexion beyond a certain range painful, let him avoid this test.
For the night-j^ains hot fomentations arc good. For pains that persist
throughout the day the Pacjuelin cautery has, in my hands, proved most
efficient. Wlicre the traumatism induces an exacerbation, rest in a plaster-
of-Paris splint for a few weeks is eminently jn-oper, but on the subsidence
of the pain the limb should be used up to the range of tolerance. The
use of adhesive jilaster has, in my hands, been of great service. The
advantage, I think, which this lias over the silk elastic knee-cap or any
kind of knec-caji is that tlie pressure is made directly over- the parts
intiltrated, and does not comj)letely encircle the linii), thus interfering
witli the return circulation and impairing more or less the tissues below,
so that I seldom ever use an elastic knee-bandage in rheumatic knees.
I sometimes use a canvas knee-bandage which is laced up along the inner
side, and under whicli can l)e placed cotton-wool for more equable pres-
sure. Wliere tlie ankle is involved as well I use a good deal the stock-
inet bandage. My cliief reliance, however, is in the brace, which is to
be worn until complete convalescence is established."
4. IxTEEXAL Derangement of Knee.
One of the most common internal derangements of the knee is a dis-
placement, more or less complete, of the semilunar cartilage. This injury
results from a sharp and sudden fiexicin of the knee with rotation inward
or outward. Where the rotation is inward, the internal semilunar is
subject to a sharp separation of some of its fibres of attachment, per-
mitting a slight slipping or a complete slipping of the cartilage, which
makes a dislocation of the same. Where the twist is external tiie exter-
nal semilunar cartilage suffers in the same way. Tlic jwin is quite severe.
The patient feels a slipping of some kind, and naturally cither extends
the liml) or gets some one to extend it fully and make traction. This
procedure often results in a replacement of the cartilage. If this could
be followed, now, by protection to the parts for a reasonable length of
time, say a fortnight, all acute symptoms would subside and the result
would be perfect. But it is not usually tluis followed by any protection ;
the patient continues to use tlie linil), and an arthritis by contiguity is
set up as a result of the repeated traumatisms. ^Mien the case comes
under the cai'c of the surgeon he usually finds a general arthritis, and it
is difficult to detect the real starting-]ioint of the lesion. A history will
usually be affiirded of subsequent slippings, and an examination, with
this liistorv, made with the knee flexed, will enable one to determine the
ridge along the upper Ixirder of the head of tlie tibia, which ridge of the
soft parts is caused by the pnijecting semilunar cartilage.
The treatment, as has already been suggested, is protection to the
parts, preferably in a plaster-of-Paris bandage, with the knee fully
358 ORTHOPAEDIC SURGERY.
extended. The patient sliould use axillary crutches for two or three
weeks, or even longer if the symptoms persist. A snug-fitting, plaster-
of-Paris bandage, however, for two or three weeks in the majority of
cases will be all that is necessary for such firm protection. On the
removal of the plaster the external parts should be strapped well with
strips of rubljer plaster, and the patient should be cautioned against
bending the knee until all symptoms have completely subsided. If the
case is one of long standing and comes under the care of the surgeon
during one of the rehpses, then something more than the above precau-
tions is necessary. In my own practice I have found a splint, such as
has been described in the preceding pages in the treatment of rheumatic
knees, most efficient. The range »jf motion is limited for a few months.
Tlie operation for removal of the cartilage or for exposing it and
anchoring the torn edges by sutures has proven very successful in the
hands of some surgeons, but as a general surgical procedure it is not
usually recommended. At least, it ought not to be recommended until
other measures have failed — measures such as have been already de-
scribed. The operation itself is simple enough. One can easily reach
the oifending body, can exjxtse the jiarts fully, and can suture the carti-
lage to the head of the tibia by silkworm gut or even good sterilized
catgut. One of the main contraindications for the operation is the ex-
istence of other loose bodies in the knee complicating the displaced
semilunar cartilage.
Loose bodies in the knee, known as loose cartilages, may arise from
hydrartlirosis or from acute attacks of rheumatism. These bodies can
be easily felt and the diagnosis is not very difficult.
The treatment is mechanical and operative.
Tiie chief form of mechanical appliance is an elastic bandage about
the knee, or laced knee-cap, as it is called, which serves to fix the loose
body in some one particular })art of the joint where it is innocuous.
The operation consists in crowding tiie cartilage toward the surface,
where it can be felt directly under the skin — a free incision thereover,
with enucleation of the body. This operation, simple as it may seem, is
not always successful, but is sometimes attended with a pretty sharp
attack of arthritis, followed by adhesions and fibrous ankylosis. It is
one of the recognized operations, however, in surgery, and is to be per-
formed under strict aseptic precautions by a surgeon who has had a
reasonable degree of familiarity with joint surgery.
5. Bursitis.
A not infrequent injury about the knee may be traced to an inflam-
mation of the bursa?. On page .j49 injury to the burs» has been discussed
in making ditt'erential diagnosis of ostitis of the knee. For diagnosis,
then, one can refer to this section.
The treatment involves a period of rest to the joint, accompanied with
strapping of the bursa when not too acutely inflamed. If the latter be the
case, hot fomentations are eminently satisfactory. The prepatellary bursa
is the one most frecpiently affected, and is known as " housemaid's knee "
or " devotional knee." Here we have often a good-sized tumor which
requires tapping or excision. Generally tapping, \\ith firm compress
OSTITIS OF THE AXKLE. 359
immediately following, is sufficient to etfect a cure. In some instances,
where the inflammatory area has extended not only about the joint, but
into the joint, a posterior splint, or even a plaster-of-Paris bandage, is
regarded as a valuable adjunct. Other bursa; about the joint are not
usually subjected to operations, because a knowledge of the existing
conditions will enable one to adopt expectant measures for relief.
6. Neurosis.
For neurosis of the knee the same principles in treatment may be
adopted which have been already outlined in the section on neurosis of
the hip. (See page 345.)
7. Charcot's Knee.
For tabetic knee or Charcot's joint we really have little in the way
of treatment. It is interesting simply from a diagnostic point of view,
and curative measures are yet to be suggested for this extraordinary
disease.
Ostitis of the Ankle.
The synonyms are — Caries of the ankle. Tuberculous ankle, Tuber-
cular ostitis of the ankle. White swelling of the ankle. Chronic syno-
vitis. The disease itself is chai-acterizcd by impairment of motion, pain
on use, reflex spasm, bony enlargement, destruction of bone, destruction
of the joint-surfaces, abscess, and deformity generally.
The etiology and pathology have already been discussed. It remains
now to note the clinical history.
Clinical History. — The invasion of this joint by disease is very
similar to the invasion of other joints. The patient favors the foot in
walking. One can easily recognize the ankle-limp. We have the cha-
racteristic exacerbations following upon trauma — extra heat about the
bony prominences, preferably the malleoli, sometimes the head of the
astragalus, sometimes the scaphoid. The contour of the joint is soon
changed, so that a comparative examination will enable one to detect
filling up of normal depressions, exaggerations of bony prominences,
atrophy of the calf, and increasing disability. Later we have abscess,
which is attended usually with severe jtain enormously aggravated by use.
The al)scess may be multiple, and the whole joint may l)e ultimately riddled
with sinuses. The history of ostitis of the ankle difl^ers a little from
that of the knee and hip in that resolution in children is sure to follow,
and that complete destruction of the joint and death from suppuration are
the exceptions. It is a curious fact that the farther removed that a tuber-
culous joint is from the centre of circulation the lietter result we may
expect. In the ankle, for instance, a child may go through all the stages
of this disease, extending over a period of from two to five years, may be
subjected to various kinds of treatment irregularly carried out, and will,
as a rule, make a good recovery — a recovery which enables the child to
walk without lameness and to have very nearly normal use of the foot.
Ostitis (if the ankle as it aifects adults is altogether a different dis-
ease, and ra<lical measures are nmch more frecpiently demanded. The
course is Ijy no means benign. It is difficult to secure adequate pro-
360 ORTHOPAEDIC SURGEBY.
tection to tlie ;inkle in an adult, and for tliis reason expectant treatment
is, as a rule, unsatisfactory.
Diagnosis. — -A number of lesions almut tJic ankle, such as periar-
thritis, sprain, synovitis, teno-synovitis, unreduced suhluxation.s, simulate
ostitis of the ankle, but a careful comi)arative examination of the parts
will enable one, as a rule, to detect localized areas of inflammation ; for
example, over one or the other of the malleoli, over the bones of the
tarsus ; reflex spasm, atrophy of the calf. These signs, taken in con-
nection with a satisfactt)rv history, enable one to differentiate this dis-
ease from any that have Ix'cn named. It is unnecessary, therefore, to
go over the points in differential diagnosis.
Treatment. — The management of a case depends largely u])on the
age at which the disease develojis. If it occurs in a young child under
four years of age, fixation of the foot in a skin-fitting plaster-of-Paris
bandage, with strict injunctions against walking, will suffice to bring
about a very satisfactory result. This treatment must extend over a
period of twelve months at least. If abscesses have already formed,
these may be aspirated, or, if the aspiration fails, incision may be made
and foci of bone, which can be reached through the incisions, removed
by the spoon. Fenestra can be cut in the plaster, so that immobilization
can be continued, or the plaster itself may be cut down in front and
made into a splint. In lieu of the plaster, wire or leather splints may
be employed — anything, in fact, which secures adequate immobiliza-
tion. If the child is over four years of age, or even over three in some
instances where it is desirable to have the child walk, a splint may be
employed very much like the Thomas knee-splint, with a patten or high
shoo on the sound foot. The weight is thus transferred from the sole
of the foot to the ])erineum, and the child will soon learn to walk about
very comfortably. Where a light support, such as plaster or leather or
wire cast, is not used to immobilize the foot, a sliding foot-plate should
be applied to the Thomas knee-splint, near the lower end, and in that
way the foot can be kept at right angles, thus affiirding all the jiro-
tection that is re(|uired. In older patients, adolescents and adults, im-
mobilization supplemented by axillary crutches will give relief in a
certain number of cases. Where, after a reasonable length of time, this
treatment proves valueless, operative measures should be instituted, such
as removal of the astragalus, excision of the joint, or even, in desperate
eases, amputation.
Such, in a general wav, is the treatment for ostitis of the ankle. In
children where abscesses form and Inii-row throughout the foot the man-
agement is often exceedingly diflicult. If one is familiar with the
clinical history, the temptation to excise or partially excise is not great.
If the abscesses are properly drained and if the foot is kept in good
position, recovery in a large jiercentage of cases ^\ill take place, with a
useful foot — a foot on which the jwtient can walk Mith very little lame-
ness and without a sujiport. It is interesting to note, too, that a child
may suffer from numerous abscesses about the ankle, the suppuration
may not only be extensive, but prolonged over a period of years, and
still the liver and kidneys M'ill not be involved in amyloid changes.
One need not, therefore, fear amyloid degeneration in a case of ostitis
of the ankle in a child. Exhaustion is exceptional too, yet the surgeon
SPRAINS. 3G1
must be prepared to follow up these sinuses from time to time, afford
efficient drainage, attend to the a:eneral health, encourage an out-of-door
life, avoid too long- confinement in hospital?, and even excise or ampu-
tate if the case should seem to demand so radical a ]>rocedure. In a
word, then, a case must be managed on souud surgical principles. The
surgeon must not take fright at the occurrence of numerous abscesses
and sinuses, but must rely very largely upon the recuperative powers of
nature. Excision of the ankle may be better studied in other sections
of this work, and for this reason I have omitted any extensive reference
to it in this connection.
Sprains.
The term " sprain" is used to designate a sudden rupture of the soft
tissues immediately surrounding a joint, a stretching of these tissues
without necessarily a rupture of any of the parts. The lesion, however,
is followed by swelling, pain, ecchymosis, disability of the joint, and
sometimes a deformity. A sprain varies in degree, and leaves one at a
loss sometimes to decide just how much injury has been wrought. It
is common to speak of rupture of ligaments or separation of the liga-
mentous attachments, but when such occurs the injury is very severe.
Indeed, it is difficult to make out just whether a ligament is ruptured
or not. More freciuently some fibres of the tendon are torn in two or
the bruising takes jilace al:)out the insertion of the ligaments or tendons,
which gives rise to the signs above mentioned. Ordinarily, acute si)rains
do not come within the scope of orthopaedic surgery. A disability of
the joint which has resulted from a sprain weeks or months previously
often comes under the care of the orthopffidic surgeon, because of this
disability and Ijecause a cure has not been effected. The mode of pro-
duction of this injury and the history of the symptoms and signs for the
first few days are cpiite familiar to all medical men, hence details are
unnecessary.
Diagnosis. — The diagnosis is very important, and it is difficult at
times to differentiate a sprain from a fracture or a sul)luxation. The
foot may be so distorted that one of the tarsal bones may project unduly
and give rise to the suspicion of a dislocation. Again, the swelling
about the malleoli may be so great that it is very difficult, by reason of
the extreme tenderness associated with this swelling, to get a satisfiictory
examination. Ordinarily, however, the diagnosis is simple enough. A
comparative examination of the ankles can be made, the functions of
the joint tested, and a little manii>ulation is all that is necessary to detect
crepitation. If it is impossiljle to get a satisfactory test by manipulation,
tiien it would be l)etter to treat the case as a fracture for a few days
until the swelling shall have subsided, when the examination can be
made quite easily.
Treatment. — In an acute sprain, or one that is seen even within a
week or ten days after the injury, the jdan which I have adopted with
exceedingly gratifying results is the Cotterell dressing. I have already
published two articles on this subject, the last one of which, in the Xcw
Yorf: Medical Journal for February 16, 1895, was fully illustrated. The
details are as follows : After making the examination, employ massage
for five or ten minutes with the foot well elevated. Next apply strips
362 ORTHOPEDIC SVRQERY.
of rubber plaster, about an inch in width and from twelve to eighteen
inches in length, over the [)art sprained, beginning back of the injury.
Aim to leave the part of the foot not ati'ected as well uncovered as pos-
sible, but reinforce well as the stri])s are applied under the malleolus or
malleoli. The first strip for a sprain of the external malleolus is applied,
l)eginning just above the ankle on the unaffected side of the foot, and
ending on the affected side about half the way u]i the calf. This strip
is usually alongside the tendo Achillis and makes firm su])port under the
heel. The second strip starts on the inner side of the unaftected part of
the foot, near the ball of the toe, comes around over the back of the heel,
and ends aliout the base of the little toe. It crosses the first one just
al)0ve the Ijorder of the heel. The thii'd strip overlaps the first halfway,
the fourth the second, and so on until the jiart sprained is fully covered
by this criss-cross strapping. A cheese-cloth bandage is applied, more
with the idea of securing close adhesion of the plaster, and is removed
within twenty-four hours. As soon as the dressing is completed the
stocking and boot should be applied. The patient is now ready to begin
walking, and this should be insisted upon in the presence of the surgeon.
Direct him, for instance, to walk about the room eight or ten times. At
first strong objections ai'e offered, but after two or three turns it is
asserted that walking becomes much more easy, and by the time the task
is completed there will be very little lameness or disability. "While it is
imdesii'able to insist on too much walking for the next few days, it is
essential that the patient should walk as much as it is necessary for him
to walk — that is, attend to his business or any duties that require a mod-
erate amount of walking. At the end of a week it is well to remove the
strips and reapply in the same manner as above. Two or three such
dressings suffice to complete the cure.
In old sprains a support must be worn for a much longer period, and
where adhesions have already formed it has seemed to me that a plan
which was recommended by the late R. O. Cowling, M. D., of Louisville,
Kentucky, should be adopted before the strips are aj)plied — namely,
under primar}- aufesthesia move the foot about, break up the adhesions —
produce, in fact, an acute sprain — and then treat this by the adhesive
strips. Whei'e one desires to raise the side of the foot a little, the sole
of the shoe may be built up on that side from a ijuarter to three-eighths
of an inch.
I have refrained from presenting the ordinary treatment by fomenta-
tions, plaster bandage, etc., because I found these methods very unsatis-
factory, and because these methods arc fully illustrated in all the text-
books of surgery. Incidentally, I have found adhesive strips very useful
in s])rains about the knee and other joints. Where the spinal column
has been sprained, I have also used the adhesive strips with decided
advantage.
Diseases of the Joints of the Upper Extremity.
The Shoulder.
Tubercular ostitis of the shoulder is rare in childhood, and still less
frequently observed in adults. The lesions which are met most fre-
quently are the results of old sprains of the shoulder, rheumatic periar-
DISEASES OF THE JOiyTS OF THE UPPER EXTREMITY. 363
thritis, and luxatious. The diseases which the orthopaedic surgeon is
called upon to treat are ostitis of the shoulder, filjrous periarthritis the
result of rheumatism or exposure, and congenital luxations and snl)lux-
ations.
Ostitis is characterized hy very nearly the same signs that one hnds
in ostitis of the hip or knee, such as reflex spasm, atrophy, limitation of
movements, pain on use, extra heat. With a knowledge of these signs
and symptoms diagnosis is compai-atively easy. One naturally looks for
an injury in getting the history, but if one fails to get a satisfactory ex-
planation of the symptoms by reason of some trivial injury, it is fair to
assume that an ostitis presents for consideration.
In the way of treatment it has for a long time been regarded as un-