Page images
PDF
EPUB

massage in two weeks. Positive passive motion is begun in three or four weeks. In old injuries, when the ends cannot be brought into apposition, lengthen one end or both ends, either by the method of Anderson (Fig. 150) or by the method of Czerny (Fig. 151). Poncet makes

FIG. 151.-Czerny's method of tendon-lengthening.

the

FIG. 152.-Method of suturing the annular ligament of wrist.

several zigzag incisions on each side of the tendon, and when the tendon is pulled upon it elongates decidedly. These methods of lengthening may be used in cases of deformity from a contracted tendon. If the tendon cannot be lengthened sufficiently, make a bridge of catgut from one end of it to the other, or graft in another tendon from the same person or from one of the lower animals.

The annular ligament is sutured as shown in Fig. 152.

In some cases in which a muscle has been paralyzed, Nicoladoni and others have divided the tendon of the paralyzed muscle and have united its distal end with the tendon of a normal muscle, the normal tendon being split to receive it.

XXI. ORTHOPEDIC SURGERY.

This branch of surgery formerly dealt only with the treatment of deformities by means of mechanical appliances, but of recent years its domain has been enlarged to include the treatment, surgical and mechanical, of deformities, contractures, and many joint-diseases.

Torticollis (wry-neck) is a condition in which contraction of certain of the neck-muscles causes an alteration in the position of the head. The disease is one-sided; the sterno-cleido-mastoid is the muscle chiefly involved, though the trapezius, splenius, and other muscles sometimes suffer. Acute torticollis, which is rare, results from cold or from injury (see Myalgia). Chronic torticollis may be congenital, it may be due to nerve-irritation, or it may be due to an assumed attitude because of eye-defect. Chronic torticollis may be intermittent, but is usually persistent. The muscle stands out in bold outline, the head is turned to the opposite side, the ear of the disordered side is turned toward the shoulder, and the chin is thrown forward. There is no pain. Spinal curvature may arise. The head may often be restored

to its normal position by passive movement or by voluntary effort, but it at once returns to its habitual position. The corresponding side of the face atrophies. Mikulicz asserts that torticollis is a chronic fibrous myositis, due often to compression during labor. He further says that the lesion known as hematoma of the sternomastoid, which occasionally follows labor, is not hematoma, but thickening due to myositis. Symptoms.-Congenital wry-neck is due to central nervous disease, to spinal deformity, or to injury during birth, and in this form the sternomastoid is shortened, hardened, and atrophied. It may not be noticed for some years because of the short neck of infancy, and it is associated with asymmetrical development of the face. It is almost invariably upon the right side. Spasmodic wry-neck may present tonic spasm only, intermittent spasm alone, or both may appear alternately. It is a disease especially of adults; in women it is often linked with hysteria. The exciting cause may be a cold, a blow, or a mental storm; the predisposing cause is the neurotic temperament. In some rare cases bilateral spasm occurs, the head being pulled backward and the face being turned upward. Clonic spasms may come on unannounced, or they may be preceded by pain and stiffness; the head can be held still for a moment only; there is sometimes pain, always fatigue, but during sleep the contractions cease. The attack will probably pass away, but will almost certainly recur.

Treatment.-Congenital wry-neck is treated by myotenotomy (through an open wound) and the use of proper braces and supports. The old subcutaneous myotenotomy should be abandoned, as aseptic incision enables the surgeon to see and to feel all the contracted bands of fascia, muscle, and tendon, and to avoid vital structures (page 516). In spasmodic wry-neck treat the neurotic temperament; in persistent cases stretch, or divide and exsect a part of the spinal accessory nerve. To reach this nerve make an incision along the posterior edge of the sternocleidomastoid, find the nerve as it emerges from under the middle of the muscle, and retract the muscle at this point (Keen). For the treatment of rheumatic wry-neck see Myalgia (page 504).

Dupuytren's contraction is a contraction of the palmar fascia, of its digital prolongations, and of the fibers joining the fascia and skin. Fixed contraction of one or more fingers occurs. The ring-finger and the little finger most often suffer. The condition may be symmetrical. The disease arises oftenest in men beyond middle age. The cause

of this disease is unknown: some refer it to gout or rheumatism, others to traumatism, reflex irritation, or neuritis.

Symptoms.-Dupuytren's contraction is indicated by a small hard lump or crease which appears over the palmar surface of the metacarpophalangeal joint. This nodule grows and the corresponding finger is pulled down. In some cases the tip of the finger is forced against the palm. The skin becomes dimpled or puckered.

Treatment. In treating Dupuytren's contraction subcutaneous multiple incisions may be made, the tense fascia and the fasciocutaneous fibers being cut. The finger is straightened and is placed upon a straight splint, which is worn continuously for a week or ten days and is worn at night for at least a month. Keen divides the skin by a V-shaped cut, the base of the V being downward, lifts up the flap, and dissects out the contracted tissue.

Syndactylism (webbed fingers) is always congenital, and may persist through several generations. Simple incision of the web is useless; the operation to be performed is that of Agnew or of Diday (Figs. 153, 154).

In Agnew's operation a flap of skin from the dorsum is inserted between the fingers.

In Diday's operation a flap is taken from the dorsal surface and another flap is raised from the palmar surface, and each flap is sutured to the finger from which it springs.

[ocr errors]

FIG. 153. Agnew's operation for webbed FIG. 154. Diday's operation for
fingers (Pye).

webbed fingers (Pye).

Polydactylism (supernumerary digits) is always congenital, is often hereditary, and is usually symmetrical. There may be an incomplete digit, or there may be an entire and well-developed finger or toe with a metacarpal or metatarsal bone. The connection to the metatarsus or metacarpus may be by a fibrous pedicle only. If the digit is complete, with a metacarpal bone, no operation is required; if it is incomplete or is ill-developed, it should be removed.

Trigger-finger or Jerk-finger.-The patient can close the fingers, but on trying to open them one finger remains

closed. It can be opened by grasping it with the other hand, but flies open with a snap like an opening knife (Abbe). The condition is due to enlargement of the flexor tendon, or to contraction of the groove in the transverse ligament in the palm (Tubby). This condition may be due to ganglion, enchondroma, or tenosynovitis.

Treatment. If a trauma, a ganglion, or inflammation exists, treat by ordinary means. If there is no obvious cause, put a compress over the tunnel in the ligament and apply a splint. Mallet-finger.-This is called also drop-finger and rupture of the extensor tendon. It is due to a blow in the direction of flexion when the finger is extended. It is supposed to be due partly to stretching and partly to rupture of the extensor tendon at the point at which it is the posterior ligament of the distal interphalangeal joint. Abbe has shown that baseball players are liable to a condition which is the reverse of this, in which the last phalanx is dislocated backward. Drop-finger is treated by incision and suture of the tendon to the periosteum (Abbe).

Genu valgum (knock-knee) results from an unnatural growth of the internal condyle, causing the shaft of the femur to curve inward and the internal lateral ligament of the knee-joint to stretch, the knees coming close together and the feet being widely separated. This deformity is usu ally noted when the child begins to walk, but it may not appear until puberty or even long after. Knock-knee may arise from rickets, from an occupation demanding prolonged standing, or from flat-foot. It may be noted in one knee or in both knees.

Treatment.-Mild rachitic cases of knock-knee may remain in slight deformity, or may get well from improvement of the general health. In ordinary cases simply treat the . rickety condition. The patient is forbidden to stand or to walk, and the limb, after being put as straight as it can be, is fixed on an external splint and a pad is put over the inner condyle. Later in the case plaster-of-Paris is used. Some surgeons prefer to immobilize while the leg is flexed to a right angle with the thigh. In a severe case the surgeon can immobilize after forcibly straightening (causing an epiphyseal separation) or after the performance of osteotomy (Fig. 127). Osteotomy is preferable to fracture by a mechan ical appliance (osteoclasis).

Genu varum (bow-legs) is the opposite of knock-knee. Usually both legs are bowed out, the knees being widely separated, the tibia and femurs, as a rule, being curved, and

the feet being turned in. This disease is due to rickets, the weight of the body producing the deformity in early life. In older people incurable

[merged small][graphic][merged small][merged small]

Club-hand.-A congenital deformity in which the hand deviates from the normal relation to the forearm. It is usually associated with other deformities. In some cases the radius and possibly some of the carpal bones are absent.

Treatment. By massage and passive motion, by immobilization, by tenotomy or osteotomy.

Talipes (club-foot) is a permanent deviation of the foot. There are several forms. Talipes equinus (Fig. 155) is a confirmed extension; talipes calcaneus (Fig. 156) is a confirmed flexion; talipes varus is a confirmed adduction and inversion; and talipes valgus is a confirmed abduction and eversion. Two of these forms may be combined, as in talipes equino-varus (Fig. 157), talipes equino-valgus, talipes calcaneo-varus, and talipes calcaneo-valgus. The causes of talipes are congenital or acquired. The congenital form is due to persistence of the fetal form of the foot. Acquired cases may arise from infantile paralysis, from spastic contractions, from cicatrices, from traumatisms, from arrest of bony growth following upon bone inflammation, or from hysterical contractures. Talipes equinus is rarely congenital.

[graphic]

In

this condition the pa

tient walks upon the

L J

FIG. 157.--Double equino-varus (Am. Text-book of Surgery).

toes and cannot bring the heel to the ground.

Talipes Calcaneus.-The patient walks upon the heel and

[graphic]
« PreviousContinue »