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stretch the shortened muscles. When operation is necessary, the biceps tendon should be lengthened by an open incision so as to avoid injury to the external popliteal nerve; the semitendinosus and gracilis, subcutaneously. Only in rare instances is it necessary to divide the semi-membranosus; to do this, an open incision is necessary.

6. Equinus position of the foot, due to contracture of the gastrocnemius and soleus, is seldom open to correction by bloodless methods. I favor the subcutaneous tenotomy in all cases where the surgeon is convinced he is dealing with a normal muscle. If there is any evidence pointing to spasticity, or if through the reflex action of any irritant the muscle might be abnormally stimulated to contraction (as by the presence of foreign bodies within its substance), the subcutaneous method is to be replaced by a plastic operation. In my hands, two methods have given equally good results: first, the double L-shaped lengthening; second, the suture method of Jones. In performing the first, the tendon is exposed by a longitudinal incision 2 to 3 inches long, depending upon the degree of shortening. The tendon is slit longitudinally in the midline with a very sharp narrow-bladed knife, and divided transversely on opposite halves at each end of the longitudinal incision. After correcting the equinus deformity, the two halves, which should overlap at least 1 inch are sutured together with several interrupted chromic gut stitches. In the Jones method, a 1-inch longitudinal incision exposes the tendon which is lifted from the subjacent tissues by a blunt instrument (periosteal elevator). Two strong sutures are taken in the tendon about 12 inch from one another, the tendon is divided transversely between the sutures and after correcting the equinus, the ends of the sutures are knotted, so as to prevent retraction of the tendon ends. Care must be taken not to apply a pressure pad to the gap between the tendon ends, since this would prevent its regeneration. The same precaution must be exercised after the subcutaneous tenotomy.

7. Torticollis.This and the following are rare types of contracture in military work. Torticollis results from an injury to the neck which has not been splinted in the proper position (see p. 54). When once developed, it can seldom

be corrected except by division of the sternocleido mastoid. Contrary to the usual conception, this can in most cases be safely performed by the subcutaneous method. Only when

[graphic]

Fig. 80.—Elevation of the left shouder with subsequent secondary scoliosis due to gunshot injury in the neighborhood of the left trapezius muscle. Treatment by the “Abbott" method unavailing until supplemented by open incision of the contracted muscular fibers.

the contracture is very marked, involving division of the deep cervical fascia, do I find it necessary to make an incision.

8. Scoliosis.-I have seen only two instances as the result of gunshot injuries. In both, the injury occurred to the shoulder muscles, the shoulder was drawn upward as a consequence, and a convexity of the spine toward the side of the injury developed in the upper dorsal region (see Fig. 80). Correction by the Abbott method, which would seem to be particularly applicable to cases of this type, gave only fair

[graphic]

Fig. 81.—Illustration of the type of splint applicable to injuries of the left cerebral cortex or pyramidal tract, producing a spastic paralysis of the right arm and hand. The splint overcomes the pronator spasm of the forearm muscles and the flexion contracture of the hand and fingers.

results. In the one case, I secured a complete cure by open division of the fibres of the trapezius, which were drawing the scapula upward, followed by correction in the Abbott frame and immobilization in plaster.

9. Contractures subsequent to lesions of the Rolandic area or of the pyramidal tract. These injuries result in a spastic paralysis in which the adductors, flexors and pronators overcome the antagonistic weaker muscles. A splint should of course be applied to prevent a formation of contractures. Fig. 81 illustrates a simple apparatus which overcomes the tendency to flexion at the elbow and hand and keeps the forearm supinated. For the lower extremity an abduction frame with a device to prevent toe-drop is indicated.

The Orthopedic Treatment of Burns. The prevention of contractures subsequent to extensive burns in the neighborhood of joints, constitutes an important and difficult phase of orthopedic work. If the limb be immobilized in the flexed position, a flexion contracture is bound to occur, whereas the extended position increases the area denuded of skin, rendering the problem of wound healing more difficult, and at the same time creates the danger of a joint stiffened in the extended position. The essential in the treatment, therefore, is constant change in the position of the limb so far as this is compatible with effective treatment of the wound. A specific example will make the method clear. Assume that the patient has an extensive burn over the front of the elbow. A splint is applied holding the forearm at an angle of about 145o. This is kept on until the sloughs have disappeared and the wound has begun to granulate. From this time on two splints are used. One holding the arm flexed to about 90°, the second extended to 170°. These are changed on alternate days. As the wound epithelializes the patient is allowed to change the splints himself every few hours and is encouraged to exercise the flexors and extensors of the joint. This motion causes some delay in the healing of the wound but has the great advantage that it maintains the function of the part.

CHAPTER VIII

THE TREATMENT OF NERVE INJURIES

The types of splint applicable to nerve injuries have already been described (see p. 50), as well as the symptoms by means of which a nerve lesion can be recognized. When the patient reaches the base hospital the splint applied at the front should be kept on, or, in case this postural treatment has been neglected, it should be instituted at once. In addition, every

. measure should be taken to keep the paralyzed muscles in condition of maximal tone by massage and electrical stimulation. Galvanic, faradic, and high frequency currents can all be applied with excellent effect. This portion of the work should be controlled by an experienced technician. The custom of turning over this branch of therapy to a half-trained assistant cannot be too strongly condemned. Electro-therapy in particular requires the most careful anatomical and technical training if it is to be anything except a therapeutic placebo.

Primary nerve suture is seldom possible after a gunshot injury, since in almost all instances of extensive laceration the danger of infection constitutes a contraindication. As soon, however, as the primary reaction has subsided and the infection has been controlled, the surgeon stands before the question of whether to operate or to wait for the spontaneous return of function in the injured nerve. On this subject there is the greatest difference of opinion among men of experience. Some maintain that the operation should be performed as soon as the operative field is reasonably aseptic; others claim that by postponing the operation five or six months a great proportion of the nerve injuries recover without operative interference. I shall state a few practical rules of guidance which have stood me in good stead:

1. When the symptoms of a nerve lesion are progressive, operate at once. Thus, for instance, a patient brought to me three days after the injury complained of slight tingling

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