V. INJURIES IN THE REGION OF THE WRIST AND HAND…

V. INJURIES IN THE REGION OF THE WRIST AND HAND

Surgical Anatomy--FRACTURE OF LOWER END OF RADIUS: Colles' fracture; Chauffeur's fracture; Smith's fracture; Longitudinal fracture; Separation of epiphysis--FRACTURE OF LOWER END OF ULNA: Shaft; Styloid process; Separation of epiphysis--FRACTURE OF CARPAL BONES--DISLOCATION: Inferior radio-ulnar joint; Radio-carpal joint; Carpal bones; Carpo-metacarpal joint--SPRAINS--INJURIES OF FINGERS: Fractures; Dislocations; Mallet finger.

INJURIES IN THE REGION OF THE WRIST

These include fractures of the lower ends of the bones of the forearm and separation of their epiphyses; sprains and dislocations of the inferior radio-ulnar, and of the radio-carpal articulations; and fractures and dislocations of the carpus.

#Surgical Anatomy.#--The most important landmarks in the region of the wrist are the styloid processes of the radius and ulna. The tip of the radial styloid is palpable in the "anatomical snuff-box" between the tendons of the long and short extensors of the thumb, and it lies about half an inch lower than the ulnar styloid. The ulnar styloid is best recognised on making deep pressure a little below and in front of the head of the ulna, which forms the rounded subcutaneous prominence seen on the back of the wrist when the hand is pronated.

The tubercle of the navicular (scaphoid) and the greater multangular (trapezium) can be felt between the radial styloid and the ball of the thumb, a little below the radial styloid; and the pisiform and hook of the hamatum (unciform) are palpable, slightly below and in front of the ulnar styloid.

In examining an injured wrist, the different bony points should be located, and their relative positions to one another and to the adjacent joints noted; and the shape, position, and relations of any unnatural projection or depression observed, using the wrist on the other side as the normal standard for comparison. The power and range of movement--active and passive--at the various joints should also be tested.

FRACTURE OF THE LOWER END OF THE RADIUS

#Colles' Fracture.#--This injury, which was described by Colles of Dublin in 1814, is one of the commonest fractures in the body, and is especially frequent in women beyond middle age. It is almost invariably the result of a fall on the palm of the hand, in the three-quarters pronated position, the force being received on the ball of the thumb, and transmitted through the carpus to the lower end of the radius which is broken off, the lower fragment being driven backwards.

The fracture takes place through the cancellated extremity of the bone, within a half to three-quarters of an inch of its articular surface (Fig. 45). It is usually transverse, but may be slightly oblique from above downwards and from the radial to the ulnar side. In a considerable proportion of cases it is impacted, and not infrequently the lower fragment is comminuted, the fracture extending into the radio-carpal joint.

When impaction takes place, it is usually reciprocal, the dorsal edge of the proximal fragment piercing the distal fragment, and the palmar edge of the distal fragment piercing the proximal. The periosteum is usually torn and stripped from the palmar aspect of the fragments, while it remains intact on the dorsum.

In the majority of cases the styloid process of the ulna is torn off by traction exerted through the medial ulno-carpal (internal lateral) ligament, and in a considerable proportion there is also a fracture of one of the carpal bones.

The resulting displacement is of a threefold character: (1) the distal fragment is displaced backwards; (2) its carpal surface is rotated backwards on a transverse diameter of the forearm; while (3) the whole fragment is rotated so that the radial styloid comes to lie at a higher level than normal.

Clinical Features.--In a typical case there is a prominence on the dorsum of the wrist, caused by the displaced distal fragment, with a depression just above it (Fig. 43); and the wrist is broadened from side to side. The natural hollow on the palmar aspect of the radius is filled up by the projection of the proximal fragment. The carpus is carried to the radial side by the upward rotation of the distal fragment, and the radial styloid is as high, or even higher, than that of the ulna. The lower end of the ulna is rendered unduly prominent by the flexion of the hand to the radial side. The fingers are partly flexed and slightly deviated towards the ulnar side; and the patient supports the injured wrist in the palm of the opposite hand, and avoids movement of the part. Occasionally the median nerve is bruised or torn, causing motor and sensory disturbances in its area of distribution.

The general outline of the wrist and hand has been compared not inaptly to that of "an inverted spoon." Pronation and stipulation are lost, the joint is swollen, and there is tenderness on pressure, especially over the line of fracture. Tenderness over the position of the ulnar styloid may indicate fracture of that process, although it is sometimes present without fracture. No attempt should be made to elicit crepitus in a suspected case of Colles' fracture as the manipulations are painful, and are liable to increase the displacement.

Treatment.--It cannot be too strongly insisted upon that success in the treatment of Colles' fracture with displacement and impaction depends chiefly upon complete and accurate reduction, and to enable this to be effected a general anaesthetic is almost essential. The surgeon grasps the patient's hand, as if shaking hands with him, and, resting the palmar surface of the wrist on his bent knee, makes traction through the hand, and counter-extension through the forearm, with lateral movements, if necessary, to undo impaction. When the fragments are freed from one another, the wrist is flexed, and the hand carried to the ulnar side, while the lower fragment is moulded into position by the thumb of the surgeon's disengaged hand. When reduction is complete, the deformity disappears, and the two styloid processes regain their normal positions relative to one another.

As there is no tendency to re-displacement and no risk of non-union, no retentive apparatus is required, but, if it adds to the patient's sense of security, a bandage or a poroplastic wristlet may be applied. In severe cases, however, anterior and posterior splints, similar to those used for fracture of both bones of the forearm, or a dorsal splint padded so as to flex the wrist to an angle of 45 deg., but somewhat narrower, may be employed. The hand and forearm are in any case supported in a sling.

To avoid the stiffness that is liable to follow, massage and movement of the wrist and fingers should be carried out from the first, the range of movement being gradually increased until the function of the joints is perfectly restored. If splints are used, they should be discarded in a week, and the patient is then encouraged to use the wrist freely.

The various special splints recommended for the treatment of Colles' fracture, such as Carr's, Gordon's, the "pistol splint," and many others, are all designed to correct the deformity as well as to control the fragments. It has already been pointed out that if reduction is complete there is no deformity to correct, and if it is not complete the deformity cannot be corrected by any form of splint.

Unreduced Colles' Fracture.--When union has been allowed to take place without the displacement having been reduced, an unsightly deformity results. In young subjects whose occupation is likely to be interfered with, and in women for aesthetic reasons, the fracture is reproduced and the displacement of the lower fragment corrected. This is conveniently done by means of Jones' wrench, which grasps the distal fragment and affords sufficient leverage to break the bone.

#Chauffeur's Fracture.#--A fracture of the lower end of the radius frequently occurs from the recoil of the crank, "by back firing," in starting the engine of a motor-car. The injury may be produced either by direct violence, the handle as it recoils striking the forearm, or by indirect violence, from forcible hyper-extension of the hand while grasping the handle. The fracture may pass transversely through the lower end of the radius, as in Colles' fracture, but is more often met with two or three inches above the wrist (Fig. 46). It is treated on the same lines as Colles' fracture.

A fracture of the lower end of the radius with forward displacement of the carpal fragment, was first described by R. W. Smith of Dublin (Colles' fracture reversed, or #Smith's fracture#) (Fig. 47). It is nearly always due to forcible flexion, as from a fall on the back of the hand. Like Colles' fracture, it may be transverse or slightly oblique, impacted, or comminuted. The deformity is characterised by an elevation on the dorsum running obliquely upwards from the ulnar to the radial side of the wrist, and caused by the head of the ulna, which remains in position, and the distal end of the proximal fragment. Below this, over the position of the distal radial fragment, is a gradual slope downwards on to the dorsum of the hand. Anteriorly there is a prominence in the flexure of the wrist, and the distal fragment may be felt under the flexor tendons. The hand deviates to the radial side, and thereby still further increases the prominence caused by the lower end of the ulna. The radial styloid is displaced forward, upward, and to the radial side, and the ulnar styloid may be torn off.

When the deformity is not well marked, this injury may be mistaken for forward dislocation of the wrist, for fracture of both bones low down, or for sprain of the joint.

The treatment is carried out on the same lines as in Colles' fracture.

Longitudinal fractures of the lower end of the radius opening into the joint usually result from the hand being crushed by a heavy weight or in machinery. They are often compound and comminuted.

#Separation of the lower epiphysis# of the radius, which is on the same level as that of the ulna and lies above the level of the synovial membrane of the wrist-joint, is comparatively common between the ages of seven and eighteen, especially in boys, and is caused by the same forms of violence as produce Colles' fracture.

Although clinically the appearances in these two injuries bear a general resemblance to one another, separation of the epiphysis may usually be identified by the directly transverse line of the dorsal and palmar projections, the folding of the skin observed in the palmar depression, the absence of abduction of the hand and the ease with which muffled crepitus can be elicited (E. H. Bennett). The deformity is readily reduced, and the fragments are easily retained in position.

This injury is often complicated with fracture of the shaft or styloid process of the ulna, or with dislocation of the radio-ulnar joint, and it is not infrequently compound, the lower end of the shaft being driven through the skin on the palmar aspect immediately above the wrist. Impairment of growth in the radius seldom occurs; when it does, it results in a valgus condition of the hand (Fig. 48), calling for resection of the lower end of the ulna.

The treatment is the same as for Colles' fracture.

#Fracture of the Lower End of the Ulna.#--The lower end of the shaft of the ulna is seldom fractured alone. The styloid process, as has already been pointed out, is frequently broken in association with Colles' and other fractures of the lower end of the radius.

Separation of the lower epiphysis of the ulna sometimes occurs, and in rare cases results in arrest of the growth of the bone, leading to a varus condition of the hand and bending of the radius. Sometimes the separated epiphysis fails to unite, and although this gives rise to no disability, it is liable to lead to errors in the interpretation of skiagrams.

The treatment is similar to that for the corresponding injuries of the radius.

Simultaneous separation of the epiphysis of both radius and ulna sometimes occurs, and, as a result of severe violence, may be compound, the lower ends of the diaphyses projecting through the skin on the palmar aspect above the wrist.

#Fracture of Carpal Bones.#--The use of the Roentgen rays has shown that fracture of individual carpal bones is commoner than was previously supposed, and that many cases formerly looked upon as severe sprains are examples of this injury.

The navicular (scaphoid) and lunate (semilunar) are those most commonly fractured, usually by indirect violence, by forced dorsiflexion from a fall on the extended hand. The clinical features are: localised swelling on the radial side of the wrist, increase in the antero-posterior diameter of the carpus, marked tenderness in the anatomical snuff-box when the hand is moved laterally, especially in the direction of adduction, and, rarely, crepitus. The median nerve is sometimes over-stretched or partly torn. In many cases, however, the symptoms are so obscure that an accurate diagnosis can only be made by the use of the X-rays (Fig. 49). Codman recommends taking pictures of the navicular by placing the two wrists of the patient in adduction, and of the lunate, in abduction.

The treatment of simple fractures consists in massage and movement. Codman and Chase recommend excision of the proximal half of the fractured bone, through a dorsal incision to the lateral side of the extensor digitorum communis. When the fracture is compound, the loose fragments should be removed.

DISLOCATIONS IN THE REGION OF THE WRIST

Dislocation may occur at the inferior radio-ulnar, the radio-carpal, mid-carpal, inter-carpal, or carpo-metacarpal joints, but the strong ligaments of these articulations, the comparatively free movement at the various joints, and the relative weakness of the lower end of the radius whereby it is so frequently fractured, render dislocation a rare form of injury.

Dislocation of the #inferior radio-ulnar# articulation may complicate fracture of the lower end of the radius, or accompany sub-luxation of the head of the radius. The head of the ulna usually passes backward.

In children, the commonest cause is lifting the child by the hand, and the displacement is only partial. In adults, it may result from forcible efforts at pronation or supination, as in wringing clothes, or from direct violence, the separation being frequently complete, and sometimes compound.

The head of the ulna is unduly prominent, and there is a depression on the opposite aspect of the joint. The hand is generally pronated, the rotatory movements at the wrist are restricted and painful, while flexion and extension are comparatively free.

Reduction is effected by making pressure on the displaced bone and manipulating the joint, especially in the direction of supination. If the ligaments fail to unite, the head of the ulna tends to slip out of place in pronation and supination--recurrent dislocation.

Dislocation at the #radio-carpal# articulation, usually spoken of as dislocation of the wrist, is attended by tearing of the ligaments and displacement of tendons, and is frequently compound. The carpus may be displaced backward or forward, and the articular edge of the radius towards which it passes may be chipped off.

Backward dislocation is commonest, the injury resulting from a severe form of violence, such as a fall from a height on the palm while the hand is dorsiflexed and abducted. The clinical appearances closely simulate those of Colles' fracture, or of separation of the lower radial epiphysis, but the unnatural projections, both in front and behind, are lower down, and end more abruptly (Fig. 50). The hand is more flexed, and the palm is shortened. The styloid processes retain their normal relations to one another, and the carpal bones lie on a plane posterior to the styloids, the articular surfaces may be recognised on palpation. The forearm is not shortened.

Forward dislocation of the carpus may result from any form of forced flexion, such as a fall on the back of the hand, or from direct violence. The displaced carpus forms a marked projection on the palmar aspect of the wrist, and there is a corresponding depression on the dorsum. The attitude of the hand and fingers is usually one of flexion.

In both varieties reduction is readily effected by making traction on the hand and pushing the carpus into position. A moulded poroplastic splint, which keeps the hand slightly dorsiflexed, adds to the comfort of the patient, but this should be removed daily to admit of movement and massage being employed.

#Dislocation of Carpal Bones.#--The two rows of carpal bones may be separated from one another, or any one of the individual bones may be displaced. These injuries are rare, and result from severe forms of violence, usually from a fall on the extended hand. Pain, deformity, and loss of function are the ordinary symptoms. The treatment consists in making direct pressure over the displaced bone, while traction is made on the hand, which is alternately flexed and extended.

Of these injuries that most frequently observed is displacement of the head of the capitate bone (os magnum) from the navicular (scaphoid) and lunate (semilunar) bones. Frequently these bones are fractured, and fragments accompany the displaced os magnum. In full palmar flexion of the wrist the displaced head of the os magnum forms a prominence on the dorsum opposite the base of the third metacarpal, which temporarily disappears when the hand is dorsiflexed. There is an increase in the antero-posterior diameter of the wrist, situated on a lower level than that which accompanies fracture of the lower end of the radius; flexion and extension of the wrist are limited; and in some cases there are symptoms referable to pressure on the median nerve. By keeping the hand in the dorsiflexed position for a week or ten days, the bone may become fixed in its place and the function of the wrist be restored, but it is often necessary to excise the bone.

The lunate may be displaced forward by forcible dorsiflexion of the hand, and forms a projection beneath the flexor tendons; there is usually loss of sensibility in the distribution of the ulnar nerve in the hand. The most satisfactory treatment is removal of the bone.

In a few cases the navicular has been displaced (Fig. 51), and has had to be subsequently replaced by operation. Separation of any of the other bones is rare.

#Carpo-metacarpal Dislocations.#--Any or all of the metacarpal bones may be separated from the carpus by forced movements of flexion or extension. The commonest displacement is backward. The thumb seems to suffer oftener than the other digits. These injuries, however, are so rare, and the deformity is so characteristic, that a detailed description is unnecessary.

#Sprain of the wrist# is a common injury, and results from a fall on the hand, a twist of the wrist, or from the back-firing of a motor-crank dorsiflexing the hand. The marked swelling which rapidly ensues may render it difficult to distinguish a sprain from the other injuries that are liable to result from similar causes--Colles' fracture, separation of the lower radial epiphysis, dislocation of the wrist, and fractures and dislocations of the carpal bones.

In a sprain the normal relations of the styloid processes and other bony points about the wrist are unaltered, and there is no radial deviation of the hand, as in Colles' fracture. The most marked swelling is over the line of the articulation on the anterior and posterior aspects of the joint. There is usually some effusion into the sheaths of the tendons passing over the joint, and in some cases on moving the fingers a peculiar creaking, which may simulate crepitus, can be elicited. There is marked tenderness on making pressure over the line of the joint, as well as over one or other of the collateral ligaments, depending upon which ligament has been over-stretched or torn. Movements that tend to put the damaged ligaments on the stretch also cause pain. It has to be borne in mind, however, that in many cases of Colles' fracture there is extreme tenderness on pressing over the ulnar styloid and medial ulno-carpal ligament, as these structures are frequently injured as well as the radius, but the point of maximum pain and tenderness is over the seat of fracture of the radius. In all doubtful cases the X-rays should be employed to establish the diagnosis.

The treatment consists in the immediate employment of massage and movement, supplemented by alternate hot and cold douches, on the same lines as in sprains of other joints.

INJURIES OF THE FINGERS

#Fracture.#--Fractures of the metacarpals of the fingers are comparatively common. When they result from direct violence, such as a crush between two heavy objects, they are often multiple and compound. Indirect violence, acting in the long axis of the bone and increasing its natural curve, such as a blow on the knuckle in striking with the closed fist, usually produces an oblique fracture about the middle of the shaft, the proximal end of the distal fragment projecting towards the dorsum. Apart from this there is little deformity, as the adjacent metacarpals act as natural splints and tend to retain the fragments in position. A sudden sharp pain may be elicited at the seat of fracture on making pressure in the long axis of the finger; and unnatural mobility and crepitus may usually be detected. These fractures are readily recognised by the X-rays. Firm union usually results in three weeks.

The shaft of the metacarpal of the thumb is frequently broken by a blow with the closed fist. The fracture is usually transverse, and situated near the proximal end of the shaft; frequently it is comminuted, and in some instances there is a longitudinal split.

Treatment.--When the fracture is transverse, and especially when it implicates the middle or ring fingers, the most convenient method is to make the patient grasp a firm pad, such as a roller bandage covered with a layer of wool, and to fix the closed fist by a figure-of-eight bandage. In this way the adjoining metacarpals are utilised as side splints. Active and passive movements must be carried out from the first, and the bandage may be dispensed with at the end of a week or ten days.

In oblique fractures with a tendency to overriding of the fragments, especially in the case of the index and little fingers, it is sometimes necessary to apply extension to the distal segment of the digit, by means of adhesive plaster, to which elastic tubing is attached and fixed to the end of a bow splint, reaching well beyond the finger-tips (Fig. 52). This should be worn for a week or ten days.

#Bennett's Fracture of the Base of the First Metacarpal Bone.#--Bennett of Dublin described an injury of the thumb which, although comparatively common, is often mistaken for a sub-luxation backward of the carpo-metacarpal joint, or a simple "stave of the thumb." It consists in an "oblique fracture through the base of the bone, detaching the greater part of the articular facet with that piece of the bone supporting it which projects into the palm" (Fig. 53). We have frequently observed the fracture extend for a considerable distance along the palmar aspect of the shaft.

It usually results from severe force applied directly to the point of the thumb, driving the metacarpal against the greater multangular bone (trapezium), and chipping off the palmar part of the articular surface, but it may result from a blow with the closed fist. The rest of the metacarpal slips backward, forming a prominence on the dorsal aspect of the joint. The pain and swelling in the region of the fracture often prevent crepitus being elicited, and as the deformity is not at once evident, the nature of the injury is liable to be overlooked. The fracture is recognised by the use of the X-rays. Unless properly treated this injury may result in prolonged impairment of function, full abduction and fine movements requiring close apposition of the thumb being specially interfered with.

The treatment consists in reducing the fracture by extension in the attitude of full abduction and applying an accurately fitting pad over the extremity of the displaced bone, maintained in position by a light angular splint. This splint is first fixed to the extended and abducted thumb, and while extension is made by pushing it downwards the upper end is fixed to the wrist (Fig. 54 A). The apparatus is worn for three weeks, being carefully readjusted from time to time to maintain the extension and abduction. A moulded poroplastic splint added on the same principle may be employed, and is more comfortable (Fig. 54 B). Excellent results are obtained after reduction of the displacement, by massage and movement from the first, and the support merely of a figure-of-eight bandage (Pirie Watson).

#Fractures of phalanges# usually result from direct violence, and on account of the superficial position of the bones, are often compound, and attended with much bruising of soft parts. Force applied to the distal end of the finger may also fracture a phalanx. The proximal phalanges are broken oftener than the others. The deformity is usually angular, with the apex towards the palm, and if union takes place in this position, the power of grasping is interfered with. Unnatural mobility and crepitus can usually be recognised, but, on account of the swelling and tenderness, the fracture is apt to be overlooked. Firm union takes place in two or three weeks. In oblique and comminuted fractures, union may take place with overlapping, producing a deformity which may prevent the wearing of a glove or of rings. In compound fractures, non-union sometimes occurs, and causes persistent disability. In doubtful cases radioscopy renders valuable aid, as the parts are readily seen with the screen.

Treatment.--Early movement and massage are all-important. The contiguous fingers may be utilised as side splints, and a long palmar splint projecting beyond the fingers is applied. In oblique and comminuted fractures it may be necessary to anaesthetise the patient to effect reduction. When it is particularly desirable to avoid deformity, an open operation may be advisable.

#Dislocation.#--Dislocation of the Metacarpo-phalangeal Joint of the Thumb.--The commonest dislocation at this joint is a backward displacement of the proximal phalanx, which may be complete or incomplete. Its special clinical importance lies in the fact that much difficulty is often experienced in effecting reduction.

This dislocation is usually produced by extreme dorsiflexion of the thumb, whereby the volar accessory (palmar) and the collateral ligaments are torn from their metacarpal attachments, the phalanx carrying with it the volar accessory ligament and sesamoid bones. The head of the metacarpal passes forward between the two heads of the short flexor of the thumb, and the tendon of the long flexor slips to the ulnar side. The phalanx passes on to the dorsum of the metacarpal, where it is held erect by the tension of the abductor and adductor muscles.

The attitude of the thumb is characteristic. The metacarpal is adducted, its head forming a marked prominence on the front of the thenar eminence, and the phalanges are displaced backwards, the proximal being dorsiflexed and the distal flexed towards the palm.

Many explanations of the difficulty so often experienced in reducing this variety of dislocation have been offered, but the consensus of opinion seems to be that it is due to the interposition of the volar accessory ligament and the sesamoid bones between the phalanx and the metacarpal, and that this is most frequently the result of ill-advised efforts at reduction. In some cases the tension of the long flexor tendon may be a factor in preventing reduction, but the "button-holing" by the short flexor is probably of no importance.

Reduction is to be effected by flexing and abducting the metacarpal while the phalanx is hyper-extended and pushed down towards the joint and levered over the head of the metacarpal.

When this manipulation fails, the volar accessory ligament should be divided longitudinally through a puncture made with a tenotomy knife on the dorsal aspect of the joint, so as to separate the sesamoid bones and permit the passage of the head between them. An open operation is seldom necessary.

Dislocation forward is rare. It results from forced flexion of the thumb with abduction, tearing the posterior and medial collateral ligaments. The deformity is characteristic: the rounded head of the metacarpal projecting behind the level of the joint, while the base of the phalanx forms a prominence among the muscles of the thenar eminence.

Reduction is easily effected by making traction on the phalanges and carrying out movements of flexion and extension. The deformity, however, is liable to be reproduced unless a retentive apparatus is securely applied.

Dislocation of the thumb to one or other side is rare.

Dislocations of the metacarpo-phalangeal joint of the fingers may be backward or forward. They are less common than those of the thumb, but present the same general characters. In the backward variety the same difficulty in reduction occurs as is met with in the corresponding dislocation of the thumb, and is to be dealt with on the same lines.

Inter-phalangeal Dislocation.--The second and the ungual phalanges may be displaced backwards, forwards, or to the side. The clinical features are characteristic, and the diagnosis, as well as reduction, is easy. These dislocations are frequently the result of machinery accidents, and being compound and difficult to render aseptic, often necessitate amputation.

Persistent flexion of the terminal phalanx of the thumb or fingers (drop or mallet finger) may result from violence applied to the end of the digit when in the extended position--as, for example, in attempting to catch a cricket-ball. The terminal phalanx is flexed towards the palm, and the patient is unable to extend it voluntarily. A palmar splint is applied securing extension of the distal joint for three or four weeks. If the deformity has been allowed to occur it can only be corrected by an open operation, suturing or tightening the extensor tendon at its insertion into the base of the terminal phalanx.

VI. INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH

FRACTURES OF PELVIS: Varieties--INJURIES IN REGION OF HIP: Surgical anatomy; Fracture of head of femur; Fracture of neck of femur; Fracture below lesser trochanter--DISLOCATION OF HIP: Varieties--Sprains--Contusions--FRACTURE OF SHAFT OF FEMUR.

FRACTURE OF THE PELVIS

For descriptive as well as for practical purposes, it is useful to divide fractures of the pelvis into those that involve the integrity of the pelvic girdle as a whole, and those confined to individual bones.

In all, the prognosis depends upon the severity of the visceral lesions which so frequently complicate these injuries, rather than upon the fractures themselves.

#Fractures implicating the pelvic girdle as a whole# usually result from severe crushing forms of violence, such as the fall of a mass of coal or a pile of timber, or the passage of a heavy wheel over the pelvis. The force may act in the transverse axis of the pelvis, or in its antero-posterior axis. The pelvic viscera may be lacerated by the tearing asunder of the bones, or perforated by sharp fragments, or they may be ruptured by the same violence as that causing the fracture.

As a rule, more than one part of the pelvis is broken, the situation of the lesions varying in different cases.

Separation of the pubic symphysis may result from violence inflicted on the fork, as in coming down forcibly on the pommel of a saddle; from forcible abduction of the thighs; or it may happen during child-birth. In some cases the two pubic bones at once come into apposition again, and there is no permanent displacement, the only evidence of the injury being localised pain in the region of the symphysis elicited on making pressure over any part of the pelvis. In other cases the pubic bones overlap one another, and the membranous portion of the urethra, or the bladder wall, is liable to be torn. The displaced bones may be palpated through the skin, or by vaginal or rectal examination.

The pubic portion of the pelvic ring is the most common seat of fracture. The bone gives way at its weakest points--namely, through the superior (horizontal) ramus of the pubes just in front of the ilio-pectineal eminence, and at the lower part of the inferior (descending) ramus (Fig. 55). The intervening fragment of bone is isolated, and may be displaced. These fractures are frequently bilateral, and are often associated with separation of the sacro-iliac joint, with longitudinal fracture of the sacrum (Fig. 55), or with other fractures of the pelvic-bones.

Injuries of the membranous urethra and bladder are frequent complications, less commonly the rectum, the vagina, or the iliac blood vessels are damaged.

Localised tenderness at the seat of fracture, pain referred to that point on pressing together or separating the iliac crests, and mobility of the fragments with crepitus, are usually present. The fragments may sometimes be felt on rectal or vaginal examination. In all cases shock is a prominent feature.

The lateral and posterior aspects of the pelvic ring may be implicated either in association with pubic fractures or independently. Thus a fracture of the iliac bone may run into the greater sciatic notch; or a vertical fracture of the sacrum or separation of the sacro-iliac joint may break the continuity of the pelvic brim. In rare cases these injuries are accompanied by damage to the intestine, the rectum, the sacral nerves, or the iliac blood vessels.

Treatment.--It is of importance that the patient be moved and handled with care lest fragments become displaced and injure the viscera. He should be put to bed on a firm mattress, which may be made in three pieces, for convenience in using the bed-pan and for the prevention of bed-sores.

Before the treatment of the fracture is commenced, the surgeon must satisfy himself, by the use of the catheter and by other means, that the urethra and bladder are intact. Should these or any other of the pelvic viscera be damaged, such injuries must first receive attention.

The treatment of the fracture itself consists in adjusting the fragments, as far as possible by manipulation, applying a firm binder or many-tailed bandage round the pelvis, and fixing the knees together by a bandage (Fig. 57).

When there is displacement of fragments extension should be applied to both legs, with the limbs abducted and steadied by sand-bags.

Compound fractures, being commonly associated with extravasation of urine, are liable to infective complications. Loose fragments should be removed, as they are prone to undergo necrosis.

The patient is confined to bed for six or eight weeks, and it may be several weeks more before he is able to resume active employment.

The #acetabulum# may be fractured by force transmitted through the femur, usually from a fall on the great trochanter, less frequently from a fall on the feet or other form of violence. It may merely be fissured, or the head of the femur may be forcibly driven through its floor into the pelvic cavity, either by fracturing the bone or, in young subjects, by bursting asunder the cartilaginous junction of the constituent bones. When the femoral head penetrates into the pelvis--the central dislocation of the hip of German writers--the condition simulates a fracture of the neck of the femur, but the trochanteric region is more depressed and the trochanter lies nearer the middle line. The limb is shortened, and movements of the joint are painful and restricted, especially medial rotation. In some cases there is pain along the course of the obturator nerve.

On rectal or vaginal examination there is localised tenderness over the pelvic aspect of the acetabulum, and in some cases a convex projection, or even crepitating fragments can be detected. The diagnosis is completed by an X-ray picture.

When the head of the femur penetrates the acetabulum, reduction should be attempted by traction and manipulation. The pelvis is held rigid, and the thigh is flexed and forcibly adducted, while the medial side of the thigh rests against a firm sand-bag; the femoral head is thus lifted out of the pelvis. In a recent injury the amount of force required is relatively slight. The head is kept in its corrected position by extension.

Fracture of the upper and back part of the rim of the acetabulum may accompany or simulate dorsal dislocation of the hip. Crepitus may be present in addition to the symptoms of dislocation, and after reduction the displacement is easily reproduced. The treatment is by extension with the limb adducted.

#Fracture of Individual Bones of the Pelvis.#--Ilium.--The expanded portion of the iliac bone is often broken by direct violence, the detached fragments varying greatly in size and position (Fig. 56).

The whole or part of the crest may be separated by similar forms of violence.

When the fracture implicates the ala of the bone, it usually starts at the triangular prominence near the middle of the crest, and runs backwards or forwards, passing for a variable distance into the iliac fossa. The displaced fragment can sometimes be palpated and made to move when the muscles attached to it are relaxed. This is done by flexing the thighs and bending the body forward and towards the affected side. Pain and crepitus may be elicited on making this examination.

These fractures are treated by applying a roller bandage or broad strips of adhesive plaster over the seat of fracture, and by placing the patient in such a position as will relax the muscles attached to the displaced fragment--in the case of the iliac spine by flexing the thigh upon the pelvis; in the case of the crest or ala by raising the shoulders. Union takes place in three or four weeks.

In young persons, the anterior superior spine has been torn off and displaced downwards by powerful contraction of the sartorius muscle; and the anterior inferior spine by strong traction on the ilio-femoral or [inverted Y]-shaped ligament. These injuries are best treated by fixing the displaced fragment in position by a peg or silver wire sutures and relaxing the muscles acting on it.

Fracture of the ischium alone is rare. It results from a fall on the buttocks, the entire bone or only the tuberosity being broken. There is little or no displacement, and the diagnosis is made by external manipulation and by examination through the rectum or vagina.

A longitudinal fracture of the sacrum may implicate the posterior part of the pelvic ring, as has already been mentioned. In rare cases the lower half of the bone is broken transversely from a fall or blow, and the lower fragment is bent forward so that it projects into the pelvis and may press upon or tear the rectum, or the sacral nerves may be damaged, and partial paralysis of the lower limbs, bladder, or rectum result. These fractures are frequently comminuted and compound, and the soft parts may be so severely bruised and lacerated that sloughing follows. On rectal examination the lower segment of the bone can be felt, and on manipulating it pain and crepitus may be elicited.

Fracture of the coccyx may be due to a direct blow, or may occur during parturition. As a result of this injury the patient may have severe pain on sitting or walking, and during defecation. The loose fragment can be palpated on rectal examination. There is considerable difficulty in keeping the fragment in position, and if it projects towards the rectum it should be removed. If the lower fragment unites at an angle so as to cause pressure on the rectum, it gives rise to the symptoms of coccydynia, which may call for excision.

INJURIES IN THE REGION OF THE HIP

These include the various fractures of the upper end of the femur; dislocation and sprain of the hip-joint; and contusion of the hip.

#Surgical Anatomy.#--The strength of the hip-joint depends primarily on its osseous elements--the rounded head of the femur filling the deep socket of the acetabulum, to the bottom of which it is attached through the medium of the ligamentum teres. The edge of the acetabulum is specially strong above and behind, while at its lower margin there is a gap, bridged over by the labrum glenoidale (cotyloid ligament).

In relation to fractures of the upper end of the femur, it is to be borne in mind that as the antero-posterior diameter of the neck is less than that of the shaft, and as a considerable portion of the great trochanter lies behind the junction of the neck with the shaft, the greater part of any strain put upon the upper end of the femur is borne by the neck of the bone and not by the trochanter. The head and neck of the femur are nourished chiefly by the thick, vascular periosteum, and through certain strong fibrous bands reflected from the attachment of the capsule--the retinacular or cervical ligaments of Stanley. The integrity of these ligaments plays an important part in determining union in fractures of the neck of the femur, both by keeping the fragments in position and by maintaining the blood-supply to the short fragment. Whether it be true or not that an alteration in the angle of the femoral neck takes place with advancing years, it is generally recognised that this change is of no importance in relation to fractures in this region.

The articular capsule of the hip is of exceptional strength. It is attached above to the entire circumference of the acetabulum, and below to the neck of the femur in such a way that while the whole of the anterior and inferior aspects of the neck lies within its attachment, only the inner half of the posterior and superior aspects is intra-capsular. The capsule is augmented by several accessory bands, the most important of which is the ilio-femoral or [inverted Y]-shaped ligament of Bigelow, which passes from the anterior inferior iliac spine to the anterior inter-trochanteric line, its fasciculi being specially thick towards the upper and lower ends of this ridge. The medial limb of this ligament limits extension of the thigh, while the lateral limits eversion and adduction. The weakest part of the capsular ligament lies opposite the lower and back part of the joint.

The hip-joint is surrounded by muscles which contribute to its strength, the most important from the surgical point of view being the obturator internus, which plays an important part in certain dislocations, and the ilio-psoas, which influences the attitude of the limb in various lesions in this region.

Except in thin subjects, the constituent elements of the hip-joint cannot be palpated through the skin. A line drawn vertically downwards from the middle of Poupart's ligament passes over the centre of the joint, which in adults lies on the same level as the tip of the great trochanter. In children it is somewhat higher.

For purposes of clinical diagnosis it is necessary to locate certain bony prominences, the most important being--(1) The anterior superior iliac spine, which is most readily recognised by running the fingers along Poupart's ligament towards it. (2) The ischial tuberosity, which in the extended position of the limb is overlapped by the lower margin of the gluteus maximus muscle, and is therefore not easily located with precision. By flexing the limb and making pressure from below upwards in the gluteal fold, the smooth, rounded prominence can usually be detected. (3) The quadrilateral great trochanter is readily recognised on the lateral aspect of the hip. Its highest point or tip can best be felt by pressing over the gluteal muscles from above downwards.

Clinical Tests.--If a line is drawn from the anterior superior iliac spine to the most prominent part of the ischial tuberosity, it just touches the tip of the great trochanter. This is known as Nelaton's line (Fig. 58).

Bryant's test (Fig. 59) is applied with the patient lying on his back, and consists in dropping a perpendicular AB from the anterior superior iliac spine, and drawing a line CD from the tip of the great trochanter to intersect the perpendicular at right angles. This is done on both sides of the body, and the length of the lines CD compared. Shortening on one side indicates an upward displacement of the trochanter, lengthening a downward displacement. The third side AC of the triangle indicates the distance between the anterior spine and the tip of the trochanter.

Chiene's test, which is simpler than either of these, consists in applying a strip of lead or tape across the front of the body at the level of the anterior superior iliac spines, and another touching the tips of the two trochanters. Any want of parallelism in these lines indicates a change in the position of one or other trochanter.

FRACTURE OF THE UPPER END OF THE FEMUR

The fractures of the upper end of the femur that are liable to be confused with one another and with dislocations of the hip, include fractures of the head, the neck, the trochanters, and separation of the upper epiphyses, and fracture of the shaft just below the trochanters.

Fracture of the #head of the femur# is rare, and is usually a complication of backward dislocation of the hip. It takes the form of a split of the articular surface caused by impact against the edge of the acetabulum, and is analogous to the indentation fracture of the head of the humerus, which may accompany dislocation of the shoulder.

The #epiphysis of the head#, which lies entirely within the capsule of the joint (Fig. 60), is occasionally separated, and the symptoms closely simulate those of fracture of the narrow part of the neck. If the condition is overlooked or imperfectly treated, it may in course of time be followed by coxa vara.

FRACTURE OF THE NECK

It has long been customary to divide fractures of the neck of the femur into two groups--"intra-" and "extra-capsular"; but as in a considerable proportion of cases the line of fracture falls partly within and partly without the capsule, this classification is wanting in accuracy. It is more correct to divide these fractures into (1) those occurring through the narrow part of the neck, which are nearly always purely intra-capsular; and (2) those occurring through the base of the neck in which the line of fracture lies inside the capsule in front, but outside of it behind.

It is of considerable importance to distinguish between fractures in these two positions. The first group occurs almost exclusively in old persons as a result of slight forms of indirect violence, and it is liable, on account of the feeble vascular supply to the upper fragment, to be followed by absorption of the neck, which delays or may even entirely prevent union (Fig. 61). The second group usually occurs in robust adults, and results from severe forms of violence applied to the trochanter. In this group firm osseous union usually takes place.

#Fracture of the Narrow Part of the Neck# or #Intra-capsular Fracture#.--This fracture is most frequently met with in elderly persons, especially women, and is usually produced by comparatively slight forms of indirect violence--such, for example, as result from the foot catching on the edge of a carpet, a stumble in walking, or missing a step in going downstairs.

The line of fracture, which is usually transverse but may be oblique or irregular, lies for the most part within the capsule, and the posterior part of the neck is more comminuted than the anterior. The distal fragment, which includes the base of the neck, the trochanters, and the shaft, is usually displaced upward and rotated laterally. If the periosteum and the retinacular ligaments remain intact, displacement is prevented and union favoured.

Impaction is less common than in fracture through the base of the neck; it usually results from the patient falling on the trochanter, the distal fragment being driven as a wedge into the proximal (Fig. 62).

Clinical Features.--In non-impacted cases the limb is at once rendered useless, and the patient is unable to rise. There is pain and tenderness in the region of the hip on making the slightest movement; and a specially tender spot may be localised, indicating the seat of fracture.

On placing the pelvis as square as possible, and comparing the measurements of the limbs from the anterior superior spine to the medial malleolus, shortening of the injured limb to the extent of from 1 to 3 inches may be found. On applying Nelaton's, Bryant's, or Chiene's test, the tip of the great trochanter will be found elevated. It is also farther back and less prominent than normal.

The whole limb is usually everted to a greater or less degree, and is slightly abducted. In some cases, when the impaction is of the anterior portion of the neck, the limb is inverted. On comparing the ilio-tibial band of the fascia lata on the two sides, it is found to be relaxed on the side of the injury.

The violence being as a rule indirect, there is at first little or no discoloration in the vicinity of the hip, but this may appear a few days later.

Crepitus is not a constant sign, and should not be sought for, as the necessary manipulations are liable to disengage the fragments and to increase the deformity. For the same reason rotatory movements are to be avoided.

In all cases in which the diagnosis is uncertain, the patient should be put to bed, and treated as for a fracture. In the course of a few days it is nearly always possible to make an accurate diagnosis.

In examining an old person who has sustained an injury in the region of the hip, it should be borne in mind that the limb may be shortened and everted as a result of arthritis deformans, and that the symptoms of that disease may simulate those of fracture. In arthritis deformans, however, the ilio-tibial band of the fascia lata is not relaxed as it is in fracture.

In some cases, and particularly in those in which the periosteum of the neck and the retinacular ligaments remain intact, the shortening does not become apparent till a few days after the accident. As the other symptoms are correspondingly obscure, the condition is apt to be mistaken for a bruise. In all doubtful cases the part should be examined from day to day, and, if possible, the X-rays should be used.

In impacted cases the signs of fracture are often obscure, and the patient may even be able to walk after the accident. The skin over the trochanter is generally discoloured from bruising. Eversion is usually present, but there may be little shortening. Crepitus is absent. In old people it is never advisable to undo impaction, as the interlocking of the bones favours the occurrence of osseous union.

Prognosis.--A fracture of the neck of the femur in an old person is always attended with danger to life, a considerable proportion of the patients dying within a few weeks or months of the accident from causes associated with it. In some cases the mental and physical shock so far diminishes the vitality of the patient that death ensues within a few days. It is possible that fat embolism may account for death in some of the more rapidly fatal cases. In others, the continued dorsal position induces hypostatic congestion of the lungs, or, owing to the difficulties of nursing, bed-sores may form and death result from absorption of toxins. Frequently the prolonged confinement to bed, the continuous pain, and the natural impairment of appetite wear out the strength. In many cases the patient becomes peevish, irritable, or mentally weak.

Osseous union is the exception in intra-capsular fracture, especially when the periosteum and the retinacular ligaments have been completely torn, but in sub-periosteal and in impacted fractures it sometimes occurs. As a rule, however, the neck of the femur becomes absorbed and disappears, the head of the bone comes to lie in contact with the base of the trochanter, and a false joint forms (Fig. 64). Chronic changes of the nature of arthritis deformans may occur in and around such false joints.

When osseous union fails to take place, although the patient may eventually be able to get about, he can do so only with the aid of a stick or crutch, and as there is marked shortening, he walks with a decided limp. There is considerable antero-posterior thickening of the neck of the femur, and the femoral vessels may be pushed forward in Scarpa's triangle.

Treatment.--In treating a fracture through the narrow part of the neck, it is necessary to consider the age and general condition of the patient; whether the fracture is impacted or not; and the site of the fracture--whether in the narrow part of the neck or at its base. "The first indication is to save life, the second to get union, and the third to correct or diminish displacements" (Stimson).

In old and debilitated patients, bony or even firm fibrous union seldom takes place, and it is generally advisable to get them out of bed as speedily as possible. For the first few days the patient may be kept on his back, the limb massaged daily, and in the interval steadied by sand-bags; but on the first sign of respiratory or cardiac trouble he should be propped up in bed, and as soon as possible lifted into a chair. In all such cases care should be taken to avoid undoing impaction.

When the general condition of the patient permits of it, an attempt should be made to secure bony union.

Extension is applied by one or other of the methods described for fracture of the shaft (p. 149), so modified as to maintain the limb in the abducted position, which ensures the most accurate apposition of the fragments (Royal Whitman). This position may be maintained by a hinged long-splint, an adaptation of Thomas' hip splint. The fragments may be fixed to one another by a long steel peg introduced through the skin over the great trochanter, and passed so as to transfix them; or they may be exposed by operation and sutured together. Albe uses a bone peg.

#Fracture of the Neck of the Femur in Children.#--The use of the X-rays has shown that this fracture is comparatively common in children, as a result of a fall or a forcible twist of the leg. The fracture is most frequently of the greenstick variety; when complete, it is usually impacted. There is shortening to the extent of a half or three-quarters of an inch, a slight degree of eversion, the movements of the hip are restricted, and there is some pain. The patient is often able to move about after the accident, but walks with a limp. Unless the use of the X-rays reveals the fracture, the condition is liable to be overlooked.

When the lesion is diagnosed, the deformity should be completely corrected, any impaction that exists being undone; and the limb is put up in a wide abduction splint (p. 221) or in a plaster-of-Paris case in the position of extreme abduction.

If the condition is not recognised and treated, it is liable to be followed by the development of coxa vara (Royal Whitman) (Fig. 65).

#Fracture through the Base of the Neck.#--This fracture is usually produced by a fall on the great trochanter, although it is occasionally due to a fall on the feet or knees.

Although often spoken of as "extra-capsular," the line of fracture is generally partly within and partly without the capsule. The fracture usually lies close to the junction of the neck with the shaft, and in the great majority of cases is accompanied by breaking of one or both trochanters. This is due to the neck being driven as a wedge into the trochanters, splitting them up. When the fragments remain interlocked, the fracture is of the impacted variety (Fig. 67).

Clinical Features.--Although this fracture is commonly met with in strong adults, it may occur in the aged.

The lateral aspect of the hip shows marks of bruising, and there is severe pain and a considerable degree of shock. The limb lies helpless; there is generally marked eversion, with shortening, which, in non-impacted cases, may amount to 1-1/2 or 2 inches, and is evident immediately after the accident; it is due to the distal fragment being drawn up by the muscles inserted into the great trochanter and upper end of the shaft. In a limited number of cases the distal fragment lies in front of the proximal, and there is inversion of the limb.

On applying the various tests, the great trochanter is found to be displaced upwards, there is some antero-posterior broadening of the trochanteric region, and the ilio-tibial band is relaxed. On pressing the fingers into the lateral part of Scarpa's triangle, a mass consisting of the bony fragments may be felt, and is tender on pressure. Unnatural mobility with crepitus may be elicited.

In the impacted variety, the shortening seldom exceeds one inch; the eversion is less marked; there is some power of voluntary movement; and crepitus is absent. The broadening of the trochanteric region is greater, and the great trochanter is approximated to the acetabulum.

Prognosis.--The risks to life in the aged are similar to those of intra-capsular fracture. In youths and healthy adults the chief danger is that the limb may be shortened and its function thereby impaired.

As the periosteum and retinacular ligaments which transmit the blood vessels to the proximal fragments are intact, bony union is the rule. There is always, however, considerable thickening in the region of the trochanter due to displaced fragments and callus, and in a certain number of cases, even with the greatest care in treatment, there is a varying degree of shortening and eversion of the limb. In cases in which the distal fragment lies in front of the proximal there is permanent inversion.

Treatment.--As this fracture usually occurs in robust patients, there is no danger from prolonged confinement to bed; and as union without deformity can be attained in no other way, this is always advisable. When the shortening and eversion are excessive, they should be completely corrected under anaesthesia before the retentive apparatus is applied, any impaction that exists being undone. When the deformity resulting from impaction is slight, however, it is best to leave it, as it facilitates speedy and firm union.

Extension is obtained by the same appliances as are used in fracture of the shaft, and the limb should be kept in the abducted position.

Fracture of the #greater trochanter# occurring apart from fracture of the neck usually results from direct violence, but may be due to muscular action. The trochanter is displaced by the gluteal muscles, causing broadening of the lateral aspect of the hip. In young persons the epiphysis of the great trochanter may be separated, but this is rare. The treatment consists in retaining the fragments in position by keeping the limb abducted between sand-bags, or by pegs driven in through the skin.

#Fracture immediately below the lesser trochanter# may be produced by direct or by indirect violence, and the displacement depends largely on whether the line of fracture is transverse or oblique. The proximal fragment is kept tilted forward, rotated laterally, and abducted by the ilio-psoas muscle and the lateral rotators inserted in the region of the great trochanter. The lower fragment passes upward, and is rotated laterally by the weight of the limb; the displacement is aggravated by the contraction of the flexor and adductor muscles. The tilting of the proximal fragment may be increased by the displaced distal fragment pushing it forward.

On account of the difficulty of controlling the short proximal fragment, union is liable to take place with considerable shortening and deformity (Fig. 69).

Treatment.--When it is found, under an anaesthetic, that the displacement can be completely reduced, and does not tend to recur, this fracture is treated on the same lines as fracture of the shaft of the bone.

In cases in which the proximal fragment cannot be brought into line with the distal one, however, it is necessary to flex, evert, and abduct the thigh in order to get the fragments into apposition and into line. A Hodgen's splint (Fig. 77) is applied with the highest sling under the upper end of the lower fragment and with sufficient extension to correct overriding. The upper end is then strongly lifted by a counter-weight of about 15 lbs. This secures apposition of the fragments with slight forward angulation at the seat of fracture. By the end of a month sufficient callus has formed to prevent re-displacement, and if the counter-weight is gradually diminished the two fragments sag back together into a normal alignment (J. N. J. Hartley). A double-inclined plane (Fig. 70), with extension applied in the axis of the thigh, gives satisfactory results.

DISLOCATION OF THE HIP

It is unnecessary for our present purpose to attempt a comprehensive classification of the numerous varieties of dislocation that have been met with at the hip-joint. It will suffice if we divide them into those in which the head of the femur passes backward, and comes to rest on the dorsum ilii, or in the vicinity of the great sciatic notch; and those in which it passes forward and comes to rest in the obturator foramen, or on the pubes (Fig. 71).

The backward are much more common than the forward dislocations, in contrast to what obtains at the shoulder, where the forward varieties predominate.

On account of the great strength of the hip-joint, dislocation is by no means a common injury. It occurs most frequently in strong adults after the epiphyses have ossified, and before the bones have commenced to become brittle; and it is much more common in men than in women. It is invariably the result of severe violence, the limb at the moment being in such a position that the ligaments are on the stretch and the muscles taken at a disadvantage. The head of the femur usually leaves the joint at the lower and back part, where the socket is most shallow and the ligaments weakest. The ligamentum teres is almost always torn from its femoral attachment, and one or more of the muscles inserted in the region of the trochanters may be ruptured. The [inverted Y]-shaped ligament, on the other hand, is seldom torn, and so long as it remains intact the dislocation belongs to one or other of the types above named. All atypical dislocations, such as the supra-cotyloid, infra-cotyloid, ilio-pectineal, are due to rupture of some part of the [inverted Y]-ligament, and are so rare as not to call for individual description. The central dislocation of German authors, in which the head is driven through the floor of the acetabulum, is described on page 126.

Like other dislocations, those of the hip may be complicated by laceration of muscles, blood vessels, or nerves, or by fracture of one or other of the bones in the vicinity.

#Dislocation on to the Dorsum Ilii.#--This, the commonest form of dislocation of the hip, is usually the result of the patient falling from a height, or receiving a heavy weight on the back while stooping forward with the thigh flexed, slightly adducted, and rotated medially. It is also said to have occurred from muscular action. The shaft of the femur acts as the long limb of a lever of which the neck is the short limb, the femoral attachment of the [inverted Y]-ligament forming the fulcrum. The head, thus brought to bear upon the lower and back part of the capsule, tears it and leaves the socket, passing upwards and coming to rest on the dorsum of the ilium, above and anterior to the tendon of the obturator internus (Fig. 73). The articular surface is directed backward, while the trochanter looks forward.

Clinical Features.--The affected limb is flexed, adducted, and inverted, so that the knee crosses the lower third of the opposite thigh, and the ball of the great toe lies on the dorsum of the sound foot. There is shortening to the extent of from 1-1/2 to 2 inches, the trochanter being displaced above Nelaton's line, and lying nearer to the anterior superior iliac spine than on the normal side. The patient is unable to move the limb or to bear weight upon it; abduction and lateral rotation are specially painful; and traction fails to restore the limb to its proper length. On making these attempts a characteristic elastic resistance is felt.

The head of the femur in its new position may sometimes be felt through the fibres of the gluteus maximus, but swelling of the soft parts often obscures this sign. The normal depression behind the great trochanter is lost, the gluteal fold is raised, and there is often a degree of lordosis which compensates for the flexion. The fingers can be pressed more deeply into Scarpa's triangle on the dislocated than on the normal side--a point in which this injury differs from fracture of the base of the neck of the femur.

In a certain number of cases the lateral limb of the [inverted Y]-ligament is ruptured and the limb is everted--dorsal dislocation with eversion.

#Dislocation into the Vicinity of the Great Sciatic Notch#, or "dislocation below the tendon."--This variety of backward dislocation is less common than that on to the dorsum, although produced in the same way. The head of the femur passes beneath the obturator internus, and this tendon, catching on its neck, checks its upward movement (Fig. 74).

The clinical features are the same as those of the dorsal variety, but, on the whole, are less marked.

Differential Diagnosis.--Backward dislocation of the hip is usually easily recognised. When dislocation below the tendon occurs in a stout person, however, it is liable to be overlooked on account of the difficulty of feeling the displaced bone, and of the comparatively slight amount of deformity present. The nature of the accident, the absence of broadening of the trochanter, and the adduction and inversion of the limb are usually sufficient to prevent a dislocation being mistaken for an impacted extra-capsular fracture.

#Dislocation into the Obturator Foramen# (Fig. 71).--This dislocation is produced by great force applied from behind while the thigh is flexed and abducted, as when a weight falls on the back of a man stooping forward with the legs wide apart. It may also result from violent abduction by wide separation of the thighs.

The capsule gives way at its medial and lower part, and the head of the femur comes to rest on the surface of the external obturator muscle, its articular surface looking forward, while the trochanter looks backward.

Clinical Features.--In the standing position the thigh is slightly flexed and abducted, with the foot pointing directly forward or a little outward. The body is bent forward to relax the ilio-psoas muscle and the [inverted Y]-ligament, the foot is advanced and the heel drawn up. It is not uncommon for the patient to be able to walk after the accident, and only to seek advice some time later on account of inability to adduct and extend the limb. There is apparent lengthening of the limb due to tilting of the pelvis downward on the affected side. The hip is flattened, the trochanter less prominent than usual, and the head of the bone may sometimes be felt in its abnormal position.

#Dislocation on to the pubes# is a further degree of the obturator form (Fig. 71). It is usually produced by forcible hyper-extension and lateral rotation of the hip, such as occurs when the body is bent back while the thigh remains fixed.

The capsule is torn farther forward than in the other varieties, and the head rests on the horizontal ramus of the pubes against the ilio-pectineal line.

Clinical Features.--There is marked eversion, flexion, and abduction, but the shortening is inconsiderable. The ilio-psoas and [inverted Y]-ligament are tense. The head of the femur may be felt in the groin, with the femoral vessels over, or to one or other side of it. There is sometimes pain and numbness in the distribution of the femoral (anterior crural) nerve. The prominence of the great trochanter is lost.

#Treatment of Dislocation of the Hip.#--For the reduction of a dislocation of the hip complete anaesthesia is necessary, and the patient should be placed on a firm mattress on the floor to give the surgeon the best possible purchase upon the limb. The surgeon grasps the ankle with one hand, while the other is placed behind the head of the tibia, the leg being held at right angles to the thigh. An assistant meantime steadies the pelvis by making firm pressure over the iliac crests.

As the chief obstacle to reduction is the tension of the ilio-femoral ligament, the first indication is to relax this structure by flexing the hip to its fullest extent.

In the backward varieties (dorsal and sciatic) the [inverted Y]-ligament is relaxed by flexing the thigh upon the pelvis in the position of adduction. The thigh is then fully abducted, to cause the head of the bone to retrace its steps forwards towards the rent in the capsule; and at the same time rotated laterally to relax the rotator muscles. This combined movement tends also to open up the rent in the capsule. Finally, the limb is quickly extended to cause the head to enter the socket. This object is often aided by making vertical traction or lifting movements on the abducted and laterally rotated limb before extending.

For the reduction of the forward varieties (obturator and pubic), the thigh is first fully flexed on the pelvis, but in the abducted position. The limb is then strongly rotated medially and abducted, and finally extended. Lifting movements may be found useful in these cases also.

All methods of reduction by forcible traction on the extended limb are to be avoided, as they fail to meet the primary indication of relaxing the [inverted Y]-ligament.

After reduction, the limb is steadied by sand-bags; massage is carried out from the first, and movement after a few days. The range of movement is gradually increased, and the patient is allowed to use the limb with caution in from two to three weeks.

When the rim of the acetabulum has been fractured, the patient must be confined to bed with extension for six to eight weeks, to avoid the risk of re-dislocation.

Changes of the nature of chronic arthritis are liable to occur in and around the joint in old and rheumatic subjects; and atrophy or paralysis of muscles may follow, if their nerves are implicated.

#Old-standing Dislocation.#--It is impossible to lay down any time-limit for attempting reduction in old-standing dislocations of the hip. Manipulation may succeed in cases of some months' standing, and may fail when the bone has been out only a few weeks. In certain cases, even after reduction has been effected, there is a marked tendency to re-displacement. In any case, the attempt does good by breaking down adhesions, provided no undue force is employed such as may damage the sciatic nerve or vessels, or fracture the neck of the femur, and success may attend on a second or even a third attempt at intervals of from three to five days. If manipulation fails, and if the deformity is great and the usefulness of the limb seriously impaired, an attempt may be made to effect reduction by operation; the operation, however, is one of considerable difficulty, and in the event of failure the head of the bone should be excised. If the head has formed a new socket for itself and there is a fairly useful joint, the condition should be left alone.

Congenital dislocation of the hip is described with Deformities of the Extremities.

#Sprain# of the hip is comparatively rare. It results from milder degrees of the same forms of violence as produce dislocation. The ligaments are stretched or partly torn, and there is effusion of fluid into the joint. Pressure over the joint elicits tenderness; and the limb assumes the position of slight flexion, abduction, and lateral rotation, but there is no alteration in length. Such injuries, unless carefully treated by massage and movement from the outset, are apt to be followed by the formation of adhesions, resulting in stiffness of the joint.

#Contusion# in this region, on the other hand, is not uncommon. It is produced by a fall on the trochanter, and gives rise to symptoms which simulate to some extent those of fracture of the neck. The limb lies in the position of slight flexion, but the bony points retain their normal relationship to one another, and there is no shortening. The swelling and tenderness often prevent a thorough examination being made, and when any doubt remains as to the diagnosis, the patient should be kept in bed till the doubt is cleared up by the use of the X-rays. If the bone has been broken, this will reveal itself in the course of a few days by the occurrence of shortening and other evidence of fracture.

In elderly patients, contusion of the hip may be followed by changes in the joint of the nature of arthritis deformans; and it has been stated, although proof is wanting, that absorption of the neck of the femur sometimes occurs. These injuries are treated by rest in bed, massage, and the other measures already described as applicable to sprains and contusions.

FRACTURE OF THE SHAFT OF THE FEMUR

This group includes all fractures between that immediately below the lesser trochanter and the supra-condylar fracture.

In adults, when due to direct violence, the fracture is usually transverse, and may be attended with comparatively little displacement. Indirect violence, on the other hand, usually produces an oblique fracture, which is frequently comminuted and often compound. The break is most commonly situated a little above the middle of the shaft, the obliquity being downward, forward, and medially, and of such a nature that the fragments tend to override one another (Fig. 75). The most serious forms are those associated with gun-shot wounds.

The direction and nature of the displacement depend more upon the fracturing force, the weight of the lower part of the limb, and the action of the muscles attached to the respective fragments, than upon the direction of the obliquity. As a rule, the proximal fragment passes forward and laterally, and is maintained in this position by the ilio-psoas and glutei muscles, while the distal fragment is displaced upward and medially and is rotated outward by the combined action of the weight of the limb, the longitudinal muscles, and the adductors.

Clinical Features.--The limb is at once rendered useless, and there is great swelling from effusion of blood in the region of the fracture. This, together with the muscularity of the part, often renders an accurate diagnosis as to the site and direction of the fracture exceedingly difficult. The shortening varies from 1/2 inch to 3 or 4 inches--averaging about 1 inch in adults--and eversion is always marked. Mobility may be detected and crepitus elicited without disturbing the patient, by placing the hand under the seat of fracture and gently attempting to raise the limb; or by fixing the proximal fragment by one hand placed in front of it while the distal part of the limb is carefully lifted. It will be found that the great trochanter does not rotate with the lower segment of the femur. These tests must be employed with great caution lest the deformity be increased or the fracture rendered compound.

In many fractures of the thigh, and especially in those produced by indirect violence, the knee is sprained, and there is a considerable effusion into the joint, and this may lead to stiffness unless massage is employed from the outset.

Treatment.--Fracture of the shaft of the femur is one of the most difficult fractures in the body to treat successfully. In cases of oblique fracture, the patient should be warned that shortening to the extent of from 3/4 to 1 inch is liable to result, however carefully the treatment may be carried out. This does not necessarily imply a permanent limp, as by tilting the pelvis he may be enabled to walk quite well; if this is not sufficient to equalise the length of the limbs, the sole of the boot may be raised. A general anaesthetic is necessary to ensure accurate reduction, and extension must be applied to maintain the fragments in apposition and prevent shortening. The splint which has been found most generally useful is the Thomas' knee splint, the ring of which rests against the ischial tuberosity. To admit of flexion at the knee the Thomas' splint should have a hinged attachment on which the leg is supported. This leaves the knee free and allows of movement being made to prevent stiffness. The limb is suspended by broad strips of flannel or linen, fixed to the side bars of the splint by means of safety pins or strong spring paper clips.

In simple fractures extension may be obtained by means of broad strips of adhesive plaster applied to each side of the thigh and reaching well above its middle. The plaster is secured by a bandage, and to its lower ends are attached broad tapes which are buckled to a stirrup through which traction is made by means of a cord passing over a pulley fixed to an upright at the foot of the bed.

The lower end of the splint is suspended, and the counter-extension is obtained by pressing the ring against the ischial tuberosity. To prevent the ring overriding the tuberosity and pressing on the soft tissues of the buttock, it is slung by the rope to a cross-bar above the bed, e.g. the Balkan frame (Fig. 81).

In compound fractures the presence of a wound may prevent adhesive plaster being used, and it is necessary to take the extension directly through the bone. A posterior gutter splint is applied to prevent sagging. After pulling the skin upward, a small incision is made over the upper expanded border of each condyle, and the points of an ice-tong calliper are made to grip the bone without penetrating into the cancellous tissue. A cord attached to the handles of the calliper passes over a pulley and supports the weight necessary to give the desired amount of traction (Fig. 81).

An alternative method of exerting traction directly through the bone is by means of Steinmann's apparatus (Fig. 76). In a moderately muscular adult, a weight of from 12 to 15 pounds by means of strips of plaster applied to the skin, or 10 to 25 pounds by direct traction on the bone, should be applied in the first instance. The correct weight to employ is that which maintains the length of the limb at its normal, and is therefore liable to revision from time to time.

Hodgen's splint is a comfortable and efficient means of treating these fractures, as it allows the patient a certain amount of movement, admits of the part being massaged, and facilitates nursing.

It consists of a wire frame (Fig. 77) to one side of which a series of strips of flannel about 4 inches wide are attached. Extension strapping is first applied, and then the frame, which extends from the level of Poupart's ligament to well beyond the sole, is placed over the front of the limb, and the loose ends of the flannel strips brought round behind the limb, and fixed to the other side of the frame, convert it into a sling. The tapes attached to the extension strapping are now tied to the end of the frame. By suspending the limb in this splint by means of cords passing obliquely over a pulley attached to an upright at the foot of the bed, the weight of the limb is made to act as the extending force.

The retentive apparatus should be worn for from six to eight weeks, after which the patient is allowed up with crutches, which he usually requires to use for three or four weeks longer, before he can bear his weight upon the limb. The old dictum of Nelaton, that the treatment of fracture of the thigh should last for a hundred days, is a safe working-rule. In fractures of the shaft an ordinary Thomas' knee splint, or a "walking calliper splint" which is fixed to the heel of the boot, may be worn when the patient gets up.

Union may be exceedingly slow in fracture of the femur, and may even be delayed for months. Mal-union sometimes occurs, the fracture uniting with an angular deformity outward and forward.

Re-fracture is liable to occur if the patient falls or twists the limb within a few months of the original injury. It has happened not infrequently just after the retentive apparatus has been removed from the nurse raising the limb by the foot in order to wash it.

Liston's long splint is only employed as a temporary expedient for immobilising the fragments during transport; a Thomas' splint, if available, is better for this purpose.

Operative treatment is sometimes called for when simpler measures fail to reduce the displacement, and in cases of un-united fracture or of vicious union. The incision, which must be free, is preferably placed in the line of the lateral intermuscular septum; the periosteum is interfered with as little as possible. The application of extension by the calliper method is often of great service, during the operation, in enabling the operator to get the fragments into position; sometimes no fixation is required, but, if necessary, recourse is had to plating or pegging, or an intra-medullary pin. The extension apparatus is retained for three or four weeks. The after-treatment is carried out on the same lines as for simple fracture, but the retentive apparatus must be worn for a considerably longer period.

#Fracture of the Femur in Children.#--In children, especially below the age of ten, this fracture is quite common. It is often of the greenstick variety, or, if complete, is transverse and sub-periosteal, and as it is accompanied by few symptoms and but little deformity, is liable to be overlooked.

When there is displacement, the deformity is similar to that in adults, and the treatment is carried out on the same lines.

In young children the nursing is greatly facilitated by applying vertical extension to one or both lower extremities (Fig. 79). If the fracture is transverse and shows little tendency to displacement, the local Gooch splints may be dispensed with; in any case, massage should be employed from the first.

The patient may be allowed out of bed in from three to four weeks, wearing a retentive apparatus.

The shaft of the femur is sometimes fractured during delivery, particularly in breech cases. The simplest and most efficient means of controlling the fracture is by extension strapping fixed to the lower end of a Thomas' knee splint.

VII. INJURIES IN THE REGION OF THE KNEE AND LEG

Surgical Anatomy--FRACTURE OF LOWER END OF FEMUR: Supra-condylar; T- or Y-shaped; Separation of epiphysis; Either condyle--FRACTURE OF UPPER END OF TIBIA: Of head; Separation of epiphysis; Avulsion of tubercle--DISLOCATIONS OF KNEE: Dislocations of superior tibio-fibular joint--INTERNAL DERANGEMENTS OF KNEE--INJURIES OF PATELLA: Fractures; Dislocations--INJURIES OF LEG: Fracture of both bones; Fracture of tibia alone; Fracture of fibula alone.

INJURIES IN THE REGION OF THE KNEE

These include the supra-condylar fracture of the femur, the T- or Y-shaped fracture opening into the joint, separation of the lower femoral epiphysis; fracture of the head of the tibia, and separation of its upper epiphysis; the various sprains and dislocations of the knee, as well as its internal derangements; and fractures and dislocations of the patella.

#Surgical Anatomy.#--Of the two epicondyles the medial is the more prominent and palpable. The adductor tubercle, which is situated on the upper and back part of the medial epicondyle, gives attachment to the round tendon of the adductor magnus, and marks the level of the epiphysial line and of the upper limit of the trochlear surface of the femur. Between the medial condyle of the femur and the medial condyle (tuberosity) of the tibia, when the limb is in the flexed position, the line of the joint can be recognised as a groove or cleft, and this is made use of in measuring the length of the tibia. The lateral condyle (tuberosity) of the tibia can also be palpated, and must not be mistaken for the head of the fibula, which lies farther back and at a slightly lower level, and can readily be identified by tracing to it the tendon of the biceps. The tuberosity of the tibia, into which the quadriceps extensor tendon is inserted, lies on the same level as the head of the fibula. In the extended position of the limb, the patella is loose and movable on the front of the trochlear surface of the femur, while in the flexed position it sinks between the condyles, resting chiefly on the lateral one and becoming fixed.

The popliteal artery and vein and the tibial (internal popliteal) nerve lie in close relation to the posterior aspect of the joint; and the common peroneal (external popliteal) nerve passes behind and to the medial side of the biceps tendon.

The knee is an example of a joint which depends for its strength chiefly on its ligaments. Not only are the tibial and fibular collateral (external and internal lateral) ligaments and the posterior part of the capsular ligament particularly strong, but the cruciate ligaments and the menisci (semilunar cartilages) inside the cavity of the joint further add to its stability. The powerful tendon of the quadriceps extensor muscle, in which the patella is developed as a sesamoid bone, protects and strengthens the front of the joint and functionates as the anterior ligament of the joint. In the attitude of complete extension in which the joint is locked, no demand is made on the quadriceps apparatus; with the commencement of flexion, the stability of the joint, and the weight-bearing capacity of the limb as a whole, depend largely on the controlling influence of the quadriceps muscle; this becomes evident on going down an incline and more markedly on going down stairs. Hence it is, that in recurrent sprains of the knee, including under this term the various forms of internal derangement of the joint, the wasting with loss of tone of the quadriceps is an important factor in aggravating the disability of the limb and in retarding and preventing recovery. In the treatment of recurrent sprains of the knee, therefore, special attention must be directed towards the wasting of the quadriceps by means of massage and appropriate exercises.

The synovial cavity extends from the level of the head of the tibia to an inch or more above the trochlear surface of the femur, passing slightly higher on the medial aspect of the joint than on the lateral (Fig. 80). The large bursa between the quadriceps muscle and the femur (sub-crural bursa) generally communicates with the cavity of the joint. The synovial cavity of the superior tibio-fibular articulation is usually distinct from that of the knee-joint, but may communicate with it through the popliteal bursa.

A large bursa (pre-patellar) lies over the lower part of the patella and upper part of the ligamentum patellae; and a smaller one separates the ligamentum patellae from the tuberosity of the tibia. Several important bursae are found in the popliteal space, one of which--the semi-membranosus bursa--sometimes communicates with the knee-joint.

FRACTURE OF THE LOWER END OF THE FEMUR

Fractures involving the lower end of the femur, especially the supra-condylar and T-shaped fractures, are to be looked upon as serious injuries, on account of the difficulties attending their treatment, and the risk of damage to the popliteal vessels and of impairment of the usefulness of the knee-joint.

#Supra-condylar# fracture is usually the result of a fall on the feet or knees, or of direct violence, and is most common in adult males. The line of fracture is generally irregularly transverse, or it may be slightly oblique from above downwards and forwards, so that the proximal fragment passes forward towards the patella, while the distal is rotated backward on its transverse axis by the gastrocnemius muscle.

Clinical features.--Soon after the accident a copious effusion of blood and synovia takes place into the cavity of the knee-joint, adding to the swelling caused by the displaced bones, and rendering it difficult to recognise the precise nature of the lesion. As it is important to make an accurate diagnosis, the X-rays should be employed if possible, and a general anaesthetic should be given when necessary.

The proximal end of the distal fragment is usually palpable in the popliteal space, while the proximal fragment is unduly prominent in front. By flexing the knee the fragments may be brought into apposition and crepitus elicited. In oblique fractures, the pointed lower end of the proximal fragment may transfix the quadriceps extensor muscle and may be felt under the skin, or it may perforate the skin and thus render the fracture compound. It should be disengaged by fully flexing and making traction on the knee. The thigh is shortened to the extent of from 1/2 to 1 inch.

The popliteal vessels lie so close to the bone that they are liable to be torn by the displaced distal fragment, giving rise to the usual signs of ruptured artery. Sometimes, owing to the feeble state of the circulation from shock, the bleeding does not take place at the time of the accident, but ensues some hours later. The vessels may merely be pressed upon by the displaced bone, but the nutrition of the limb beyond is endangered and gangrene may ensue if early reduction be not effected.

Treatment.--The small size of the distal fragment, its depth from the surface, and the accompanying effusion into and around the joint, render its control difficult. In the majority of cases the two fragments can only be brought into apposition when the knee is flexed on the thigh and the thigh on the pelvis, and it is almost always necessary to carry out the reduction under anaesthesia.

In the few cases in which the fragments can be accurately approximated in the extended position of the limb, retention may be effected by means of a box splint reaching well up the thigh (p. 180).

In the majority, however, flexion is necessary, and a Thomas' knee splint with flexion attachment bent to an angle of 30 deg. (Fig. 81) and extension by means of ice-tong callipers secures the best apposition. If this apparatus is not available the limb must be fixed on a double-inclined plane, so constructed that the angle of flexion can be adjusted to meet the requirements of the individual case (Fig. 70).

Hodgen's splint, bent nearly to a right angle, may also be employed.

A careful watch must be kept on the circulation of the limb during the first few days, lest it be interfered with by the pressure of the apparatus.

In a considerable number of cases these means of retaining the fragments in apposition prove ineffectual, and it is necessary to have recourse to operative measures for mechanical fixation. Division of the tendo calcaneus (Achillis) is not to be recommended as a means of combating the backward tilting of the distal fragment.

In all cases the retentive apparatus must be worn for about four weeks, after which the limb is flexed over a pillow; but massage and movement should be employed as soon as possible, as persistent stiffness of the knee is one of the most troublesome sequelae of these injuries.

Compound and complicated fractures are dealt with on the general principles governing the treatment of such injuries. Amputation may become necessary should gangrene ensue from injury to the popliteal vessels, or if infective complications threaten the life of the patient.

Operative interference may be called for to rectify deformities resulting from mal-union.

The #T- or Y-shaped fracture# is, as a rule, produced by direct violence, the force first breaking the bone above the condyles and then causing the proximal fragment to penetrate the distal and split it up into two or more pieces. The fracture implicates the articular surface, and the main fissure is usually through the inter-condylar notch; the lower end of the bone is sometimes severely comminuted.

The knee is broadened, and pain and crepitus are readily elicited on moving the condyles upon one another or on pressing them together. On moving the patella transversely, it may be felt to hitch against the edge of one or other of the fragments. The shortening may amount to one or two inches.

The treatment is carried out on the same lines as in supra-condylar fracture, but as the joint is implicated there is greater risk of subsequent impairment of its functions.

#Separation of the lower epiphysis# is a comparatively common injury. It is seldom pure, a portion of the diaphysis usually being broken off and remaining attached to the epiphysis. It occurs usually in boys between the ages of thirteen and eighteen, from severe violence such as results from the limb being caught between the spokes of a revolving wheel, or from hyper-extension of the knee. It has also been produced in attempting forcibly to rectify knock-knee and other deformities in this region, and in making traction on the limb to correct deformities following recovery from tuberculous disease of the knee. As a rule, there is little displacement of the loose epiphysis, but it may pass in any direction, forward being much the most common (Fig. 82), and when displaced it is difficult to reduce and to maintain in position. The age of the patient, the mode of injury, the finding of the smooth broad end of the diaphysis in the popliteal space or on the front of the thigh, according to the displacement, usually serve to establish the diagnosis. The X-rays afford reliable information as to the position of the fragments. Pressure on the popliteal vessels is a serious aggravation of the injury, and adds greatly to the difficulties of treatment.

The treatment is the same as for supra-condylar fracture, but, owing to the serious disability that follows on incomplete reduction, it may be necessary to have recourse to operation. After an epiphysial separation, the growth of the limb is sometimes, although not always, interfered with.

#Either condyle# may be broken off without the continuity of the shaft being interrupted, by a direct blow or fall on the knee, or by violent twisting of the leg. The separated condyle may not be displaced, or it may be pushed upwards or rotated on its transverse axis.

There is broadening of the knee but no shortening of the thigh, and the ecchymosis, crepitus, and pain are localised to the affected side of the joint; the knee can usually be moved towards the injured side in a way that is characteristic. If allowed to unite with the condyle displaced, the articular surface is oblique and bow- or knock-knee results.

If there is difficulty in replacing the broken condyle and maintaining it in position, it may be fixed by means of a steel nail inserted through the skin.

FRACTURE OF THE UPPER END OF THE TIBIA

#Fracture of the head of the tibia# is a comparatively rare injury. It may result from a direct blow, such as the kick of a horse, or from indirect forms of violence, and the line of fracture may be transverse or oblique. Occasionally the distal fragment is impacted into the proximal and comminutes it. In oblique fracture a gliding displacement is liable to occur and cause bow- or knock-knee. Transverse fracture of the head of the fibula sometimes accompanies fracture of the head of the tibia, and there is always considerable effusion into the knee-joint. One or other of the condyles may be chipped off by forcible adduction or abduction at the knee.

The ordinary clinical features of fracture are well marked, and the diagnosis is easy. From some unexplained cause this fracture may take a long time, sometimes several months, to consolidate.

#Separation of the upper epiphysis# of the tibia, which includes the tongue-like process for the tubercle and the facet for the fibula, is also rare. It usually occurs between the ages of three and nine. The displacement of the epiphysis is almost always forward or lateral, and is accompanied by the usual signs of such lesions. The growth of the limb is sometimes arrested, and shortening and angular deformity may result.

Treatment.--After reduction under an anaesthetic these fractures are usually satisfactorily treated in a box splint (Fig. 91), carried sufficiently high to control the knee-joint. When the head of the tibia is comminuted or split obliquely, weight-extension--direct from the bone, the ice-tong callipers grasping the malleoli or the calcaneus--may be used. Massage and movement are employed from the outset.

Avulsion of the #tuberosity of the tibia# occasionally occurs in youths, from violent contraction of the quadriceps--as in jumping. The limb is at once rendered powerless; the osseous nodule can be felt, and on moving it crepitus is elicited.

This is best treated by pegging the tuberosity in position, and fixing the extended limb on an inclined plane to relax the quadriceps muscle.

In young, athletic subjects, the tongue-like process of the epiphysis (Fig. 85), into which the ligamentum patellae is inserted, may be partly or completely torn away, giving rise to localised swelling, and pain which is aggravated by any muscular effort--Schlatter's disease or "rugby knee." It has been frequently observed in cadets as a result of kneeling at drill. The treatment consists in rest and massage, but the symptoms are slow to disappear.

The condition is liable to be mistaken for some chronic inflammatory condition of the bone, such as tubercle, unless an X-ray examination is made.

The #upper end of the fibula# is seldom broken alone. The chief clinical interest of this fracture lies in the fact that it may implicate the common peroneal nerve, and cause drop-foot.

DISLOCATIONS OF THE KNEE

Dislocation of the knee is a rare injury, and occurs as a result of extreme degrees of violence, especially of a wrenching or twisting character.

Rupture of the popliteal vessels, or pressure exerted on them by the displaced bones, may lead to gangrene of the limb, and necessitate amputation. The common peroneal nerve is frequently damaged. When the lesion is compound, also, amputation may become necessary on account of infective complications.

The varieties of dislocation are named in terms of the direction in which the tibia passes: forward, backward, medial, and lateral.

#Dislocation forward# is the most common variety, and results from sudden hyper-extension of the knee, tearing the collateral and cruciate ligaments. The leg remains fully extended, and lies on a plane anterior to that of the thigh. The condyles of the femur are palpable posteriorly, and the skin is tightly stretched over them, or may even be torn, rendering the dislocation compound. The patella is projected forward, the quadriceps tendon is lax, and the skin over it is thrown into transverse folds. The limb is shortened by two or three inches.

#Dislocation backward# is usually due to a direct blow driving one of the bones past the other. The leg remains hyper-extended, the head of the tibia occupies the popliteal space, while the lower end of the femur projects forward with the patella either in front or to one side of it.

The #medial and lateral dislocations# are generally incomplete, and are liable to be mistaken for separation of the lower epiphysis of the femur. When the tibia passes medially, the lateral condyle of the femur forms a prominence, and there is a depression below it. The head of the tibia projects on the medial side, and the medial condyle is in a depression.

When the tibia is displaced laterally, the relative position of the prominences and depressions is reversed.

Treatment.--In dislocations of the knee no special manipulations are necessary to restore the displaced bone to its place, and reduction is not accompanied by a distinct snap.

If, while the patient is fully anaesthetised, traction is made on the leg and counter-traction on the thigh with the knee in the flexed position, the bones can usually be replaced by manipulation.

After reduction has been effected, in antero-posterior dislocations, the limb should be flexed and placed on a pillow, massage and movement being employed from the first. The patient is usually able to walk within a month.

In medial and lateral dislocations there is at first considerable tendency to re-displacement, and it is therefore necessary to secure the joint in a box splint, specially padded, for about fourteen days, massage being employed from the first, and movement commenced when the splint is removed. It is usually about six weeks before the patient can use the limb with freedom.

In compound dislocations, and in those complicated by injury to the popliteal vessels, the question of amputation may have to be considered.

#Dislocation of the Superior Tibio-Fibular Articulation.#--This joint may be dislocated by twisting forms of violence applied to the foot or leg, or by forcible contraction of the biceps muscle. The displacement may be forward or backward, and the head of the fibula can be felt in its new position with the prominent tendon of the biceps attached to it. The movements of the knee are quite free, but the patient is unable to walk on account of pain. Reduction and retention are, as a rule, easy, and the ultimate result satisfactory. We have frequently met with this injury accompanying compound fractures of both bones of the leg resulting from railway and similar accidents.

By applying direct pressure over the displaced bone with the knee flexed, the dislocation is easily reduced. It is kept in position by a firm bandage or a light rigid splint.

#Total Dislocation of Fibula.#--Very rarely the fibula is separated from the tibia at both ends and displaced upwards. Bennett of Dublin has pointed out that in some persons the upper end of the fibula does not reach the facet on the tibia--a condition which might be mistaken for a dislocation.

INJURIES OF THE SEMILUNAR MENISCI

The semilunar menisci are two crescentic plates of white fibro-cartilage, which lie upon the upper end of the tibia, and serve to deepen the articular surface for the condyles of the femur. Each cartilage is firmly attached to the tibia by its anterior and posterior ends, and, through the medium of the coronary ligaments, is loosely attached along its peripheral, convex edge to the head of the tibia, the medial meniscus being connected also to the capsular ligament of the joint. The tendon of the popliteus muscle intervenes between the lateral meniscus and the capsule. The central, concave edges of the menisci are thin and unattached.

The cartilages enjoy a limited range of movement within the joint, passing backwards during flexion, and forwards again when the limb is extended; under normal conditions the lateral moves more freely than the medial. While the limb is partly flexed, a slight degree of rotation of the leg at the knee is possible, and during this movement the cartilages glide from side to side, and the tibia rotates below them.

Any abnormal laxity of the ligaments of the joint may render the cartilages unduly mobile, so that they are liable to be displaced from comparatively slight causes, and when so displaced it is not uncommon for one or other to be torn by being nipped between the femur and the tibia. It is convenient to consider these "internal derangements of the knee-joint" separately, according to whether the meniscus is merely abnormally mobile, or is actually torn.

#Mobile Meniscus--Displacement of Medial Semilunar Cartilage# (Fig. 86).--The medial meniscus exhibits undue mobility much more frequently than the lateral, and the condition is usually met with in adult males who engage in athletics, or who follow an employment which entails working in a kneeling or squatting position for long periods, with the toes turned outwards--for example, coal-miners. The tibial collateral ligament, and through it the coronary ligament, are thus gradually stretched, so that the cartilage becomes less securely anchored, and is rendered liable to be displaced towards the centre of the joint during some sudden movement which combines flexion of the knee with medial rotation of the femur upon the tibia, as, for example, in rising quickly from a squatting position, or turning rapidly and pushing off with the foot, in the course of some game such as football or tennis. It may occur also from tripping on a loose stone or slipping off the kerbstone.

What actually happens when the meniscus is displaced would appear to be, that the combined flexion and abduction of the knee opens up the medial side of the joint by separating the medial condyles of the femur and tibia, and that the medial meniscus in its movement backward during flexion slips under the femoral condyle and is caught between it and the tibia. It may even slip past the condyle and into the intercondyloid notch, and come to lie against the cruciate ligaments.

The mechanism by which this lesion is produced doubtless explains the greater frequency with which the left knee is affected, as most sudden movements are made from right to left, thus throwing the strain upon the left knee.

Clinical Features.--When seen immediately after the accident, the patient usually gives the history that while making a sudden movement he was seized with an intense sickening pain in the knee, accompanied, it may be, by a sensation of something giving way with a distinct crack, and followed by locking of the joint. He may fall to the ground and be unable to rise. On examination, the knee is found to be fixed in a slightly flexed position; and while the surgeon may be able to carry out movements of flexion to a considerable extent without increasing the pain, any attempt to extend the joint completely is extremely painful. Tenderness may be elicited on making pressure to the medial side of the ligamentum patellae in the groove between the femur and the tibia, but the meniscus cannot be recognised by palpation. Considerable effusion rapidly takes place into the synovial cavity.

The condition is liable to be mistaken for a sprain of the joint, particularly one implicating the tibial collateral ligament, but whereas in the lesion of the meniscus the maximum tenderness is in the interval between the bones, in the sprain of the ligament the maximum tenderness is over its attachment to the bone, usually the tuberosity of the tibia.

Treatment.--To reduce the displacement, the patient is placed on a couch, and, after the knee is fully flexed, the leg is rotated laterally and abducted, to separate the medial femoral condyle from the tibia, and while the rotation and abduction are maintained the leg is quickly extended. The return of the meniscus to its place is sometimes attended with a distinct snap, but in other cases reduction is only recognised to have taken place by the fact that the joint can be completely extended without causing pain.

Alternate flexion and extension combined with rotatory movements is sometimes successful. Several attempts are often necessary, and a general anaesthetic may be called for. After reduction, the limb is fixed with sand-bags, and massage and movement are employed to get rid of effusion, care being taken that no rotatory movement at the knee is permitted. Rest and support are necessary to allow of repair of the torn ligaments, and when the patient begins to use the limb he must be careful to avoid movements which throw strain on the damaged ligaments.

In a considerable proportion of cases no recurrence takes place, and in the course of a month or two the patient is able to resume an active life with a perfectly useful joint. In other cases there is a tendency to recurrence of the displacement.

#Recurrent Displacement.#--In cases of recurrent displacement, each attack is accompanied by symptoms similar in kind to those above described, but less severe, and the patient usually learns to carry out some manipulation by which he is able to return the meniscus into position. He seeks advice with a view to having something done to prevent displacement occurring, and to restore the stability of the joint, which, in many cases, is impaired, preventing him following his occupation. There persists a variable amount of fluid in the joint, the ligaments are stretched and slack, and the quadriceps muscle is markedly wasted.

The symptoms closely resemble those of a "loose body," and it is often difficult to differentiate between them. In the case of a body free in the cavity of the joint, the site of the pain varies in different attacks, and the body can sometimes be palpated. Loose bodies wholly or partly composed of bone may be identified with the X-rays.

Attempts may be made to retain the meniscus in position by pads, bandages, or other forms of apparatus, so arranged as to prevent rotation and side-to-side movement at the knee. In the majority of cases, however, the best results are obtained by opening the joint and excising the meniscus in whole or in part, as may be necessary.

The limb is flexed on a splint until the wound has healed, after which massage should be employed and movement of the joint commenced. At the end of two or three weeks the patient is allowed up, wearing an elastic bandage. In most cases the use of the joint is completely regained in from four to six weeks. As an indication of the perfect recovery of the functions of the joint after removal of the meniscus, professional football players are often able to resume their occupation.

#Displacement of the lateral meniscus# is comparatively rare. It is in every way comparable to displacement of the medial meniscus, and is treated on the same lines.

#Torn or Lacerated Meniscus.#--In a large proportion of cases of displaced meniscus in which the condition assumes the recurrent type, it is found, on opening the joint, that, in addition to being unduly mobile, the meniscus is torn or lacerated. The experience of surgeons varies regarding the nature of the laceration. In our experience the most common form is a longitudinal split, whereby a portion of the inner edge of the cartilage is separated from the rest and projects as a tag towards the centre of the joint (Fig. 86). As a rule, it is the anterior end that is torn, less frequently the posterior end. Sometimes the meniscus is split from end to end, the outer crescent remaining in position, while the inner crescent passes in between the condyles and lies curled up against the cruciate ligaments. Occasionally the anterior end is torn from its attachment to the tibia, less frequently the posterior end. In one case we found the meniscus separated at both ends and lying between the bones and the capsule.

The clinical features are similar to those of mobile meniscus with displacement, and as a rule the exact nature of the lesion is only discovered after opening the joint.

The treatment consists in excising the loose tag or the whole meniscus, according to circumstances. The recovery of function is usually complete. It is not advisable to attempt to stitch the torn portion in position.

#Rupture of the Cruciate Ligaments.#--A few cases have been recorded in which, as a result of severe twisting forms of violence, the cruciate ligaments have been torn from their attachments, leaving the joint loose and unstable, so that the tibia and the femur could be moved from side to side on one another. When the disability persists, the joint may be opened and the ligaments sutured in position (Mayo Robson).

#Sprains# of the knee are comparatively common as a result of sudden twisting or wrenching of the joint. In addition to the stretching or tearing of ligaments, there is usually a considerable effusion of fluid into the synovial cavity, and examination with the X-rays occasionally reveals that a portion of bone has been torn away with the ligament--sprain-fracture. The swelling fills up the hollows on either side of the patella, and extends for some distance in the synovial pouch underneath the quadriceps. The patella is raised from the front of the femur by the collection of fluid in the joint--"floating patella"--and, if firmly pressed upon, it may be made to rap against the trochlear surface.

A sprain is to be diagnosed from separation of one or other of the adjacent epiphyses, fracture involving the articular ends of the bones, and displacement of the semilunar menisci. On account of the swelling, which obscures the outline of the part, the differential diagnosis is often difficult, but as the swelling goes down under massage it becomes easier. Chief reliance is to be placed upon the bony points retaining their normal relationships, and upon the fact that the points of maximum tenderness are over the attachments of one or other of the collateral ligaments. As the tibial collateral ligament suffers most frequently, the most tender spot is usually over its attachment to the medial aspect of the head of the tibia--less frequently over the medial condyle of the femur.

Unless efficiently treated, a sprain of the knee is liable to result in weakness and instability of the joint from stretching of the ligaments, and this is often associated with effusion of fluid in the synovial cavity (traumatic hydrops). This is more likely to occur if the joint is repeatedly subjected to slight degrees of violence, such as are liable to occur in football or other athletic exercises--hence the name "footballer's knee" sometimes applied to the condition.

A further cause of disability, following upon sprains of the knee, is wasting of the quadriceps muscle. The stability of the joint, whenever the position of full extension has been departed from, is largely dependent upon its capacity of controlling the amount of flexion, notably in descending a stair or in walking on uneven ground, hence it is that with a wasted quadriceps there is increasing liability to a repetition of the sprain. With each repetition of the sprain, there is an addition to the fluid in the joint, stretching of ligaments, and further wasting of the quadriceps. A form of vicious circle is established in which there is at the same time increased liability to sprain and diminished capacity of recovering from it. Even after the repair of the damaged ligament or the removal of the mobile or torn meniscus, wasting of the quadriceps remains a source of weakness and disability and calls for treatment by massage and electricity.

Treatment.--In recent and severe cases the patient must be confined to bed, and firm pressure applied over the joint by means of cotton wool and a bandage. This may be removed once or twice a day to admit of the joint being douched, and at the same time it should be massaged and moved to promote absorption of the effusion and prevent the formation of adhesions.

Chronic effusion into the joint is most rapidly got rid of by rest and blistering. If the patient is unable to lie up, massage should be systematically employed, and a firm elastic bandage worn. A patient who has once had a severe sprain of the knee, or who has developed the condition of "footballer's knee," must give up violent forms of exercise which expose him to further injuries, otherwise the condition is liable to be aggravated and to result in permanent impairment of the stability of the joint.

INJURIES OF THE PATELLA

#Fracture of the patella# is a comparatively common injury in adult males. Most frequently it is due to muscular action the patella being snapped across the lower end of the femur by a sudden and forcible contraction of the quadriceps extensor muscle while the limb is partly flexed--as, for example, in the attempt to avoid falling backward. The bone is then broken as one breaks a stick by bending it across the knee, and the line of fracture, which is transverse or slightly oblique, crosses the bone a little below its middle. Fractures produced in this way are almost never compound.

The degree of displacement of the fragments depends upon the extent to which the expansion of the quadriceps tendon is lacerated. As a rule, it is but slightly torn, so that the separation of the fragments does not exceed an inch. In other cases it is widely torn, and the contraction of the quadriceps muscle is then able to separate the fragments by three or four inches, and sometimes causes tilting of the upper fragment. The blood effused into the joint tends still further to increase the separation. As the periosteum is usually torn at a level lower than the fracture, its free margin hangs as a fringe from the proximal fragment, and by getting between the broken ends may form a barrier to osseous union (Macewen).

Clinical Features.--Immediately the bone breaks, the patient falls, and he is unable to rise again, as the limb is at once rendered useless, and in attempting to do so we have known him to fracture the patella of the other limb. The power of extending the limb is lost, and the patient is unable to lift his foot off the ground. The knee-joint is filled with blood and synovia, which usually extend into the bursa under the quadriceps. The two fragments can be detected, separated by an interval which admits of the finger being placed between them, and which is increased on flexing the knee. On relaxing the quadriceps, the fragments may be approximated more or less completely.

Prognosis.--In cases with little displacement, if the fragments have been kept in perfect apposition, osseous union may take place, but in the great majority of cases the union is fibrous. The shortening of the quadriceps and the gradual stretching and thinning of the connecting fibrous band may allow of further separation of the fragments (Fig. 88), which to a variable extent interferes with the stability and functions of the limb. The proximal fragment sometimes becomes attached to the front of the femur, and moves with it, and the fibrous band between the two fragments gradually becomes stretched. After bony union has occurred, it is not uncommon for the patella to be fractured again by a fall within a month or two of the original accident.

Treatment.--It is probably true that the best functional results are most speedily obtained by operative measures. The laceration of the aponeurosis of the quadriceps, the tilting of the fragments, and the interposition of the torn periosteum between them, can in no other way be rectified with certainty. The operation, however, should only be undertaken by those who are familiar with wound technique, and who have the means at their disposal for carrying it out. Operative treatment is specially indicated in young subjects who lead an active life, and in labouring men, particularly those who follow dangerous employments necessitating stability of the knee.

As soon as the wound is healed,--in a week or ten days,--massage and movement of the limb are commenced, and the patient is encouraged to move his limb in bed. At the end of another week he may be allowed up with sticks or crutches.

Non-operative Treatment.--In the majority of cases occurring in patients who do not follow a laborious occupation or otherwise lead an active life, a satisfactory result can be obtained without having recourse to operation. We have reason to be satisfied with the following method: the patient is kept in bed for a few days, the injured region being supported on a pillow and massaged daily, and the patella moved from side to side as a whole to prevent adhesion to the femur. About the fourth day he is allowed to get about with crutches. As osseous union of the fragments is not essential to a good functional result, and as fibrous union does not necessarily entail any material interference with the usefulness of the limb, no attempt need be made to approximate the fragments, but every effort must be made to maintain the function of the quadriceps muscle and the mobility of the joint.

If it is desired to bring the fragments into contact and to secure osseous union, the limb should be placed upon an inclined plane to relax the quadriceps muscle, and means taken to arrest effusion and to diminish the swelling by systematic massage and a supporting bandage. When, in the course of a few days, this has been accomplished, the attempt is made to approximate the fragments, by fixing a large horseshoe-shaped piece of adhesive plaster to the front of the thigh, embracing the proximal fragment. Extension is made upon this by means of rubber tubing, which is fixed to the foot-piece of the splint. The bandage which binds the limb to the splint should make upward pressure on the distal fragment, or this may be done by a special piece of adhesive plaster with elastic tubing pulling in an upward direction.

The retentive apparatus is kept on for about three weeks, and a rigid, but easily removable, apparatus is thereafter applied, and the patient allowed up on crutches, the limb being massaged and exercised daily to improve the tone of the muscles.

When the fracture is caused by direct violence, such as a fall on the knee or the kick of a horse, it may be transverse, oblique, or vertical, but in many cases it is stellate, the bone being broken into several irregular pieces. These comminuted fractures are frequently compound. In transverse and oblique fractures, the displacement depends upon the same causes as in fracture by muscular action. In vertical and stellate fractures, unless the knee has been forcibly flexed after the bone has been broken, there is little or no displacement. The treatment is governed by the same considerations as in fractures by muscular action.

Old-standing Fracture.--As fibrous union, even with an interval of several inches between the fragments, is not incompatible with a useful limb, it is not often necessary to operate for this condition, but when the usefulness of the limb is seriously impaired, operative treatment is indicated. The operation is carried out on the same lines as for recent fracture, the ends of the bones being rawed and adhesions divided. When the proximal fragment has become attached to the femur, it should be separated and a layer of fascia interposed; it is sometimes necessary to lengthen the quadriceps muscle by making a number of V-shaped incisions through its substance; or a flap may be turned down from the rectus and stitched to the patella and the ligamentum patellae.

When operative treatment is contra-indicated, the patient should be fitted with a firm apparatus which will limit flexion of the knee and support the fragments.

#Dislocation of the patella# is rare. It results from exaggerated muscular movements when the limb is in the fully extended position, or from a blow on one or other edge of the bone. Laxity of the ligaments and knock-knee are predisposing factors. It is sometimes associated with fracture of the edge of the trochlear surface, which renders retention in position difficult.

The lateral is the most common variety--the medial being rare. Either may be complete or incomplete. Sometimes the bone is rotated so that its edge rests on the front of the femur--vertical dislocation; and in a few cases it has been completely turned round, so that the articular surface is directed forwards.

Clinical Features.--The joint is fixed, usually in a position of slight flexion, and the displaced patella can readily be palpated. The deformity is a striking one, and at first sight suggests a much more serious injury. Although easily reduced, the dislocation is liable to recur.

To effect reduction, the quadriceps must be thoroughly relaxed by extending the leg upon the thigh and flexing the thigh upon the pelvis; the patella is then tilted by making firm pressure on that edge which lies farthest from the middle of the joint, and at the same time pushing towards the middle line. The limb is placed on a posterior splint, and firm elastic pressure made on the joint to prevent or diminish effusion. Massage and movement are carried out from the first.

As the displacement is liable to recur, the patient should wear a firm elastic bandage or a strong knee-cap.

Permanent and recurrent dislocation of the patella will be described later.

FRACTURE OF THE BONES OF THE LEG

The bones of the leg may be broken together or separately.

#Fracture of both Bones.#--The features of this injury depend to a large extent upon the nature of the violence producing it. In fracture by direct violence, such as the passage of a wheel over the limb or a severe blow, the bones give way at the point of impact, and the line of fracture tends to be transverse, both bones being broken at the same level (Fig. 89). There is little or no displacement, and such as there is is angular, and is determined by the direction of the fracturing force.

When the violence is indirect, as from a fall on the feet, or a twist of the leg, the tibia usually gives way at the junction of its lower and middle thirds, and the fibula at a higher level (Fig. 90). Torsion of the tibia is probably the most important factor in the production of the fracture, the distal fragment being fixed by the pressure of the foot upon the ground, while the proximal fragment is rotated by the impetus of the body. Both fractures are usually oblique--that in the tibia running from above downward, forward, and medially, and it is generally found that the obliquity of the fibular fracture corresponds with that in the tibia.

There is usually considerable displacement, the weight of the lower portion of the limb causing it to fall backwards and to roll away from the middle line, and the traction of the calf muscles pulling up the heel and pointing the toes. The proximal fragment forms a projection on the front of the limb.

On account of the superficial position of the tibia and the pointed character of the fragments, this fracture is frequently rendered compound by the bone being forced through the skin. The projecting piece of bone is usually the distal end of the proximal fragment. This fracture is often comminuted. It has been observed that when the line of fracture forms the letter V on the subcutaneous surface of the tibia, there is invariably a fissure passing down along the back of the bone into the ankle-joint--a complication which adds to the risk of subsequent stiffness and impaired usefulness of the limb. Apart from this, the ankle is usually sprained in fractures by indirect violence, and we have frequently found the superior tibio-fibular articulation torn open in severe fractures of both bones of the leg from indirect violence.

Clinical Features.--The tibial fracture is readily recognised by detecting an irregularity on running the fingers along the crest of the shin, and at this point abnormal mobility, tenderness, and crepitus can usually be elicited. It is often difficult to detect the fibular fracture, and it is not always advisable to attempt to do so, especially if the manipulations cause pain or tend to increase the displacement. The condition of the fibula is usually to be inferred by noting the amount of displacement and the extent of mobility of the tibial fragments. Not infrequently the seat of fracture may be recognised by locating a point at which pain is elicited on making pressure over the bone at a distance--pain on distal pressure.

On account of the close connection of the skin to the periosteum on the subcutaneous aspect of the tibia, the tension caused by extravasated blood is often extreme; blisters frequently form over the area of ecchymosis, and when these become infected, sloughing of the skin may take place and the fracture thus be rendered compound.

The vessels and nerves of the leg are seldom seriously damaged.

Treatment.--If there is marked displacement, reduction is most satisfactorily accomplished under anaesthesia. Traction is made upon the foot and the fragments are manipulated into position, the pointing of the toes and the outward rotation of the foot being at the same time corrected. The normal outline of the foot in relation to the leg is restored when the ball of the great toe, the medial malleolus, and the medial edge of the patella are in the same vertical plane. As in other fractures of the lower extremity, the limb should be placed in the natural position of slight eversion: not with the toes pointing straight forward.

The retentive apparatus to be applied depends upon the tendency to re-displacement, the degree of swelling, and the extent of the damage to the skin.

In the average case, the leg is supported between sand-bags, and massage and movements are employed from the outset. When there is a tendency to re-displacement, the limb may be immediately enclosed in a rigid apparatus, such as lateral poroplastic splints retained in position by an elastic bandage, or a Cline's splint, which can readily be removed to admit of massage. When the fracture is in the lower third of the leg, the ambulatory splint gives excellent results, and is of special service in hospital practice (Fig. 95).

As an emergency appliance, for example for purposes of transport, the box splint (Fig. 91) is simple and efficient. We have not found it effectual in controlling the fragments, particularly in oblique fractures, and it requires constant supervision and readjustment. It consists of two pieces of wood extending from above the knee to an inch or two beyond the sole, and a little broader than the maximum diameter of the leg. These are rolled into the opposite ends of a folded sheet, so as to form two sides of a box, of which the sheet constitutes a third side. It is found advantageous to insert another board, fitted with a foot-piece, between the folds of the sheet forming the third side of the box, to add to the rigidity of the splint, and to aid in controlling the foot. By folding one side of the sheet somewhat obliquely, the box is made a little wider at the knee than at the ankle, and so fits the limb more accurately.

The limb is placed in this box, the sides of which have been carefully padded. Ring pads are applied to take pressure off the condyles, the head of the fibula, the malleoli, and the prominence of the heel, and a large supporting pad is placed behind the tendo calcaneus. A folded towel is laid over the front of the leg, forming a lid to the box, and the whole is bound to the limb by three slip-knots. Finally, the foot is fixed at right angles to the leg and slightly abducted by a figure-of-eight bandage or a piece of elastic webbing. Sand-bags placed alongside serve to steady the limb. In fractures of the lower third of the leg, the box splint may stop short of the knee and the limb may then be suspended in a Salter's cradle, which allows the patient to move about more freely in bed.

To prevent shortening in oblique fractures and in those near the ankle-joint, where it is often difficult to control the lower fragment, extension, applied by weight and pulley, or through a Thomas' knee splint, may be of service. The strapping may be applied only to the distal fragment, but we prefer to carry it to the upper third of the leg. If the overriding of the fragments persists, extension may be taken directly from the bone, the ice-tong callipers gripping the malleoli or the calcaneus.

When the skin is damaged, as it so frequently is on the medial aspect of the tibia, means must be taken to prevent infection.

Massage is carried out daily, and, to prevent stiffness, the ankle is moved from the first. In the course of three weeks, lateral poroplastic splints retained by an elastic bandage may be substituted, and the patient allowed up on crutches. In simple fractures without displacement, union is usually complete in from six to eight weeks, but when the fracture is oblique, comminuted, or compound, union is often delayed, and the functions of the limb may not be fully regained for three or even four months after the accident.

Operative Treatment.--When overriding cannot otherwise be corrected, it is advisable to replace the fragments by operation. A curved incision with its convexity backward is made over the medial side of the tibia, exposing the fragments, which are then levered into position and if necessary plated or otherwise fixed according to circumstances. It is seldom necessary to deal separately with the fibula. A box splint is applied till the wound has healed, after which a poroplastic splint is substituted and massage commenced.

We do not share in the dissatisfaction expressed by some surgeons, notably Arbuthnot Lane, as to the results obtained by non-operative means in the common fractures of the leg, and do not recommend a systematic resort to operative treatment.

Un-united fracture of the bones of the leg is sometimes met with. It is treated on the same lines as in other situations, but may prove extremely intractable, especially in children, in whom, indeed, it is sometimes incurable.

Mal-union, on account of the disability it entails, may call for operative treatment in the form of osteotomy of one or both bones.

Compound fractures of the leg are common, and are treated on the lines already laid down for the treatment of compound fractures in general (p. 25).

#Fracture of the tibia alone#, when due to direct violence, is usually transverse, there is little displacement, and as the fibula retains the fragments in position, union usually takes place rapidly and without deformity. Oblique and spiral fractures result from indirect violence.

#Fracture of the fibula alone# may result from direct violence, and, on account of the support given by the tibia, is usually unattended by displacement. Bennett of Dublin has pointed out that it is common to meet with an oblique fracture of the upper third of the fibula as the result of an outward twist of the ankle while the foot is extended. It is characterised by pain localised at the seat of the break, on moving the foot in such a way as to bring the talus to bear against the fibula. Local pressure also may make the fibula yield and may elicit crepitus. In some cases this fracture is associated with sprain of the ankle-joint. It is often overlooked, and from want of proper treatment may result in prolonged impairment of usefulness.

Fractures of the tibia or fibula alone are treated on the same lines as fractures of both bones, and splints are rarely necessary. The ambulant method is useful in these cases (Fig. 95).

VIII. INJURIES IN REGION OF ANKLE AND FOOT

Surgical Anatomy--FRACTURES: Pott's fracture; Converse of Pott's fracture; Separation of lower epiphysis; Fracture of talus; Fracture of calcaneus; Fractures of other tarsal bones; Fractures of metatarsal bones; Fractures of phalanges--DISLOCATIONS: Of ankle joint; Of inferior tibio-fibular joint; Complete dislocation of talus; Sub-taloid dislocation; Medio-tarsal dislocation; Tarso-metatarsal dislocation; Dislocations of toes.

The fractures in this region include Pott's fracture, and its converse; separation of the lower epiphysis of the tibia; fractures of the talus, calcaneus, and other tarsal bones; and fractures of the metatarsals and phalanges. Various dislocations also occur, the most important being those of the ankle joint, of the talus, and the sub-taloid dislocation.

#Surgical Anatomy.#--For the study of injuries in the region of the ankle-joint it is of importance to define the terms employed in describing the movements of the foot. Thus by flexion or dorsiflexion is meant that movement which approximates the dorsum of the foot to the front of the leg; while extension or plantar flexion means the drawing up of the heel so that the toes are pointed. In inversion the medial edge of the foot is drawn up so that the sole looks towards the middle line of the body, an attitude which is analogous to supination of the hand. In eversion the lateral edge of the foot is drawn up, the sole looking away from the middle line--analogous to pronation of the hand. Adduction indicates the rotation of the foot so that the toes are turned towards the middle line of the body; while in abduction the toes are turned away from the middle line.

The most prominent bony landmarks in the region of the ankle are the two malleoli, the lateral lying slightly farther back, and about half an inch lower than the medial. On the medial side of the foot from behind forward may be felt the medial process (internal tuberosity) of the calcaneus; the sustentaculum tali, which lies about 1 inch vertically below the tip of the malleolus; the tubercle of the navicular, about 1 inch in front of the malleolus, and at a slightly lower level; the first (internal) cuneiform, and the base, shaft, and head of the first metatarsal.

On the lateral side may be recognised the lateral process (external tuberosity) of the calcaneus; the trochlear process (peroneal tubercle) on the same bone; the cuboid; and the prominent base of the fifth metatarsal.

The talo-navicular joint lies immediately behind the tuberosity of the navicular, and a line drawn straight across the foot at this level passes over the calcaneo-cuboid joint.

The ankle-joint, formed by the articulation of the tibia and fibula with the talus, lies about half an inch above the tip of the medial malleolus, and is so constructed that when the foot is at a right angle with the leg it is only possible to flex and extend the joint. When the toes are pointed, however, slight side-to-side and rotatory movements are possible. The chief seat of side-to-side movement of the foot is at the talo-navicular and calcaneo-cuboid articulations--"the mid-tarsal or Chopart's joint."

The ankle-joint owes its strength chiefly to the malleoli and the collateral ligaments, and to the inferior tibio-fibular ligaments, which bind together the lower ends of the bones of the leg. The numerous tendons passing over the joint on every side also add to its stability.

The synovial membrane of the ankle-joint passes up between the bones of the leg to line the inferior tibio-fibular joint; but it is distinct from that of the intertarsal joints, which communicate with one another in a complicated manner. The epiphysial cartilage at the lower end of the fibula lies on the level of the talo-tibial articulation, while that of the tibia is about half an inch higher (Fig. 93).

FRACTURES IN THE REGION OF THE ANKLE

#Pott's Fracture.#--It must be understood that various lesions occurring in the region of the ankle-joint are included under the clinical term "Pott's fracture." Although of a similar nature, and produced by the same forms of violence, these vary considerably in their anatomy and clinical features. They are all the result of combined eversion and abduction of the foot--produced, for example, by slipping off the kerbstone, or by jumping from a height and landing on the medial side of the foot.

When forcible eversion is the chief movement, the tightening of the deltoid (internal lateral) ligament usually tears off the medial malleolus across its base. The talus is then brought to bear on the lateral malleolus, and the force continuing to act, the lower end of the fibula is pressed laterally, and breaks close above the malleolus. The tibio-fibular interosseous ligament may rupture, or the outer portion of the tibia, to which it is attached, may be avulsed. This form is sometimes called Dupuytren's fracture. When the bones are widely separated in Dupuytren's fracture the talus may be forced up between them.

When the movement of abduction predominates, the deltoid ligament is usually ruptured, or the anterior edge or tip of the medial malleolus torn off. The tibio-fibular interosseous ligament usually resists, and an oblique fracture of the fibula 2 or 4 inches above its lower end results.

Clinical Features.--In a considerable proportion of cases--in our experience in the majority--this fracture is not accompanied by any marked deformity of the foot, and the patient is often able to walk after the injury with only a slight limp.

In others, however, the deformity is marked and characteristic (Fig. 94). The foot is everted, its inner side resting on the ground. The medial malleolus is unduly prominent, stretching the skin, which may give way if the patient attempts to walk. The foot, having lost the support of the malleoli, is often displaced backward, and the toes are pointed by the contraction of the calf muscles. There is abnormal mobility--both from side to side and antero-posteriorly--and crepitus may be elicited. The points of tenderness are over the deltoid ligament or medial malleolus, the inferior tibio-fibular joint, and at the seat of fracture of the fibula. Distal pressure over the shaft of the fibula, or on the extreme tip of the malleolus, may elicit pain and crepitus at the seat of fracture. There is usually considerable ecchymosis and swelling in the hollows below and behind the malleoli; and the malleoli appear to be nearer the level of the sole. In Dupuytren's fracture, when the talus passes up between the tibia and fibula, there is great broadening of the ankle.

There is often considerable difficulty in distinguishing a sprain of the ankle from a fracture without displacement, as both forms of injury result from the same kinds of violence, and are rapidly followed by swelling and discoloration of the overlying soft parts. In a sprain, the point of maximum tenderness is over the ligaments and tendon sheaths that have been damaged, while in fracture the site of the break is the most tender spot. The X-rays are useful in the diagnosis of doubtful cases.

Treatment.--In those cases of fracture of the lower end of the fibula in which there is no marked displacement,--and they constitute a considerable proportion,--the limb should be massaged and laid on a pillow between sand-bags, or placed in a box splint for two or three days, until the swelling subsides. Some form of rigid apparatus, such as side poroplastic splints fixed in position with an elastic bandage, which will allow the patient to get about with crutches, is then applied. This is removed daily to permit of massage and movement being carried out--a point of great practical importance, because, if this is neglected, not only does union take place more slowly, but the stiffness of the ankle and oedema of the leg and foot which ensue, prolong the period of the patient's incapacity and endanger the usefulness of the limb.

It is in cases of this kind that the ambulatory method of treatment yields its best results. When, in the course of two or three days, the swelling has subsided, a plaster-of-Paris case (Fig. 95) is applied in such a way that when the patient walks the weight is transmitted from the condyles of the tibia through the plaster case to the ground, no weight being borne by the bones at the seat of fracture. The apparatus is applied as follows: A boracic lint bandage is applied to the limb as far as the knee, and protecting pads or rings of wool are placed over the condyles of the tibia, the head of the fibula, and the malleoli. A pad of wool about 3 inches thick is then placed under the sole and fixed in position by a plaster-of-Paris bandage, which is carried up the limb in the usual way. The case is made specially strong on the sole, around the ankle, up the sides of the leg, and at the bearing-point at the head of the tibia. After the plaster has thoroughly set, the patient is allowed to walk about with a stick, crutches being unnecessary. In the course of three weeks the plaster case may be removed and the limb massaged. It is usually found that the movements of the ankle are scarcely interfered with, and the patient is generally able to resume work within a month of the accident.

When there is marked eversion of the foot, it may be necessary to administer a general anaesthetic to reduce the deformity; and to prevent recurrence of the displacement Dupuytren's splint (Fig. 96) may be used. This splint, which is of the same shape as Liston's long splint, but on a small scale, is applied to the medial side of the leg extending from just below the knee to well beyond the sole of the foot. A large pad is placed in the hollow above the medial malleolus, and it must be thick enough to carry the splint so far from the limb that when the foot is fully inverted it does not touch the splint. The upper end of the splint having been fixed to the leg at the level of the condyles of the tibia, a bandage is applied to correct the eversion of the foot, and at the same time to support the heel, and, as far as possible, to overcome the pointing of the toes. Care must be taken to avoid carrying the turns of this bandage over the seat of fracture. The limb may then be slung in a cradle, or placed on a pillow resting on its lateral side with the knee flexed. In the course of a few days, a poroplastic splint may be substituted and massage commenced.

When backward displacement of the heel is the prominent deformity, Syme's horse-shoe or stirrup splint (Fig. 97) may be employed. It is applied to the anterior aspect of the limb, which is carefully padded to prevent undue pressure on the edge of the shin bone. After the upper end of the splint has been fixed, the heel is pulled forward by a few turns of bandage passed over the prongs at the lower end of the splint. The foot is then inverted and brought up to a right angle by a few supplementary turns of the bandage. In a few days this appliance may be replaced by a poroplastic splint.

Operative Treatment.--If the displacement is not completely corrected by the measures described, the fibular fracture is exposed by a free incision and the fragments are levered into position, and if necessary fixed by lashing with catgut or by other mechanical means.

Mal-union of Pott's fracture may necessitate re-fracture by means of a Jones' wrench, used in the same manner as for club-foot, or the parts are exposed by operation; the bone is divided by means of an osteotome, the foot forcibly inverted, and the limb put up in the same way as in a recent fracture.

#The Converse of Pott's Fracture--sometimes called "Pott's Fracture with Inversion."#--This injury is fairly common, and results from forcible inversion of the foot. The lateral malleolus is broken across its base, or, in young subjects, along the epiphysial line. The medial malleolus alone may be carried away, or a portion of the broad part of the tibia may accompany it.

The foot is inverted, the heel falls back, and the toes are pointed. In other respects it corresponds to the typical Pott's fracture, and is treated on the same principles. When Dupuytren's splint is required, it is, of course, applied to the lateral side of the leg.

#Separation of the lower epiphysis of the tibia# is not common. It occurs most frequently between the ages of eleven and eighteen, as a result of forcible eversion or inversion of the foot. It is usually accompanied by fracture of the diaphysis of the fibula (Fig. 98), and is not infrequently compound. When the epiphysis is displaced to one side, the deformity is characteristic. In rare cases the growth of the tibia is arrested, the continued growth of the fibula causing the foot to become inverted. The treatment is the same as for Pott's fracture.

#Fracture of the talus# usually occurs as a result of a fall from a height, the bone being crushed between the tibia and the calcaneus. It is usually associated with other fractures, and is sometimes impacted, the foot assuming the position of equino-varus. The diagnosis is only to be made by exclusion, or by the use of the Roentgen rays. In interpreting radiograms of injuries in this region, care must be taken not to mistake the os trigonum tarsi for a fracture. In uncomplicated cases, the treatment consists in immobilising the foot and leg in a poroplastic splint and applying massage. In comminuted and in impacted fractures with persistent deformity, complete excision of the bone yields good results.

The #calcaneus# is most frequently broken by the patient falling from a height and landing on the sole of the foot, and the injury may occur simultaneously in both feet.

The primary fracture is usually longitudinal, passing through the facets for the talus and cuboid, and from this various secondary fissures radiate; the cancellated tissue is much crushed, so that the whole bone is flattened out. In spite of the great comminution, it is often impossible to elicit crepitus, as the fragments are held together by the investing soft parts. In other cases the foot may feel like "a bag of bones." The lesion is often mistaken for a fracture of the lower end of the fibula, or is not diagnosed at all. The chief clinical feature is pain on movement of the foot, or on attempting to walk; the foot appears flat, and the hollows on either side of the tendo Achillis are filled up. In many cases there is a persistent tenderness which delays restoration of function for some months, but the ultimate result is usually satisfactory.

Treatment.--In simple comminuted fractures the patient should be anaesthetised, and the foot moulded into position, care being taken to restore the arch in order to avoid any tendency to flat foot. The foot is supported on a pillow, and to prevent stiffness, massage and movements of the ankle and tarsal joints should be commenced without delay.

Compound fractures confined to the calcaneus may be treated on conservative lines, but if associated with other injuries of the foot they may necessitate amputation.

The tuberosity of the calcaneus, into which the tendo Achillis is inserted, is sometimes separated by forcible contraction of the calf muscles, or from a fall on the ball of the foot. The separated fragment may be pulled up for a distance of 1 or 2 inches, and the rough surface from which it has been torn may be recognisable. The patient may be able to walk immediately after the accident, although with difficulty; or he may have pain for many months.

A good functional result is usually obtained by relaxing the calf muscles and fixing the foot in the position of extreme plantar flexion with the knee flexed, but in some cases it is advisable to peg the fragments, either through the skin or after exposing them by operation.

The #other bones of the tarsus# are rarely fractured separately. The tuberosity of the navicular is sometimes torn away by violent traction on the ligaments attached to it.

#Fractures of the metatarsals and phalanges# usually result from direct violence, such as a crush of the foot, in which the soft parts are severely damaged. The use of the Roentgen rays has shown, however, that certain painful conditions in the foot following comparatively slight injuries, such as kicking a stone, are due to a fracture of one of the metatarsals or phalanges.

When simple, these injuries are often overlooked, on account of the difficulty of eliciting the signs of fracture from the swelling which accompanies them. They are best treated in a moulded splint.

Compound fractures are more common, and are to be treated on the same principles as govern such injuries elsewhere.

A fracture of the base of the fifth metatarsal has been described by Sir Robert Jones. It is produced by the patient coming down forcibly on the lateral edge of the foot while the foot is inverted and the heel raised--as, for example, in dancing. There is a localised swelling over the base of the fifth metatarsal, and pain when the patient puts weight on the foot. There is no crepitus or deformity. The fracture is readily recognised by the Roentgen rays. Massage and movement are employed from the first.

DISLOCATIONS IN THE REGION OF THE ANKLE

#Dislocation of the Ankle-Joint.#--In describing dislocation of the talus from the tibio-fibular socket, the varieties are named according to the direction in which the foot passes--backward, forward, medially, laterally, or upward.

All of them may be complete, but they are more frequently incomplete, and are liable to be rendered compound, either from tearing of the skin at the time of the injury, or by its sloughing later. Although as a rule there is little difficulty in effecting reduction by manipulation, these injuries are liable to be followed by stiffness and impaired usefulness of the joint.

The backward dislocation is the most common, and results from extreme plantar flexion of the foot, as from a fall backwards while the foot is fixed, wedging the talus between the tibia and fibula. The collateral ligaments are torn, and one or both malleoli may be broken, or the posterior part of the articular edge of the tibia chipped off (Fig. 99).

The foot appears shortened, the heel is unduly prominent behind, and the lower ends of the tibia and fibula project in front, sometimes coming through the skin. The tendons around the joint are stretched or torn.

Forward dislocation results from extreme dorsal flexion at the ankle-joint. The foot appears lengthened, the heel is less prominent than normal, and the hollows on each side of the tendo Achillis are obliterated. The talus is felt in front of the tibia, and the malleoli appear to be displaced backwards and to lie nearer the sole.

Medial or lateral dislocation is only possible after fracture of one or both malleoli, and may be looked upon as a complication of these injuries.

In cases in which the interosseous ligament is ruptured, and in severe cases of Dupuytren's fracture, the talus may be driven upwards between the bones of the leg. There is great broadening in the region of the ankle, and the malleoli are unduly prominent under the skin, which is tightly stretched over them. They are also nearer to the sole than normally. The movements of the ankle-joint are lost.

Dislocation of the inferior tibio-fibular joint is exceedingly rare, except in association with fractures of the lower ends of the bones of the leg, particularly Dupuytren's fracture, or with dislocation of the ankle-joint proper.

Treatment of Dislocation of Ankle.--The patient having been anaesthetised, the foot is extended and the knee and hip joints flexed to relax the calf muscles as completely as possible. Traction is then made upon the foot, while counter-extension is applied to the leg, and the bones are manipulated into position. Reduction usually takes place gradually without the characteristic snap which accompanies reduction of most dislocations. It is sometimes necessary to divide the tendo Achillis, particularly in cases of forward dislocation.

When the talus passes 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 massage 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).

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 assistant 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 circumstances 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 pass backward and medially, or backward and laterally. When the foot passes 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.

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 massage 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 passing towards the dorsum (Fig. 102). Diagnosis and reduction are alike easy.

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

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 attitude 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 passive 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 associated 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 space. 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 associated with disappearance of the upper end of the humerus (Fig. 104).

#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 attitude is that of flexion with pronation 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.

#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.

The occurrence of articular caries without swelling of the synovial membrane is exceptional, and is associated 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.

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-pronated 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 anticipated 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.

#Arthritis deformans# occurs as a hydrops with hypertrophy of the synovial fringes and loose bodies, or as a dry arthritis with eburnation and lipping of the articular margins.

#Neuro-arthropathies# are met with chiefly in syringomyelia, and are attended with striking alterations in the shape of the bones and with abnormal mobility.

#Pyogenic diseases# result from staphylococcal osteomyelitis--chiefly of the humerus or ulna--and from gonorrhoea.

The remaining diseases at the elbow include syphilitic disease in young children, bleeder's joint, hysterical affections, and loose bodies, and do not call for special description.

#Ankylosis# of the elbow-joint, if interfering with the livelihood of the patient, may be got rid of by resecting the articular ends of the bones, or by inserting between them a flap of fascia and subcutaneous fat derived from the posterior aspect of the upper arm--arthroplasty.

THE WRIST-JOINT

The close proximity of the flexor sheaths to the carpal articulations permits of infective processes spreading readily from one to the other. The arrangement of the synovial membranes also favours the extension of disease throughout the numerous articulations in the region of the wrist.

#Tuberculous disease# is met with chiefly in young adults, but may occur at any age. It usually originates in the synovial membrane, but foci are frequently present in the carpal bones, and less commonly in the lower ends of the radius and ulna, or in the bases of the metacarpals. The clinical features are almost invariably those of white swelling, which is most marked on the dorsum where it obscures the bony prominences and the outlines of the extensor tendons. Wasting of the thenar and hypothenar eminences, and filling up of the hollows above and below the anterior annular ligament, render the appearance on the palmar aspect characteristic.

The attitude is one of slight flexion with drooping of the hand and fingers. The fingers become stiff as a result of adhesions in the tendon sheaths, and the power of opposing the thumb and fingers may be lost. Pain is usually absent until the articular surfaces become carious. Softening of the ligaments may permit of lateral mobility, and sometimes partial dislocation occurs. Abscess may be followed by sinuses and infection of the tendon sheaths, especially those in the palm.

The localisation of disease in individual bones or joints can be determined by the use of the X-rays.

Treatment.--Conservative measures may be persevered with over a longer period than in most other joints. The forearm, wrist, and metacarpus are immobilised in the attitude of dorsal flexion, while the fingers and thumb are left free to allow of passive movements. It may be necessary to give an anaesthetic to obtain the necessary degree of dorsiflexion. To inject iodoform, the needle is inserted immediately below the radial or the ulnar styloid process. Sometimes the carpal bones are so soft that the needle can be made to penetrate them in different directions. Operative treatment is indicated in cases which resist conservative measures, or when the general health calls for speedy removal of the disease.

Other diseases of the wrist are comparatively rare. They include pyogenic affections, such as those resulting from infective conditions in the palm of the hand, different types of gonorrhoeal, rheumatic, and gouty affections, and arthritis deformans. An interesting feature, sometimes met with in arthritis deformans, consists in eburnation of the articular surfaces of the carpal bones, although the range of movement is almost nil.

THE HIP-JOINT

Owing to the depth of this joint from the surface, it is not possible to detect the presence of effusion or of synovial thickening as readily as in other joints, hence in the recognition of hip disease we have to rely largely upon indirect evidence, such as a limp in walking, an alteration in the attitude of the limb, or restriction of its movements.

The whole of the anterior and fully one-half of the posterior aspect of the neck of the femur is covered by synovial membrane, so that lesions not only of the epiphysis and epiphysial junction, but also of the neck of the bone, are capable of spreading directly to the synovial membrane and to the cavity of the joint. Conversely, disease in the synovial membrane may spread to the bone in relation to it. Infective material may escape from the joint into the surrounding tissues through any weak point in the capsule, particularly through the bursa which intervenes between the capsule and the ilio-psoas, and which in one out of every ten subjects communicates with the joint.

TUBERCULOUS DISEASE

Tuberculous disease of the hip, morbus coxae, or "hip-joint disease," is especially common in the poorer classes. It is a frequent cause of prolonged invalidism, and of permanent deformity, and is attended with a considerable mortality. It is essentially a disease of early life, rarely commencing after puberty, and almost never after maturity.

#Pathological Anatomy.#--Bone lesions bulk more largely in hip disease than they do in disease of other joints--five cases originating in bone to one in synovial membrane being the usual estimate. The upper end of the femur and the acetabulum are affected with about equal frequency.

In addition to primary tuberculous lesions, secondary changes result from the inflamed and softened bones pressing against one another subsequent to the destruction of their articular cartilages. The head of the femur undergoes absorption from above downwards, becoming flattened and truncated, or disappearing altogether. In the acetabulum the absorption takes place in an upward and backward direction, whereby the socket becomes enlarged and elongated towards the dorsum ilii. To this progressive enlargement of the socket Volkmann gave the suggestive name of "wandering acetabulum" (Fig. 108). The displacement of the femur resulting from these secondary changes is one of the causes of real shortening of the limb.

#Clinical Features.#--It is customary to describe three stages in the progress of hip disease, but this is arbitrary and only adopted for convenience of description.

Initial Stage.--At this stage the disease is confined to a focus in the bone which has not yet opened into the joint or to the synovial membrane. The onset is insidious, and if injury is alleged as an exciting cause, some weeks have usually elapsed between the receipt of the injury and the onset of symptoms. The child is brought for advice because he has begun to limp and to complain of pain. There is a history that he has become pale and has ceased to take food well, that his sleep has been disturbed, and that the pain and the limp, after coming and going for a time, have become more pronounced. On walking, the affected limb is dragged in such a way as to avoid movement at the hip, and to substitute for it movement at the lumbo-sacral junction. The child throws the weight of the trunk as little as possible on to the affected limb, and inclines to rest on the balls of the toes rather than on the sole. There is usually some wasting of the muscles of the thigh and flattening of the buttock. Diminution or loss of the gluteal fold indicates flexion at the hip which might otherwise escape notice. Pain is complained of in the hip, or is referred to the medial side of the knee, in the distribution of the obturator nerve. Sometimes the pain is confined to the knee, and if the examination is restricted to that joint the disease at the hip may be overlooked. At this stage the attitude of the limb is not constant; at one time it may be natural, and at another slightly flexed and abducted. Tenderness of the joint may be elicited by pressing either in front or behind the head of the bone, but is of little diagnostic importance. Pain elicited on driving the head against the acetabulum may occasionally assist in the recognition of hip disease, but the diagnostic value of this sign has been overrated and, in our opinion, this test should be omitted.

Most information is gained by testing the functions of the joint, and if this is done gently and without jerking, it does not cause pain. The child should lie on his back, either on his nurse's knee or on a table; and to reassure him the movements should be first practised on the sound limb. On slowly flexing the thigh of the affected limb, it will be found that the range of flexion at the hip is soon exhausted, and that any further movement in this direction takes place at the lumbo-sacral junction. The child is next made to lie on his face with the knees flexed in order that the movements of rotation may be tested. The thigh is rotated in both directions, and on comparing the two sides it will be found that rotation is restricted or abolished on the side affected, any apparent rotation taking place at the lumbo-sacral junction. These tests reveal the presence of rigidity resulting from the involuntary contraction of muscles, which is the most reliable sign of hip disease during the initial stage, and they possess the advantage of being universally applicable, even in the case of young children.

Second Stage.--This probably corresponds with commencing disease of the articular surfaces, and progressive involvement of all the structures of the joint. The child complains more, and usually exhibits the attitude of abduction, eversion, and flexion (Fig. 109).

At first the attitude is maintained entirely by the action of muscles; but when it is prolonged, the muscles, fasciae, and ligaments undergo shortening, so that it becomes fixed.

On looking at the patient, the abnormal attitude may not be at once evident, as he usually restores the parallelism of the limbs by lowering the pelvis on the affected side and adducting the sound limb. This obliquity or tilting of the pelvis causes apparent lengthening of the diseased limb, and is best demonstrated by drawing one straight line between the anterior iliac spines, and another to meet it from the xiphoid cartilage through the umbilicus; if the pelvis is in its normal position, the two lines intersect at right angles; if it is tilted, the angles at the point of intersection are unequal. The flexion may be largely compensated for by increasing the forward curve of the lumbar spine (lordosis), and by flexing the leg at the knee. There may also be an attempt to compensate for the eversion of the limb by rotating the pelvis forwards on the affected side.

To demonstrate the lordosis, the patient should be laid on a flat table; in the resting position the lordosis is moderate, when the hip is flexed it disappears, when it is extended the lordosis is exaggerated, and the hand or closed fist may be inserted between the spine and the table (Fig. 112).

When the functions of the joint are tested, it will be found that there is rigidity, and that both active and passive movements take place at the lumbo-sacral junction instead of at the hip. While rigidity is usually absolute as regards rotation, it may sometimes be possible with care and gentleness to obtain some increase of flexion. For diagnostic purposes most stress should therefore be laid on the presence or absence of rotation.

If the sound limb is flexed at the hip and knee until the lumbar spine is in contact with the table, the real flexion of the diseased hip becomes manifest, and may be roughly measured by observing the angle between the thigh and the table (Fig. 113). This is known as "Thomas' flexion test," and is founded upon the inability to extend the diseased hip without producing lordosis.

Swelling is seen on the anterior aspect of the joint; it may fill up the fold of the groin and push forward the femoral vessels. It is doughy and elastic, but may at any time liquefy and form a cold abscess. Swelling about the trochanter and neck of the bone may be estimated by measuring the antero-posterior diameter with callipers, and comparing with the sound side. Swelling on the pelvic aspect of the acetabulum can sometimes be discovered on rectal examination.

Third Stage.--This probably corresponds with caries of the articular surfaces, since pain is now a prominent feature, and there are usually startings at night. The attitude is one of adduction, inversion, flexion, and apparent or real shortening of the limb (Fig. 114). The flexion is usually so pronounced that it can no longer be concealed by lordosis, so that when the patient is recumbent, although the spine is arched forwards, the limb is still flexed both at the hip and at the knee; with the spine flat on the table, the flexion of the thigh may amount to as much as a right angle. The adduction varies greatly in degree; when it is slight, as is most often the case, the toes of the affected limb rest on the dorsum of the sound foot. When moderate, it is compensated for by raising the pelvis on the affected side, with apparent shortening of the limb, this being the result of an effort on the part of the patient to restore the normal parallelism of the limbs, the sound limb being abducted to the same extent as the affected limb is adducted. It is important to recognise the cause of this shortening, as it can be corrected by treatment. As a result of the obliquity of the pelvis, the patient, when erect, exhibits a lateral curvature of the spine with the dorso-lumbar convexity to the sound side.

When adduction is pronounced, the patient is unable to restore the normal parallelism of the limbs, and the knee on the affected side may cross the sound limb. There is a deep groove at the junction of the perineum and thigh, great prominence of the trochanter, and the pelvis may be tilted to such an extent that the iliac crest comes into contact with the lower ribs.

As a result of the pressure of the carious articular surfaces against one another, the acetabulum is enlarged and the upper end of the femur is drawn gradually upwards and backwards within the socket. Examination will then reveal the existence of a variable amount of actual shortening; it will also be found that the trochanter is displaced above Nelaton's line, while above and behind the trochanter there is a prominent hard swelling corresponding to the enlarged acetabulum.

There may, therefore, be a combination of real and apparent shortening together amounting to several inches (Fig. 115).

In cases of long standing, beginning in childhood, the shortening is still further added to by deficient growth in length of the femur, and it may be of all the bones of the limb; even the foot is smaller on the affected side.

The most reasonable explanation of the attitudes assumed in hip disease is that given by Koenig. If the patient walks without crutches, as he is usually able to do at an early stage of the disease, the attitude of abduction, eversion, and slight flexion enables him to save the limb to the utmost extent; on the other hand, if he uses a crutch, as he is obliged to do at a more advanced stage, he no longer uses the limb for support, and therefore draws it upwards and medially into the position of adduction, inversion, and greater flexion. Similarly, if he is confined to bed, he lies on the sound side, and the affected limb sinks by gravity so as to lie over the normal one in the position of adduction, inversion, and flexion. Koenig's explanation accords with the fact that in the exceptional cases which begin with adduction and inversion we have usually to deal with a severe type of the disease, associated with grave osseous lesions--precisely those cases in which the patient is compelled from the outset to lie up or to adopt the use of crutches. Further, the transition from the abducted to the adducted position usually follows upon such an aggravation of the symptoms that the patient is no longer able to walk without the assistance of a crutch.

During the third stage the other signs and symptoms become more pronounced; the patient looks ill and thin, he is usually unable to leave his bed, his sleep is disturbed by startings of the limb, and the rigidity of the joint and the wasting of the muscles are well marked. The temperature may rise slightly after examination of the limb, or after a railway journey.

#Abscess Formation in Hip Disease.#--The formation of abscess is not related to any stage of the disease; it may occur before there is deformity, and it may be deferred until the disease is apparently cured. Its importance lies in the fact that if a mixed infection with pyogenic organisms occurs, the gravity of the condition is greatly increased.

An abscess may appear in the thigh in front or behind the joint. The anterior abscess emerges on one or other side of the psoas muscle; from the resistance offered by the fascia lata, the pus may gravitate down the thigh before perforating the fascia. It has occasionally happened that when such an abscess has been opened and become infected with pyogenic organisms, the femoral vessels have been eroded, and serious or even fatal haemorrhage has resulted. The posterior abscess appears in the buttock and may make its way to the surface through the gluteus maximus; more often it points at the lower border of this muscle in the region of the great trochanter, or it may gravitate down the thigh.

Abscesses which form within the pelvis originate either in connection with the acetabulum or in relation to the psoas muscle where it passes in front of the joint. Those that are directly connected with disease of the acetabulum may remain localised to the lateral wall of the pelvis, or may spread backwards towards the hollow of the sacrum. They may open into the bladder or rectum, or may ascend into the iliac fossa and point above Poupart's ligament (Fig. 115), or descend towards the ischio-rectal fossa. The abscess which develops in relation to the psoas muscle may be shaped like an hour-glass, one sac occupying the iliac fossa, the other filling up Scarpa's triangle, the two sacs communicating with each other through a narrow neck beneath Poupart's ligament.

So long as the skin is intact, the abscess is unattended with symptoms, and may escape notice. If it bursts externally, pyogenic infection is almost inevitable, and the patient gradually passes into the condition of hectic fever or chronic toxaemia; he loses ground from day to day, may become the subject of waxy disease in the viscera, or may die of exhaustion, tuberculous meningitis, or general tuberculosis.

#Dislocation# is a rare complication of hip disease, and is most likely to occur during the stage of adduction with inversion. It has been known to take place during sleep, apparently from spasmodic contraction of muscles. In the dorsal dislocation, which is the most common form, adduction and inversion are exaggerated, the trochanter projects above and behind Nelaton's line, and the head of the bone may be felt on the dorsum ilii. It is a striking fact that after dislocation has occurred there is less complaint of pain or of startings than before, and passive movements may be carried out which were previously impossible.

#Diagnosis of Hip Disease.#--The diagnosis is to be made not only from other affections of the joint, but also from morbid conditions in the vicinity of the hip, as in any of these the patient may seek advice on account of pain and a limp in walking. The patient should be stripped, and if able to walk, his gait should be observed. He is then examined lying on his back, and attention is directed to the comparative length of the limbs, to the attitude of the limbs and pelvis, and to the movements at the hip-joint, especially those of rotation. When there is any doubt as to the diagnosis, the examination should be repeated at intervals of a few days. In children, there are three non-febrile conditions attended with a limp and with shortening of the limb, which may be mistaken for hip disease,--congenital dislocation, coxa vara, and paralysis following poliomyelitis--but in all of these the movements are not nearly so restricted as they are in disease of the joint.

In tuberculous disease of the sacro-iliac joint, while the pelvis may be tilted, and the limb apparently lengthened, the movements at the hip are retained. In tuberculous disease of the great trochanter, or of either of the bursae over it, while there may be abduction, eversion, impairment of mobility, and swelling in the region of the trochanter followed by abscess formation, the movements are less restricted than in disease of the joint.

In psoas abscess associated with spinal disease, or in disease of the bursa underneath the psoas, the limb is flexed and everted, there may be lordosis, and the patient may limp in walking, but the movements at the hip are restricted only in the directions of extension and inversion, while in hip disease they are restricted in all directions.

New-growths in the vicinity of the hip--especially central sarcoma of the upper end of the femur--are difficult to differentiate from hip disease without the help of the X-rays.

Among other conditions which by interfering with the free mobility of the hip may simulate hip disease, are appendicitis, inflammation of the glands in the groin, staphylococcal disease of the upper end of the femur, and sciatica.

The diagnosis from other diseases of the hip-joint is made by careful consideration of the history, symptoms, and X-ray appearances.

#Prognosis.#--The prognosis in hip disease is more serious than in tuberculosis of other joints, excepting only those of the spine, and it is most unfavourable when there are gross lesions of the bones and infected sinuses.

Whatever the stage of the disease, recovery is a slow process, and even in early and mild cases it seldom takes place in less than one or two years, and is liable to be attended with some impairment of function. During the process of cure, complications are liable to occur, and after apparent recovery relapses are not uncommon. When arrested during the initial stage, recovery may be complete; but when there has been destruction of the articular surfaces, there is apt to be ankylosis of the joint and shortening of the limb.

In cases which terminate fatally, death usually results from meningeal, pulmonary, or general tuberculosis, or from pyogenic complications and waxy degeneration.

#Treatment.#--A large proportion of cases recover under conservative treatment, and the functional results are so much better than those following operative interference that unless there are special indications to the contrary, conservative measures should always be adopted in the first instance.

Conservative Treatment.--The first essential is to take the weight off the limb and secure its fixation in the attitude of almost complete extension and moderate abduction. When the symptoms are well marked, the child is kept in bed and the limb is extended with a weight and pulley.

Extension by Weight and Pulley (Fig. 116).--The weight employed varies from one to four pounds in children, to ten or more pounds in adolescents and adults, and must be adjusted to meet the requirements of each case. If pain returns after having been relieved, it is due to stretching of the ligaments, and the weight should be diminished or removed for a time. If there is deformity, the line of traction should be in the axis of the displaced limb until the deformity is got rid of. The extension should be continued until pain, tenderness, and muscular contraction have disappeared, and the limb has been brought into the desired attitude.

In restless children, in addition to the extension, a long splint is applied on the sound side and a sand-bag on the affected one; or, better still, a double long splint and cross-bar, the long splint on the affected side being furnished with a hinge opposite the hip to permit of varying the degree of abduction (Fig. 117).

When the deformed attitude does not yield rapidly to extension, it should be corrected under an anaesthetic, and if the adductor tendons and fasciae are so contracted that this is difficult, they should be forcibly stretched or divided.

The immediate correction of deformed attitudes under anaesthesia has largely replaced the more gradual method by extension with weight and pulley; and in hospital practice it is usually followed by the application of a plaster case. The plaster bandages are applied over a pair of knitted drawers; the pelvis and both thighs, the diseased one in the abducted position, are included. The case may be strengthened by strips of aluminium, and should be renewed every six weeks or two months.

Ambulant Treatment.--When the patient is able to use crutches, the affected limb is prevented from touching the ground by fixing a patten on the sole of the boot on the sound side. This may suffice, or, in addition, the hip-joint is kept rigid by a Thomas' (Fig. 118) or a Taylor's splint. The Thomas' splint must be fitted to the patient under the supervision of the surgeon, who must make himself familiar with the construction of the splint, and its alteration by means of wrenches.

In children who are unable to use crutches, a double Thomas' splint is employed; the child thereby is converted into a rigid object, capable of being carried from one room to another and into the open air. Personally we have obtained satisfaction from the double Thomas' splint employed for spinal disease, which extends from the occiput to the soles of the feet.

The fixation of the hip-joint and the taking of the weight off the limb by one or other of the above methods, should, as a general rule, be continued for at least a year.

Should an abscess develop, it is treated on the usual lines.

Operative Interference.--Widely diverse opinions are held on the question as to whether or not recourse should be had to operative interference.

Some surgeons are opposed to operative interference, on the grounds that however advanced the disease may be it will yield to conservative measures if judiciously and perseveringly carried out. Other surgeons advocate operative treatment in all cases which do not speedily show improvement under conservative treatment. An intermediate attitude may be adopted which recommends operation in cases in which the disease progresses in spite of conservative treatment, and in which periodic examination with the X-rays shows that there are progressive lesions in the upper end of the femur or in the acetabulum.

It is claimed by those who advocate operation under these conditions that pain and suffering are at once got rid of, sleep is restored, appetite returns, and there is a marked improvement in the general health, and that this result is obtained in months instead of years, and that the cure is more likely to be permanent. It is certainly unwise to delay operation until sinuses have formed, as such a course is largely responsible for the bad results which formerly followed excision of the joint.

Amputation for tuberculous disease of the hip has become one of the rarest of operations, but is still required in cases which have continued to progress after excision, and when there is disease of the pelvis or of the shaft of the femur, with sinuses, albuminuria, and hectic fever.

#The Correction of Deformity resulting from Antecedent Disease of the Hip.#--From neglect or from improper treatment, deformity may have been allowed to persist, while the disease has undergone cure. It is associated with ankylosis of the joint, or contracture of the soft parts or both. The contracture of the soft parts involves specially the tendons, fasciae, and ligaments on the anterior and medial aspects of the joint, and is usually present to such a degree that, even if the joint were rendered mobile, these shortened structures would prevent correction of the deformity. The usual deformity is a combination of shortening, flexion, and adduction.

#Bilateral Hip Disease.#--Both hip-joints may become affected with tuberculous disease, either simultaneously or successively, and abscesses may form on both sides. The patient is necessarily confined to bed, and if the disease is recovered from, his capacity for walking may be seriously impaired, especially if the joints become fixed in an undesirable attitude. The most striking deformity occurs when both limbs are adducted so that they cross each other--one variety of the "scissor-leg" or "crossed-leg" deformity--in which the patient, if able to walk at all, does so by forward movements from the knees. An attempt should be made by arthroplasty to secure a movable joint at least on one side.

OTHER DISEASES OF THE HIP-JOINT

#Pyogenic Diseases# are met with in childhood and youth as a result of infection with the common pyogenic organisms, gonococci, pneumococci, or typhoid bacilli. While the organisms usually gain access to the tissues of the joint through the blood stream, a direct infection is occasionally observed from suppuration in the femoral lymph glands or in the bursa under the ilio-psoas.

The clinical features are sometimes remarkably latent and are much less striking than might be expected, especially when the hip affection occurs as a complication of an acute illness such as scarlet fever. It may even be entirely overlooked during the active stage, and only noticed when the head of the femur is found dislocated, or the joint ankylosed. In the acute arthritis of infants also, the clinical features may be comparatively mild, but as a rule they assume a type in which the suppurative element predominates. The limb usually becomes flexed and adducted, and a swelling forms in front of the joint at the upper part of Scarpa's triangle; the upper femoral epiphysis may be separated and furnish a sequestrum.

The flexion and adduction of the limb favour the occurrence of dislocation. A child who has recovered with dislocation on to the dorsum ilii is usually able to walk and run about, but with a limp or waddle which becomes more pronounced as he grows up. The condition closely resembles a congenital dislocation, but the history, and the presence of gross alterations in the upper end of the femur as seen with the X-rays, should usually suffice to differentiate them.

Treatment.--In the acute stage the limb is extended by means of the weight and pulley, and kept at rest with the single or double long splint, or by sand-bags. If there is suppuration, the joint should be aspirated or opened by an anterior incision, and Murphy's plan of filling the joint with formalin-glycerine may be adopted. In children, it is remarkable how completely the joint may recover.

If there is dislocation, the head of the femur should be reduced by manipulation with or without preliminary extension; it has been successful in about one-half of the cases in which it has been attempted. Preliminary tenotomy of the shortened tendons is required in some cases. When reduction by manipulation is impossible, the joint structures should be exposed by operation and the head of the bone replaced in the acetabulum. When the upper end of the femur has disappeared, the neck should be implanted in the acetabulum, and the limb placed in the abducted position.

#Arthritis Deformans.#--This disease is comparatively common at the hip, either as a mon-articular affection or simultaneously with other joints.

The changes in the joint are characteristic of the dry form of the disease, and affect chiefly the cartilage and bone. The atrophy and wearing away of the articular surfaces are accompanied by new formation of cartilage and bone around their margins. The head of the femur may acquire the shape of a helmet, a mushroom, or a limpet shell, and from absorption of the neck the head may come to be sessile at the base of the neck, and to occupy a level considerably below that of the great trochanter (Fig. 120). These changes sometimes extend to the upper part of the shaft, and result in curving of the shaft and neck, suggesting a resemblance to a point of interrogation (Fig. 121). The acetabulum may "wander" backwards and upwards, as in tuberculous disease. It is usually deepened, and its floor projects on the pelvic aspect; its margins may form a projecting collar which overhangs the neck of the femur, or grasps it, so that even in the macerated condition the head is imprisoned in the socket and the joint locked. There is eburnation of the articular surfaces in those areas most exposed to friction and pressure.

These changes are necessarily associated with restriction of movement, and in advanced cases with striking deformity, which consists in shortening of the limb, usually with eversion and displacement of the trochanter upwards and backwards in relation to Nelaton's line.

The clinical features are usually so characteristic that there is little difficulty in diagnosis. Restriction of the movements of abduction and adduction, the presence of cracking and of grating of the articular surfaces, and the aggravation of the pain and stiffness after resting the limb, are characteristic of arthritis deformans. The prominence of sciatic pain may lead to the disease being regarded as sciatica.

The greatest difficulty is met with in cases in which the disease occurs as mon-articular affection in adolescents, for the resemblance to tuberculous disease of the hip and to coxa vara may be close. Skiagrams do not always enable one to differentiate between them.

Treatment is conducted on the same lines as in other joints. The normal movements are maintained by suitable exercises, and an effort is made to diminish the pressure on the articular surfaces in walking by the use of sticks or crutches.

Shortening of the limb may be compensated by raising the sole of the boot. When the X-rays show that the disability is mainly due to new bone locking the head of the femur, such new bone may be removed by operation, cheilotomy (Sampson Handley). Excision of the joint has in some cases yielded satisfactory results; it is indicated in young patients who are otherwise healthy, and who are unable to walk on account of pain and deformity.

#Osteo-chondritis Deformans Juvenilis.#--Under this term Perthes describes an affection of the hip in children which differs in many respects from the juvenile form of arthritis deformans. Islands of cartilage appear in the epiphysis of the head of the femur, and the epiphysis itself becomes flattened without involvement of the articular surface or of the acetabulum.

The disease is met with in children between five and ten; there is a limp in walking without pain or sensitiveness, so that the child continues to take part in games. Abduction is markedly restricted and the trochanter is elevated and prominent. There is no crepitation on movement or other signs of involvement of the articular surfaces. The X-rays show the deformity of the head and clear areas in the interior of the upper epiphysis corresponding to the islands of cartilage; these clear areas resemble those due to caseous foci in tuberculous coxitis.

The disease runs a chronic course, and in the course of a year or two the limp and the restriction of abduction disappear, so that no active treatment is called for.

#Neuro-Arthropathies.#--Charcot's disease is usually met with in men over thirty who suffer from tabes dorsalis. One or both hip-joints may be affected. Sometimes the first manifestation is a hydrops and a fluctuating swelling in the upper part of Scarpa's triangle. In many of the recorded cases, however, attention has first been directed to the disease by the deformity and limp associated with disappearance of the head of the femur, or by the occurrence of pathological dislocation. The absence of pain and tenderness is characteristic. When dislocation has occurred, the limb is short, and the upper end of the femur is freely movable on the dorsum ilii. When both hips are dislocated, the attitude and gait are similar to those observed in bilateral congenital dislocation. The rotation arc of the great trochanter may be much reduced as a result of the disappearance of the head of the femur. There may be considerable formation of new bone, giving rise to large tumour-like masses in relation to the capsular ligament and the muscles surrounding the joint.

The treatment consists in protecting and supporting the joint. When the affection is unilateral, advantage may be derived from a Thomas' or other form of splint, along with a patten and crutches; in bilateral cases, from the use of crutches alone.

Loose bodies in the hip are mostly the result of hypertrophy of synovial fringes in arthritis deformans and in Charcot's disease, and do not figure in the clinical features of these affections; Caird has observed a case in which the cavity of the joint and the bursa beneath the psoas were filled with loose bodies, many of which had undergone ossification and gave a characteristic picture with the X-rays.

Hysterical affections of the hip resemble those in other joints.

THE KNEE-JOINT

The knee is more often the seat of disease than any other joint in the body.

The synovial membrane extends beneath the quadriceps extensor as a cul-de-sac, which either communicates with the sub-crural bursa, or forms with it one continuous cavity. When the joint is distended with fluid, this upper pouch bulges above and on either side of the patella, and this bone is "floated" off the condyles of the femur. When there is only a small amount of fluid, it is most easily recognised while the patient stands with his feet together and the trunk bent forwards at the hip-joints, and the quadriceps completely relaxed; the fluid then bulges above and on each side of the patella, and its presence is readily detected, especially on comparison with the joint of the other side.

On account of the great extent of the synovial membrane, a large quantity of serous effusion may accumulate in the joint in a comparatively short time, as a result either of injury or disease. The villous processes and fringes may take on an exaggerated growth, and give rise to pedunculated and other forms of loose body.

The bursae in the popliteal space, especially that between the semi-membranosus and the medial head of the gastrocnemius, as well as the sub-crural bursa, frequently communicate with the synovial cavity of the knee and may share in its diseases.

As the epiphyses at the knee are mainly responsible for the growth in length of the lower extremity, and are late in uniting with their respective shafts--twenty-one to twenty-five years--serious shortening of the limb may result if their functions are interfered with, whether by disease or injury. The epiphysial cartilages lie beyond the limits of the synovial cavity, so that infective lesions at the ossifying junctions are less likely to spread to the joint than is the case at the hip or shoulder, where the upper epiphysis lies partly or wholly within the joint; disease in the lower end of the femur is more likely to implicate the knee-joint than disease in the upper end of the tibia.

One of the commonest causes of prolonged disability and feeling of insecurity in the knee, is to be found in the wasting and loss of tone in the quadriceps extensor muscle; the feeling of insecurity is most marked in coming down stairs. The instability of the joint is often added to by stretching of the ligaments and lateral mobility. As a result of both of these factors the joint is liable to repeated slight strains or jars which irritate the synovial membrane and tend to keep up the effusion and excite the overgrowth of its tissue elements.

TUBERCULOUS DISEASE

While tuberculous disease of the knee is specially common in childhood and youth, it may occur at any period of life, and is not uncommon in patients over fifty. The disease originates in the synovial membrane and in the bones respectively with about equal frequency.

When the synovial membrane is diseased, it tends to grow inwards over the articular surfaces (Fig. 122), shutting off the supra-patellar pouch and fixing the knee-cap to the femur, and diminishing the area of the articular surfaces. The ingrowth of synovial membrane may fill up the cavity of the joint, or may divide it up into compartments. Ulceration of the cartilage and caries of the articular surfaces are common accompaniments.

The femur and tibia are affected with about equal frequency, and the nature and seat of the bone lesions are subject to wide variations. Multiple small foci may be found beneath the articular cartilage of the tibia, or along the margins of the femoral condyles--especially the medial. Caseating foci are comparatively rare, but they sometimes attain a considerable size--especially in the head of the tibia, where they may take the form of a caseous abscess. Sclerosed foci, which form sequestra, are comparatively common (Fig. 123).

#Clinical Types.#--(1) Hydrops usually arises from a purely synovial lesion, but the joint may suddenly become distended with fluid when an osseous focus ruptures into the synovial cavity.

It is met with chiefly in young adults. As the fluid accumulates it gradually stretches the capsule, and pushes the patella forwards, so that it floats. There is little pain or interference with function; the patient is usually able to walk, but is easily tired. The amount of fluid diminishes under rest, and increases after use of the limb. In a certain number of cases it may be possible to recognise localised thickening of the synovial membrane, or the presence of floating masses of fibrin or melon-seed bodies. This is best appreciated if the knee is alternately flexed and extended by the patient while the surgeon grasps and compresses it with both hands. If the joint is opened, fibrinous material, often in the form of melon-seed bodies, may be found lining the synovial membrane.

Tuberculous hydrops is to be diagnosed from the effusion that results from repeated sprain, from the hydrops of loose body, gonorrhoea, arthritis deformans, Charcot's disease, and Brodie's abscess in the adjacent bone, and from the haemarthrosis met with in bleeders.

(2) Papillary or Nodular Tubercle of the Synovial Membrane.--This is a condition in which there is a fringy, papillary, or polypoidal growth from the synovial membrane. It is most often met with in adult males. The onset and progress are gradual, and the chief complaint is of stiffness and swelling which are worse after exertion. Sometimes there are symptoms of loose body, such as occasional locking of the joint, with pain and inability to extend the limb; but the locking is easily disengaged, and the movements are at once free again. The patient may give a history of several years' partial and intermittent disability, with lameness and occasional locking, although he may have been able to go about or even to continue his occupation.

There is a moderate degree of effusion into the joint, and when this has subsided under rest it may be possible to feel ill-defined cords, or tufts, or nodular masses, and to grasp between the fingers those in the supra-patellar pouch. There is little wasting of muscles, and it is exceptional to have signs of disease of the articular surfaces or of cold abscess.

On opening the joint, there may escape fluid and loose bodies similar to those described under hydrops, and if the finger is introduced into the cavity, the upper pouch is felt to be occupied by fringes or polypoidal processes derived from the synovial membrane.

The diagnosis is to be made from arthritis deformans, and in some cases from loose body of other than tuberculous origin.

(3) Cold abscess or empyema of the knee is a rare condition, in which the joint becomes filled with pus. It usually results from a primary tuberculosis of the synovial membrane occurring in children reduced in health and the subject of tuberculosis elsewhere.

(4) Diffuse Thickening of the Synovial Membrane--White Swelling.--So long as this form of the disease remains confined to the synovial membrane, the chief feature is that of an indolent elastic swelling in the area of the joint. The swelling tapers off above and below, so that it acquires a fusiform shape, and from the wasting of the muscles it appears greater than it really is. The range of movement is moderately restricted.

At first the patient limps, keeps the knee slightly flexed, and complains of tiredness and stiffness after exertion. As the articular surfaces become affected, there is pain, which is readily excited by jarring of the limb, or by any attempt at movement; the joint is held rigid, and there may be startings at night. If untreated, flexion becomes more pronounced--it may be to a right angle--the leg and foot are everted, and, in children, the tibia may be displaced backwards (Fig. 124). The wasting of muscles continues, the part becomes hot to the touch, the swelling increases, and may show areas of softening or fluctuation from abscess formation.

White swelling is to be differentiated from peri-synovial gummata, from myeloma and sarcoma of the lower end of the femur, and from bleeder's knee. In the first of these the swelling is nodular and less uniform, and there may be tertiary ulcers or depressed scars in the neighbourhood of the patella. In tumours the swelling is more marked on one side of the joint, it is uneven or nodular, it does not correspond to the shape of the synovial membrane, and may extend beyond the limits of the joint, and it involves the bone to a greater extent than is usual in disease of the joint. Skiagrams show expansion of the bone in central tumours, or abundant new bone in ossifying sarcoma. The diagnosis of bleeder's knee is to be made from the history.

(5) Primary Tuberculous Disease in the Bones of the Knee.--So long as the foci are confined to the interior of the bone, it is impossible to recognise their existence, unless they are of sufficient size to cause enlargement of the bone or to be discernible in a skiagram.

#The formation of peri-articular abscess# takes place in rather more than fifty per cent. of cases. When left to themselves, such abscesses tend to spread up the thigh, or down the back of the leg between the superficial and deep layers of calf muscles, and numerous sinuses may result from their rupture through the skin.

#Attitudes of the Limb in Knee-Joint Disease.#--The attitude most often assumed is that of flexion, with or without eversion of the leg and foot. The flexion is explained by its being the resting attitude of the joint, and that which affords most ease and comfort to the patient. Once the joint is flexed, the involuntary contraction of the flexor muscles maintains the attitude, and if the patient is able to use the limb in walking, the weight of the body is a powerful factor in increasing it. The eversion of the leg is probably associated with contraction of the biceps muscle. Backward displacement of the tibia is met with chiefly in neglected cases of chronic disease of the knee when the child has walked on the limb after it has become flexed.

In certain cases, genu valgum or abduction of the leg is present along with a slight degree of flexion. The valgus attitude is associated with slight lateral displacement of the patella, with prominence and apparent enlargement of the medial condyle, with depression of the pelvis on the diseased side and apparent lengthening of the limb.

#Treatment of Tuberculous Disease of the Knee.#--Conservative measures are always indicated in the first instance, and are persevered with so long as there is a prospect of obtaining a movable joint.

Conservative Treatment.--If the joint is sensitive and tends to be flexed, the patient is confined to bed, the limb is secured to a posterior splint, and extension with weight and pulley persevered with until these symptoms have disappeared; during this time, from three to six weeks, methods of inducing hyperaemia and other anti-tuberculous procedures are employed. If it is proposed to inject iodoform or other drug, the needle is inserted into the interval between the bones on the medial side of the ligamentum patellae or into the upper pouch when this is distended with fluid.

If there is no pain or tendency to flexion, or when these have been overcome, the limb is put up in a Thomas' splint (Fig. 125) and the patient allowed to go about. The splint is worn for a period varying from six to twelve months; before being discarded it may be left off at night; it is ultimately replaced by a bandage.

The indications for operative treatment are: (1) marked symptoms of destruction of the articular cartilages; (2) a deformed attitude incapable of being rectified without operation; (3) a condition of the general health which requires that the disease should be got rid of as speedily as possible; (4) progress or persistence of the disease in spite of conservative treatment. When there is no prospect of recovery with a movable joint it is a waste of time and a possible source of danger to persevere with conservative measures. Operation permits of the disease being eradicated and the restoration of a useful limb within a reasonable time, averaging from three to six months.

In adults, the operation consists in excising the joint; in children the aim is to remove the diseased tissues without damaging the epiphysial cartilages.

Amputation is performed when the disease has relapsed after excision and there is persistent suppuration, and when life is threatened by the occurrence of tuberculosis in the lungs or elsewhere.

#Treatment of Deformities resulting from Antecedent Diseases of the Knee.#--Flexion is the commonest of these; when due to contracture of the soft parts, these are either stretched by degrees, the limb being encased in plaster after each sitting, or they are divided by open dissection in the popliteal space. If there is fibrous or osseous ankylosis, the choice lies between arthroplasty, the removal of a wedge of bone which includes the joint, or, in patients who are still growing, of a wedge from the femur above the level of the epiphysial cartilage. Backward displacement of the tibia, genu recurvatum, and genu valgum also require operative treatment.

OTHER DISEASES OF THE KNEE-JOINT

#Pyogenic diseases# result from infection through the blood stream, from one of the adjacent bones, or from a penetrating wound of the joint. The commoner types include the synovitis associated with disease in the adjacent bone, acute arthritis of infants, joint suppuration in pyaemia, pyogenic arthritis following upon penetrating wounds, and the affections which result from gonorrhoeal or pneumococcal infection.

Treatment.--The limb is immobilised on a posterior splint so padded as to allow slight flexion at the knee, and extension applied with sufficient weight to relieve the pain; it is also of benefit to induce hyperaemia by one or other of the methods devised by Bier. To tap the joint, the needle is introduced obliquely into the supra-patellar pouch, and if it is necessary to open the joint, the incision is made on one or on both sides of the patella, and Murphy's plan of inserting formalin-glycerine may be employed. If the infection progresses and threatens the life of the patient, it may be necessary to lay the joint freely open from side to side, sawing across the patella, and, the limb being flexed, the whole wound is left open and packed with gauze. As the infection subsides, the limb is gradually straightened. If these methods fail, amputation through the thigh may be the only means of saving life.

#Arthritis deformans# affects the knee more frequently than any of the other large joints. The changes related to the synovial membrane here attain their maximum development, and may assume the form of hydrops with or without fibrinous bodies, or of overgrowth of the synovial fringes and the formation of pedunculated loose bodies. It is suggested that these synovial changes follow upon repeated sprains or upon a previous pyogenic infection of the joint. The effusion and stretching of the ligaments that follow upon a sprain are incompletely recovered from; the synovial membrane becomes puckered, the quadriceps atrophies and no longer puts the ligamentum mucosum on the stretch; and the infra-patellar pad of fat, not undergoing the normal compression during extension, is readily nipped between the femur and tibia. Each nipping implies a fresh sprain, with return of the effusion, and so a vicious circle is set up which terminates in what has been called a villous arthritis, with fringes and loose bodies; in time, the articular cartilage at the line of the synovial reflection undergoes fibrillation and conversion into connective tissue, and the process spreading to the articular surfaces, the picture of a rheumatoid arthritis is complete. Fibrillation of the cartilage imparts a feeling of roughness when the joint is grasped during flexion and extension, and lipping of the margins of the trochlear surface of the femur may be felt when the joint is flexed; it is also readily seen in skiagrams. When a portion of the "lipping" is broken off, it may give rise to a loose body. In advanced cases with destruction of the cartilages, there may be movement from side to side, with grating of the articular surfaces.

In the early stages, treatment consists in limiting the movements of extension by means of a splint provided with a hinge that locks at thirty degrees from full extension and vigorous massage of the quadriceps. In the dry, creaking forms of arthritis, the symptoms are relieved by introducing liquid vaseline into the joint. When the symptoms are due to the presence of fringes and loose bodies, these may be removed by operation. When the disease is of a severe type, and is confined to one knee, the question of excising the joint may be considered.

Bleeder's knee, Charcot's disease, hysterical knee, and loose bodies in the joint have already been described.

THE ANKLE-JOINT

There is a common synovial cavity for the ankle and the inferior tibio-fibular joints. The epiphysial cartilage of the tibia lies above the level of this synovial cavity, but that of the fibula is included within its limits (Fig. 93). The talus is related to three articulations--the ankle above, the talo-navicular joint in front, and the calcaneo-taloid joint below. The tendon sheaths, especially those of the peronei and of the tibialis posterior, are liable to be infected by the spread of infective disease from the joint.

#Tuberculous Disease.#--Tuberculous disease at the ankle is met with at all ages. In the majority of cases the disease affects both bone and synovial membrane. Gross lesions in the bones are comparatively rare, and are chiefly met with in the head or neck of the talus.

Primary synovial disease usually exhibits the features of white swelling, projecting beneath the extensor tendons on the dorsum, and, posteriorly, filling up the hollows on either side of the tendo Achillis and below the malleoli (Fig. 126). The foot may retain its normal attitude, or the toes may be pointed and adducted. The calf muscles are wasted, there is little complaint of pain, and the movements of the joint may be so little interfered with that the patient can walk without a limp. When the disease involves the articular surfaces, there is pain and sensitiveness, the movements are restricted or abolished, and the patient is unable to put the foot on the ground.

A primary focus in the bone causes localised pain and tenderness, and a limp in walking, but the first sign may be the formation of abscess or the rapid development of articular symptoms. In such cases skiagrams afford valuable information.

Abscess formation is an early and prominent feature, whether the disease is of osseous or synovial origin, and sinuses are liable to form around the joint. Outlying abscesses and sinuses are usually the result of infection of the tendon sheaths in the neighbourhood.

Diagnosis.--When teno-synovitis occurs independently of disease of the ankle, the swelling is confined to one aspect of the joint. In sarcoma of the lower end of the tibia, the swelling lacks the uniform distribution of that met with in joint disease. In Brodie's abscess of the lower end of the tibia there may be swelling of the ankle, but there is an area of special tenderness on percussion over the bone.

Treatment.--The foot is immobilised at a right angle to the leg by splints or plaster of Paris; if articular symptoms are absent or have subsided, a Thomas' knee splint should be applied to enable the patient to move about without bearing his weight on the affected foot (Fig. 125). To inject iodoform, the point of the needle is inserted below either malleolus, and is then pushed upwards alongside of the talus. If localised disease in one of the bones is recognised before the joint is infected, it should be eradicated by operation.

When the disease is diffuse and resists conservative treatment, excision should be performed, the articular surfaces of the constituent bones being removed, and if necessary the whole of the talus.

Amputation is only called for in adults with rapidly progressing disease and diffuse suppuration, and in cases which have relapsed after excision.

The other diseases of the ankle include pyogenic, gonorrhoeal, rheumatic, gouty, and hysterical affections, arthritis deformans, and Charcot's disease. The last-named is generally associated with a rapid and painless disintegration of the bones of the ankle and tarsus, resulting in great deformity and loss of the arch of the foot--sometimes associated with perforating ulcer of the sole.

Tuberculous disease in the #tarsus#, #metatarsus#, and #phalanges# has been considered in the chapter on Diseases of Bone.