The principles of orthopedic surgery for nurses

Front matter

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Preface

THE material in this book is the result of many lectures to nurses on orthopedic surgery. It has been found that lectures alone will not fill the need for more detailed and visual knowledge. Most nurses never have adequate training in the care of orthopedic cases, as such cases generally make up but a small part of the work in a general hospital. It has seemed necessary, therefore, to the author that adequate and primary knowledge of orthopedic surgery and its essentials of nursing technique should be supplied, so that all training schools should be able to provide, at least through a text book, satisfactory and fundamental knowledge of orthopedic surgery to their pupils. It is in no sense intended to be a medical text book, but is intended to supply the nurses with a knowledge of what orthopedie surgery comprehends, and the most accepted methods of treatment. The material is largely drawn from the Children’s Hospital, Boston, and the nursing technique is the result of many years’ experience in its wards.

I am under the greatest obligation to Miss Ida C. Smith,

Superintendent of the Children’s Hospital, for valuable aid and —eodperation in obtaining material for this book; also to Miss Wakefield, Superintendent of Nurses, and her assistants, Miss Gilman and Miss Tabor, for their assistance in reading and suggestions in regard to the manuscript.

Introduction

OrtTHopepic Surgery has been described and accepted by the American Orthopedic Association as the surgery of deformities and disabilities of the apparatus of locomotion. This broad field includes deformities and disabilities of the trunk as well as those of the arms and legs. They may be divided roughly into those which are congenital in origin, and those which have been acquired by accident or disease. In this book, the congenital defects will be presented first as the natural order suggests.

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Contents

PAGE EE ra, ta Bay, eR RP a ny tn Re 1 Ouvs Paar... +... > Pe sh oie al pve en 4 1 CONGENITAL Simeiseion OF THE «To. SVE eee ae ge tae hoe! be 6 TORTICOLLIS OR Wry NECK eee hee aie et Moe Ws ec 2 i Spina Brripa OccuLTA . . . a i yg CONGENITAL DEFORMITIES Antsiaaeen WITH ‘Baraotien Darnton: MENT. fe Chip Ga EES Maia gh cd 20 CONGENITAL or Saiee Pe SEPM Oa 4 Th 24 CONGENITAL Rapio-ULNAR SYNOSTOSIS . ....... 24 CONGENITAL ELEVATION OF THESCAPULA . . .. ... . 25 ee eee arenes Se a ee a See ge ee cs a a 26 RE 8 gy hg) Go tte te aes Me Ne a MS oF ie ene ge Roe 2b eee ee eS ak Ve MMII? eb Pinna te re eg ae GE ee be LN bok 41 ScHooL SEATING . . . Se Ct a ae eee i ee rn 54 PAINFUL AND IRRITABLE ieee Se ey Wenn et Ot) Ba oh te ee 60 SUMP ee ey oe ee a ee) dy ed eS get MO et 6 Tr TOBEROULOSIS.OF TH BPINE. .o . 9 oie eet we ate 71 TUBERCULOSIS OF THE HIP . 5, 9 <¢ «© «ws «© «6 « © «© «@ 89 TOREROULGEIA OP TUS NER «5s 6 6 ow el le el 99 TUSEROULOSIS GF Tum ANKIN-.).. . « « « «se « « » 100 TUBERCULOSIS OF THE SHOULDER ......... . «2116 TUBERCULOSIS OF THE ELBOW .... =.=... i... 120 Tommcviess op tun Whee . st lk ltl ll et ltl lo 188 eee ee ee a gl, A a OR ke fw Cee PANIC, Meat So fu i eA et as hl ee 8 Uw AO OBSTETRICAL PARALYSIS. . . re che ae oss he Oe Ee VOLKMANN’sS ISCHEMIC Dixicrens Ee tee al ee enema (3 MipeOuLe-Grimat, Passive 2 «lt lt lhl} Uw es | | ee See eee sper wm yh fen ge oe ee ee INTERNAL DERANGEMENTS OF THE KNEE. . . . .. . . 159 PeerParentan Bomeivie .. 05 8 sw cw wl Ue! Ue 160 DUPUYTREN’S CONTRACTION AT eae ee en Sale ol i cy Er rr: |; | xi xii CONTENTS

GANGLION TENNIS ELBOW SUBDELTOID BurSITIS

CHAPTER VII

Chapter II

Osteomyelitis —Osteomyelitis is an acute suppurative inflammation of the bone, and secondary to an infection by some pyogenic bacteria. The process in the bone is frequently secondary to suppurative foci elsewhere, such as running ears, infection of the tonsils, pneumonia, pleurisy or empyema, scarlet fever, typhoid fever, ete. The infection is carried in the blood stream from its original source to the bone affected. The most common organism is the staphylococcus pyogenes aureus. The other two most common are the staphylococcus albus and the streptococcus pyogenes.

The disease usually occurs in children, and about one half the cases occur between the ages of 13 and 17, although it is very often seen in young children. Boys are more often affected than girls, and the condition appears to follow injury, fatigue, or exposure to cold or wet. It is more apt to occur in individuals whose bones have not fully developed, and before the diaphysis has fused with the epiphysis.

Osteomyelitis nearly always begins in the diaphysis of the bone, usually near the epiphyseal line. The femur and tibia are the bones most frequently attacked, but no bones are exempt. Usually only one bone is affected primarily, but others may be involved secondarily.

The primary area of infection is always in the bone marrow, near the epiphyseal line. The infection may extend very rapidly along the shaft of the bone, and involve the entire marrow. It may extend quite easily through the dense cortical bone, and so produces an inflammatory exudate and abscess between the periosteum and the outer layer of cortical bone. It may strip the periosteum from the entire length of the shaft. This condition may exist as early as the third or fourth day. As the periosteum is raised, new bone forms under it and around the infected 26 shaft. This new bone is known as the involucrum. This involucrum. later develops into a new shaft or bone to take the place of the one destroyed by the infection.

No. 28.—AcuTe CAsE oF OSTEOMYELITIS OF TIBIA INVOLVING WHOLE SHAFT.

The disease usually begins with sudden local pain, generally becoming quite severe and occasionally throbbing in character. The pain is usually referred to the shaft of one of the long bones near the epiphyseal end. Pressing the bone with the fingers oftentimes elicits pain. Local swelling may appear early, which at first is not red but soon becomes much reddened. The adjacent joint frequently becomes tender, hot and swollen. The temperature of the child may rise to 103 or 104, and the pulse usually is rapid. There is considerable evidence of constitutional disturbance, and the child may be very sick and delirious.

There are certain types of lo-

No. 29.—BropiE’S ABSCESS OR LOCALIZED OSTEOMYELITIS IN LOWER END oF TIBIA.

cal osteomyelitis known as

Brodie’s abscess which are

small circumscribed areas of

necrosis in the shafts of the long bones, generally in the tibia or femur, which may persist for a long time without symptoms except that the

No. 30.—BoneE Cyst IN HuMERUS RESEMBLING BropigE’s Asscess. Note pain in the leg or throb- lack of bone proliferation.

child complains of occasional bing in the legs in the night. These pains are sometimes accompanied by a certain amount of local swelling over the areas of bone abscess. They may exist for years without developing further, or they may suddenly light up as a result of trauma or some other unknown cause, and go on to an acute inflammatory condition, requiring operation.

The diseases which are most frequently mistaken for osteomyelitis are early tuberculosis of the bones, acute articular rheumatism, gonorrheal rheumatism and typhoid fever. The most commonly mistaken diagnosis is acute articular rheumatism, and much valuable time is lost in the treatment of these cases by such a diagnosis.

In the acute stages where there is of course definite bone inflammation with oftentimes an abscess, the only thing to do is to operate on the part, evacuate the pus, and establish drainage. Incision down to the bone is not enough, but the exploration must be carried to the epiphyseal line which can be explored by means of a drill in order to locate the origin of the infection. Early drainage in the acute stages is absolutely essential to prevent increasing bone destruction. If drainage is not established early, acute osteomyelitis tends to become general septicemia through absorption of the toxic products. If the adjacent joint is not involved in the process, motion in the joint eventually is restored, but if the pus invades the joint, the eventual result will be a stiff joint. If drainage has been adequately insured by means of an incision, the wound may be kept washed out by a Carrel-Dakin solution, the infected part being meanwhile supported by a plaster cast, posterior wire splint, or a Thomas leg splint, in a position to prevent contracture deformities. When the disease has become subacute, the original bone becomes necrotic, and develops into a sequestrum or piece of dead bone surrounded by involucrum, which is new bone formed from the periosteum. When the sequestrum has definitely separated, it is then necessary to remove it, because if it is not removed, it simply lies in situ, acts as a foreign body, and so prevents healing. Weight bearing or functional use of the part must be prevented until the involucrum has developed sufficiently to support body weight without becoming deformed.

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Rickets.—Rickets is a constitutional disease which affects young children and infants. It occurs usually in children in the first dentition period, and is closely connected with impaired nutrition. There is an alteration of the bones during the period of growth in rickets, and normal ossification does not take place, the bones remaining soft because of the fact that there is a diminution of the proper amount of lime in the bones which is deposited under normal conditions, and gives the bones their hardness. There is a very definite deficiency in the amount of inorganic phosphorus deposit, and to that deficiency is to be described the failure of the calcium deposition. It may occur in anybody’s child, but is more likely to occur as the result of poor environment, improper hygiene, improper feeding, lack of exercise, fresh air and sunshine.

There is no evidence that rickets is hereditary.

The early manifestations may be seen as early as No. 31.—HEALED CASE OF OSTEOMYELITIS the sixth month, and it or TiBIA FOLLOWING RESECTION. : rarely begins later than the third year. The first and second years seem to be the two years during which it occurs most frequently. There is no difference in the occurrence in sexes, boys and girls being equally affected. In hospital clinics in America, it occurs most commonly in Italians and colored people. It is not as common among native born Americans, except the Latin races. It is more apt to develop in late winter and spring than at any other time, and as a rule the following social factors are of importance: the social conditions of a rachitic family are usually not so good as those of a non-rachitic. The average number of persons per room is greater, the air space is 32% less, and the home is more dirty in a rachitic family. It is evident so far as can be found out at present that rickets is a definite deficiency disease from the point of view of nutrition.

The symptoms of rickets are those of a slowly developing constitutional disease. The early symptoms are _ restlessness at night, profuse sweating especially of the head, constipation, capricious and impaired appetite; the child is fretful, its abdomen is prominent, and often, although the child looks fat, it is anemic and the muscles are soft. The liver and spleen may be enlarged, the child is slow to walk, and the muscles are very much thinned out or weakened. Occasionally, although the child may be old enough to learn to walk, any attempt made to put him on his feet will cause a great deal of pain, due to the fact that the growing ends of the bones or so-called epiphyses, which undergo marked changes in rickets, are tender and soft, and therefore weight bearing causes a great deal of pain and discomfort. This condition has sometimes been confused with paralysis, and at times has been known as the ‘‘paralysis of rickets.’’ It is not, however, a paralysis, and should not be confused with such a condition. It is merely due to tender and irritable epiphyses which are painful in attempted weight bearing.

As the disease becomes more manifest, there takes place a very definite, and at times extremely marked, enlargement of the ends of the long bones, particularly the bones of the wrist, that is, the radius and ulna; the lower end of the tibia and fibula at the ankle, and especially the fusion of the ribs with the cartilaginous extensions at the costosternal junction. This enlargement where the ribs join the sternum has become known as a rosary. This rosary can always be felt, often seen, and is much larger on the inside of the chest than on the outside. The increase of the epiphyses at the wrist is generally more noticeable than the increase in the epiphyses of the other bones of the body. This enlargement does not involve the bones, but is simply a manifestation of bone softening at the ends of the bones.

In the head, the following symptoms may be noticed: the head becomes somewhat large and square, the forehead high and oceasionally protruding, the skull may be thin, the anterior fontanelle often stays open until the third year, and the posterior

No. 32.—FuUNNEL CHEST FROM FRONT ward so that the depression oftentimes is very marked.

There are also two other conditions of fontanelle sometimes may remain open for months. Normally the anterior fontanelle usually closes at about the sixteenth or eighteenth month, and the posterior fontanelle usually closes after the sixth week.

There occurs also in rickets a transverse depression in the chest which is known as _ Harrison’s groove. This is due to a softening of the ribs and cartilages of the sternum, and as a result of this, the attachment of the diaphragm on the inner side of the chest pulls the ribs in at its point of attachment, and so creates a depression, which is very marked on the anterior portion of the chest. The ribs below this depression or Harrison’s groove, or sulcus, flare outthe chest which are associated with rickets, namely, funnel chest, where there is a depression of the breast bone known as Pectus Excavatum, and another one known as chicken breast where the breast bone sticks out either definitely in the middle line or perhaps on one side more than the other. This condition is known as Pectus Carinatum. These deformities may be and often are due to bone softening of the ribs and sternum.

As the child gets older and as the tenderness of the epiphyses gets less,

No. 33.—FUNNEL CHEST FROM SIDE.

No. 34.—Markep CASE or Bow LEGS.

No. 36.—KNoCK-KNEES—ONE LEG MorE MarkKep THAN OTHER.

No. 35.—CAsE or MODERATE KNOCK-KNEE. Note flat feet and enlarged epiphyses at wrist and ankle. Note Harrison’s sulcus on chest.

walking is attempted. As a result of the super-incumbent weight on the legs, plus the condition of soft bones, bow legs or knock-knee may develop. Curvature of the spine may develop as a result of softening of the vertebree, and deformities of the arms may develop. Oftentimes parents will lift the

No. 37.—KNOCK-KNEES FROM Front. Note overlapping of legs at knee.

child by the upper arms, and so create bowing of the humerus, or a child with a soft rachitic spine will tend to support himself by transferring the weight of his body on to his arms as he sits, and in that way will develop bowing of the arms. There is also a condition known as coxa vara in these cases of rickets, which is a depression of the neck of the femur, so that the neck of the femur instead of forming an angle of 130° or

140° to the long axis of the shaft of the femur will become depressed so that in many instances it is almost a right angle. As a result of this deformity of the neck of the femur, the trochanters are high, and tle child walks with a hollow back and a waddling gait. There is considerable limitation in abduction of the legs, and the picture suggests up to a certain point that seen in cases of double congenital dislocation of the hips.

No. 38.—X-rRAY or CASE oF RICKETS WITH CoxA VARA, OR DIMINUTION OF NorMAL ANGLE OF NECK OF FEMUR WITH SHAFT.

So far as the treatment of rickets goes, it is essential first of all that the general treatment be carried out, which is essentially dietetic and hygienic. The child should be kept in the open air and sunlight as much as possible. Simple food without too much starch can be given, particularly foods which have antiscorbutie properties. It has been found recently that cod liver oil possesses practically all the necessary elements for the cure of rickets, and five to fifteen drops of cod liver oil three times a day is usually enough in the course of a few weeks to show its effect on the bones as demonstrated by x-ray pictures. Sunlight is essential, and quite as much a part of the cure as the feeding of cod liver oil. This does not mean sunlight filtered through

1 2 3 +

No. 39.—DIAGRAMMATIC DRAWING OF Four STAGES OF RICKETS FROM X-RAY Stupies. 1. Acute; 2. Sub-acute; 3. Healing, and 4. Healed. Note changes in epiphyseal line. From ‘‘Rickets,’’ by R. W. Lovett, J.A.M.A., December 11, 1915,

No. 40.—X-ray or KNEE IN AN AcuTE CASE oF RICKETS, SHOWING LACK oF BonE FoRMATION IN THE ENDS OF THE FEMUR AND TIBIA,

Tt “ON glass, but direct sunlight.

Sunlight coming through glass loses its efficiency from the point of view of any curative effect.

No. 43.—CaAsrE or ANTERIOR Bow Leggs.

Treatment of the bony deformity is as follows: the child with a rachitic spine, that is, the child who has a long backward curve in the spine and who has signs and symptoms of rickets, should be kept flat on his back all the time, either on a hard hair pillow or on a Bradford frame. He should not be allowed to sit up, and should be kept in this position, except for bathing and turning, and any necessary nursing care, for a _ considerable period of time, preferably six months or a year.

The child that has developed knock-knees can be helped considerably in the early stages by means of knock-knee braces. These braces are to be applied and worn all the time the child is up. As a rule they are not efficient or curative particularly after the age of three or three and a half years because by that time rickets, so far as the constitutional or acute stages have gone, has tended to cure itself, and the bones are generally not soft enough to allow much correction by means of apparatus. When the bones have become sufficiently hard following the cure of rickets, and if knock-knees still exist, the only thing to do is to operate on the leg and break the bone just above the knee. The leg is then straightened, and a plaster cast is applied which is to be worn for a period of seven or eight weeks. If this operation is done too early during the subacute stage of rickets, the deformity is almost sure to recur following resumption of weight bearing.

Many children develop bow legs as a result of rickets, and this bowing may be either lateral or anterior bowing, particularly marked generally in the lower third of the tibia. Lateral bowing

No. 44.—X-ray oF CASE OF ANTERIOR Bow LzcGs.

most marked in the tibia is the more common deformity, and more easily corrected. Up to the age of three years, bow leg braces properly applied and constantly worn will correct most of the lateral bow legs. No brace so far as I know will correct anterior bow legs to any advantage. After the child gets beyond the age of three, and bow legs either lateral or anterior still exist, an operation will have to be performed. If the child is fairly young, that is, between three and four, lateral bow legs ean be corrected by means of an osteoclast, which is a machine that breaks the legs at the point of greatest deformity, or if the bone is too hard, then an open operation has to be done. In anterior bow legs, an operation which has for its purpose the removal of a wedge of bone from the apex of the deformity is performed. Usually the result is a fairly satisfactory looking one, but one which is not always a cosmetic success, but is an improvement. So far as the life of the child with rickets goes, the prognosis is usually good. There are a great many children with a slight degree of bow legs and knock-knees who grow up without any particular deformity. The decision of operation of course in these cases has to be left to the surgeon. In walking with bow legs, the child is very apt to toe in, and has a considerable degree of waddling. In knock-knees when the child walks, there is usually a considerable degree of flat foot which may have to be corrected at the same time by means of pads in the shoes, or a lift on the shoes. If the child develops deformities of the spine as a result of rickets, these deformities have to be treated by means of plaster jackets in later stages, and by rest on the back, as previously spoken of, in the earlier cases.

Chapter III

SCOLIOSIS. SCHOOL SEATING. PAINFUL AND IRRITABLE BACKS

Scoliosis.—There are two varieties of lateral curvature, first, the postural or functional, and second, the organic or structural.

The first is really nothing but a faulty attitude. The child, who is generally from 5 to 15 years old, stands with a slight or very moderate lateral curve of the whole spine, in most instances to the left. The left shoulder is higher than the other, the trunk is displaced to the left, uncovering the right iliac crest, and making it more prominent than the left. There is no marked rotation or twisting of the curved region, but when the child bends forward from the hips and the trunk becomes horizontal, the right side of the back of the thorax can be seen to be very slightly higher than the left. ‘The curve disappears when the patient lies down.

The condition is often associated with round shoulders and round back, and where statistics have been taken regarding it, it has been found to occur in from 20 to 25 per cent of the children of school age. The curve is always single, and compensatory curves do not exist. It is sometimes described as total scoliosis, which should be interpreted as being synonymous with functional or postural scoliosis.

Two mistakes are frequently made in dealing with this condition. In the first place, the curve is so slight that it is frequently overlooked, and second, if it is recognized, the parents are frequently told that the child will outgrow it. There is no reason for overlooking the existence of any postural curve, because it is perfectly simple to hang a plumb-line in the cleft of the buttocks and see if the spinous processes form a straight line under that plumb-line. If they deviate in a gradual curve, total scoliosis exists.

With regard to the second point, so far as observations go, 41

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N there is no tendency to spontaneous outgrowth of the condition. It is extremely common in adults, and the tendency of growth is entirely toward an increase of the deformity rather than toward a straightening of the spine. Such cases frequently change to the structural type in the process of growth, double curves forming out of single ones; but such cases do not as a rule change to the severe type of structural curves, so that having recognized the existence of a postural lateral curve, the parents should be told that it will probably increase somewhat, will undoubtedly persist into adult life unless efficiently treated, but will probably not cause serious or disabling deformity.

The treatment is simple. The general hygiene should be looked into, overwork at school and at home prevented, and if the resistance of the child is below normal, the day should be shortened slightly by a period of recumbency during the day.

The question of clothes is an important one and should be investigated. Most children of this age wear a waist with shoulder straps which rest near the tips of the shoulders. To this waist are attached the clothes and also side elastic garters running to the stockings, which are kept very tight. The tension of these elastics is transmitted by the waist to the straps over the shoulders, and the shoulders are continually pulled downward and forward. Round garters should be substituted for side elastics in these cases, the clothes suspended from the waist should be as light as possible, and in many instances thev may be supported from a belt.

If there is any reason to suspect a visual error leading to an improper position in reading, the eyes should be examined and such error corrected. It is advisable in all instances to go into . the question of a short leg, not by a measurement from anterior superior spine to the internal malleolus, which is of little practical value and often misleading, but by placing under the foot on the side to which the spine curves, a lift sufficient to raise the pelvis on that side and see if an improved position of the spine results. If it does, a higher sole should be worn on that side with a view to inducing a constant improvement in the spinal position.

With these preliminaries taken care of, the treatment should consist of a special set of gymnastics which are within the range of any good teacher of gymnastics, consisting practically of a setting-up drill similar to that given to army recruits. Such patients should exercise daily for half an hour or an hour under the supervision of the teacher until they can maintain a symmetrical position for a few minutes, when they can be allowed to do the exercises at home under the supervision of a parent, and report for observation. The gymnastic work should be individual and class work discouraged.

The daily active treatment should generally not cover a period of more than from one to three weeks under favorable conditions, but the observation period should last for at least a year. Under these conditions the prognosis for a complete cure is excellent, but exercises must be done with precision and vigor, and the general condition of the child must be regarded.

Organic or Structural Lateral Curvature.—This is accompanied by changes in the spinal structure, with deformity of the vertebre. The phenomena cannot be reproduced experimentally, and the condition is outside of the normal behavior of the spine and implies structural change. Severe cases in childhood are due to one of five causes:

1. A congenital anomaly of the spine, such as split vertebre, defective ribs, ete., a class of cases only recently recognized as so important, and until the general use of the x-ray not generally understood.

3. Empyema.

4. Rickets.

5. A softness of the bones which we must assume without direct evidence of rickets, but in which bony deformity is so great that it is evident that the bony resistance is below the normal,

The characteristics of organic lateral curvature are definite curves, either single or double—more often the latter—and much more marked than in the postural class, in some cases running to extreme deformity. There is always a rotation of the vertebre or horizontal twist at the site of the curve, and in bending forward, with the trunk horizontal and the arms hanging, there is always to be seen a more or less marked prominence in the affected region on the side to which the spine curves, that is, on the convex side of the lateral curve. If the curve is double, there are two rotations corresponding to the two curves. This

No. 48.—X-RAy oF CASE OF CoNGENITAL ScoLiosis Dur To DEFECTIVE DorsaL VERTEBRA AND FUSED Rips ON THE Lerr. There is apparently only a partial development of the fifth dorsal vertebra.

is a constant characteristic, and is diagnostic of this type of curvature. A right curve has always a right prominence, and vice versa on the other side. The curve does not disappear on lying down, and the x-ray shows a deformity of the vertebra, with compression of the intervertebral disks on the concave side, and in the more advanced cases, with a wedge-shaped deformity of the vertebre. Distortion of the figure, the elevation of one shoulder, the prominence of one ilium, a general displacement of the body to the side, ete., are the results and expression of this bony spinal deformity.

It must be clearly recognized that these are the cases that . present the difficulty in treatment, the vertebral column in these eases being deformed to some extent, with the changes mentioned, namely, shortened ligaments and muscles, compressed disks, and, in the severe cases, wedge-shaped vertebre. In addition to these deformities to the side, the vertebre twist on a vertical axis and are thus distorted along with the ribs and the bony structures of the thorax, which share in the deformity in severer cases. These changes in the lateral and in the horizontal direction result in distortion of the viscera, compression of the lungs, displacement of the heart and disturbance of the abdominal viscera, which in severe cases predispose to impaired digestion, deficient chest capacity, and in general to impaired resistance, so that it is safe to say that as a rule patients with severe scoliosis in adult life are badly nourished and have an impaired resistance. Extreme deformity may result in the severest cases.