A manual of orthopedic surgery

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Preface

In this little book the attempt is made to present Orthopedic Surgery in a simple way to the student and practitioner by re-arranging the subject so that the deformities which fall to the orthopedist are grouped both etiologically and chronologically. Part I comprises the ante-natal deformities, errors of development of the skeleton or of the nervous system, fetal bone diseases, accidents of birth like obstetrical paralysis or intracranial hemorrhage with spastic paralysis: Part II, deformities due to the action of external forces on growth, like weight-bearing, improper restraint from clothing, unequal or asymmetrical muscular development as in flat-foot: Part III, the diseases and injuries of the bones and joints excepting those of the fetus: Part IV, deformities from acquired diseases of the nervous and muscular systems: Part V is a technical description of the use of plaster-of-Paris, and of the way to make, fit and use some of the orthopedic appliances in vogue in this vicinity. While freely admitting the impossibility of an absolute classification of this sort because there are many deformities like coxa vara which arise from diverse causes, it is earnestly hoped that the student may be saved from confusing in his mind the identity of things essentially dissimilar like spondylitis and scoliosis, or congenital and acquired club-foot.

The writer desires to express his thanks to his colleagues and others who have helped him, especially to Professors D wight and Bradford, of the Harvard Medical School, to Dr. Schulthess, of Zurich, Avhose exhaustive article on Scoliosis in Joachimsthals Handbuch der Orthopaedischen Chirurgie has been freely used, and to Dr. Max Bohm now of Berlin, likewise to Dr. R. W. Lovett, from whose book on Lateral Curvature a chapter is borrowed; and for aid in illustrating to Dr. A. W. George, radiographer to the Children's Hospital and of the Department of Anatomy.

Augustus Thorndike.

Boston, Massachusetts, September, 1907.

I I

Part I

Deformities Originating Before or During Birth. Malformations, Fetal Diseases.

Chapter I

Congenital deformities of the extremities. Greater defects; the ectromelian, i ; hemimelian, i ; phocomelian. Partial defects, 3 ; humerus, 3 ; ulna, 4 ; radius, 4 ; club-hand, 4 ; femur, 7 ; patella, 7 ; fibula, 8; tibia, 9. Parts of the foot. Supernumerary parts. Hypertrophy of a limb or part of a limb 1

Chapter II

Congenital deformities of the trunk. The spine, 12; thorax, 15; and pelvis. Numerical variations of the column, 12; their association with scoliosis. Other anatomical causes of curvatures, 16; the thorax and ribs, 18; the pelvis, 18; the clavicle and scapula. . 12

Chapter III

C Congenital luxations and subluxations : Club-foot, 25 ; cause, 25 ; frequency, 25; prognosis, 27; treatment, mechanical and operative.. 25

Chapter IV

Congenital dislocation of the hip, 38; frequency, 38; disability, 38; pathological anatomy, 40; symptoms, 43; signs, 44; diagnosis, 45; treatment, 47; manipulative reduction, 48; after-care, 51; Mueller's modification, 53; muscle-stretching machines, 53; Hoffa's manipulative reduction, 55; anterior transpositions, 57; cutting operations. 38

CHAPTER V Congenital subluxations of the hip, 60; congenital dislocations and subluxations of the knee, 60; ankle, 62; shoulder, 62; elbow, 63; and wrist 60

Chapter VI

Fetal bone diseases, 65; syphilis, 65; tuberculosis, 65; rickets, 6^: osteogenesis imperfecta, 66; chondrodystrophia fcetalis. Diseases of the nervous system of congenital origin, 69; spina bifida, 69; hereditary ataxia, 70; the dystrophies, 71 ; Erb's juvenile atrophy and paralysis, 73; Landouzy-D6jerine type, 74; pseudomuscular hypertrophy. Those caused by an accident during birth, 74; Little's disease and obstetrical paralysis 65

X CONTENTS.

Part II

Deformities Caused By the Influence of External Forces Acting Upon the Growth of the Skeleton.

Chapter VII

Irregularities of the skull, 85; gravity, 85; influence of defective sight or hearing on one side only, 87; lateral curvature of the spine, 87; frequency, 87; terminology, 88; normal curves at different ages, 89; pathological anatomy, 90; spine, 90; thorax, 93; pelvis?- Lateral curvatures of different parts of the spine, 96; simple and complicated, 102; causes, 104; congenital, 104; osteogenous, 105; mechanic, 106; functional 85

Chapter VIII

Lateral curvature continued, 109; examining and recording scoliosis, 109; the normal movements of the spine, 112; treatment for malpostures and slight curvatures by exercise, 113; exercises in general 109

Chapter IX

Lateral curvature concluded, 132; treatment of structural scoliosis, 132; exercises for flexibility, 132; corrective jackets, 134; exercises for self-correction, 136; those for strengthening the trunk to maintain erect position, 137; Wullstein's jackets and braces, 137 ; operation of Hoke. Malpostures and their prevention, 138; school desks, 139. Round shoulders, 140; normal attitude, 140; round back, 140; hollow-round back, 140; forward shoulders, 141; the recording of antero-posterior curves and the attitude in standing. Funnel chest 132

Chapter X

Coxa vara, 145; congenital, 145; from bone diseases, 145; rickets, 145; trauma, 147; from growth, 145; diagnosis and treatment. Coxa valga, 149; from growth, 149; paralysis, 149; rickets, 149; osteomyelitis, 149; congenital dislocation of hip, 149; in amputation stumps, 149; treatment in plaster bandages, 150; by operation. Acquired curves of long bones, 150; from growth, 150; femur, 151 ; knock-knee, 152; bow-leg, 152; back knee, 152. Deformities of the foot from the influence of external forces, 153; hollow or contracted foot, 153; flat-foot, 156; congenital, 156; traumatic, 156; paralytic, 156; and static, 156; mechanics, 157; diagnosis, 158; treatment, 159; rigid flat-foot from sprain, 161; metatarsalgia, 162; cause and treatment, 164; painful foot from exostoses and bursitis, 164; policeman's heel, 165; hallux valgus, 165; hallux varus, 167; hammer toe 145

Chapter XI

General considerations for study. Trauma and repair of bones and joints. True inflammations from microorganisms in bones, 173; joints and periarticular structures. Affections due to nutritional disturbances or autointoxications. Functional joint disease 171

CONTENTS. XI

Chapter XII

Injury and repair. Bone, 179; subperiosteal hemorrhages, 179; bone growth from torn periosteum, 1 79 ; avulsion of the tubercle of the tibia, 179; superficial necrosis from trauma, 180; fractures. Joints, 180; fractures, 180; dislocations, 180; sprains. Acute synovitis from sprain, 180; dislocations of the semilunar cartilages ,180; treatment, 183; villous proliferation of the synovial membrane, 183; its causes, 184; and results, 184; lipoma arborescens, etc., 184; treatment, 185; hemorrhages into joints, 185 ; in hemophilia and fractures into joints, 185; appearance, 186; deformity, 186; results, 187; and treatment.. 179

Chapter XIII

True inflammations from microorganisms, 188; acute, 188; subacute and chronic, 189; periostitis, 188; actinomycosis, 189; osteomyelitis. Acute osteomyelitis, 190; its frequency, 191; age, 191; origin, 191 ; symptoms, 191; treatment, 192; usual seat in the shaft, 191; osteomyelitis of the epiphysis, 191; acute arthritis of infancy, 191 ; course and treatment. Osteomyelitis after typhoid fever and after measles. Joints. Septic arthritis, 195; microorganisms, 196; source of infection, 196; changes in the joints, 196; treatment. Forms differentiated from septic arthritis, 197; rheumatic fever, 197; acute arthritis of infants, 197; arthritis in the course of typhoid fever, 198; scarlet fever, 198; pneumonia, 199; gonorrhoea 188

Chapter XIV

Chronic inflammations of bones and joints. Syphilis, 203; inherited and acquired. Infantile syphilis, 203 ; osteochondritis, 203 ; separation of the epiphysis, 203; suppurative arthritis, 204; pseudoparalysis, 204; craniotabes, 204; syphilis of little children's bones, 204; dactylitis, 204; periostitis, 205 ; enlargement of the epiphysis, 205; in older children eburnation, 205; bow-leg, 205; chronic serous synovitis, 205; pathology, 205 ; diagnosis, 206 ; acquired syphilis, 207 ; the spine, 207 ; the tibia. Tuberculosis. Vertebral tuberculosis, 207; pathological anatomy, 208; symptoms, 210; physical signs, 211 ; complications, 212; abscess and paralysis, 214; diagnosis, 217; prognosis, 217; treatment, general and local, 217; recumbency, 219; ambulatory treatment, 223; care of complications. Tuberculosis in or around the sacro-iliac joint, 226; diagnosis and treatment 203

Chapter XV

Tuberculosis of the hip, 230; frequency, 230; pathological anatomy, 230; clinical course, 233 ; physical examination, 235 ; differential diagnosis, 237; prognosis, 239; treatment; general and local, 239; recumbency and traction, 241; traction splints, 243; fixation splints, 243; plaster bandage, 243 ; correction of deformity, 243 ; osteotomy, 244 ; double hip disease, 245; abscess in hip disease, its treatment, 246; early removal of diseased foci of tuberculous bone, 246; excision of the hip, 247 ; amputation 230

Chapter XVI

Tuberculosis in and around other joints. Knee, 250; symptoms, 251; diagnosis, 253; course, 252; prognosis, 253; treatment, general and local,

Xll CONTENTS.

254; conservative treatment, 255; early removal of foci in bone, 255; drainage, 256; resection, 256; arthrectomy, 256; abscess, 256; conservative and operative correction of deformity, 258. Ankle: Pathology, 260; symptoms and signs, 261; diagnosis, 261 ; prognosis, 262; treatment, 262; abscess, 262; excision of tarsal bones, 262; excision of ankle. Shoulder: Symptoms, 264; treatment by excision and amputation. Elbow: Symptoms, 265; prognosis, 265; general treatment, 265; excisions, 266; results. Wrist: Symptoms, 267; diagnosis, 267; treatment, 267; excision and partial excision. Passive hyperemia for treatment of tuberculous joints and sinuses 250

Chapter XVII

Affections caused by nutritional disturbance of the skeleton, 284; the nervous system or the general system. Scurvy of infancy, 270; subperiosteal hemorrhages, 270; symptoms and course, 271 ; pathological appearances, 270; scurvy in the spine. Rickets, 272; age affected, 272; frequency, 272; pathology, 272; deformities, 273; coxa vara, 273; bow-legs, 273; knock-knees, 273; diagnosis, 276; treatment, 276; bow-leg, 276; knock-knee, 279; general treatment, 281; operations, osteotomy ,281 ; osteoclasis, 283 ; epiphyseolysis, 281 ; splints, 282 ; deformities of the arms and treatment, 284; spontaneous fractures in rickets. Osteomalacia, 284; pathology, 285; the spine in osteomalacia. Ostitis deformans, 287; frequency, 287; age, 287; symptoms, 287; pathology and treatment. Secondary hypertrophic osteoarthropathy, 288; appearance and occurrence. Acromegaly. Its three clinical forms. Charcot's disease or tabetic joint disease, 289; occurrence, 289; symptoms, 289; diagnosis, 289; the spine, 290; hip, 290; and knee, 289; treatment. Arthritis deformans, 290; the atrophic and the hypertrophic forms, 291; symptoms and course of atrophic form, 291; treatment, 291: symptoms and course of the hypertrophic form, 292; the spine in the hypertrophic form, 293 treatment, 293; Still's disease, course, symptoms, lack of pathological material, 293; treatment. Gout, 294; acute and chronic, 295; atypical gout, 295; course and symptoms, 296; ulcerated tophi, 296; resemblance of some chronic cases to arthritis deformans. Functional joint disease, 297; simulated and neuromimetic, 297; differentiation from true hip disease, 297; tumor albus, 297; club-foot, 298; paralysis, 298; the spine in neurasthenia 270

Part IV

Acquired Diseases of the Nervous and Muscular Systems with Deformities.

Chapter XVIII

Infantile paralysis, 303; sporadic and epidemic, 304; pathology, 304; symptoms, 305; deformities, 306; disabilities and sequelae, 308; scoliosis, 308; dislocations, 309; treatment for paralysis and deformity, 310; walking apparatus, 311; appliances to correct deformities, 312; surgical measures to correct malpositions, 313; to transfer muscle attachments, 315; to restore control and power by nerve grafts, 320; to correct flexions, 313; to stiffen flail joints, 314; tenodesis and arthrodesis 3°3

CONTENTS. Xlll

Chapter XIX

Diseases of the muscles, 323; torticollis, 323; varieties, 323; congenital, 323; spasmodic, 323; symptomatic, 324; transitory, 325; dermatogenous, 325; acquired, 325; diagnosis, 325; treatment, 325; stretching, 325; division of the sternomastoid, 326; plaster for after-treatment, 327; apparatus. Myositis ossificans, 327; two types, progressive and simple, 328; latter of two sorts irritative and traumatic which is often combined with osteomata growing from bone, 328; clinical characters, 328; age of onset, 328; treatment, 329; method of removal 323

Chapter XX

Plaster-of-Paris, 330; plaster bandages, how made, 331; applied, 331; removed. Plaster jacket for Pott's disease, 7,^^; applied recumbent, 334; hammock frame, 334; Goldthwait's frame, 337; Lovett's frame, 338; appliance for vertical traction and correction, the kyphotome, 339. The plaster bed for Pott's disease. Plaster jackets for lateral curvature, 339; jackets for support and mild correction, how applied on the hammock frame, 340; corrective jackets on the Adams frame. Removable plaster jackets, 340; casts and removable jackets of leather, 340; celluloid, etc, 341 ; how made and fitted. Plaster jackets for resistant round shoulders. Plaster bandages for club-foot. Wolff's method of correction by stages. Plaster spica bandage for hip disease, 345; and for general use. How to apply them for congenital hip after reduction. Plaster casts of the trunk and of the foot. Casts for flat-foot plates 330

Chapter XXI

Molded leather splints and jackets. The modified Taylor back brace for Pott's disease. Head supports for same, the oval ring, 353; the wire chin rest, 354; Goldthwait's head support. 355; the Thomas' collar, 357 ; modified head support for torticollis. The quadrilateral brace of Dane, 358; writer's modification of the back brace. Braces for lateral curvature, 362; Keen's modification of Dollinger's brace, 363; Wullstein's brace. Hip splints, 364; traction hip splint and its modifications, 365 ; convalescent splint, 367; with knee-joint, etc., 36Q; Dane's hip splint, 369; the abduction hip splint, 371; Thomas' splint for fixation of the hip. Thomas' knee splint, 373; the caliper splint. Fixation splint for the ankle. Knock-knee irons, 377; bow-leg irons, 378; Dane's bow-leg irons, 379; adaptation of the caliper splint for toe-drop and calcaneus, 380; other infantile paralysis splints, 381; the valgus shoe, 382; the equinus shoe, ^8^; the club-foot shoe. Flat-foot plates 349

L

I

ORTHOPEDIC SURGERY.

Chapter I. Malformations Of The Limbs

Congenital human deformities are so various that the author cannot here describe all of the varieties; selected examples must suffice instead of a detailed complete list. The student must not be surprised to meet at the clinic congenital deformities which are not described here, but should store in his mind, from his study of the examples, certain typical classes into which malformations fall and from which they may vary. He should strive by careful observation to study each individual case so as to recognize the true nature of the deformity and to evolve independently of his teacher something to restore the function of the limb or lessen the disability.

Many congenital deformities shorten life to a few days or weeks or are found in the still-born, such as anencephalus, rachischisis, etc.; others, like spina bifida, are often curable; the latter is considered in works on general surgery and is therefore omitted.

TOTAL DEFECTS.

Absence or extensive malformation of the extremities is not fatal but is very disabling for when both the arms and legs are lacking it is obviously impossible to supply the deficiency. A total deficiency of all four members occurs but rarely and produces great helplessness. The term ectromelian designates a person with complete absence of one or more limbs; hemimelian, one without the terminal portion of a limb or limbs, without hand or foot; phocomelian, one whose much shortened limb bears a hand or foot close to the trunk like the flipper of a seal. These are the result either

ORTHOPEDIC SURGERY.

of lack of development, or of amputation in ntero; only the phocomelian necessarily represents lack of growth, the other two may arise either because they failed to form or because they grew and were cut off. Non-formation of a limb must be due to some process beginning before the fourth week of embryonic existence, for the limbs appear about that time. Congenital amputations are of later origin — the earliest one recorded showed the remains of a foot corresponding to that of a ten weeks fetus. A limb is amputated either by tight encircling coils of umbilical cord or by so-called amniotic bands forming a constriction around it. An amniotic band is a string-like structure connecting the skin of the fetus with a point on the amniotic lining of the fetal membranes. When these bands are present at birth, some sort of congenital malformation is generally present.

ABSENCE OF ONE PAIR OF EXTREMITIES.

When one pair of limbs is absent, the helplessness is less; absence of both legs may give rise to but little inactivity, for artificial limbs or any serviceable rigid support may be used with crutches, and little ones soon learn to walk on their hands.

Absence of the arms is more disabling, but one often finds useful fingers or a partly formed hand near the shoulder as in the accompanying photograph. (Fig. 3.) This boy, with his fingers, could write with pencil or pen and do a variety of things which he learned at the public school; he also learned at the Industrial School for Cripples to typewrite with his toes, to draw on the blackboard with them, and to use his feet for hands in many ways.

In Denmark, Norway and Finland, special schools for cripples exist w r here ingenious machines and contrivances are used to take

Fr i. 1. — Fetus with congenita] amputations. (Cast in the Warren Museum.)

MALFORMATIONS OF THE LIMBS.

the place of hands. Handless cripples are taught to weave cloth, to make brushes, baskets, and shoes, using the tongue and teeth principally. Some women even embroider with the teeth and the toes may be trained to great usefulness. For many years a handless artist was seen in the art gallery at Antwerp painting pictures with his feet. Boston, New York, and Philadelphia now give industrial training to cripples.

Artificial hands and arms are made lighter and more serviceable than they used to be, but their field of usefulness is limited.

Less disabling are the deficiencies of one or more of the long bones of the limbs; these partial defects may occur ;n one, two, or even four extremities. For instance, a woman in Germany has the following malformations: the left upper extremity consists of an upper arm bearing a single finger; the right arm is a tapering stump, containing half of the humerus; the left leg lacks the femur and the fibula; the right is a rounded stump, containing two short bones bearing a small foot, of which the heel, sole, and two toes are present. With the help of special artificial legs and arm she can write, knit, wash, partly dress herself, and feed herself with fork, knife, and spoon; she walks easily, keeps busy and enjoys life.

Fig 2. — Fetus with absent right lower extremity. (Warren Museum.)

PARTIAL DEFECTS OF THE UPPER EXTREMITY.

Club-hand. — Absence or defect of the radius or ulna produces club-hand, a term which designates a deviation of the hand

ORTHOPEDIC SURGERY.

at the wrist from its alignment with the forearm; a lateral deviation means a congenital deficiency of the radius or ulna — the hand turns to the side of the missing or defective bone. Congenital displacements of the hand in extension or flexion may be called club-hand and this kind is not associated with bony defect, but with some other cause, such as early developed paralysis. Club-hands

Fig. 3. — Armless boy typewriting. {Industrial School jor crippled and deformed children.)

like club-feet have been described by adjectives, which define the direction of the malposition, such as palmar, dorsal, radial and ulnar club-hand, radio-palmar, radio-dorsal, ulno-palmar, and ulno-dorsal club-hand. Radio-palmar is the common type, with the ulna usually strongly bowed inward and the hand pointing at right angles to or somewhat up the arm. Deficiency of the ulna is rare,

MALFORMATIONS OF THE LIMBS.

and all elbow motion is lost if the ulna be absent; only part of the carpus is developed and the little and fourth fingers are often lacking. One finds the thumb missing with most defects of the radius. The changes in the articular facets and the formation of the wrist bones are analogous to those in congenital club-foot. Kirmisson describes curious anomalies of the muscles of the forearm. Treatment. — Mild club-hands, especially in little babies, are treated by gentle manipulations, bandaging to a light splint, or the child is etherized, and the hand held by a plaster bandage in an

Fig. 4. — Cast of radiopalmar club hand. ^Warren Museum.)

overcorrected position gained after forcible stretching. One treated this way for a year, at the Children's Hospital, had the hand firmly grown into a normal position at the end of that time. A small tin splint was used six months longer as a precaution. Three years later, the child had a good, straight, useful hand. In older children, whenever the difficulty of reduction demands it, tenotomies or tendon transferences may be tried, or shortening and lengthening of certain tendons. When there is only one bone in the lower forearm, especially if it be crooked, osteotomy and retention for a long time in a plaster bandage has given excellent results in a few cases. The after treatment demands careful muscle training and massage. The following bone operations have been performed on rebellious cases: cuneiform osteotomy of the ulna, by Thompson; suture to the semilunar bone of the split styloid process of the ulna, by McCurdy;

Fig. 5. — Bones of same. (Warren Museum.)

the removal of two carpal bones and fastening the end of the ulna into the hole in the middle of the wrist, by Sayre; wedging the carpus into the split open end of the ulna, by Bardenheur; Kirmisson aims at a stiff wrist, for he regards instability of the hand after operation as the most serious obstacle to its utility. Operations for muscle transference have been little tried so far.

PARTIAL DEFECTS OF THE LOWER EXTREMITIES.

The femur is far more often defective than absent. According to Reiner, there may be (i) a congenital coxa vara with the shaft and the femoral neck short and crooked; or (2) the femur may be divided into two different parts, the head and trochanters forming the upper portion, while the distal end articulates both with it and with a fairly normal knee-joint; or (3) in extreme cases, only the head, neck and trochanters exist with a small remnant of the distal end of the femur growing on top of the tibia without knee-joint. Reiner considers all these conditions are due to the same sort of maldevelopment. The modelling action of the muscles determines the amount of crookedness of the femur. These deformities of the femur are often associated with absence of the fibula, the patella, or part of the foot, and produce much shortening of the leg.

A young woman who has been under the writer's care for several years with a shortened leg of this sort, walks with ease, using an artificial limb designed by Gibney, of FlG " 6 -- Absent or tard >' Patella - New York, which takes advantage of the flexed position of her hip and knee and offers a broad shelf on which the under surface of the thigh rests and the body-weight is supported. She is better off with this apparatus than she would be with an amputation stump and an ordinary artificial limb.

Absence of the patella is infrequent. In a baby, one cannot tell if the patella will form later or not; doubtless, many a case of tardy development has been reported as absence of the patella. This bone should appear as a cartilaginous deposit in the third month of fetal life, and ossification begins between the ages of four and seven years and should be completed at puberty. The defect may be double or single, and the sexes are equally affected.

Other malformations were found in half the cases in literature. Ankylosis of the knee associated with defective femur is not infrequent; general laxity of the knee may be present, or a subluxation; sometimes the tendon of the quadriceps is inserted into the joint capsule instead of into the tubercle of the tibia. Unless these malformations accompany the deformity, the prognosis for a useful limb is good. While children they fall easily and are unsteady, in later life there is little disability and the gait satisfactory. Some are easily tired, totter a little, go down stairs cautiously, fearing a fall; others are not impeded in any way.

Treatment. — Surgical skill cannot make a patella grow. In lax knees prevention of abnormal movements in the joint does good, for by restricting side movements, the knee ligaments in a child soon tighten and the joint regains its utility. A serviceable appliance for this purpose consists of a light double upright splint with a hinge joint at the knee so arranged as to allow less than the normal amount of flexion and extension. Where a faulty attachment of the quadriceps tendon into the joint capsule occurs (a rare condition) it might be transplanted into the tubercle of the tibia, by an operation.

Absence or Defect of the Fibula. — The fibula is deficient more often than the tibia but both conditions are uncommon. When this malformation exists, the foot is always displaced. It is more common for the fibula to be absent completely or for the upper part of the bone to be present. In the foot, the little toe, or the little and fourth toes may be absent with their metatarsals. The tibia is rarely straight and it may bend sharply, suggesting the so-called intra-uterine fracture. The misplaced foot rolls out in valgus, sometimes in equino-valgus, and there may be an upward displacement of the foot at the ankle — a condition which has been described as congenital dislocation of the ankle. Left without treatment, great shortening and atrophy always occur.

Treatment. — Treatment aims to hold the foot in a good position to walk on, either by mechanical means, by a surgical operation, or by both methods combined. The problem is not unlike that which is presented after destruction of the fibula by osteomyelitis.

MALFORMATIONS OF THE LIMBS. Q

Francke, of Brunswick, Germany, in order to compensate for the shortening which usually takes place after three or four years, resected the ankle-joint and fastened the os calcis to the tibia in the position of extreme equinus. He placed the articular surface of the tibia against the upper surface of the calcis behind the astragalus and refreshed the astragalus and the front of the tibia to secure bony union between them. For temporary fixation he drove a long steel nail through the sole of the foot, the os calcis and lower epiphysis of tibia, removing the nail in three weeks. The result two years afterward was excellent, and there was no tendency to valgus.

Curving of the tibia may be remedied by osteotomy, overcorrection and immobilizing in plaster. Tenotomies or muscle transferences, may prevent a return of valgus, but, so far, a mechanical support, or a valgus shoe (Chapter XXI) and a high sole have to be employed unless union is obtained between the foot and the tibia, as in Francke's case.

Congenital Deficiencies of the Tibia. — These are often bilateral. Myers, of New York, found 46 cases in literature, 11 of which were observed in the fetus or new-born. It is often considered hopeless to use the limb for walking, and of the reported cases 6 had been amputated. The bone was absent 43 times in 34 children; defective 22 times in 12 children. Twice as many boys as girls had the deformity, and other deformities were present in 80 percent of the cases.

Treatment. — Many, however, have operated to restore functional use of the limb. In little children, they have opened the knee-joint, trimmed the head of the fibula and transplanted it into the intercondyloid notch or into a hole bored in the external condyle, straightening the foot at the same operation by tenotomies. Myers did this and then he opened the ankle-joint, cut off the external malleolus, denuded the articular surface of the astragalus, and sutured the fibula firmly to its center by coarse absorbable catgut suture. He kept the foot in a moderate equinus position in plaster for six months, and allowed the boy to walk upon it in plaster eight weeks after operation. Later on, a double upright steel splint with a

ORTHOPEDIC SURGERY.

waist-band and perineal straps was worn, which was jointed at the ankle, knee, and hip; the knee-joint could be straightened and fixed and had a leather knee cap. The perineal straps were soon discarded and a cork sole was added to the boot to equalize the length of the limbs. A year afterward, he walked all day, had

gained muscle power, so that he could flex the knee to a right angle and straighten it perfectly.

Deficiencies of the Skeleton of the Foot. — Several of these defects may come in connection with deficiencies of the tibia and fibula. The inner side is defective with a malformed tibia, the outer with the fibula. These deformities may also occur independently. Absence of a toe usually gives no trouble, but extreme defects of the foot demand mechanical support or amputation. Once in a while one sees the skeleton reduced like that in the illustration. This boy was bereft, in both feet, of all his bones except the os calcis, one metatarsal, and the phalanges of a single toe. Amputation and two artificial legs now enable him to walk and run almost as well as anybody.

Fig. 7. — Malformation of the foot. (Warren Museum.)

EXTRA LIMBS.

Supernumerary Deformities. — The occurrence of supernumerary limbs has been explained by the inclusion of part of a twin, they are rare except in the side-show of the circus. Supernumerary fingers and toes are, however, a frequent occurrence and are usually amputated early in babyhood. Their treatment and that of web fingers is found in all works on general surgery. Extra bones are sometimes formed in the wrist and ankle which have more interest for anatomists than for clinicians. With increasing use of the X-ray, they may, however, be mistaken for fractures and dislo-

MALFORMATIONS OF THE LIMBS.

II cations, and it is probable that their presence alters the statics of the foot in a way not yet understood.

CONGENITAL HYPERTROPHIES.

Hypertrophies of Limbs or Parts of Limbs. — One-half the body may outstrip the other (unilateral hypertrophy), or a limb may

Fig. 8. — Cast of a hand showing hypertrophy of finger (Warren Museum.)

grow much faster than its mate, or one finger may grow as in this cast of a hand.

Chapter II

CONGENITAL DEFORMITIES OF THE TRUNK; SPINE, PELVIS, THORAX AND SHOULDER-GIRDLE.

THE SPINE.

Until lately malformations of the spine were limited in the minds of most student to spina bifida; other deformities were considered unimportant. If a baby had a lateral curvature it was attributed to carrying the child on one arm or to fetal rickets. Very rarely was a congenital deformity of the thorax recognized, but with the use of the X-ray malformations are now becoming more common and the occurrence of a form of congenital scoliosis is now generally conceded. Some, like Whitman, have palpated and detected the absence of a lumbar vertebra and demonstrated it by the X-ray.