SPRAINS AND ALLIED INJURIES OF JOINTS R.H.ANGLIN WHITELOCKE LIBRARY University of California. Class Mmm mmml mmm OXFOBD MEDICAL PUBLICATIONS SPRAINS AND ALLIED INJURIES OF JOINTS OXFOBD : HORACE HART PRINTER TO THE UNIVERSITY OXFORD MEDICAL PUBLICATIONS SPRAINS AND ALLIED INJURIES OF JOINTS BY R. H. ANGLIN WHITELOCKE M.D., M.C. (Edin.), F.R.C.S. (Eng.) HONORARY SURGEON TO THE RADCLIFEE INFIRMARY AND COUNTY HOSPITAL AT OXFORD ; LICHFIELD LECTURER IN SURGERY IN THE UNIVERSITY Of THE UNIVERSITY OF LONDON HENRY FROWDE HODDER & STOUGHTON Oxford University Press Warwick Square, E.G. 1909 BIOLOGY «5te «H Of THE UNIVERSITY OF PREFACE Three events in recent times have suggested the writing of this volume, and seem to justify its existence. The more extensive employment of radiography by surgeons as an aid to diagnosis has led to the discovery that a great many injuries which formerly were believed to be simple sprains, and treated as simple sprains, are in reality injuries to bones, and therefore of more serious consequence. The passing of the new Workmen's Compensation Act and its operations have not only drawn the attention of the lay public to these accidents, but have placed them on a much more important footing in the estimation of the members of the profession than formerly. It is incumbent upon every practitioner that he should not only be able to treat these affections successfully, but that he should also be able to give a sound and reliable prognosis concerning them. Every succeeding day brings the medico-legal aspect of the subject into greater prominence, for not only is the question of compensation an impor- tant one with Insurance Companies, but it is found that it is in this particular class of slight or minor 204140 vi PREFACE injuries that the greatest difficulty is experienced in estimating the exact monetary value of a claim. At the present time not only do the uneducated and those of the lower orders of society seek the advice of unqualified practitioners only too fre- quently, but it has become the fashion for the ' smart set ' to flock in increasing numbers to the waiting-rooms of those who proclaim loudest their skill, and who perhaps pay most for their daily advertisements. It is not claimed for the present treatise that it represents all that is known on the subject, but rather that it supplies certain details, operative and otherwise, which are not to be found in the ordinary textbooks on Surgery. It is the embodiment for the most part of the writer's own personal experience, and as such may be helpful to some who may not have had his almost unique opportunities for dealing with athletic and other injuries. As in the text certain terms, as ' wobbly- joint ', ' weak-joint', ' drop-top ', ' mallet-finger', have been introduced, some explanation seems necessary. It was found almost impossible to do without them, for to the lay mind they convey a definite and specific meaning, and are expressions presumably intro- duced by and remaining in the daily use of bone- setters and others. It is to be regretted also that the expressions PREFACE vii ' rider' s-sprain ', ' tennis-leg ', and many others similar, should have crept into surgical literature. Certain repetitions, especially in relation to ana- tomical points, are to be found ; they are made with a view to the accentuation of important facts. Mr. W. Elliot Stanford, of New College, kindly wrote the details of the accident to his wrist, entail- ing a fracture of the scaphoid bone. All the illustrations, excepting Fig. 45, the block for which was lent by Messrs. Lindsey and Sons, surgical instrument makers at London and Oxford, are original, and were taken, with few exceptions, from the author's own cases. The radiograms, with the single exception of Fig. 18, kindly lent by Mr. Edwin Dening, together with most of the photographs, were taken for me by my friend and colleague, Mr. R. H. Sankey, M.A., M.B., B.Ch., Oxon., Honorary Radiographer to the Radcliffe Infirmary and County Hospital at Oxford. Only four drawings appear in the work, those with the photographs of the specimens of semilunar cartilages were made by Mr. A. Robinson of the Oxford Museum. The temperature charts are all the work of Miss Agnes Still. I wish to take this opportunity of expressing to each of those who have so kindly and ably contri- buted to the illustrations, my best thanks for the trouble and skill they have bestowed, and to acknow- viii PREFACE ledge my thorough appreciation and indebtedness to those of my undergraduate friends who have kindly allowed themselves to be photographed. I wish also to place on record my indebtedness to those members of the profession who from time to time have written on these and kindred subjects, and especially to Sir William Bennett, Professor Howard Marsh, and Mr. L. B. Rawling, to each of whom I have made reference in the text. To my friends at 35 Harley Street, Drs. G. C. Cathcart and Theodore Thompson, for reading the proofs, and to the authors of that excellent textbook on Surgery, Messrs. Thomson and Miles, whose arrangement of surgical anatomy I have in a measure adopted, my best thanks are here offered. St. Giles' Gate, Oxford February, 1909. CONTENTS CHAPTER I PAGE Introductory 1 Concerning the Structure and Function of Joints. CHAPTER II Sprains considered generally Introduction — Definition — Classification — Articular Sprains — Muscular Sprains — Simple Sprain — Strain — Complicated Sprain — Sprain-fracture — Sprain with fracture — Sprain- dislocation — Sprain with gross nerve lesion — Hsematomata Diagnosis — Prognosis — Treatment — of Strains — of Sprains with immediate swelling — Elastic Pressure — Method of AppHcation — Special advantages — Active Voluntary Move- ments — Passive Movements — Constitutional Complica- tions — Tension in joints after sprains — Arthrotomy and digital exploration — Sprain complicated with injury to the nerves — Sprains with fractures. CHAPTER III Sequels of Sprains 41 Preventable sequelce — Stiff and painful joints — Atrophy and wasting of muscles acting on joints — Recurring or relapsing synovitis — A relaxed condition of joints known as ' wobbly joint ' or ' weak joint ' — Persistent pain in a joint — Crippled or deformed joint — Improperly united muscles and tendons — Ankylosis. Unavoidable sequelce — Localized paresis or paralysis — Ossifying myositis — Osteo-arthritis — Loose Bodies. X CONTENTS CHAPTER IV PAGE Individual Articular Sprains . . . . . .74 Of the Upper Extremity — Sterno- clavicular joint — Acromio- clavicular — Shoulder — Elbow — ' Dislocation by elonga- tion ' — Wrist — Fracture of Scaphoid bone — Sprain of the thumb — ' Drop-top ' or ' mallet finger ' — Sprains of the finger-joints. Of the Lower Extremity — Hip-joint — Ankle-joint — ' Meta- tarsal pain ' — Tarso-metatarsal joint. Sprains of the Body — of the side (intercostal muscles) — sacro-coccygeal sprain — coccygodinia. CHAPTEil V Sprains in the Eegion of the Knee-joint .... 109 Surgical anatomy — Sprains of the knee considered generally — Traumatic Hydrops — Sprains in which the internal lateral ligament is most concerned — Sprains in which the external lateral ligaments are most concerned — Separation of the body of the internal semilunar cartilage from the deep fibres of the internal lateral ligament. CHAPTER VI Internal Derangements of the Knee-joint . . .124 Displaced, detached, or torn internal semilunar cartilage — Anatomy — Symptoms and clinical characteristics — Diag- nosis — Causation — Treatment of first attack (immediate and subsequent) ; of recurrent or relapsing cases — Pal- liative treatment — Operative treatment — Essential pre- liminaries to operations — Displaced external semilunar cartilage — Hypertrophied synovial fringes. CHAPTER VII General Injuries to Muscles and Tendons . . .169 Muscle sprain — Hernia of muscle — Displacement or dis- location of tendons — Rupture of muscle or tendon. CONTENTS xi CHAPTER VIII PAGE Individual Injuries to Muscles and Tendons . . .187 Ruptures of muscles and tendons — Muscles of the Trunk — Rectus abdominis — Oblique muscles of the abdomen — Ilio-psoas muscle — Sacro- lumbalis. Of the Upper Extremity — Deltoid, ' cricket shoulder ' — Biceps cubiti — Triceps — Muscles of forearm. Of the Lower Extremity — Rectus femoris — Quadriceps exten- sor — Hamstrings — Adductor longus — Brevis and pectineus — Adductor magnus — Ligamentum patellae — Muscles of the calf, ' lawn-tennis leg ' — Tendo-AchilUs. CHAPTER IX Massage, Movement, and Exercises in the Treatment of Sprains and Bruises 210 Massage — Passive movements — Active voluntary move- ments — Forcible movements of stiff joints under an anaesthetic — Means adopted for preventing muscle waste by active exercises — Movements and exercises against resistance — by means of weights and pulleys. APPENDIX 222 INDEX 229 LIST OF ILLUSTRATIONS FIGURE PAGE 1. Fracture -sprain of ankle-joint ... . . 11 2. Linear fracture of tibia in lower third as complication of sprained ankle ; illustrating ' sprain- with-fracture ' . 13 3. Knee-joint permanently flexed and stifE as result of enforced movements and exercise while the semilunar cartilage remained displaced . . . . . . .17 4. Knee-joint fully distended with fluid as result of severe sprain .......... 21 5. Photograph of knee-joint with elastic compression applied 23 6. Radiogram of fracture of left olecranon without displace- ment 39 7. Photograph of knee showing scar indicating author's line of incision for exploratory arthrotomy ... 45 8. Photograph of old injury to knee-joint with atrophy of muscles of the thigh and hypertrophy of those of the calf 49 9. False joint at hip, result of faulty treatment of fracture of the neck of the femur by movement and exercises . 52 10. Radiogram of fracture of first phalanx of little finger with permanent deformity ....... 53 11. Radiogram of false joint in the lower third of the humerus of ball-and-socket type, resulting from too early move- ments at the elbow in the treatment of a fractured arm 54 12. Radiogram showing ossifying myositis in extensor muscles of the thigh 57 13. Radiogram of same case at a later stage ... 58 14. Radiogram of extensive ossifying myositis in extensor muscles of thigh, result of sprain at football, showing distinct lamination .59 15. Photograph of thigh with swelling on the extensor surface due to mass of ossifying myositis . . . .61 16. Radiogram of knee-joint with partial detachment of a portion of the rim of the external femoral condyle . 67 xiv LIST OF ILLUSTRATIONS FIGURE PAGE 17. Photograph of structures removed from a knee-joint by operation in which there was displacement of an internal semilunar cartilage of long standing with chronic synovitis 69 18. Eadiogram of oblique fracture through lower end of radius in which there was no displacement . . . .84 19. Eadiogram of a fracture of the tip of the styloid process of the ulna ......... 85 20. Eadiogram of sprain-dislocation at the wrist in a child, showing separation of the radial epiphysis and tearing of the periosteum 86 21. Complicated sprain of wrist. Greenstick fracture of lower radius, and detachment of the tip of the styloid process of the ulna 87 22. Fracture-sprain of wrist. The scaphoid bone fractured into three pieces by blow while boxing ... 88 23. Fracture of scaphoid of wrist into two pieces . . 89 24. Fracture of scaphoid of wrist (football accident) . . 90 25. 1 Eadiograms of Bennett's fractures at the base of the 26.) metacarpal bone of the thumb 95 27. Linear fracture of the metacarpal bone of the thumb without displacement 96 28. Eadiogram of fractured first phalanx of index finger . 98 29. Eadiogram of greenstick fracture of the first phalanx of the index finger 98 30. Eadiogram of a greenstick fracture of the metacarpal bone of the second finger, showing well-marked callus as result of rubbing 99 31. Photograph of a sprained ankle, which had been incorrectly bandaged during treatment 102 32. Eadiogram of sprain of ankle with fracture (linear) through the lower third of the tibia 104 33. Photograph of sprain of knee-joint taken four hours after the accident, showing full distension of the capsule . 115 34. Photograph of case of acute traumatic synovitis of knee-joint as result of displacement of the external semilunar cartilage taken two hours after the accident . .117 LIST OF ILLUSTRATIONS xv FIGURE PAGE 35. Photograph of two knees with chronic thickening of the synovial membranes in a case of recurrent displacement of the semilunar cartilages . . . . . .118 36. Photograph of anterior half of a semilunar cartilage of the knee 125 37. Photograph of anterior half of a left internal semilunar cartilage of the knee 126 38. Photograph of a drawing from a specimen of an internal semilunar cartilage showing longitudinal tearing into three strips 129 39. Drawing from the upper surface of the head of left tibia 131 40. \ * I Three stages in the author's method of reducing displaced * r semilunar cartilages 141 43. Schemes to illustrate further the method of reduction . 143 44. Piece of bone detached from the edge of the patella, which had become rounded off and formed a loose body in the knee-joint 147 45. Block of hinge apparatus for the knee .... 150 46. Photographs of knees to show old transverse scars in the removal of semilunar cartilages 152 47. ] The three stages in the author's operation for exploratory 48. - arthrotomy and for removal of semilunar cartilages 49.) from the knee 154, 155, 156 50. Long-standing displacement of left external semilunar cartilage of knee, showing atrophy of muscles of the thigh and hypertrophy of those of the calf, also flexion and fore-shortening of the limb 165 51. Recent case of displaced external semilunar cartilage, with flexion and swelling of the left knee .... 167 52. Photograph, showing hernia of muscle of thigh . .171 53. Dislocation of peroneus longus tendon on to the external malleolus . . 174 54. Back view of a displacement of both the peroneus longus and brevis tendons from their groove behind the malleolus 175 55. Strapping applied for rupture of right rectus abdominis muscle 189 xvi LIST OF ILLUSTRATIONS FIGUEE PAGE 56. A. Strapping applied for sprained side (intercostal muscles), b. Strapping applied for sprain or rupture of the oblique muscles of che abdomen — ' bowler's side ' 191 57. Rupture of the rectus femoris muscle, also old scar for removal of semilunar cartilage of the knee . . . 195 58. Strapping applied for rupture of the hamstring muscles in the upper half of the thigh 196 59. Long- standing case of rupture of the ligamentum patellae on both sides with characteristic deformity . . . 204 60. Radiogram of the left knee of the same case . . 205 61. Apparatus worn for rupture of both patellar ligaments to enable patient to walk . . . . , . 206 62. Strapping applied for ' tennis-leg ', a rupture of fibres of the soleus or plantaris muscles ..... 207 63. Ankle strapped for strain by author's plan . . . 225 64. Strapping of shoulder for contusion or sprain , . 226 65. Elbow-joint with elastic pressure applied for sprain with effusion 227 CHARTS 1.] Represent the average temperature after arthrotomy of 2.) the knee-joint when no drainage is used . . 158, 159 3. 1 Represent the same when drainage of the joint is employed 4.) for twenty- four hours after operation . . . 160, 161 OF THE UNIVERSITY OF SPRAINS AND ALLIED INJURIES OF JOINTS ^ CHAPTER I INTRODUCTORY The subject of sprains is quite inadequately treated in the ordinary manuals of surgery. Modern methods of diagnosis have taught us much concerning the anatomical conditions underlying strains and sprains, and these injuries can only be adequately diagnosed and treated by their means. The present widely divergent views on the treatment of sprains is itself evidence of the want of exact knowledge concerning the pathological conditions present. On the one hand the bone-setter treats every sprain by massage and movement, while the usual custom among medical practitioners is to treat these con- ditions by rest, the joint being fixed in splints. Both these rule-of-thumb methods may do a great deal of harm. The bone-setter who manipulates a sprain complicated by fracture may displace the fragments, and by his unscientific movements cause an excessive amount of callus to be thrown out, with resulting permanent deformity of the joint. The consequence of putting every sprained joint at rest by fixing it in splints is often equally or even more disastrous. The resulting atrophy of the WHITELOCKE ^ 2 SPRAINS AND ALLIED INJURIES muscles moving the joint, and the formation of adhesions within it, produce not infrequently total disablement of a joint which, with proper treatment, might have recovered entirely. For the last eighteen years the writer has made a special study of these injuries, and has had unusual opportunities of treat- ing a large number of such cases. Concerning the Structure and Functions of Joints. Joints are constructed for movement. The bones which enter into their formation are covered with a thin layer of smooth, highly polished, hyaline cartilage. This enables them to move smoothly upon one another with a minimum of friction, and no jarring. They are tensely and firmly bound together by the ligaments and tendons which surround them. The capsule which envelops the ends of the bones is invariably continuous with the periosteum, and securely encloses them in what is but a potential space. The capsular ligament is lined by the synovial membrane, which extends to the edges of the cartilaginous border. This mem- brane is polished, and lined on its visceral surface by endothelium, and serves to secrete a fluid which lubricates the inner surface of the joints. It is thrown into folds wherever it is not in contact with the articular surfaces, and is covered with villi, or papillae, which, in certain conditions of disease, are liable to thickening and hypertrophy. The inter- articular ligaments are closely enveloped by it. It secretes a viscous fluid known as synovia, the chief constituent of which is mucin. The function of synovia is that of a lubricant. The bones, cartilages, ligaments, periosteum, synovial membrane, and, in INTRODUCTORY 3 fact, all the tissues which enter into the formation of a joint, are developed from a common embryonic origin, the mesoblast ; hence, in certain cases of injury, and as a result of certain pathological states, they become interchangeable and take the place of one another, though to a limited extent. The villi of the synovial membrane may develop cartilage, or even bone, when unduly stimulated, and the ligaments may undergo ossification. A healthy joint contains but a potential cavity. This becomes a real one if the capsule should be distended either with blood or serous effusion, in consequence of injury or disease. Such distension gives rise to stretching and elongation of the ligaments, allowing of greater movement between the bones, while the joint becomes weakened and unstable, and more liable to injury. The synovial cavity empties itself through stomata into the lymphatics, which pass through the capsule and enter the lymph spaces in the inter-muscular and fascial strata. Blood is freely supplied by the articular vessels. The nervous supply of a joint is generally the same as that for the muscles which act upon it, and for the skin over its surface. The importance of this interesting physiological relationship will again be referred to. The strength of a particular joint depends upon — (1) the arrangement of its bony surfaces one to the other ; (2) the nature, strength, and disposition of its ligaments ; (3) the muscles and tendons which surround it ; (4) its normal amount of mobility. Some joints derive their stability from the accurate B 2 4 SPRAINS AND ALLIED INJURIES adaptation of the opposing bony surfaces to one another. The ball-and-socket arrangement of the hip, and the hinge of the elbow, are mainly respon- sible for the great strength of these articulations. It requires very great force to dissociate or undo the bony apposition, and dislocations are rare without being associated with serious ligamentous tearing or fracture of one or other bone. On the other hand one may cite such an articula- tion as the shoulder, a joint quite devoid of any bony influence, and dependent entirely for its integrity upon the strength of its ligaments and the muscles enveloping and tendons passing over and around it. A very trifling amount of violence exerted unexpectedly, catches, so to speak, the muscles unawares and the bones in an unusual position, and is sufficient to produce a complete dislocation. The very range of movement enjoyed by the shoulder is its source of weakness ; for what it gains in mobility it loses in stability. Between these two extremes is an intermediate group of joints, dependent, on the one hand, partly on the formation of their bony surfaces, and partly on the support afforded by the muscles and tendons that envelop or surround them. The knee, wrist, clavi- cular, tarsal, carpal, and many other smaller articu- lations, derive their strength mainly from the liga- ments which firmly bind their several bones together. It is in this group that we meet for the most part with strains and sprains. When such a joint is subjected to external violence, whereby strain is put upon it, the brunt has to be borne by the liga- ments. If the violence is slight, pr the ligament INTRODUCTORY 5 a strong one, nothing more serious than an over- stretching or strain results ; if, on the other hand, the violence is extreme, not only individual ligaments, but whole groups of ligaments may be completely torn across. This class is represented by those joints whose chief strength is derived from their ligaments. Some joints possess inter- articular cartilages which, though technically ligaments, since they bind bones to bones, are a source of natural strength in an indirect way. The amount of gliding or similar movements allowed by these inter- articular structures serves often to turn off, as it were, the main strain into some other direction as soon as violence is brought to bear on them. While every variety of joint is liable to sprain, it may be stated generally that those joints dependent on the strength of their ligaments are those most prone to this form of injury. CHAPTER II SPRAINS CONSIDERED GENERALLY All classes of society are liable to sprains, the rich as well as the poor. They are very frequently met with, and although they cannot be classed as accidents of a dangerous kind, they are nevertheless serious. Great numbers of persons are incapacitated from their daily calling, wage-earners as well as pleasure-seekers. There is, perhaps, no more fruit- ful field than the athletic. For some inexplicable reason, the importance due to such crippling ailments has been little considered by surgeons in the past. Such disablements, in the vast majority of cases, seem to have been relegated to the rule-of-thumb attentions of the bone-setter, a class of persons with little or no scientific training or interests. At the present time, when the achievements of modern operative surgery everywhere resound, and new advances are made in different departments, in the scientific as well as the practical, these so- called ' little things ' of minor surgery are apt to be neglected and considered as of subsidiary impor- tance. Yet, if the wage-earning capacity of the nation is taken into consideration, the annual loss must be enormous, and under the new Workmen's Com- pensation Act the expenses of the employers of labour are not likely to be diminished. This latter consideration, perhaps more than any other, may SPRAINS CONSIDERED GENERALLY 7 in the future redirect the attention of surgeons to a branch of surgery which, to say the least of it, has been somewhat neglected. Already there are signs that the empiricism of the much-consulted and the much-in-request wiseacre or bone-setter, the person who invariably finds ' something out of place ', ' a bone out of joint ', and whose stock treat- ment is to ' move everything ', is giving way slowly, though surely, to a more rational and, if one may be permitted to say so, scientific and discriminating regime. Nevertheless, there are still thousands of persons, men and women of education and culture, who resort to these unregistered, irresponsible prac- titioners, and consult them with a confidence that is truly surprising. It surely behoves our profession to pause, con- sider, and make inquiries, as to whether means may not and should not be taken to remedy this state of things ; for not only is it an opprobrium to ourselves, but hundreds of people, owing to improper rule-of- thumb and irresponsible treatment, are rendered permanently incapacitated and crippled. The vic- tims, unprotected by the legislature of the country, often find out their mistake when the time for remedial measures is past, with frequently a legacy in the shape of a damaged limb for the rest of their lives. Definition. When the movements in a joint are carried beyond their normal and physiological limita- tions, owing to some wrenching or twisting form of violence, and the soft structures which bind the component bones together are overstretched or torn across, such an injury is said to be a strain or sprain. At one time the classical conception of 8 SPRAINS CONSIDERED GENERALLY a sprain was ' a wrench or strain resulting in stretch- ing or laceration of the soft parts without external wound '. Such a definition at the present time requires some modification, for although in the main it is an accurate description of the anatomy of the affection, yet there is a certain proportion of cases which, formerly classified with sprains, would at the present time be more properly grouped with frac- tures. For example, in the injuries to the larger joints it is not an uncommon experience to find small fragments of bone detached with the ligaments where they have been torn from their periosteal attachments. Again, in the smaller articulations, as those of the wrist, hand and foot, the small bones may be fissured, chipped or even crushed ; so also small epiphyses are sometimes dragged away by the tendons in muscular sprains. The use of the X-rays as a means of diagnosis has revealed many such bony defects where formerly they might not have been suspected. For clinical purposes, however, these injuries may still be regarded as sprains, for the symptoms of fracture are of minor importance as compared with those of sprain, which usually greatly predominate. Their true pathological significance must never be lost sight of nevertheless, for the existence of a fracture however slight materially changes the treatment. To this, reference will be made later, when the question of treatment is under consideration. Classification. For the purposes of classification, sprains may be divided into two large classes. 1. Articular, or those affecting the joints them- selves ; ^ UNIVERSITY OF. SPRAINS CONSIDERED GENERALLY 9 2. Muscular, concerned with the overstretching, dislocation or rupture of muscles and their tendons. 1. Articular Sprains, for clinical purposes, may be arranged into two divisions or classes : (a) simple, (h) complicated. (a) Simple Sprain, By the term ' simple sprain ' is here meant only those cases where, as the result of some external violence, the soft parts are over- stretched or torn across, and in which no gross lesion of the bone is to be found. In the simplest form of sprain, that technically described as strain, the soft parts are merely stretched beyond their usual capacity, and there is no true laceration. No swelling is to be found, and the symptoms are only those of pain and stiffness with some loss of function. In the more severe forms of simple sprains, in which there has been more or less tearing, as well as stretching of the ligaments and other structures of the joint, in addition to pain and loss of power, we get swelling. When the swelling follows immediately after an injury it is due to haemorrhage. Arteries as well as veins are torn across, and pour their contents into the tissues around. Haemorrhage is sometimes, as we shall see when dealing with mus- cular sprains, of large amount and serious conse- quence. The bleeding usually ceases as the tension in the parts increases, but it sometimes happens that, when the injured vessel is a comparatively large and important one, and when the tissues into which it drains are loose and distensible (as may be met with in some of the fascial planes of the body), it may continue for a considerable time after the 10 SPRAINS CONSIDERED GENERALLY injury, and give rise to extensive swelling. Haemato- mata result from the blood clotting in the tissues. When the swelling in a joint comes on some hours or it may be even days later, it is due to serous effusion, and is known as ' deferred swelling '. This varies considerably in amount in different cases, depending upon a variety of causes such as the nature and severity of the injury, health and idio- syncrasy of the individual, and sometimes even to improper treatment early in the case. It is regarded by some authorities as inflammatory in nature ; by others, as a necessary concomitant, and as afford- ing more of a physiological than a pathological significance, and even of being concerned in the process of repair. There is something to be said for both views. That it is of pathological significance it must be admitted, since it is the result of injury and is only present to any appreciable quantity when diseased conditions coexist. (b) Complicated Sprains, I. Simple sprains become complicated when there are gross injuries to the bone or its periosteum, as when portions of bone or epiphyses are detached, and when the bones are fissured or even crushed. Such a lesion is now loosely designated a sprain- fracture, or fracture-sprain. It should, however, be clearly understood that there is a marked differ- ence between a fracture-sprain and a sprain with fracture. When the sprain is complicated by an injury to a bone entering directly into the joint, or to a neigh- bouring epiphysis, it is called a fracture-sprain or SPRAINS CONSIDERED GENERALLY 11 sprain-fracture. If in addition to the sprain of a joint there is a fracture of one of the bones in its immediate neighbourhood but not involving the joint itself, the expression sprain with fracture may Fig. 1. Fracture-sprain of ankle — note the separation through the internal malleolus — taken from a boy of 14. The lower epiphysis of tibia, including the malleolus, is normally developed in one piece. Accident the result of a twdst of the joint. To illustrate sprain-fracture. 12 SPRAINS CONSIDERED GENERALLY be used. Figs. 1 and 2 illustrate these definitions, and should be compared. 2. In some joints, such as the knee, tempero- maxillary, and clavicular, in which inter-articular cartilages are to be found, it is no uncommon circumstance for these structures to become partially detached or torn across and displaced, either inwards towards the cavity, or out of the joint. Though technically a semiluxation or partial dislocation, since the symptoms of sprain so greatly predominate, it has been customary to regard such an accident as a sprain, and to treat it as such. This, from analogy, may be styled a strain-dislocation, 3. In a few cases the nerves suffer injury and complicate matters. They may be overstretched, resulting in temporary paresis, or a sensation of numbness may be experienced in some branch far removed from the injured joint. Pain is generally the chief symptom when nerves are pressed upon by inflammatory exudation, or overstretched in some part of their course. It may be localized to the seat of injury, or radiate along a nerve-trunk around the body or into the extremities. If not detected early, or if improperly treated, this com- plication gives rise to serious and prolonged crippling. A form of chronic atrophic neuritis may supervene, and atrophy of the muscles supplied by the special nerve, of a peculiar and lasting kind, result. Unless carefully sought for at the time, such lesions are apt to be overlooked by the surgeon, for patients seldom attach importance to sensations referred to parts of the body distantly removed from the main injury ; nor is it difficult to miss some small area of numbness SPRAINS CONSIDERED GENERALLY 13 or altered sensation in the skin. When large or important nerves, such as the sciatic, or branches of the brachial plexus are concerned, for obvious Fig. 2. Linear fracture of tibia in lower third without displacement, from a boy who walked into hospital complaining of having sprained his ankle. The fracture does not extend to the joint. To illustrate author's ' sprain-with-fracture '. Radiogram taken two days after the accident. reasons the symptoms are more readily noticed. It is therefore a wise precaution in all severe sprains 14 SPRAINS CONSIDERED GENERALLY for the surgeon to direct his attention towards searching for possible nerve lesions. 4. Sprains with very large hsematomata may be regarded as complicated sprains, for they may require even operative measures for their successful treatment. Large collections of effused blood are met with not infrequently as the result of sprains and lacerations of muscles ; especially in situations where there is little resistance offered to the extra- vasated blood, as afforded by the loose planes of cellular tissue between groups of muscles, as those of the thigh and abdomen, and the sheath of the psoas and iliacus. Diagnosis. The importance of an early diagno- sis in all cases cannot be too strongly advocated, nor can this advice be too often repeated. It may not always be possible to make an exact or complete diagnosis, but to get as near to the truth as possible should be the first aim. The difficulty or otherwise in arriving at a correct diagnosis will depend largely upon the period at which the surgeon is called to see the case. If he is fortunate enough to be con- sulted before such swelling has taken place, his task may be comparatively simple ; on the other hand, when much material has had time to be poured out into the surrounding tissues and increased by subsequent inflammation, his difficulties may be almost insurmountable. It is always a sound plan, when in doubt, to completely anaesthetize the patient. This should be done in all cases where there is no potent contra-indication such as the presence of advanced organic disease or insuperable objection by the patient. The joint should then be SPRAINS CONSIDERED GENERALLY 15 put through all its movements. In doing this the synovial membrane will be put fully on the stretch, and any folds which may have been made will be unfolded, the curling in of torn fragments of the capsule replaced (and this is no uncommon occur- rence), and any undue fixity or abnormal mobility of the joint itself noted. When the inter-articular fibro-cartilage has been torn or displaced, the movements, at first limited and incomplete, may be at once restored by a free and painless manipulation. Crepitus may or may not be elicited, and it is of importance to direct attention to this important symptom. The absence of or failure in detecting crepitation does not at once dispose of the possi- bility of fracture any more than does its presence give positive proof of its existence. By this is meant that there are cases of fracture in which crepitation cannot by any means be detected, such as in fissured injuries of bone, while it is often distinct and quite easily palpable in joints the subject of osteo-arthritis, or where sticky material is effused into tendon-sheaths in the neighbourhood of injured joints, and where no fracture exists. Where there is no fracture, unusual mobility will give the observer a fair estimate of the amount of damage sustained by the ligaments as a whole, as well as by the particular ligament, or group of ligaments, which have borne the brunt of the inci- dence of the violence. Having ascertained all that can be learned by manipulation with the aid of a general anaesthetic, if it be possible or practicable, the limb or part should be examined by means of the 16 SPRAINS CONSIDERED GENERALLY X-rays, under the management of a competent person, and I say competent advisedly, for the correct interpretation of a radiogram requires con- siderable surgical knowledge and practice. The X-rays will settle once and for all the existence or otherwise of a fracture, a point of incalculable service, as will be noted when treatment is considered. The X-ray photograph should be taken from different points of view, or it may fail to show a fracture. A sprain complicated with injury to a bone or displaced, torn, or otherwise detached inter-articular cartilage, or with gross nerve lesion, or exten- sive extravasation, will require special and careful handling. Prognosis. The immediate prognosis in the case of simple sprains and strains is good, but in com- plicated cases some caution must be exercised. Sprain-fractures, when not detected and when treated by ordinary means like simple sprains, may lead to prolonged stiffness and much unnecessary suffering. So in cases of gross nerve lesion, continued pain and muscle atrophy, even of a permanent kind, may supervene, as well as actual local paresis or palsy. Disorganization of a knee-joint has been known to result from enforced exercises in a case of undetected displaced semilunar cartilage (Fig. 3). These extreme cases, however, are rare. Certain remote contingencies arise which are quite beyond the control of the surgeon, such as osteo- arthritis, myositis ossificans, palsy, tumour or tuber- culosis, loose bodies in the joint, as well as others, such as deformity, which can be, for the most part, prevented. These remote and permanent conse- SPRAINS CONSIDERED GENERALLY 17 quences will be referred to again when dealing with the sequelae of sprains. Prognosis is daily becoming of much practical importance. The new Workmen's Fig. 3. Photograph of knees. The left shows permanent flexion and stiffness, result of unreduced semilunar cartilage. Owing to mistaken diagnosis case had been treated at a gymnasium for many months with movements, exercises, and massage. Patient now quite lame. Correct diagnosis had not been made in the first instance, as he was treated by a bone-setter. Compensation Act makes it almost imperative that surgeons should be able to give a reliable opinion in cases of injury. Treatment. Simple sprains, as distinguished from c WHITELOCKE 18 SPRAINS CONSIDERED GENERALLY sprains complicated with lesions of bone or nerve, are of two classes : those in which pain, stiffness, and loss of function are the only symptoms, and those in which there is swelling in addition. For the former class the term ' strain ' is used. Simple strains are for the most part limited to strains about joints and to the muscles of the back and neck, and the short flat muscles of the trunk. They are not a large class. Those suffering from strains seek assistance mainly for the relief of pain, which may be intense. Absolute rest to the injured part is the first indication where pain is concerned, jand this may best be attained by the aid of strapping. Various materials are used for this purpose. The best are those which give a more or less resilient or elastic support, such as wash-leather strapping and leucoplast. Mead's or Leslie's plaster may be used, but do not answer the purpose so well ; they are, however, much cheaper. Perhaps, all things con- sidered, Seabury's adhesive perforated rubber plaster is the most universally applicable ; it is strong, allows of evaporation, and is not quite as irritating as some other forms ; it has a further advantage of being comparatively cheap, and may be had in convenient sizes. All strapping must be carefully and evenly applied, so as to ensure perfect rest to the parts concerned. As soon as the pain ceases, or is materially lessened, gentle stroking massage may be employed twice or of tener in a day. Massage, in some instances, will further reduce pain, but slight voluntary movements should be encouraged from the very first, as thereby stiffness, the other symptom of strain, is readily and speedily overcome. SPRAINS CONSIDERED GENERALLY 19 and the healthy physiological nutrition of the joint or muscle promoted, with complete restoration to function. Sprains with ^ immediate swelling '. Bleeding into the tissues follows almost immediately upon the injury, the blood being poured out from the ruptured vessels. The swelling is usually established before the surgeon is called to the case. If, however, the case is seen early, an attempt should be made to arrest or check further haemorrhage. Various means have been employed to effect this, and while one practitioner will employ cold as a routine, another will, with equal confidence, use nothing but warm applications. The writer has for years entirely abandoned the use of either cold or hot applications — neither is, in his opinion, sufficiently efficacious. Cold, to be of any real value, must be continuous and intense, and this is not without danger to persons suffering with organic (cardiac or renal) disease. Cases are on record where extensive sloughing has followed upon the continued use of cold in persons suffering from albuminuria, glycosuria and other debilitating affections. Warm amplications are better tolerated, and even liked by patients, but they would only seem to encourage rather than check the extravasation of blood. Any application of heat that would be sufficient to reflexly pro- duce contraction and retraction of the torn ends of deeply situated blood-vessels, would not be borne with any comfort, nor would this be safe as a routine proceeding. The skin of some indi- viduals is peculiarly liable to be damaged by high degrees of temperature, whether the heat is dry or c 2 20 SPRAINS CONSIDERED GENERALLY moist. The most efficacious, and at the same time the most readily appHed remedy is firm elastic pressure. Elastic pressure is suitable for all cases of extravasation, whether of little or great amount, whether immediate or deferred. It has the advan- tages of being absolutely safe, easily applied, and of universal application ; it ensures perfect rest, and if employed immediately or soon after an injury, decidedly diminishes or completely prevents those secondary effusions so apt to follow. Furthermore, it promotes, to a marked degree, the rapid absorption of extravasated material, the next great desideratum in the treatment of all kinds of sprains. Thus, by insuring rest, checking or limiting immediate haemorrhage, preventing or at any rate diminishing secondary effusion, promoting the absorption of all extravasated material, it serves the double purpose of meeting the two first and all-important desiderata — those of checking haemorrhage and removing extravasations. When properly applied, it takes the place of a splint and ensures rest ; its mode of action may be observed in the treatment of contusions. The principle is simple : in applying equable elastic pressure of a higher degree than that of the blood pressure, the escape of material from the blood- vessel is mechanically prevented, and this pressure, exerted on the fluid materials that have already escaped into the tissues being greater than that of the blood pressure in the vessels themselves, it happens that a process of re-absorption is soon initiated and the swelling is observed to subside apace. The same principle is at work in relation to the serous effusion which is almost invariably SPRAINS CONSIDERED GENERALLY 21 poured out secondarily into the synovial cavities of the larger joints. It is maintained that if elastic pressure can be properly and immediately applied to an injured joint, it is unusual to have secondary effusions, and when such effusions do take place they i'lG. 4. Photograph of knee-joint in profile, taken two hours after severe sprain. do so to a more limited extent than when other remedial measures are adopted. It may be used for any extravasation or effusion, whether localized or diffused, whether of rapid or more chronic formation. It matters not whether the material is confined within the capsule of the joint, or merely loosely collected in the inter- muscular and cellular planes of the trunk or extremities. The 22 SPRAINS CONSIDERED GENERALLY action is the same ; its service invariably efficient. If a joint such as the knee be taken as an illustration, and if we suppose that, as the result of a twist, its capsule has become fully distended with effusion^ and that most of the swelling took place immediately after the accident and continued to gradually increase for some hours afterwards, it will be found that such a knee assumes the posture of slight flexion (Fig. 4). This is a position which, from the nature of things, permits of the greatest relaxation of the muscles around the joint, and allows to the distended capsule its fullest capacity, and in this way best assures relief to the sufferer. This is nature's first attempt at procuring rest,, our first requirement in treatment ; to extend such a joint and fix it in the straight position in a splint^ as is so often recommended and practised, would not only violate this principle of securing rest, but render the patient exceedingly restless and uncom- fortable. On the contrary, the limb should be left in the position that it naturally assumes, which is always that which is most comfortable to the patient. When the knee is partially bent, not only are the muscles relaxed, but the surrounding ligaments are also slackened ; when, on the other hand, it is extended, these tissues are tightened up and exert pressure on the distended capsule, thereby tending to increase the pain and discomfort. Method of applying Elastic Pressure. To the slightly flexed limb thick layers of cotton- wool are adapted. They are either rolled aroimd the joint,^ or cut into shapes and so applied that a complete coating of at least one inch of thickness is attained. SPRAINS CONSIDERED GENERALLY 23 In length, the material should extend for at least two inches above and below the outside limitations of the capsular ligament. Gamgee-tissue, though more expensive, answers the purpose admirably ; it may be cut with greater nicety and exactitude than is ordinary cotton-wool, and so adapted more easily to the varying requirements. Over this thickness of material a strong roller bandage is tightly applied ; an inelastic yet resilient material, such as a domette Pig. 5. Photograph of knee with elastic pressure appUed for sprain. Author's plan. The knee is here represented as being too straight, it should be more flexed. or soft flannel bandage is all that is necessary. Stout calico or crepe- velpeau bandages are less useful, the former variety being a little too stiff, while the latter too soon lose their elasticity and become over- stretched and unsuitable. The bandage is then drawn as tightly as possible over the wadding so as to compress it to its utmost capacity, then fixed, to maintain it in this position. Great care must be taken to avoid creases in the wool, and to see that it is smoothly and equally applied, otherwise the pressure will not be evenly distributed. Four inches is a useful breadth for 24 SPRAINS CONSIDERED GENERALLY a bandage when applied to the trunk or lower ex- tremity ; a narrower one is more suitable for the upper limb. The photograph represents a knee-joint with elastic compression applied. It is of great advantage, whenever it is possible, to remove the bandage about six hours after its first application, and to thoroughly re-examine the joint. Oftentimes, points of diagnostic significance are lost sight of when making the first examination. By this time, in many cases, tension will have already become less, the patient less alarmed, and, finding his pain considerably diminished, will allow the surgeon more manipulative access to his injury. It may be assumed that whilst the first application of the elastic pressure mainly checks extravasation, the second and subsequent ones promote its re-absorption. It is well for the first three or four days, when practic- able, to remove the bandage twice in the twenty- four hours. The surgeon is thus enabled to judge of the rapidity or otherwise of the process of absorption, and what is of greater importance is that the inter- mittent removal and re-application of the bandage has a direct infiuence on the local circulation. As soon as the bandage is removed, the part that has been under compression becomes flushed with a new supply of arterial blood richly oxygenated, whilst, on its re-application the veins and lymphatics are once more compressed and their contents thereby emptied into the general blood-stream. This to-and- fro flushing and depletion will be seen to be most beneficial, both in improving the nutrition and assisting absorption. It has been noticed, whether this is a true explanation or not, that swellings are SPRAINS CONSIDERED GENERALLY 25 more rapidly reduced in cases where the pressure has been intermittently applied than in those where it has been allowed to remain constant, and this is truer and more certain when the method has been adopted during the early stages of treatment. In most cases the effusion will disappear in about four days, but such a happy result depends largely upon the time in which treatment is commenced, and upon the care and time that the surgeon is able to bestow in carrying out the details. The writer seldom uses massage in his practice until all or most of the effusion has disappeared. All that massage can effect, elastic pressure will, if properly and intelligently used. Where there are large haematomata in the tissues, or there is reason to suspect the presence of much clotted blood in a joint, the process of absorption must be expected to take longer. It is in these particular cases that the later use of massage, combined with elastic pressure, is most valuable. It has been said that elastic pressure is painful, that it produces numbness, that it is not well borne and for this reason should not be recommended. This is incorrect, and it may be here necessary to give a word of warning. Unless there is a sufficient thickness of the wadding, and unless the bandage is applied so that it does not come within at least one inch of the upper or lower limits of the wadding, painful constriction due to strangu- lation may result and produce discomfort. Pressure, when properly applied, is never uncomfortable ; it is rather the reverse. A strong elastic rubber bandage should never be used. It is hot, allows of little or no evaporation, is too powerful, causes 26 SPRAINS CONSIDERED GENERALLY too much compression and is often most uncomfort- able. Rigid splints and fixed apparatus, whether made of wood, plaster, or other material, should never be employed, even in complicated cases such as sprain-fracture. The primary object in the treatment of a joint is to restore its mobility, to avoid the possibility of adhesions forming in it or around it whereby it may become stiff or weak or painful. Much wasting of the surrounding muscles is apt to take place in a joint that is fixed in a splint. This is a serious com- plication, and must be prevented by all means. When the fluid effusion has been materially reduced, or for the most part removed, and the torn ends of the bleeding vessels have had time to be effectually sealed off, then, and not until then, should massage be employed. It is not usual to begin massage until at least seventy-two hours have elapsed. At first, gentle stroking massage should be tried for a few minutes, and then the bandage re-applied. If at the next inspection the fluid is still further diminished, and there is no heat in the joint, friction massage should be combined with stroking movements. This serves to break up the coagula and further disperse the absorbable elements of the clot into the surrounding tissues, and to promote more rapid absorption. Active voluntary movements, though at first slight, should be allowed from the very beginning, as soon as the bandages are removed, as they are of primary importance in preventing adhesions and muscle-wasting, and of maintaining the proper nutrition of the structures of the articulation. They SPRAINS CONSIDERED GENERALLY 27 relieve rather than cause pain, in most instances ; they should be permitted early in the case only in those muscles that have escaped injury, and their range should be small and limited. Passive movements are useful in a mechanical way, but possess little or no physiological merit. By stretching out the synovial membranes and capsular ligaments, they aid in restoring to their natural position fibres that are curled inwards and likely to form new and faulty attachments. Some- times they occasion pain, but they are not to be compared with active or voluntary movements as. regards their influence upon nutrition. The normal nerve-impulse, transmitted to the region of the joint through the muscles, will do more than any mechani- cal means, such as massage and passive movements, to restore physiological action and maintain the processes of repair. This fact should be steadily kept in view in dealing with other injured tissues of the body. When a distinct interval of hours and even day& occurs between the time of injury and the inci- dence of swelling, and in those cases where there is a recrudescence of symptoms after a period of apparent subsidence, it is probably due to secondary inflammatory changes. The treatment will depend upon whether or not there are present other signs of inflammation, such as pain on local pressure, heat^ and increased tension. In the absence of these acute symptoms, massage, or even movements both passive and active, may be persevered with. Especially useful are the gradu- ally increased voluntary movements and exercises 28 SPRAINS CONSIDERED GENERALLY assisted by elastic pressure. If, on the other hand, there is pain accompanied by a distinct rise in the surface temperature of the part, whether in the case of a joint or other part, all movements and massage should cease at once, and reliance be placed entirely upon the use of elastic pressure. The amount of pressure must be carefully regulated according to the degree of comfort or otherwise that it affords. A carefully applied crepe- velpeau bandage adjusted over a fair thickness of gamgee-tissue will not only give absolute rest to an inflamed joint, but will allow it to assume that degree of flexion which is at the same time the most comfortable. It is in this particular class of cases that a fixed and rigid appara- tus is most baneful ; the limb often from the method of its fixation in an extended position becomes uncomfortable ; the discomfort arising in this way leads the surgeon to believe, in many instances at any rate, that he has to deal with a progressive inflammation with increase of tension. Assuming this to be a likely explanation of the symptoms, the splints are indefinitely retained by him, with the result that adhesions form, muscles waste, and a painful, stiff and crippled joint remains. These relapsing cases, if the term is used strictly in this special sense, are not infrequently associated with and dependent upon the health of the individual. Persons of a gouty, rheumatic, tubercular, or even syphilitic tendency, are subject to effusions in their joints, the injury being merely the localizing cause. Nor must haemophilia be forgotten. It becomes of the greatest importance, therefore, to make careful inquiry into the histories of all recurrent or relapsing SPRAINS CONSIDERED GENERALLY 29 cases, to search diligently and carefully for any other clue which may be corroborative of a suspicion as to constitutional taint. In a large percentage of cases such taint will be readily found, a fact which will greatly influence our views of the local treatment. In rheumatic persons pain without effusion is often to be met with. The following case may be used as an illustration. An undergraduate, thrown from his horse while hunting, fell heavily upon his right side, jarring the right hip-joint. He was able to continue hunting for a short run, when he felt his hip- joint becoming increasingly stiff. Returning to college he had a very hot bath, went to bed, and sent for the writer. A careful examination with an anaesthetic was considered advisable and immediately made. No fracture or dislocation was discovered. Treated as a sprain, the joint rapidly improved, and the patient was able to resume gentle riding exercise fourteen days later. For the first ride or two he suffered no inconvenience whatever, and believed that he had completely recovered. He was then pressed by his friends into taking part in a football match, and went down by train for the piu-pose to his old school. He played in his accustomed place and thoroughly enjoyed the game. On his return to Oxford that evening the joint became once more stiff and exceedingly painful. Fearing lest the presence of some slight fracture had escaped detec- tion during the manipulation under the anaesthetic, or some other complication, the X-rays were used. Nothing of the nature of a fissure could be detected in the bones of the pelvis or thigh. As the pain 30 SPRAINS CONSIDERED GENERALLY became not only more severe but almost constant, and putting aside the probability of either a gouty or syphilitic taint, since he was an exceptionally healthy and clean living man, the patient was put under the influence of the salicyates and aspirin in large doses. The next morning, and as soon as he had taken as much as 40 grains of salicine and 30 of aspirin, he stated that he ' was cured '. After a few days he ceased to take any medicine and resumed his riding exercises. Again the symptoms recurred, and this time there was definite effusion into the hip- joint. The anti -rheumatic remedies once more relieved his pain, though the effusion lasted for about a week. For months off and on this patient suffered irom similar relapses whenever he over-exercised himself, and it was not until he had been prevailed upon to visit one of the well-known spas and to undergo a definite course of treatment that he finally lost all constitutional symptoms. This is but a type of innumerable instances of local injuries being influenced and exaggerated by some constitutional defect. When there is a gouty history it is the usual custom to exhibit the iodides internally, and some- times even colchicum, while at the same time local remedies are applied. Vasogen-iodine is an excellent local application ; it produces but little irritation and is a convenient substance for ' rubbing in '. With syphilitic subjects small doses of mercury pre- scribed in pill are to be preferred to the continued administration of the iodides. The treatment of haemophilia is absolute rest coupled with the internal administration of calcium SPRAINS CONSIDERED GENERALLY 31 lactate. Ergot would seem to exert but little influence. Fortunately these cases are extremely rare; nevertheless, the surgeon must not lose sight of them. Tuberculosis as a sequela and complication will be referred to later. A large, superficially situated hsematoma, especially if it is some distance from a joint, is best treated by a free incision, removal of all clots, and immediate suture. With aseptic methods drainage is not only unnecessary but usually inad- visable. Elastic pressure may with advantage be applied over the absorbable antiseptic dressing. When the skin wound is healed, which is usual in about ten days or earlier, and when the stitches have all been removed, massage may be begun. The scar should be avoided during the manipula- tion, and the movements confined for the most part to the peripheral regions at first. Extensive collec- tions of blood are to be met with in the loose parts and spaces of the body, as in the upper thigh and buttock, in the axilla, sheaths of the rectus abdo- minis and psoas and iliacus muscles. Such large collections are usually the result of arterial bleeding, and are found only in situations where a vessel of fair size may be torn. When muscles are torn across, the bleeding is mostly venous, on rarer occasions arterial. A branch of the deep epigastric artery is sometimes wounded when the rectus abdominis muscle is torn across as the result of violent muscular strain, or from blows upon the lower abdomen. Of TH8 UNIVERSITY OF 32 SPRAINS CONSIDERED GENERALLY Tension in Joints after Sprains The ' tension in joints ' of writers is the condition which sometimes follows immediately an injury to a joint, or occurs at some later period, it may be hours, days, or even weeks after. In such a con- dition we find the capsule of the joint distended, it may be to its fullest capacity, by a fluid effusion. When this is early in its appearance, immediate, in fact, it must be regarded as the result of haemorrhage ; when coming on gradually, creeping on, as it were, it is the consequence of secondary and inflammatory processes. Inflammation may result from renewed local injury or from any of the constitutional states above enumerated, such as gout or rheumatism. Local heat is invariably a symptom of tension ; it may be marked and easily to be detected with the aid of the hand, or so slight as to be hardly discernible by touch. The more rapid the incidence of the swelling, as a rule, the more distinct are the evidences of heat locally. Pain, often constant, readily in- creased by any movement, whether passive or active, is complained of. This is often severe, so severe, indeed, as to give rise to symptoms of consti- tutional disturbance such as sleeplessness, loss of appetite and general irritability. In the most severe cases, where even a bandage is tolerated with diffi- culty, one of two lines of local treatment is adopted by the writer. Where there is no important consti- tutional contra-indication existing, such as marked or severe cardiac or renal disease (glycosuria or chronic albuminuria), and where there is no suspicion of haemophilia, much relief from pain will result if,. SPRAINS CONSIDERED GENERALLY 33 with the aid of an anaesthetic, the joint is aspirated. All that is required in the majority of cases is that an ounce or at most two ounces of serum be with- drawn from the cavity. The relief afforded is as quickly experienced as is the cure of toothache when the tooth is extracted. There is no necessity for drawing off all or most of the contents of the joint ; indeed, it has been found that recurrences are more usual after the full removal than after partial. The requirements can be sufficiently met if only as much effusion is withdrawn as will diminish the tension and relieve the pain so that elastic pressure may be applied and tolerated with some degree of comfort. Not only does aspiration relieve pain, but it initiates the processes of absorption. The blood-vessels and lymphatics around a joint that is completely dis- tended are overstretched or mechanically blocked, so that either absorption ceases altogether or goes on at a disadvantage. The withdrawal of the fluid with the relief of tension in the joint, assisted by the elastic compression applied to the tissues around the joint, give such assistance as is necessary for dis- placing the fluid towards the general circulation. In this way the continual absorption of extravasated materials is insured. Such is the theory upon which the practice is based. When a patient objects to aspiration or any other form of operation, or when there are other contra- indications, the symptoms are often materially and readily relieved by submitting the joint to dry heat in a bath. This may be carried out by means of a radiant heat apparatus. In a certain proportion of cases, although not a large one, this method is WHITELOCKE J) 34 SPRAINS CONSIDERED GENERALLY useful, and may even work like a charm ; yet, occasionally, it must be admitted, that this plan of treatment is absolutely useless and fails entirely. When dry heat is unobtainable, or where it has been given a fair trial and has not come up to expecta- tions, hot fomentations with laudanum or lead lotion may have a soothing effect. As soon as it is noticed that the tension is diminishing, either of itself or as the result of treatment, elastic pressure, followed by or combined with massage, may be com- menced and continued until all or most of the fluid has disappeared. Movements, voluntary and passive, must be withheld until tension has quite or almost gone, and so long as any pain or local temperature remain. In recurrent cases, and in those in which the integrity of the joint is at stake owing to chronic distension of the capsule, and where considerable wasting of the muscles exists and seems to be in- creasing, arthrotomy and digital exploration of the joint itself may be necessary and even advisable. No open operation should, however, be hghtly under- taken, especially where the knee-joint is concerned. The writer has on several occasions found that the opening of a knee-joint is the only satisfactory means of dealing with faulty adhesions within its capsule. It should only be as a last resource and when other means have failed, and when it is considered that the joint must otherwise become permanently damaged, that arthrotomy and temporary drainage is recom- mended. The surgeon must be, moreover, one who is fully alive to the risks of opening the knee-joint and one who has the fullest confidence in the methods of his surgical technique, for unless absolute cleanli- SPRAINS CONSIDERED GENERALLY 35 ness and thorough asepsis can be guaranteed, arthrotomy should never be practised. More will be Avritten in a later chapter as to the details of arthro- tomy as advocated and practised by the writer (see p. 154). Sprains complicated with Injury to the Nerves Of the complications of sprains this is one of the most important, and requires special attention as regards diagnosis and treatment. In the laceration of muscles, as well as in the overstretching of the ligaments of joints, branches of nerves are liable to injury. Even a gross lesion in a nerve may escape the notice of the surgeon when making his first examination, unless he carefully looks for it. It is often only when imperfect recovery has taken place, and when the reasons for this are sought, that a surgeon begins to suspect that there may have been some injury to a nerve. When pain radiates along the branches of a large trunk like the great sciatic, or where there is marked and distinct paralysis, a surgeon's attention is at once arrested ; but when the nerves, coursing as they do between the abdo- minal muscles and between the ribs, are injured, as in sprains of the sacro-lumbalis, psoas, and other muscles of the trunk, they may readily escape his notice; nor is this surprising when we consider the predominance of the other symptoms in all cases of severe sprain. Numbness or tingling in some part remote from the injury is of frequent occurrence, and would seem to indicate an overstretching. Such symptoms are met with when the head of a dis- 'D 2 36 SPRAINS CONSIDERED GENERALLY located bone stretches or presses upon a nerve. Numbness usually passes off in from twenty-four to thirty-six hours, or as soon as the pressure is relieved or the stretching force relaxed. Should the symptoms persist, massage may be tried and kept up until distinct relief is afforded. When, on the other hand, the pain radiates along the course of a particular nerve or group of nerves, absolute and complete rest becomes imperative. Massage and movements do positive harm, and herein lies the inherent diffi- culty in treatment. We have seen that in simple sprains and strains, movement and massage are advocated while fixity is deprecated. In no class of complicated cases does the rule-of-thumb move- ment and exercises recommended by the bone-setter do more harm than in this. The limb or joint must be given absolute rest, though not necessarily placed in a splint, until the pain has completely disappeared or is rapidly subsiding. Then very gentle friction massage may be cautiously tried. If the pain is in the least degree increased after exercise it should be forbidden. A good alternative plan to the use of massage is that of bandaging the whole limb or part of the body, as the case may be, with a bandage of stout elastic webbing. By this device it is possible to partially deplete a limb or other part of its blood. When such a bandage is retained for say five minutes or less, and then suddenly and rapidly removed, local flushing results. In this way fresh arterial blood is brought to the injured part, while on the re-application of the bandage the vitiated materials are removed by compression and hurried into the general circulation. The advantage which SPRAINS CONSIDERED GENERALLY 37 accrues from this practice is that the general nutri- tion of the nerve-endings is improved. This is especially true of the treatment of chronic cases, and in this particular class it may be necessary to remove and re-apply the bandage two or more times in twenty-four hours. At first, progress is slow, but after a few days, as a rule, the pain will gradually subside and disappear. The local neuritis seems to be remarkably influenced by the increased oxygena- tion, just as the flushing caused by taking a glass of wine will, in many persons, rapidly dispel an attack of acute supra-orbital or facial neuralgia. The repeated and alternating depletion and flushing of the injured tissues stimulates the local circulation. Whatever the true explanation may be, the fact remains that the effect is good and that it is nearly always speedily beneficial. In the more chronic forms, those resulting from neglected treatment in the first instance, electricity in the static form has been found useful, while massage may or may not succeed. Blistering, and even the point of the actual cautery have been employed on many occasions to counteract the intensity of the pain as it courses along the nerve-trunk. Opiates should be avoided because these cases often last a long time, and the continued use of drugs is baneful and can only at best give but temporary relief. One of the most rapid and obstinate forms of the wasting of muscles results from gross nerve lesion. It is more rapid, more complete, and more lasting than any of the forms that result from mere disuse. 38 SPRAINS CONSIDERED GENERALLY Sprains with Fractures and ' Fracture- Sprains ' The treatment of this class differs from that of a simple sprain in certain particulars. Thus, where small fragments are detached, pulled away with the ligaments or tendons, it becomes necessary to aim at giving sufficient rest to enable if possible bony union to take place. Elastic pressure, applied in the same way as for simple sprain, is useful, for, when employed, a modicum of rest is assured without the necessity of making use of actual splints. Passive movements, carefully made, may be begun from the very earliest, but any forcible voluntary efforts which would tend to separate the fragments must be strictly prohibited. Massage may be used all the time, but cautiously at first. Exercises are of value late in the case. Where there is fracture without separation, as in fissures in the lower end of the fibula or tibia, the meta-carpals or small bones of the carpus, and where there is but slight effusion, strapping as for an ordinary strain is convenient. Passive movements are more helpful on the whole than active ; the latter, however, may be allowed, but only to a limited extent and providing no strain is directly put upon the region of the fracture. The patient may, in the case of the smaller joints, be allowed to flex or extend the joints fully without using much force. Exercises should be encouraged after the bones have had time to unite, but not before. Unless these rules are strictly adhered to, imperfect recovery will result, for faulty or incom- plete union must follow whenever forcible voluntary SPRAINS CONSIDERED GENERALLY 39 movements are permitted in the early stages. The main difference between simple sprains and those complicated by fracture is that, in the former, voluntary or active movements are permitted and Fig. 6. Radiogram of a fracture of the olecranon without displacement, at first regarded as a sprain. Massage and early movements in such a case are absolutely contra-indicated. encouraged from the very earliest stages, and are essential to a speedy recovery ; in the latter they must be secondary to passive movements and allowed only in the later stages. Massage is of equal service to both classes, and, speaking generally, may be begun early. In simple sprains passive movements 40 SPRAINS CONSIDERED GENERALLY are of secondary importance, while in those compli- cated with fracture they are of greater service than are voluntary exercises, and especially is this true of the early treatment ; exercises are helpful in both classes in the later stages. Many sprains with fracture produce stiffness, for the simple reason that they are not at first recog- nized and are treated by the so-called rational treatment of simple sprains. Treatment by massage and early movement by exercises is unsuitable where they are concerned. It is of the utmost importance that in all cases of unusual severity, and in doubtful cases, an X-ray photograph should be taken from different aspects. This affords our best means of diagnosis, upon which alone must depend the success or otherwise of treatment, for without a correct diagnosis much unnecessary suffering will be experi- enced and considerable time lost. CHAPTER III SEQUEL.^ OF SPRAINS Many disabilities result from the faulty or careless management of sprains, while some cannot in any way be ascribed to the fault of the surgeon. They arrange themselves into two categories : the controll- able and the uncontrollable. Of the former group there are many, of the latter, few. Of the preventable forms, we meet with : (1) Stiff joints and painful joints. (2) Atrophy and wasting of muscles acting on joints. (3) Recurring or relapsing synovitis in joints. (4) A relaxed condition of joints known as ' wobbly joint ' or ' weak joint ' ; the opposite condition to Group 1. (5) Persistent pain in a joint. (6) A crippled or deformed joint. (7) Improperly united muscles and tendons. (8) Ankylosis. Stiffness in joints as a result of sprain is almost invariably due to prolonged fixation in spUnts or other rigid apparatus, assisted by the prohibition of or delay in beginning movements during the treat- ment. For some reason, not altogether independent of textbook teaching in the past, it has been the habit to regard so-called rest as a primary and all- pervading essential in the treatment or management 42 SEQUELS OF SPRAINS of any injury. The treatment of sprains, perhaps, of all injuries has suffered most from this doctrine. That a joint, designed and constructed as it is by nature for movement, should be dealt with in pre- cisely the same way when it suffers violence as a bone arranged and planned for a purpose the very opposite, seems strange ; yet, strange as it may seem, it is only too true that even at the present day there are surgeons who treat sprained joints in pre- cisely the same way as they do fractures. Nothing can be more harmful to the normal movements of a joint than a prolonged and constant use of splints, and if for any reason a splint should be considered advisable, the same should be removed at least once a day, so that movements in the joints may be allowed. The writer, for over eighteen years, has never had occasion to use a splint, and he firmly believes that sprains will do better if left alone without any special treatment than when they are subjected to prolonged fixation. The bugbears 'inflammation' and the 'dread of tuberculosis', would seem to haunt the minds of some as if they were veritable demons. One need hardly point out that in the absence of local temperature such fears are ungrounded. Painful joints and stiff joints. Joints remain painful and stiff as the result of immobilization, whereby the surrounding tissues become matted together ; the nerve-endings are pressed upon by exudation products which are unabsorbed ; and are injured by an impeded and sluggish blood-supply deficient in oxygen ; circumstances which all lead up to an impaired nutrition. SEQUELiE OF SPRAINS 43 Atrophy and wasting of muscles acting on joints. This results from two main causes : (a) a definite injury to the nerve-supply, and (b) disuse, often associated with the long-continued application of splints and other apparatus during the course of treatment. (a) Examples of the former class are the changes observable in the distal portion of a ruptured tendo- achillis which has remained ununited. The distal part of the tendon, cut off from the nerve-supply to the muscle fibres on the proximal side, atrophies, shrivels, and takes on the consistence and appearance of a piece of wash-leather. Again, when the adductor longus muscle becomes torn from its pelvic attach- ment, in a case of so-called 'rider's sprain', it is no uncommon circumstance to find the muscle almost completely wasted away. The rapid wasting in the deltoid, resulting from overstrain or partial rupture, is doubtless due to nervous influences — possibly the cutting off of the nerve-supply. (b) Examples of wasting from disuse, arising as a consequence of unduly prolonged fixation and tardy resort to movements and exercises in the treatment of a large joint like the knee or shoulder, are of too frequent occurrence ; and it cannot be emphasized too often, in connexion with this, even at the risk of being tedious, that the wasting of muscles begins almost immediately after an injury, and that passive movements by themselves have little or no bene- ficial or preventive influence. Voluntary movements, however slight in the beginning, gradually increased as they are better tolerated, assisted by the skilful application of massage, will alone retard or prevent 44 SEQUELS OF SPRAINS this form of atrophy. Later on, properly regulated exercises, planned so as to work against resistance, do much to promote complete restoration to useful- ness. Voluntary movements and massage should be persevered with in both forms of wasting, but the surgeon must be prepared for disappointment in a certain number of cases, notably those in which a gross nerve lesion is the primary cause. Recurring and relapsing synovitis. In a certain number of severe articular sprains, in which there has been considerable tearing of the external liga- ments, the capsule and synovial membrane, the effusion, which at first was copious, clears up readily and satisfactorily under rational treatment, but as soon as the patient begins to walk or move the joint it again refills. The tension may be high or moderate, and there may be some local increase in temperature. When elastic pressure is applied the effusion is absorbed in a very short time, but relapse after relapse, recurrence after recurrence, follows, and lead to a general relaxation of all the ligaments. This troublesome condition is generally due to the presence of an adhesion or adhesions within the joint. The simple folding of a small and insignificant portion of the synovial membrane upon itself, or some irregular attachment by a tag of the capsular ligament which has become curled inward towards the articular surfaces of the bone, are sufficient to produce synovitis whenever dragged upon during the ordinary movements of the joint. Such a state of affairs is best prevented by the routine advocated in a former chapter— that of putting every severely sprained joint through its normal movements before SEQUELS OF SPRAINS 45 any treatment whatever is commenced, an anaesthetic being used if necessary. When adhesions have formed, they are best remedied by forcible move- ments under an anaesthetic, the movements being Fig. 7. To illustrate the scar left from the operations. for exploratory arthrotomy and removal of internal semilunar cartilage. From a case three months after the operation for removal of synovial fringes. followed by the usual course adopted for the treat- ment of recent sprains. If the effusion should keep on recurring in spite of this, it is well to perform an exploratory arthrotomy to remove any band or adhesion existing within the joint. The knee is the joint which is most prone to these recurrent attacks. 46 SEQUELS OF SPRAINS In some of the most obstinate cases the condition is due to the presence of thickened synovial fringes. The accompanying photograph shows the usual incision employed by the writer whenever he makes a digital exploration of the knee-joint. It extends in a slightly curved direction over the inner side of the joint for about four inches, having its centre opposite the internal semilunar cartilage. When the skin and fasciae have been divided, the capsule comes well into view. This, in its turn, is divided parallel with the skin incision ; the joint is then opened. By everting the outer edge of the wound, the under surface of the patella, with the infra-patella pad of tissue (ligamenta mucosa et alaria) may be freely exposed to view. The finger of a gloved hand may now be inserted and a careful exploration made of every corner of the articulation. The synovial membrane, in these cases, is often of a pale yellowish fine-dotted appearance, slightly granular on its visceral surface. The secretion varies in different individuals and at different stages, according as to whether the effusion is recent or late. While at times it is liquid and slightly viscid, at others it may be of the consistence and appearance of boiled sago. If the synovial membrane is examined microscopi- cally it presents the usual characteristics of a catarrhal inflammation. Adhesions, however small, should be clipped away with scissors, and any hypertrophied portions of synovial membrane carefully removed. It is imperative that all bleeding points should be carefully attended to ; dry swabbing is much prefer- able to douching or irrigation. The writer has almost entirely abandoned the practice of douching SEQUEL.^ OF SPRAINS 47 48 SEQUELS OF SPRAINS out joints, and sponges with dry swabbing instead. A gauze drain is inserted at the middle of the capsular wound, and the rest of the capsule is brought together with catgut sutures ; the skin wound, with silk- worm gut. A bicyanide gauze dressing, covered by a thick pad of salicylic or boracic wool is then applied, but no splint. The drain should be removed in twenty-four hours, the wound then sealed and left undressed for nine days, providing the temperature remains satisfactory. The accompanying tempera- ture chart is characteristic of exploratory arthro- tomy. There is usually a rise of temperature for the first two days ; this should subside on the third or at latest on the fourth day. Gentle passive move- ment may be tried at the first dressing, twenty-four hours after the operation ; massage and voluntary movements are best postponed until after the re- moval of the stitches, usually from the eighth to the ninth day, and they must be both continued until the joint becomes firm and strong and the tendency to muscular atrophy and to recurrent effusion has passed. A generally relaxed condition in a joint, popularly known as * wobbly joint' or ^weak joint'. The so- called ' wobbly joint ' is the result of muscular atrophy in the proximal muscles of a sprained joint. The accompanying photograph, taken from a case in which fixation in plaster of Paris for the greater part of six months was permitted, on the assumption that the slight elevation of local temperature indicated early tuberculosis, is typical and characteristic of the condition. The subject was a young military officer who, while playing at football, twisted his left knee. SEQUELS OF SPRAINS 49 The pain was confined to the outer and posterior region of the joint. At the time, no locking or impaired mobility was experienced, and he was immediately Fig. 8. Photograph of both thighs. The left knee shows deformity from imreduced semilunar cartilage (internal). The Hmb had been retained for nearly six months in plaster splints. Note marked atrophy of the muscles of the thigh on proximal side of the joint, also semiflexure of the knee, with hypertrophy of the muscles of calf. This is somewhat charac- teristic of knees long retained in splints without movement. Such a joint readily fills when exercised, and illustrates the so-called ' weak ' or ' wobbly joint '. able to walk. Some swelling of the joint was noticed next day when a bandage which had been applied was removed. He remained on the sofa, but being in India and many miles away from any medical WHITELOCKE -p 50 SEQUELS OF SPRAINS attendant he began to walk about in a few days. At the end of ten days, the ' pain and swelling having quite subsided', he again played football. Pain quickly returned, and this time was referred to the centre of the back of the knee. He experienced no sensation of anything giving or tearing, and although he could bend and straighten the joint freely it rapidly swelled up, as he described it, ' to an enor- mous size.' Surgical advice was now sought, but not obtained until thirty-six hours later. Rest in bed, evaporating lotions, and the usual textbook routine was gone through ; the swelling gradually subsided, and splints were used from the first. Three weeks later he was allowed to walk, with the limb encased in a moulded splint, but the joint at that time was weak, stiff and painful. As he did not seem to prosper, and as the joint swelled when- ever he stood erect, and was hotter than its neighbour, his medical attendant thought that tuberculosis was probably beginning. For the next five months the limb was kept fixed in a plaster casement. These details have been supplied here as illustrative of the line of treatment so often adopted, and with such untoward results. It is important to notice the more marked atrophy of the proximal muscles of the thigh as compared with those in the leg or distal to the joint. In these relaxed states of the ligaments the recurrent synovitis in most cases is a passive one ; the joint filling simply from loss of support to its capsule, secondary to wasting and enf eeblement in the muscles which control its movement. It is of the utmost importance that it should be clearly understood that the swelling is^ secondary to. SEQUELS OF SPRAINS 51 and dependent on, the wasting of the muscles, and that treatment should be directed towards rectifying the enfeebled condition of the controlling muscles rather than to the joint itself. Local treatment, such as blistering and other forms of counter-irrita- tion, are helpful only to a limited degree and will not cure the condition. Massage and movements, both active and passive, and those against resistance, must be strenuously persisted in until such time as the tone of the capsular ligament is restored or at any rate materially improved. The improvement will be in proportion to the amount of perseverance shown in carrying out the exercises, and the degree of recovery to the length of time that has been saved or lost before rational treatment was begun. It may take months before the strength of the limb is restored, and in some, fortunately a small percentage of cases, complete recovery must not be expected. Especially is this true when, in addition to the mismanagement by prolonged fixation, there has been extensive lacera- tion of the tendons and aponeuroses in and around the joint. Persistent pain in a joint is characteristic of gross injury to nerves. It is generally referred along the line of a particular nerve or group of nerves, notably after injury to the largest joints, the hip, knee, shoulder and elbow. In some cases it appears to be of the nature of neuritis, occasioned by the bruising of the nerves themselves, or to adhesions of their sheaths to the surrounding parts analogous to the pain experienced when a nerve is caught in callus at or near the seat of a fracture.. The normal E 2 52 SEQUELS OF SPRAINS and healthy nutrition of the nerve becomes altered. In a certain proportion, the pain or neuralgia is caused or intensified by gout or rheumatism ; as a rule these cases ai^ readily improved by the appro- FiG. 9. False joint at right hip, the result of treatment for supposed sprain by bone-setter. The neck of the bone has been worn away by continued movements and exercises, and the patient permanently lamed and left with a deformed hip. SEQUELS OF SPRAINS 53 priate remedies for these constitutional diseases. The pain is generally worse at night, and in a few exceptional cases has been so severe as to necessitate the exhibition of opiates. Friction massage at the hands of an experienced masseur will generally serve Fig. 10. Radiogram of fracture of the first phalanx of little finger of a child, treated previously as sprain. Note the absence of displacement of the fragments. The joints, both above and below, were full of fluid and masked the symptoms of fracture. An injury at the junction of the upper epiphysis with the shaft of the bone led to permanent deformity. to diminish its intensity, so that strong drugs are rarely needed. Aspirin in full doses will in many cases reUeve the attacks of aching pain, and in some remove them altogether. The crippled and deformed joint. ^ Deformities formerly were considered to be the result of osteo- 54 SEQUELiE OF SPRAINS arthritic changes, but are now known, through the experience gained by radiography, to be frequently owing to the separation of the epiphyses or even to fractures. The accompanying photographs bear out this fact. Deformities may be met with in the large as well as the small joints ; the flattening out of the Fig. 11. New false joint in lower third of humerus, the result of moving the limb to prevent stiffness at the elbow. Note ball-and-socket arrangement of false joint and development of a styloid-Uke process which had become detached by a second accident a year later. To illustrate the dangers of indiscriminate movements in the treatment of joints. hip with atrophy of the gluteal muscles, so often represented in the older textbooks as resulting from a fall with bruising, is typical. At one time this condition was ascribed to some subtle change in the neck of the femur, whereas we now know that it SEQUEL.^ OF SPRAINS 55 results from a fracture through the neck of the bone. The genu- valgum or genu-varum which follow upon a sprained knee in a growing youth are frequently the result of fracture through a condyle of the femur, or to partial separation of or severe bruising over the growing epiphysis, either at the lower end of the femur, or upper extremity of the tibia. Examples are more frequently met with at the elbow ; here, as the result of some slight strain in early life, a per- manent deflection of the forearm outward with an apparent lengthening of the inner condyle may be seen in the adult. In the fingers, fractures of the phalanges are by no means uncommon ; wicket- keepers are specially liable. Without the X-rays it is next to impossible in most cases to make a correct diagnosis ; a wise surgeon will therefore do well to bring them to his aid whenever it is practicable. Improperly united muscles or tendons. As a consequence of laceration of important muscles like those of the thigh, the adductors, as well as the extensors and flexors of the knee, wide separation is apt to take place between the torn ends. Unless in the course of treatment the fibres are brought together, so that more or less firm fibrous union takes place, the scar is apt to stretch at a later period and give rise to insecurity and disfigurement. The proximal portion has always a tendency to be drawn away from the seat of injury. It is fortunate that the other muscles of the same group will as a rule develop and increase in size proportionately to make up somewhat for the deficiency and actual loss of power in the torn muscle. It has been found. 56 SEQUEL.E OF SPRAINS however, that rupture of the rectus femoris and portions of the deltoid muscle have seriously influ- enced the stability of the knee- and shoulder- joint respectively. It is important, therefore, that close and complete apposition should be secured from the very first, even if it is necessary to obtain the union by means of an open operation. No undue strain should be permitted until the united parts have had full time to become firm. Ankylosis may result from severe sprains. Fortu- nately, the condition is an exceedingly rare one, if we except those cases of stiff -joint which at first sight similate true bony ankylosis but which readily yield to ' breaking-down ' under an anaesthetic. Such a case usually originates from a sprain with fracture, the true nature of which was unrecognized and treated by excessive and ill-advised movements. The enforced movement gives rise to increased formation of callus in the neighbourhood of the articular surfaces, which not only tends to mechanical locking, but affords opportunity for new and extensive adhesions to form. Unavoidable Sequels These permanent and remote consequences of sprain are entirely beyond the control of the surgeon, but are nevertheless of much interest to him in so far as they influence, in the main, his prognosis. They consist of : — 1. Local paresis or paralysis. 2. Ossifying myositis, as concerns sprains in muscles, and SEQUELS OF SPRAINS 57 3. Osteo-arthritis in relation to articular strain. 4. Loose bodies in the joints. Localized palsy and paresis result for the most part from overstretching or laceration of nerves or their branches ; but it is rarely met with. When wwK^»5»»fm^'>^^ Fig. 12. Ossifying myositis in muscles of thigh, the result of a blow. Note the crescent-shaped mass attached to the middle of the shaft of the femur anteriorly. From an X-ray photograph taken nine weeks after the accident. the torn ends of a muscle are widely separated, as the consequence of sudden violence, the nerve of supply may be damaged. .Repair, in the generality of instances, results from treatment, and cases of permanent defect are rare ; when they do occur they are unavoidable. Friction and kneading massage 58 SEQUELS OF SPRAINS may do good and will need to be carried on for a considerable time. Electrical stimulation, in certain cases, may also assist. Ossifying myositis is also rare. It is almost in- variably met with in the large muscles and in those Fig. 13. Myositis ossificans in extensor muscles of the thigh, result of a kick by a horse. Note the intimate connexion of the mass with the anterior surface of the femur. From an X-ray photograph taken sixteen weeks after the accident. whose fibres take origin directly from some rough bony ridge, or which are directly attached to the periosteum without the intervention of much tendi- nous material. The writer believes that in all such cases portions of the periosteum become detached with the muscle at the time of injury and are pulled away from the bone by the contraction of the muscular fibres. The detached periosteum soon OF THE \ r UNlVERSfTY J ^ '"-^QUEL^ OF SPRAINS 59 A >> o ;§• ^ ^ •4J t+H _4 c3 li »J x> (-] -tj o fl o <4-( a 13 .s rt "m ■ S 33 A cc ee ,1^ -fi •i 3 ce U Q qs pi:^ P4 ^ .5P -1-3 . % f^ ■4^ •Jl ^ CO ee 1 .a 2 eS 02 y3 ^ 1 .S U) ;+^ ce .^ '^ ^ rt a S &0 Xi d n3 w A SQ ^ 03 ^ eg &a ^0 4 Ui \ 1 1 } i ' I .,., d \ \ ui 1 1 K \ \xt K ^ UJ , ! K \ N UI "--, k * 1 \ \ t||X ■i:|- [■ 1 \ \ ^4 UI \ \ 5 s: ■■' 1,1 f 1 1. .i. V ^ O Ui ,„, '1" 'l H V V oj UI Tjl 1' ■ \ \ OQ Ui 1 }lfj,l \ \ t £ i" \ \ 5fi Ui ....j. ....... 1^ .... \ \ • UI .....i.i.... 1 1 K \, X < °>o *«^ V o o o oS5oc»o>op> < WHITELOCKE M 162 INTERNAL DERANGEMENTS OF that the presence of blood in a synovial cavity such as a knee is a serious complication when con- sidered in the light of after-treatment. Furthermore, pain is much less when drainage is employed, and if we compare the temperature charts taken of cases treated in all other respects in exactly the same way with this single difference, we may note that in those that are drained there is about one degree less, showing that the absorption from the joint and the tension are less. A thin gauze drain is inserted and the membrane and internal lateral ligament closed around it with catgut sutures. The skin is sutured with silkworm gut. An absorbent dressing is applied, and over this a tight bandage, and the limb retained in the slightly flexed position between sandbags, but with- out a splint. If the pain is severe, during the first night, aspirin (grs. 10) may be given, or an injection of morphia (gr. ^). Twenty-four hours later the drain should be removed and an absorbent dressing re-applied. On the eighth or ninth day the stitches should be taken out and a collodion or celloidin-gauze dressing substituted for the absorbent dressing. The patella should now be moved from side to side as it lies in the trochlea, but it is advisable to defer other formal passive movements and massage of the knee until a few days later. In about fourteen days, if the wound is firmly healed, the bandage may be discontinued at night, re-applied in the morning and the patient allowed to get out of bed and walk on crutches. All move- ments may now be permitted, but the patient THE KNEE-JOINT 163 should not bear the weight of the body on the affected leg for at least two weeks. In six weeks the patient should be quite well and able for most things. The results are usually excellent, and it is quite exceptional to meet with a patient who is not completely satisfied. A recent case was able to play cricket in the University freshmen's match eight weeks after the above operation had been per- formed.^ To ensure lasting success the patient must be encouraged to persevere in carrying out all his movements and not to rest satisfied until he is capable of doing everything he was able to do before the accident occurred. When walking is first tried the knee should be held stiff while the soles of the feet are placed flat on the ground. Displaced external cartilage. There are several cases of displaced external semilunar cartilage on record, in most of which the detachments were situated anteriorly ; in one or two exceptional cases the posterior horn was ruptured. The tendency in most of these was for the displacement to be inwards towards or into the inter-condyloid space. Mr. Annandale (British Medical Journal of February, 1887), relates a case in which the external cartilage could be seen and felt displaced. Mr. Godlee {The Transactions of the Path, Soc, vol. xxxi, p. 240) showed a specimen taken from the dissecting-room, in which the external cartilage had been torn from its circumference, and lay in the inter-condyloid notch. Mr. Langton, in The Pathological Society's ^ The last two cases done by the author left hospital in twenty- three days, walking well. M 2 164 INTERNAL DERANGEMENTS OF Trans., 18S8, p. 282, mentions a case in St. Bartholo- mew's Hospital of a loose body in the left knee. The external semilunar cartilage had been torn from its posterior attachment and was f m-ther detached laterally for half or more of its length. Such cases, for anatomical reasons, are extremely rare. The writer has only met with three authenticated cases in which the external cartilage had been detached ; one occurred in the practice of a friend, another in a patient from whom he had also removed both internal cartilages. In these two cases the displace- ment was into the inter-condyloid space and resulted from a laceration near the junction of the anterior and middle thirds which allowed the posterior segment to alter its position. The third case occurred in a youth who twisted his knee as the result of a fall from a ladder. The accompanying photograph shows the condition of his limb before operation. He stated that he did not know what happened to his knee, except that he ' felt something snap ', and ' suffered agonies of pain '. His knee immediately became swollen, and he was unable to put the foot to the ground, nor was he able to keep his knee fully extended. He was kept by his medical attendant in bed for three weeks ; at the end of this time, 'although most of the swelling had dis- appeared, he was unable to put his foot to the ground without pain, and he could not stretch* the limb to its fullest extent. For over seven months he was unable to walk any distance without considerable pain. His occupation was that of a milkman, and finding an increasing difficulty in doing his work, he applied to the Radcliffe Infirmary for treatment. THE JKNEE-JOINT 165 On examination, the knee was found slightly bent and could not by any means be fully extended. There was marked atrophy of the muscles on the proximal side of the joint, and though a thickening Fig. 50. Case of long-standing displacement of left external semilunar cartilage described in text. Note atrophy of muscles of thigh with com- mencing hypertrophy of those of the calf ; also flexion of knee and fore- shortening of limb. The discolouration shown was due to former blistering. 166 INTERNAL DERANGEMENTS OF of the synovial membrane was evident, there was no distinct synovitis. He complained that, besides the joint being painful, it was apt to swell if he walked more than a few hundred yards. The photo- graph shows plainly the posture of the limb and atrophy of the muscles. After due preparation, the knee was opened by a vertical incision corresponding with a line over the centre of the base of the carti- lage. The skin, the superficial fascia and the cap- sule were divided in turn, the joint opened and the cartilage exposed. It was found to have been torn across at its posterior extremity, and as some of the coronary ligaments had been detached, the cartilage thus loosened could be caught between the bones in certain movements of the limb. The movable part of the cartilage was excised and the capsule sewn up with catgut, a gauze drain inserted, and removed twenty-four hours later ; the skin sutures, of silk- worm-gut, were removed on the ninth day. The patient left the hospital in three weeks. At the end of five weeks he was completely cured as far as movements were concerned, and able to do his work as if nothing had happened. Regeneration was taking place quite satisfactorily in the wasted muscles of the thigh when he was last seen a month ago (four months after operation). From his experience of these cases the writer is of opinion that when the diagnosis can be made, especially if recurrences are frequent, the above operation is the best method of treatment. Since the above was written the author has met with two more cases, making five in all. The last one, a photograph of which is appended, occurred «-CALlFO RH^fee THE KNEE-JOINT 167 in a schoolboy aged sixteen who wrenched his knee awkwardly at football. The diagnosis was made from the history of the accident, the excessive tenderness over the line of the cartilage, together with the Fig. 51. Photograph showing characteristic flexion and swelUng in left knee-joint, from a recent case of displaced external semilunar cartilage. Note posture of Hmb as identical with that found in displacement of internal cartilage. Diagnosis was subsequently verified by operation after he had suffered a relapse. 168 DERANGEMENTS OF KNEE-JOINT characteristic posture of the limb ; the joint could not be extended fully. Reduction was performed by manipulation under complete anaesthesia, and the joint was subsequently treated as an ordinary sprain. Hypertrophied synovial fringes. In very chronic long-standing cases of recurrent synovitis, it occa- sionally happens that the synovial pad (the liga- mentum mucosum) beneath the patellar ligament becomes thickened and hypertrophied, the ligamenta alaria on each of its borders become indurated, thickened, and may even present papillated fringes. As these structures increase in size, they are liable to be caught and pinched or bruised between the femoral condyles and the tibia. The bruising further stimulates their increased growth so that in time they form definite structures constantly liable to injury. When nipped, they give rise to a sudden pain and checking, rarely to locking, of the move- ments of the knee. As a rule when the condition exists by itself, it is suspected rather than diagnosed ; an exact differential diagnosis being impossible. When once begun, the tendency is for the symptoms to increase rather than to diminish ; the disability, therefore, is a progressive one. The condition is best treated by opening the joint as for an explora- tory arthrotomy and com_pletely clipping away the whole of the infra-patellar swelling, being careful to see that no thickened folds of synovial membrane are left in the inter-condyloid space of the femur. The fringes on rare occasions develop pedunculated bodies which, although fixed or moored in the first instance, become detached later and form one variety of movable bodies in the joint. CHAPTER VII GENERAL INJURIES TO MUSCLES AND TENDONS Muscles and tendons are liable to injury in many ways, as the result of different forms of violence ; thus they may be strained or sprained from over- stretching, may become herniated or protrude through openings in the fascia enveloping them, displaced or dislocated from the grooves in which they normally course, or even partially ruptured or torn across. The tendons which surround a joint that is sprained or dislocated almost invariably suffer, though to a less extent than the ligaments. In fractures they are often seriously damaged. Muscle sprain. When the fibres of a muscle or its aponeurosis or tendon are subjected to violent overstretching or partial tearing, it is said to be strained or sprained. This is a very common occurrence in persons actively engaged in athletic performances, less frequently in those who follow laborious occupations. It is usually the result of sudden violence when the muscle or group of muscles are taken unawares, though in exceptional cases, repeated muscular efforts may be accountable. Many examples may be given, such as ' rider's sprain ' affecting the adductors of the thigh, ' jumper's sprain ' the hamstrings or muscles of the calf, ' tennis elbow ' the pronator radii teres, ' driver's 170 GENERAL INJURIES TO or angler's elbow' the common origin of the supinator extensors of the forearm, ' labourer's back ' with which the sacro-lumbalis is concerned, and ' bowler's side ' affecting the oblique muscles of the abdomen. Each of these injuries, to which the popular name has been given, is an example of muscle injury. The symptoms are pain, tenderness on pressure, with inability to carry out the particular movement or movements concerned in the injury. As a rule, recovery is rapid, though in some cases the individual may not be able to resume his duties or to take part in athletics for weeks or even months. The treatment consists in discontinuing the move- ments which give rise to spasm or pain when the muscle or group of muscles are actively exercised in performing their work. If the pain continues and the recovery is delayed, a good plan is to support the painful part with firm strapping, and to encour- age the patient to use the muscles freely. Massage and electric vibration are helpful, and may be used when the strapping is removed for readjustment ; or it may even be applied over the strapping. The term ' strain ', as in the case of articular injuries, is generally meant to indicate a disability of less severity than sprain. Herniae of muscles occur not infrequently among young and powerfully built athletes, and are the result of a sudden violent contraction of the muscle when carrying out some supreme athletic effort. The belly of the muscle, in shortening suddenly and expanding proportionately in width, bursts its way out and protrudes through its ensheathing fascia. As a rule, the cleavage in the fascia is in the longi- MUSCLES AND TENDONS 171 tudinal direction, but it may be transverse. In young cavalry soldiers, hernia of the adductor longus muscle is not infrequently met with. The recruits, often powerfully built men, trained to gymnastics or marching, are suddenly ordered to mount and to Fig. 52. Hernia of muscle in thigh, result of muscle sprain. ride on barebacked horses, without stirrups. Un- accustomed as many are to riding, it is not surprising that, in their frantic efforts to escape falling off, they rupture the sheaths of the adductor muscles in gripping the horse. The tensor vaginae femoris, the rectus femoris, the tibialis anticus, the rectus abdo- 172 GENERAL INJURIES TO minis, have all ajfforded examples. Hernise of muscles are comparatively rare, and may be recog- nized by the existence of a soft swelling in the course of the muscle, which is soft and prominent when it is relaxed, but becomes smaller and harder when it is made to contract. Often there is no pain and surprisingly little inconvenience ; the patient pre- sents himself mainly to ascertain the cause of the swelling, or for an explanation of a sensation which has been met with in a certain number of cases, and has been described ' as if water was trickling over the part '. This latter symptom is probably due to some interference in the course of a superficial nerve. A feeling of insecurity is occasionally com- plained of. The diagnosis is easy, and in some cases where the hernia is small, little or no treatment is required. When the inconvenience is considerable, it may be necessary to operate. If the case is recent, and the split a longitudinal one, a curved incision through the skin and fascia is made so that its convexity is directed upwards over the course of the muscle, the flap so marked out is turned downwards so as to expose fully the rent in the fascia ; the muscle is then put on the stretch to retract it. Any adhesions that are present must be freed, and the edges of the fascia brought together and sewn as accurately as possible. There may be considerable ecchymosis superficial to the fascia in the more recent cases. When the rent is transverse, as occurs in the abdo- minal rectus or in the long adductor of the thigh, it may not be possible to bring the edges completely together ; in such a state of affairs it is well to draw MUSCLES AND TENDONS 173 the edges together as near as possible and to fix them as best we can with a stout catgut suture. The after-treatment consists of resting the Hmb until the external wound is healed, and then in using gentle massage and encouraging slight active move- ments. The results are almost invariably satis- factory, even where the suturing of the fascia has been incomplete. It has been suggested that the hernia should be excised ; this is quite an unneces- sary mutilation, and of very doubtful utility. To prevent adhesion between the muscle fibres and the line of suture, the Faradic current may be employed with advantage, the movement occasioned by the contraction of the muscle tending to stretch or break down any adhesions that form. Displacement or dislocation of tendons. Although many cases are recorded, it may be said that, speak- ing generally, displacements of tendons are rare. The most familiar examples are the dislodgement of the peroneus longus tendon from the groove behind the external malleolus on to its external or anterior surface, the tibialis posticus to the anterior surface of the internal malleolus from its place behind it, and the long head of the biceps flexor cubiti inwards or outwards from the bicipital groove of the humerus. The small tendons at the back of the neck are occasionally displaced over the posterior tubercles of the transverse processes of the vertebrae. In the majority of cases, notably in those of the peronei (longus et brevis) and the tibialis posticus, there is in the course of the tendon a sudden and abrupt deflexion around a bony prominence which takes the place of a pulley. The bony prominence in each 174 GENERAL INJURIES TO instance is deeply grooved, so that the tendon lies securely and is roofed in, so to speak, by a liga- mentous expansion or confining sheath. The biceps cubiti is displaced by the movements of the humerus Fiu. 53. Dislocation of the peroneus longus tendon. Note formation of false bursa between it and external malleolus. Taken from a schoolboy, aged 15. Was restored subsequently by operation by author's method. Vide text. around it as it lies in a straight course in the bicipital groove. The peronei may be found dislocated in a patient who has sustained a violent twist or wrench of the foot. ' If, while the foot is either inverted or pointing MUSCLES AND TENDONS 175 straight forwards, the peroneus longus is made to contract, it cannot sUp, for its tendon is tightly drawn into the bottom of the groove at the back of the external malleolus ; but when the foot is everted. Fig. 54. Back view of displacement of both peroneal tendons (longus et brevis) on right side. Note the bursarial enlargement over the external malleolus. The photograph is unfortunately not a good one. the tendon has a tendency to leave its groove, so that its sheath becomes its pulley, and this, if the strain is severe, may give way.' (Professor Howard Marsh.) ^ A schoolboy, aged sixteen, had been running in 1 Clinical Essays and Lectures, J. and A. Churchill, pp. 1-8. 176 GENERAL INJURIES TO his stocking soles after a football ; he accidentally stepped on the ball, twisted his ankle and fell. When examined a few minutes later, there was a large extravasation of blood over the malleolus and on the outer side of the ankle ; he complained of a sickening pain and inability to move his foot, and vomited. The tendon could be distinctly felt lying in front of the malleolus, even through the effusion, and was easily replaced by manipulation. The foot was then placed at a right angle with the leg, inverted, and fixed in this position by means of a moulded felt splint. After forty-eight hours, massage and gentle passive movements were begun (the tendon being retained in position during the movements by the fingers of the manipulator's other hand, while the foot was kept inverted), and continued daily. At the end of three weeks the splint was discarded, and as all swelling had disappeared, the ankle was strapped and the patient allowed to voluntarily exercise the muscles of his foot with the movements of flexion and extension. In four weeks he was able to walk, though he complained of a feeling of weakness in the ankle ; in six weeks he was quite well and able to run. It is now over four years since the accident, and there has been no recurrence. If the foot, instead of having been everted, had been inverted, the possibility is that he might have displaced the tibialis posticus, for in this position this muscle tends to leave the groove behind the inner malleolus where it is merely retained in position by the fibrous sheath upon which it pulls directly. The author has seen a case in which both the peronei tendons (longus et brevis) could be dislodged MUSCLES AND TENDONS 177 at will by the patient, a young lady, by simply everting the foot in a sudden and jerky way. The tendons jumped out of their grooves with a snap, occasioning very little pain but producing complete disablement. All discomfort and crippling disap- peared as soon as the tendons were replaced, and this could be readily and easily performed by gentle mani- pulation. For years the patient treated the matter with indifference, until finally the recurrences became so frequent as to be annoying. The ordinary means of retaining the tendons by strapping and wearing a special appliance succeeded so long as they were persevered with, but as soon as they were left off recurrence took place. Accordingly, it was deemed advisable to do away with the difficulty, and an operation was performed. A curved incision was made over the outer malleolus and side of ankle, the flap turned upwards and the groove in the fibula exposed. This groove was found to be shallow and almost completely filled up by portions of the sheath ; all this tissue was cleared out, the groove deepened, the tendons replaced, and the remains of the sheath stitched firmly and accurately over them with catgut. The ankle was put into a moulded splint and, as soon as the skin stitches had been removed at the end of eight days, passive movements and massage were begun and practised two or three times a day. The result was in every way satisfactory. As recur- rence seems, for anatomical reasons, so liable, imme- diate operation appears to offer the best prospect for a permanent cure ; contra-indications such as enfeebled health and old age being alone considered. Given a young, athletic and energetic person, an open WHITELOCKE -j^ 178 GENERAL INJURIES TO operation gives far the best prospect of satisfactory treatment ; the same means may be employed in the case of the tibiaUs posticus. The long tendon of the biceps has on many occasions been displaced from its groove, either out- wards or inwards, generally inwards, as a result of violent or repeated movements of the upper arm, such as are made use of in wringing clothes ; the sheath which converts the groove into a tube is the tendinous expansion of the pectoralis major, and when this is torn across the tendon slips out. The patient suffers pain, is unable to extend the forearm until the tendon has been replaced by abducting the arm and manipulating it. The displacement may often be produced voluntarily, and in such cases needs no special treatment. Reduction may be brought about by manipulation ; a good plan is to direct the patient tc place his hand on the shoulder of another person, and while it is thus abducted, advise him to carry out the movements of rotation first in one direction and then the other. The small tendons at the back of the neck are not infrequently displaced, resulting in temporary locking with pain, which is sometimes very acute, and centred at the exact spot. Such accidents occur from some sudden and awkward movement of the head, as in turning hurriedly to one side or the other. An example would perhaps better explain matters. A young man, leaning out of an upstairs window and talking to his companion in the garden below, was suddenly startled by the banging of a door behind him. Turning his face to the right sharply, he heard a ' click ', felt an agonizing pain in the MUSCLES AND TENDONS 179 right side of his neck, found his chin approximated to his right shoulder and fixed in that position. Every attempt at straightening the neck or moving his head to its proper position was impossible, by reason of the pain, which was most intense. It was obvious that a small tendon had been displaced, and presumably a portion of the splenius capitus or other muscle had become caught and hitched over the posterior tubercle of one of the transverse processes of an upper cervical vertebra. Holding his head between his hands, and with an expression of mingled fear and anxiety, he presented himself, saying : ' For God's sake, doctor, be quick, for I've either broken my neck or slipped it out of joint ! ' After reassuring him with no little difficulty on this score, nitrous oxide gas was administered, and by means of gentle rotation, combined with to-and-fro movements of the neck, the trouble was after some difficulty over- come. As soon as the patient recovered from the anaesthetic he volunteered the statement that he was absolutely free from any pain. A few days ago an undergraduate arrived with his head turned to one side so that the vertex was approximated to his left shoulder ; he complained of acute pain whenever he attempted to straighten his neck, or indeed to carry out any movement other than that of bending his head towards the left shoulder. He stated that while swimming in a bath, engaged in a game of water-polo, he turned his head suddenly to the left in endeavouring to see the ball ; felt something snap, and believed that he had dis- located his neck. On making an examination it was found that he had pain on pressure over the N 2 180 GENERAL INJURIES TO fourth and fifth cervical vertebrae posteriorly, which was intensified with any attempt at movement. By gently massaging and stroking the muscles of the back of the neck on both sides of the spine, the local pain was in a short time considerably diminished ; then standing behind the patient, who was seated on a low chair, and laying hold of the painful place with the left hand and approximating the left side of his face to his shoulder so as to relax the muscles on that side, reduction was brought about by a gentle rotation of the head from left to right. While the movements of rotation were being executed, the dis- located tendons were manipulated with the fingers of the left hand. Pain was immediately relieved and the patient walked out apparently well. On the day after, he was again seen, and complained of nothing more than a slight tenderness over the left side of the neck ; no fixing apparatus was thought necessary, and the case did well. Other similar cases are on record : one in which a jockey, in riding home an easy winner, was incautious enough to suddenly turn his head over his shoulder that he might see the other riders. His head became fixed in this position and he rode home past the winning post still looking backward, much to the astonish- ment of the onlookers ! On dismounting, many attempts were made by friends and admirers to rectify matters, but their efforts were all to no pur- pose. A surgeon coming on the scene, with the aid of some chloroform, enabled him to fulfil his engage- ment to ride another race ; which he did, history relates, again with success. On a few occasions, hospital patients of the labour- MUSCLES AND TENDONS 181 ing class have applied for assistance with the history of having ' ricked ' the muscles of the back, either in lifting or in slipping awkwardly while carrying loads either up or down a ladder. These have been usually regarded as displace^ients of portions of the sacro-lumbalis muscle, since they are almost invari- ably relieved by the administration of an anaesthetic aided by deep rotatory manipulation and kneading. Indeed, these simple expedients are usually so eminently successful that they recall to one's mind in a forcible way the fabulous results of the old time bone-setters who, by their various manipulations, wrought miracles, but with this difference, that in these particular cases there is genuinely a ' something out of place '. The after-treatment is simple. There is seldom any sign of haemorrhage or ecchymosis, the pain being immediately relieved by the manipulations ; only a certain degree of tenderness remains which may last for three or four days. A bandage or some adhesive strapping may be applied over the seat of mischief, more as a placebo than a necessity. Various other tendons in the body have been at times displaced, but the occurrence is so rare that little notice need be taken regarding them here. The principles of treatment are the same for all. Rupture of muscle or tendon. A muscle or tendon may be ruptured in almost any part of its course, either in its continuity or near to its points of attach- ment. In the greatest number of cases it occurs where the muscle fibres join with the tendinous. Each individual muscle would seem to have its weak spot, and rupture takes place with remarkable regu- 182 GENERAL INJURIES TO larity at certain definite situations. Degenerated and enfeebled muscles are no more prone to rupture than are the muscles of healthy and vigorous persons. Tearing of muscle may result from outside injuries, such as blows and crushes, but is more generally occasioned by sudden, indirect, and involuntary forms of violence. When rupture takes place in the belly of a muscle, the fibres contract and retract, the amount of separation depending upon the length of the muscle between its proximal and distal attach- ments, as well as its limitations by a lateral or other attachment, to a bone or neighbouring aponeurosis. The long muscles in the extremities furnish the best examples of separation after tearing. When a muscle is torn, the space between its retracted ends becomes rapidly filled with blood, which is poured out from the lacerated veins for the most part, though occasionally the bleeding is arterial. The haemorrhage in certain cases is large in amount, and gives rise to much swelling. In all cases, how- ever slight, there is some bleeding ; this is an impor- tant fact in the matter of treatment. The blood clots and forms a temporary bridge or platform between the divided ends ; this is ultimately re- placed by fibrous tissue which in the end forms a link of union between them. Not infrequently, when a tear takes place through the belly of a long muscle, the fibres of the proximal end are curled upon themselves within the sheath of the muscle, and form adhesions in faulty positions ; or may even become tucked up behind and give rise to increased shortening and a proportionately longer interval. The distal end of a torn muscle or tendon invariably MUSCLES AND TENDONS 183 undergoes degeneration when its nerve of supply happens to be cut off. More frequently, muscles are only partially torn across, and we meet with every degree, from laceration of a few peripheral bundles of fibres to complete severance of the whole muscle. Speaking generally, partial lacerations are found in the short and flat muscles of the body, while the long muscles of the extremities afford examples of the complete. Instances of complete rupture are found amongst those which have been brought about by sudden and unexpected contractions. Athletic exercises produce many, so much so that a con- siderable number of these injuries have derived popular names from the particular form of sport or exercise in which they occur ; thus we have ' bowler's side', 'rider's sprain', 'lawn-tennis leg', 'cricketer's shoulder', and 'sprinter's thigh'. The clinical symp- toms are characteristic and alike in both groups. There is usually a history of sudden pain localized in some definite spot, with the sensation as if struck by a whip or a stone, or as if something was torn. A distinct snap may be heard and the limb becomes powerless. At the seat of rupture there is tenderness and swelling. When the swelling is insignificant, or the separation great, a distinct gap may be felt in the muscle, which increases in width whenever it is made to contract. The treatment is therefore indi- cated according to the importance of the particular muscle involved, and to the degree to which it is incapacitated. An important muscle, such as the quadriceps extensor of the thigh, may require an immediate operation, whereas a small one like the plantaris may be treated equally well by posture 184 GENERAL INJURIES TO and strapping. Approximation of the fibres is of the first importance, and whilst in the one case this may be best carried out by an open operation with careful suturing of the fibres and their sheaths with catgut, in the other, bandages, strappings, and special contrivances will be all that is required. Primary and immediate suture, if done within a few days, gives far better results than secondary suture at a later period. Partial ruptures result from the same kind of injury as complete, and give rise to the same inconveniences, though to a lesser degree. There is pain and tenderness, and even a slight depression or gap may be felt. The treatment consists of strapping, rubbing, and active movements. Absolute rest is, however, not to be recommended as a rule. Athletic exercises are responsible for lacerations in almost all the muscles and tendons of the body at some time or other, and more especially is this the case with those who take part in violent athletic exercises without first training these structures gradually. The system of training here referred to, is that of gradually increasing exercise, and has no necessary regard to dietary or other considerations. At the public schools and universities, where athleticism is a recognized accomplishment, and where youth and early manhood, and to a limited extent early middle life, enter into real competition, there is no kind of injury so commonly met with as that of sprained, overstretched, dislocated or lacerated muscles or tendons. During the last twenty years the writer has had an extensive experience at one of the old universities, and has come to the conclusion MUSCLES AND TENDONS 185 that, for some reason or other as yet unexplained, these accidents seem rather to be on the increase than otherwise. Few muscles in the extremities escape, nor are the muscles of the trunk exempt. Certain circumstances would seem to influence this tendency to rupture, and among them may be enumerated 1. The season of the year. 2. The temperature of the air. 3. Want of training or fitness. 4. Age and physique of the individual. 5. The kind of game or exercise. It has often been observed and remarked upon that at the universities and pubUc schools there are more athletic accidents during the autumn or October term than at any other time or season. The reason probably is that during the long vacation athletes have been employed in carrying out forms of exercise different from those of set athletics. When they return to school or college, without having had sufl[icient or gradual training, they plunge at once into strenuous games of football, running, and rowing. It is therefore not surprising that their tendons are ruptured and their ligaments torn. The temperature of the air undoubtedly influences the muscles. The teaching of modern physiology would have us know that while cold retards muscular contraction, warmth accelerates it ; cold renders muscle tissue more inelastic, and inelastic muscles are more prone to laceration. The winter months, the cold seasons, assisted often by a want of proper clothing, bring many to seek the assistance of the surgeon. 186 INJURIES TO MUSCLES AND TENDONS Want of training is a self-evident cause. Tendons must be made accustomed to the pull of their attached muscles if they are to meet with their attacks successfully. Unless the muscles are gradually trained to the requirements of the indi- vidual, they will, indeed are forced to yield under some unexpected and supreme effort. And this leads to the following statement, that even in the case of a thoroughly trained athlete, whose muscles are properly tuned, so to speak, it would appear that his muscle is torn not entirely by its own contraction, but rather by the contraction of the antagonistic muscles taking place before its own act of contraction was completed. Age influences in a measure. The younger the athlete, the more supple are his tendons, and perhaps within certain limits the less powerful is the pulling force of the muscular fibres proportionately to the tendinous. Men of good physique are more liable than weaklings. The kind of game affects the proportion of injuries ; thus football and rowing are more productive than sprinting or long distance running. Hugby football accounts for more accidents than Association, though generally they are of a less severe type. CHAPTER VIII INDIVIDUAL INJURIES TO MUSCLES AND TENDONS In the preceding chapter certain details were given as to the management of the lesser injuries to muscles and tendons, such as overstretching, hernia, and displacement, where, on the whole, the symptoms are never severe and the disablement not particu- larly serious. In this chapter it is proposed to deal more in detail with the rupture of muscles and tendons, since they often lead not only to considerable crippling at the time, but also, if mismanaged or improperly treated, to permanent loss of power. As has been already pointed out, almost any long muscle or its tendon may be ruptured, and as it would be tedious to treat of each individually, only certain of the most important will be considered, and no reference will be made to laceration produced by external injury, or tetanus, or during parturition ; allusion will therefore only be made to the rupture of muscles by their own forcible contraction during ordinary or violent athletic 'movements. The princi- ples of treatment are the same for all, whatever the cause. The muscles of the trunk are sometimes ruptured when direct violence is applied to them, especially when contracted ; they may also be ruptured by their own forcible contractions. 188 INDIVIDUAL INJURIES TO The abdominal rectus has been torn in a patient enfeebled by enteric fever simply turning in bed or attempting to rise from the recumbent position. Cavalry soldiers have been known to tear the muscle in mounting on to horseback, and rowing men from missing a stroke in pulling. The chief symptoms are a sudden stablike pain below the umbilicus (for rupture always is below that point) and inability to straighten the body ; a swelling is present, transverse to the line of the body and to one side of the middle line, which is often of extensive proportions. Usually there is no sulcus to be felt, nor ecchymosis to be seen at first. The swelling has been mistaken for umbilical hernia and cold abscess. Treatment consists, in a mild case or one of partial tearing, in flexing the body so that the chest ap- proaches the pelvis, and maintaining this position in bed for one or two days. Plaster strapping is very useful (vide Fig. 55), and may be applied from the chest to pelvis anteriorly in strips or in one broad piece of strapping. When the rupture is com- plete and the haemorrhage extensive, an open opera- tion with suture of the muscle and its sheath is strongly advocated ; for much time is saved, and the probability of an abdominal hernia prevented. The oblique muscles of the abdomen are often partially torn by awkward twists or wrenches of the body. The pain is referred usually to the attach- ments in the neighbourhood of the twelfth rib, but occasionally also along the crest of the ilium. Tender- ness on pressure will localize the exact seat of mischief. Swelling at first may be inconsiderable, while later MUSCLES AND TENDONS 189 the signs of bruising (play of colours) may be well marked. The affection known as ' bowler's side ' is the result of the tearing of sotne fibres of one or both oblique muscles, and results from fast bowling on a wet and slippery wicket. The most suitable treatment is to strap as for Fig. 55. Rupture of right rectus muscle of the abdomen with strapping applied of a single piece of wash-leather plaster. The strapping should reach from the upper thigh to the margins of the ribs, and be fixed above by a cross piece, and made to extend across the middle line of body. The transverse slip of plaster should be laid on firmly and not loosely as here showTi. a broken rib, from the spine around the injured side across the middle line in front to the other side, com- mencing about four inches above the last rib, and extending well below the iliac crest {vide Fig. 56 b), then allowing the patient to go about as usual after- 190 INDIVIDUAL INJURIES TO wards. Cure will usually result in from twelve to fourteen days. The ilio-psoas muscle is rarely completely torn, though partial tearing is not an uncommon occur-^ rence in beginners at rowing. It results from an awkward swing of the body in the leg drive from the stretcher, and is more often produced with a fixed than sliding seat. There is pain in straightening the body, felt in the iliac fossa and upper thigh, and there may be considerable ecchymosis immediately below Poupart's ligament. The treatment consists of rest for a few days from the particular movements in- volved. No local application seems of much service, and strapping helps but little. The ilio-psoas tendon has been ruptured in the thigh in a boy who attempted to lift a heavy basket ; the injury was followed by extensive swelling. The sacro-lumbalis may be partially dislocated or torn. Replacement of displaced fibres under an anaesthetic, and subsequent plaster strapping is usually sufficient. While there is always tenderness over the seat of the rupture, the swelling seldom shows externally, though doubtless effusion takes place between the deep muscular planes. In the upper extremity, the pectorals, deltoid, biceps (both long and short heads), are the most commonly torn; very rarely fibres of the triceps and muscles of the forearm. These result generally from indirect violence. The pectorals have been torn in violent efforts to prevent a fall by catching at a suspended rope. The symptoms are pain on movement, tender- ness on pressure, severe ecchymosis over the side MUSCLES AND TENDONS 191 of the chest, and complete inability to use the shoulder. Treatment by strapping and posture. * Cricket shoulder ' is a strain produced in throwing B Fig. 56. a. Strapping applied for sprains of the intercostal muscles and side. The plaster should encircle at least two -thirds of the circumference of the body and be laid on from above downwards during expiration. B is for sprain or rupture of the obhque muscles of the abdomen — * bowler's side '. The plaster should extend from the lower thorax to below the crest of the iUum. a ball, and is usually caused by the rupture of some fibres of the deltoid near to its insertion, or to the overstretching or partial laceration of the sheath of the pectoralis major, where it encloses the long head 192 INDIVIDUAL INJURIES TO of the biceps in the bicipital groove. It has been reported that even the head of the biceps has been displaced in the effort of throwing a cricket ball. Since the deltoid is very prone to atrophy and stiff- ness whenever it is injured, it should never be fixed in a position of rest ; on the contrary, it is wise to strap the shoulder- joint with adhesive plaster and allow the patient to begin the ordinary movements early in the treatment. The same may be said in respect to the treatment of the long head of the biceps, for, if left in repose, adhesions are liable to be formed and extend even into the. joint itself, leading to permanent stiffness. All that is really necessary is to strap, rub, and encourage early movements. When such an injury has been neglected, and the deltoid has borne the brunt of the injury, it becomes imperative to develop the powers of the muscle by special exercises, so that the muscle fibres are made to contract. Graduated weights and pulleys are sometimes needful in aggravated cases. When the biceps tendon is chiefly affected, the adhesions may be loosened and broken down under an anaesthetic preliminary to other treatment. The biceps flexor cubiti is often ruptured by its own forcible contraction and may suffer in one or other head or in the belly of the muscle after the union of its two parts.. The most common injury, and perhaps the most troublesome to deal with, is separation of the long head from its scapular origin. No method of treatment by posture seems satisfac- tory, for the end of the tendon is pulled away from its attachment in the glenoid cavity. Theoretically, an operation would seem the most suitable, but it MUSCLES AND TENDONS 193 involves opening the joint, so that it is doubtful whether it is worth the while or is really practicable. The method generally adopted is that of fully flexing both the shoulder- and elbow- joints, strapping the arm across the chest, and maintaining it in this position for at least a month. The writer has met with only two such cases in his whole experience. The first he treated after the manner just described, and obtained but a moderate result. The second he met with five months after the injury, and although in this case there had been no attempt to retain the arm in the flexed position for longer than a week, the result was, to say the least, as good if not better than in the former. This has led him to the conclusion that such a case would be better treated as other cases of rupture are, by strapping and early move- ments, avoiding for a time anything that will unduly impinge on the injured tendon itself. The diagnosis is very simple, and the treatment of rupture through the belly of the muscle is by ordinary surgical principles. Rupture of some of the tendons of the forearm has been met with, and others have been described, but they are exceedingly rare and may be dealt with by the ordinary means. In the lower extremity many of the muscles and tendons are liable to rupture, thus one or other muscle or tendon in the extensor and adductor groups of the thigh, as well as the hamstrings, suffer as the result of violent athletic exercises, while rupture of the calf muscles is no uncommon occurrence. The rectus femoris may tear in any part of its WHTTELOCKE q 194 INDIVIDUAL INJURIES TO muscular course, or its direct head may pull o& the epiphysis for the anterior inferior spinous process of the ilium in persons under the age of eighteen. The accompanying photograph shows a typical example of rupture through the body of the muscle. It happened to a gentleman in endeavouring to keep his balance while skating. This form of injury, as it sometimes occurs in a sudden effort to run while fielding at cricket, has been called ' cricket thigh '. Two cases of separation of the epiphysis for the anterior inferior spine of the ilium were reported by the writer in the Lancet for 1893.^ They occurred in undergraduates who injured themselves while start- ing in a sprinting race when the body was suddenly made to assume the erect position after being in a stooping one. The details as to the precise mechanism of the injury and its subsequent treat- ment are there fully gone into. It is sufficient to state that they were at that time treated as a fracture would be, with a plaster of Paris spica-bandage. The symptoms of rupture in the rectus femoris are surprisingly slight. There is little pain, often the feeling of snapping or tearing is experienced, followed by a weakness in the limb. Swelling may be imme- diate and extensive and even mask the presence of the usual sulcus when viewed for the first time ; palpation will, however, very readily disclose its presence. Treatment depends upon circumstances. The direct head, with its detached epiphysis, may be 1 ' Separation of the Epiphysis for the anterior inferior spinous process of the ihum through enforced muscular action.' By R. H. AngUn Whitelocke, Lancet, 1893. MUSCLES AND TENDONS 195 treated by temporary fixation !by strapping and allowing the patient to walk about, or by a plaster of Paris bandage and crutches. The former plan will Fig. 57. Rupture of rectus femoris muscle, done while skating. Patient subsequently displaced the internal semilunar cartilage of his knee, which was removed by the author. The scar on the inner surface of the joint represents the line of incision. probably, judging by analogy, yield a more satis- factory result. Where there is complete rupture through the belly of the muscle, especially where there is a large haematoma and no serious contra- o 2 , 196 INDIVIDUAL INJURIES TO indication as to general health, the open operation is the most suitable. When the rupture is only partial, strapping the thigh with broad strips of Seabury and Johnson's perforated rubber plaster so as almost to encircle the limb and draw the muscles Fig. 58. Photograph of thighs of patient to show on the right side author's method of strapping for rupture of fibres of the hamstring muscles. The plaster is not allowed to meet, or to completely encircle the Hmb. A space is left to allow of muscular expansion during exercise. For rupture of the adductors or extensors of the thigh the separated ends are placed externally. together, is quite efficacious. The plaster (vide Fig. 58) should be applied in strips at least three inches wide. It should never be allowed to encircle the thigh completely. A good plan is to leave a gap of about an inch between its ends. This gap allows MUSCLES AND TENDONS 197 enough play in the muscles of the thigh during walking and other exercises, and unless it is left, when the muscles enlarge by contraction, they will either burst asunder the application, or tear their own fibres at the point of greatest constriction. The plaster, properly applied, gives ample support, and enables the individual to walk about at once, and in the milder cases he may even resume his athletic exercises in the space of a few days. Another result of the injury is met by this method of strapping. The skin and fasciae are supported by the firm, more or less resilient, plaster, so that the extravasated material is compressed. As the patient walks, the muscles of the thigh, owing to their contraction, become alternately larger and smaller, so that a to- and-fro movement is exerted on the materials that are extravasated between them and the overlying skin ; by this churning process the extravasation becomes dispersed up and down the thigh under the strapping, and is driven by the elastic compression in the direction of the venous flow, and hurried onward into the general circulation. The effect produced on the local circulation is not unlike that of friction massage. The advantages of strapping when applied to ruptured muscles may be summarized as follows. When it is evenly and smoothly applied, further extravasation becomes impossible ; the muscles are supported so that further tearing is prevented ; it becomes safe to allow the individual to walk or to otherwise exercise his muscles, and the exercise will not only prevent weakness and muscle atrophy, but it actually disperses and drives onwards all local 198 INDIVIDUAL INJURIES TO extravasated material into the general blood-stream. Healthy local nutrition is ensured with much cer- tainty, as the general health of the patient will be bettered if he is allowed to go about rather than live in the house during convalescence. This is the whole rationale for the use of strapping in the treat- ment of ruptured muscles. The fibres that are torn seldom unite completely, and this seems a matter of little consequence, for other fibres develop to take their place, or neighbouring muscles enlarge to make up for any deficiency. The limb should be carefully shaved, washed over with a spirituous lotion and sponged dry before the rubber plaster is applied. Seabury's Rubber Plaster is sufficiently adhesive, and as it contains rubber does not readily slip. The perforations allow of a measure of evaporation, yet even this will not prevent a modicum, of eczematous irritation occurring in the skins of certain individuals. The irritation when it does occur acts therapeutically as a somewhat mild counter-irritant, and perhaps in the end does good and compensates the individual for his discomfort. As soon as the plaster becomes loose by reason of the absorption of the subjacent extravasation, it must be removed and re-applied ; this may be necessary on the second or third day when the extravasation has been copious in the first instance. Rupture of the quadriceps extensor tendon is a troublesome injury, and results from sudden effort to regain the balance. Whether the patella fractures or this tendon or the ligamentum patellae tears usually depends upon the amount of flexion in the limb at the time the strain takes place. The diagnosis is MUSCLES AND TENDONS 199 easy, the gap in the tendon with loss of power iit the limb are quite sufficient to distinguish the condition. The treatment is of the greatest importance. In slight cases, where there is only partial rupture some distance from the knee and without much extravasa- tion, the method of strapping mentioned above will suffice, providing also that the limb is kept in the extended position for about ten days. The leverage at the knee is so great that it would be unwise to allow flexion before some definite healing had had time to take place. When the rupture takes place near the patella the matter is most serious, and it should be treated just as if the patella itself had been fractured. The joint is sure to be opened into and to be full of blood. When there are no definite contra-indications such as organic disease or the patient's refusal to allow operation, the joint should be immediately opened, the clots turned out, and the fibres of the tendon sutured as accurately as possible with catgut. The writer has performed this operation on several occasions, always with success, and is fully con- vinced that if the surgeon has perfect confidence in his operative technique, he will obtain better results by the open method than by any other. The patient will be able to walk in four weeks and to do practi- cally anything in six weeks, providing always that his splints are left off not later than a fortnight, or soon after complete healing has taken place in the skin wound, and that early movements are practised. The details of the operation will be described more fully when dealing with rupture of the patella ligament. The hamstrings are seldom torn across completely ; 200 INDIVIDUAL INJURIES TO the* writer has never met with a case, though partial tears are very common in broad- jumpers, sprinters, and football players. The two most common sites are close to the common origin from the tuberosity of the ischium and about the centre of the back of the thigh. The biceps, semi-tendinosus, and semi- membranosus, may all suffer. The tearing results from an awkward landing in the broad- jump by the individual endeavouring to prevent falling backwards after the jump. Sprinters unaccustomed to run in shoes with spikes and without heels frequently tear portions of the hamstring muscles before they get into proper training. A rarer injury is one found in the neighbourhood of the insertions of the semi- tendinosus and gracilis to the inner surface of the tibia below the knee, caused by an overstretching in certain lateral movements of the leg while 'side- kicking ' at Association football. It gives rise to pain, swelling and impaired movements. A depres- sion may be felt in the hamstring tendons close to the ischial tuberosity, but in the majority of cases the diagnosis is made from the history of ' something going ' during running or jumping, and although at first there are few signs of extravasation, the usual play of colours of an old bruise will develop later. The treatment consists in raising the heel of the boot, strapping as for other muscle-tears on the thigh, and allowing the patient to walk about from the very first. As a rule the cure is effected in about fifteen days. Recurrences, however, are not uncommon. In the adductor group, the adductor longus et brevis, as well as the pectineus, are torn, from muscu- lar efforts pure and simple. MUSCLES AND TENDONS 201 The adductor longus is so frequently injured in those engaged in horse-riding — as cavalry soldiers and huntsmen — that the name of ' rider's sprain ' is now almost universally adopted in surgical literature to denote this particular affection. The muscle may be torn close to the pelvic attachment or at its lower end ; when in the former situation, which is the more usual, the nerve of supply is often damaged and atrophy follows. There is always extensive bleeding, and the swelling passes up to, or even above, Poupart's ligament, and down into the peri- neum and thigh. The pain is sometimes slight and out of all proportion to the severity of the injury, but not uncommonly there is a severe stabbing pain referred to the region of the anus. The loss of adductor power is considerable, and the tenderness on pressure over the whole region is marked. The diagnosis is simple ; the history of something ' snap- ping ' while riding a swerving horse, or in mounting a restive animal, inability or difficulty in performing adduction, followed by severe extravasation and the presence of a gap in the course of the muscle, make it certain. The treatment in recent cases is directed to pre- venting and removing the extravasation. Much time will be lost if the old regime of using cold lotions is adopted. Either elastic pressure by means of cotton- wool and a bandage, or firm rubber-strapping serves the purpose better. If a definite haematoma forms, and there is no reason against it, an incision should be made, the clots removed, and the muscle itself either sutured or excised. The loss of the muscle is sur- prisingly little felt. Cases are on record where it 202 INDIVIDUAL INJURIES TO has been removed late in the ease because the proximal end formed a painful swelling, troublesome to the rider, and in a few which were followed by ossification. The other adductor muscles develop and take on its functions. In mild or incomplete cases the part should be strapped with plaster, and the individual allowed to walk about, or even ride a quiet steady hack after a few days. Some of the writer's most successful cases have been treated in this way. When the adductor brevis or pectineus are torn they must be treated on similar lines. The adductor magnus tendon, at its insertion into the adductor tubercle, is sometimes strained in injuries involving the inner side of the knee. Tender- ness is occasionally experienced extending along the muscle high up into the thigh when the internal lateral ligament of the knee has been wrenched or torn in sprains of the knee. The ligamentum patellae may be torn either from its lower attachment to the tubercle of the tibia or from the patella above. In each case it is usual for a small fragment of bone to be detached with it. In rare cases it snaps across near its middle. It may be incompletely torn. The diagnosis is by no means difficult, for the patella is usually displaced and drawn upwards above the knee. When very small fragments of bone are detached, nothing but the X-rays will make the diagnosis certain. It is usual to regard this injury of as much serious consequence as a fracture of the patella. As to treatment, posture and fixation is a very un- certain method, and as the cavity of the knee-joint is invariably torn into, as is the case in fractures MUSCLES AND TENDONS 203 of the patella, the joint is filled with blood. Whenever there is no insuperable objection to an operation it is best to open the joint and to suture the ligament accurately with catgut. The writer has used this plan in four recent cases with the greatest satisfaction. All except one could walk freely and bend the knee well beyond the right ankle in the space of five weeks. The other, a timid boy, did not obtain full move- ments until ten weeks after the operation, but this was chiefly because he would not exercise the limb when left to himself. The technique is the same as for suture of fractured patella, an operation which the writer now invariably performs, by using catgut instead of wire. The accompanying Figs. 59 and 60 illustrate a case in which both the ligaments were torn at the same time in a man who, having slipped, tried to save himself from falling backwards. His case was subsequently treated elsewhere for months by posture and splints, with the result that there was no union on either side. He has, however, been able to walk with the aid of a somewhat cumbrous appli- ance, also depicted in Fig. 61. The case was not considered suitable for operation owing to his age and alcoholic habits. * Lawn-tennis leg ' has been variously attributed to rupture of the plantaris tendon, to rupture of fibres of the soleus, and even to an injury to the deep veins situated between the muscles of the calf. That sometimes the symptoms are due to the rupture of one muscle, and at others to another, there seems little doubt. The writer has seen cases in which he attributed the symptoms to a separation of some of the fibres of the soleus muscle from the oblique line 204 INDIVIDUAL INJURIES TO of the tibia. The symptoms are sudden pain, often described as if the individual had been struck by a stone thrown at him, or cut with the lash of a whip, followed by an inability to walk, and later by swelling of the calf. The diagnosis is made from the history of the case taken together with the symptoms. The most suitable treatment is to strap the leg Fig. 59. Old case of double rupture of the patellar ligaments. The patient had met with the accident many years before, from trjring to save himself from falling backwards after slipping in the street. He was able to walk with the aid of a hinged apparatus worn on each knee. The characteristic flexion of both joints as the result of loss of power in the extensors as well as the subsequent contraction of the hamstrings is well shown. Patient refused operation. Mr. R. H. Sankey kindly procured the patient, and made the illustrations for the author. from two inches above the ankle up to a level two or three inches below the knee, by means of stout rubber plaster, and then of allowing the patient to walk about, making a point of keeping his heel flat upon the ground all the time. A flat, low-heeled boot is best; even running may be permitted in a few days with this line of treatment ; active exercises MUSCLES AND TENDONS 205 should not, however, be permitted until all or most of the swelling has disappeared. The subsidence or not of the swelling is the best guide as to the com- mencement of active exercises. The strapping should be removed and re-applied as often as it becomes loosened by the absorption of the effused blood Fig. 60. Radiogram of case of ruptured patellar ligament of long standing to show tlie displacement of the patella upwards from the front of the joint to the anterior surface of the femur. Taken from the same case as is described in the text. beneath it. The prognosis is invariably good, and the patient should be free from all symptoms in from a fortnight to three weeks. When, however, the injury is due to tearing of the fibres of the soleus, recurrences may be met with, though they are not common. 206 INDIVIDUAL INJURIES TO The tendo-Achillis is often ruptured from one to one-and-a-half inches from its attachment to the os calcis as the result of sudden violent strain. The symp- toms are so slight that many cases are on record in which the individual walked about afterwards for even considerable distances with but little pain and Fig. 61. To show the apparatus worn for many years by a patient, the subject of rupture of the patellar Ugament on both sides. He was able to walk with tolerable comfort. inconvenience. A feeling of weakness in the ankle, whenever she got on her toes, was all that was com- plained of by a young lady of eighteen, who ruptured this tendon last year in jumping out of a punt. When she first presented herself for inspection she limped slightly into the room and seemed to have little or MUSCLES AND TENDONS 207 no pain. On making an examination, eighteen hours after the accident, there was found considerable ecchymosis over the region of the heel, and a distinct gap could be made out at the narrowest part of the tendon. There was tenderness on pressure over all Fig. 62 represents a leg that has been strapped for tearing of some of the fibres of the soleus muscle. The strapping has been too tightly applied below. To prevent constriction, the lower strap should be appUed over a piece of folded lint or proper padding. the muscles of the calf. Whenever the ankle was bent, the feeling of discomfort was increased and the gap in the tendon became more evident. The case was treated in the usual textbook fashion, by means of a laced shoe, to the heel of which an elastic 208 INDIVIDUAL INJURIES TO apparatus was fixed. The elastic band was then passed upwards to be attached to a broad leather strap which fitted accurately the middle of the thigh and was so arranged that the heel was drawn towards the knee and the toes pointed. This allowed of com- plete relaxation of the muscles of the calf. The apparatus was worn for fourteen days and then removed. After this, gentle muscular exercise was allowed while she lay on the sofa, but the f uU weight of the body was not permitted until twenty-eight days had passed. When she first began to walk she complained of a feeling of insecurity, but this passed off in two or three days, when she expressed herself as being not only able to walk but to run. John Hunter ^ is said to have ruptured his tendo- Achillis. The accident occurred when he was aged thirty-nine, while dancing. ' He did not confine himself to bed, but continued to walk during the cure.' He kept the heel raised, and compressed the muscle gently with a roller. He is said, however, to have experienced ossification of his tendon. It is interesting here to note that so long ago as Hunter's time it was considered sound practice to allow a patient to walk about with a torn tendon, providing, however, that it was strapped and supported. The fact that ossification of the tendon supervened had nothing to do with the method of the treatment, is the present writer's opinion; it was simply an example of the unavoidable sequelae of a sprain, to which reference has already been made. Do what the surgeon may, in certain cases of articular sprain, osteo-arthritis will supervene, and in muscular strains, 1 Palmer, Life, p. 34. MUSCLES AND TENDONS 209 myositis ossificans. These untoward effects are so far regarded as non-preventable. Every surgeon is aware of the ready way in which tendons unite after tenotomy, and many will have seen old cases of rupture through tendons, where very fair union has taken place, in animals and persons who had received but scanty treatment, and where walking and other exercises have been permitted, or at any rate been indulged in. The writer has recently made dissections of two such specimens, one in a horse and the other of the tendo-Achillis of a dissecting-room subject. The blood-clot which fills the intervening space in the tendon-sheath readily organizes, and will do so whether the tendons are put at rest or whether they are exercised or moved from the beginning. Pro- longed fixation by apparatus is, as a rule, quite unnecessary. If non-union should occur, and the disability is great, an open operation, with suturing the ends of the tendon, can be at any time performed. It is a safe and comparatively simple matter. There are many instances on record of the successful suturing of tendons ; indeed, such is an everyday occurrence. The treatment consists in strapping the whole length of the tendon firmly to the bones of the leg, by encircling strips of plaster, and of allowing the individual to walk about with a somewhat raised heel as soon as the tendency to swelling has ceased. The writer has been much interested in discovering that the treatment which he has been in the habit of employing for sometime in these cases, is precisely similar to that which was advocated by John Hunter many years ago. WHITELOCKE ' p CHAPTER IX MASSAGE, MOVEMENT AND EXERCISES IN THE TREATMENT OF SPRAINS AND BRUISES From time immemorial rubbings and movements have been used for the rehef of stiffness and pain in joints. The practice, Hke many other things, seems to have originated in the East. Formerly much in vogue in this country, for a time it almost dropped out, only to be revived in recent times with renewed vigour and unabating popularity. The system is the chief asset of the itinerant quack and everwise bone-setter ; and, like most good things, it is liable to be abused. Massage and movements, when employed in the cure of disease, are surgical procedures, and as such should only be used under the supervision and guidance of persons trained in surgical methods. Unless some such Umitations are imposed, harm will result. To take a single example, what could be more baneful than the daily rubbings of a joint swollen and full as the result of early tubercular infection ? Before proceeding further, it may be useful to discuss the so-called ' physiology of massage '. The various movements of massage undoubtedly improve the nutrition of an injured part by primarily increas- ing its blood-supply. By gentle friction massage the local blood-vessels become dilated, and fresh oxy- MASSAGE, MOVEMENT AND EXERCISES 211 genated blood is brought ; it is easy to satisfy one as to this, for not only does the skin of a joint formerly cold and pale become reddened, but it is warmer to the touch. By experiment, Brunton and Tunnicliffe demonstrated that not only does more blood pass through the muscles in a given time while they were being massaged, but that the increased flow lasted for some time after. Doubtless all the tissues in the neighbourhood of the injury partake of the increased blood-supply and reap the advantage. The kneading and percussion movements act me- chanically in breaking up all coagulated material, such as blood-clot and lymph, found amongst the muscles and tendons and other tissues around an injured joint ; and by dispersing the fragments over a larger absorption area and into more healthy parts, aid most materially in the absorption of the effete material by the neighbouring lymphatics and veins. Mechanically by stimulating the nerve-endings, fric- tion massage would seem to reflexly produce a dila- tation of the vessels of the part. In that way it increases the blood-flow through the muscles and other tissues. It has a decided influence in diminish- ing pain, for most persons will have experienced the soothing effect it has if applied gently to a painful spot. This effect is probably due to some reflex act, for the relief follows on too quickly to be explained by any direct effect it may produce upon the nerve- endings themselves. Some of us may have experi- enced the almost immediate relief of neuralgic pain as the result of taking a hot cup of tea or a dose of caffein. The action in this latter instance is doubt- less due to an alteration in the circulation of the p2 212 MASSAGE, MOVEMENT AND EXERCISES nerve-endings following upon the ingestion of a rapidly diffusable stimulant. Whatever the true explanation, it is a fact that massage readily relieves pain when carefully applied to a strain. Muscle- waste is probably in a measure prevented, partly by a direct stimulation of the nerves of supply and partly by indirectly increasing the local blood-supply. It promotes the absorption of effused materials, whether they are enclosed in the synovial cavities or are extravasated diffusely into the tissues generally. Limitations of massage. The immediate use of massage in sprains, either with or without passive movement, which it should at all times precede, is a practice much in vogue at the present time. By some surgeons it is adopted from the very beginning of the treatment and kept up until even long after recovery is complete. While in no way wishing to under-estimate the value of massage, especially in long-standing cases and in the later stages of ordinary cases, the writer is strongly of opinion that its imme- diate use, in the large majority of cases, is not only not necessary but may be even harmful. This state- ment requires some explanation. It is an everyday experience that cases such as those in which a cutting operation has been per- formed, or in which, from the presence of some abrasion or wound of the skin, local massage was impracticable, get on just as well and recover quite as quickly in the end as those in which rubbing was applied from the very first. Again, it is an undoubted fact, that, given a joint with commencing effusion, rubbing, however gently performed, will at once increase the extravasation. IN THE TREATMENT OF SPRAINS, ETC. 213 and if persevered in for any length of time will lead to marked increase of tension and even pain. Nor is it difficult to understand that a haemorrhage resulting, say, from laceration of a large muscle like the crureus or rectus abdominis will be increased by manual manipulation, and this is just what actually does take place when immediate massage is applied to any large collection of blood. Massage should not be used until the effusion in a joint has ceased to increase, and never till all risk of encouraging and promoting haemorrhage has passed. It must be applied with extreme caution in all cases in which there is any likelihood of constitutional disease appearing as a complication. Such diseases as gout, tuberculosis, haemophilia, acute or sub- acute rheumatism, are especially likely to be made worse by such treatment. The main indications are found in 1. All cases of strain or sprain without swelling. 2. All articular sprains, after the effusion has dis- appeared or has nearly disappeared either spon- taneously or after treatment with elastic pressure. 3. Muscular sprains, when all risk of increasing the swelling has passed. 4. All old, long-standing, chronic cases, where pain, stiffness, swelling, matting together of the tissues, or atrophy, exist. It is useful for muscular as well as articular sprains. In sprains complicated hy fracture, separation of epiphyses, and displaced inter-articular cartilages, it must be very cautiously employed. If the movements increase the pain rather than 214 MASSAGE, MOVEMENT AND EXERCISES diminish it, they should be withheld, at any rate for a time. It is unusual for pain to be increased in ordinary eases, so that when massage is uncomfort- able and badly borne some complication may be suspected. Passive movements are of more limited applica- tion, should be employed as an assistant to massage, and always follow, never precede it. The movements are mechanical in character and are of service chiefly in restoring to their natural positions tissues that are torn and displaced, in stretching or breaking down recent adhesions, and in preventing the formation of new adhesions after old ones have been forcibly torn asunder in the treatment of stiff and ankylosed joints. It has been stated that they assist in the absorp- tion of extra vasated material, but this is doubtful ; they certainly have no influence in preventing mus- cular atrophy. The contra-indications are precisely those of early massage. In sprains with fracture, when there is a proba- bility that active voluntary movements would pro- duce a separation of the fragments, passive movements are preferable to active. Even in this class of cases they must be employed with much caution, and whenever it is convenient the surgeon himself should carry out the manipulations. Active or voluntary movements act physiologically and are of the very greatest service. Their applica- tion is almost universal, and, with certain simple and rare limitations, may be employed at all stages and in all conditions of sprain whether articular or muscular. IN THE TREATMENT OF SPRAINS, ETC. 215 A voluntary movement implies the passage of a voluntary nervous impulse such as controls the whole process of nutrition in the tissues of the body. The several indications that require surgical assis- tance, such as the presence of extravasated material within or around a joint, the formation of adhesions, stiffness as a consequence of matting of the tissues together, and muscular atrophy, may all be removed by muscular movements. All that massage and passive movements are said to be capable of effecting may be more speedily and efficiently attained by means of elastic pressure combined with voluntary movements executed either simply or against resistance. Elastic pressure, as explained when dealing with the treatment of effusion in another chapter, is the surest and safest means which we possess for attain- ing rapid and complete absorption of fluids. It has all the advantages claimed for massage in early treatment, without any of its disadvantages, and when combined with active movements, may be described for all practical purposes as ideal. For by mechanically and rapidly removing the effusions and passing them on again into the general circulation, tension is diminished, pain relieved, adhesions pre- vented, and taken conjointly with muscular move- ments, which alone can prevent muscular atrophy, meets every ordinary desideratum. In urging early voluntary movements it must be understood that it is not suggested that all the muscles of an injured part should be exercised, or that they should be vigorously moved ; for, on the contrary, it is of the greatest importance that the 216 MASSAGE, MOVEMENT AND EXERCISES movements at first should be of the gentlest possible kind, and only just sufficient to ensure the passage downwards of nervous impulses. It is also important that until repair is fairly advanced, the particular muscles that have borne the brunt of the incidence of the violence should be subjected to very little or no strain, while the neighbouring muscles, tendons, and ligaments are freely exercised. In the later stages of treatment, and especially in neglected sprains, definite muscular exercises and movements often against resistance are of the greatest possible service in restoring movement, preventing atrophy, and assisting in the regeneration of muscles already wasted. Various gymnastic exercises, performed with or without the aid of mechanical contrivances, have been instituted for promoting the development and regeneration of muscles, and for removing stiffness and incapacity. Forcible movements of stiff joints under an anaesthetic. These should never be undertaken until a careful diagnosis has been made ; which is often only arrived at after much trouble and difficulty. Unless the surgeon is prepared to bring into play his most discriminating powers, he may do as much harm as the bone-setter who, in a routine way, treats everything by movement. Movements under an anaesthetic find their chief utility in healthy joints, and they for the most part act mechanically. For the replacement of inter- articular cartilages, stretch- ing or breaking down synovial adhesions, restoring lacerated portions of a capsular ligament to their natural situations, altering the angle in which IN THE TREATMENT OF SPRAINS, ETC. 217 a joint may become fixed, they are of special value. If the joint, however, has already undergone any definite organic change in its structure, such as may result from Charcot's disease or other forms of osteo- arthritis, or if the stiffness is mainly due to the taint of some such constitutional affection as tuberculosis, chronic rheumatism, of gout or pyaemia, it is quite unsuitable for any forcible movement. The con- ditions in which most good may be expected are those in which a joint is stiff or even painful because its action is hampered, not by any disability within the joint itself, but owing rather to the matting together of its surrounding tissues by unabsorbed extravasated material. The shoulder, as we have seen, is, of all the joints, the one which affords the best example of such a state of affairs, and it is the one from the treatment of which the surgeon is most likely to gain satis- faction. Stated broadly, it may be said that the results of forcible movement are not as good as we may be led to expect from theoretical considerations, that they are often very disappointing, and will assuredly be even disastrous unless employed only after the strictest discrimination and selection, and with the greatest care and skill in management. Pain and stiffness are the general indications for forcible movement in a joint. It is often a difficult matter to decide at once whether a joint is or is not suitable. A good and serviceable plan is to carefully investigate the range of movement and to notice whether the pain is experienced when only a wide range is attempted, or whether it is felt during every 218 MASSAGE, MOVEMENT AND EXERCISES movement, however slight. Thus a shoulder crippled for months, with shining surface, atrophied deltoid, and apparent absolute fixity, painful whenever any extensive movements are attempted, may prove, after close investigation, to be eminently suitable. When the movements, if ever so limited in range, are smooth and afford no sensation of roughness or jarring, one may be fairly confident that the trouble is outside the joint and not within it. A joint with perfectly smooth movements is rarely, if ever, disorganized or organically wrong. So long as the stiffness is outside the capsular cavity and is mainly concerned with the structures around the joint, forcible movements may be under- taken with every prospect of complete success. Simple means adopted by the author for prevent- ing muscle-wasting by using gentle active exercise. For developing the muscles of a thigh and leg that have atrophied as the result of prolonged fixation in splints, the following manoeuvre has proved of great service in many recent cases. It is of more certain value than are the movements against resistance as practised in gymnasia with the aid of pulleys and elastic apparatus. It consists, when practicable, in making the patient assume the squatting position. In this posture the hip, knee, ankle, and mid-tarsal joints are all flexed, the hamstrings are relaxed, while the extensors of the thigh are fully stretched. The ligamentum patellae is held taut all the while. During flexion of the mid-tarsal joint the muscles of the calf are stretched by the fixity of the tendo-Achillis below, while the muscles of the front of the leg are also put on the stretch. At the commencement of IN THE TREATMENT OF SPRAINS, ETC. 219 treatment this is all that is necessary, and the squatting position may be assumed for two or three minutes at a time, three or four times in a day. In this way all those tissues which, while retained in the extended position were relaxed and placed at rest, are now put upon the stretch and exercised. It is surprising with what rapidity restored power begins to show itself with the assistance of this simple plan. As soon as the erect, or even the sitting position is resumed after squatting, a sense of relief is immediately felt, and a feeling as of work done is experienced. This simple device of stretching the muscles, tendons and ligaments by squatting, brings into play nervous and other stimuli which were wanting in a limb made to assume for a prolonged period the extended position. The natural stimula- tion thus brought about in the muscles which for weeks, or longer, had been thrown out of use, i& most beneficial. The individual experiences at once a feeling of increased warmth and renewed vigour in the limb. After the squatting has been practised for a few times, the patient should be encouraged to raise himself gently on to his toes as in attempting to rise. A little more time should be devoted to this each day, until by degrees he is able to raise himself completely to the erect posture, and to carry out the exercises of alternately squatting and rising, slowly and gradually. This should be continuously prac- tised till the limb becomes again strong and the muscles regenerated. These principles of graduated exercise may be adapted with equal advantage to the muscles of the upper extremity, or indeed to any muscles in the body. 220 MASSAGE, MOVEMENT AND EXERCISES The means whereby the individual is enabled to fully exercise his muscles by lifting his own body weight are not only more easily and conveniently employed, but they seem to be more rapidly effi- cacious than are the stock exercises by means of weights and pulleys, so often recommended. The movements when carried out naturally, and gradually and carefully increased, may be said to be ideal in their results. An improved nutrition is the first sign of progress, and this is soon succeeded by true regeneration and growth. At first, both limbs, the sound as well as the affected, should be made to execute the movements, and as improvement takes place, the unsound limb should be made to do more and more in proportion. The natural and voluntary impulses thus sent down from the brain to the muscles on both sides at the same time that muscular efforts are made, would seem to promote more readily the regeneration of muscle-tissue than does any more mechanical plan of action, such as pulling or working against resistance. With such a plan of treatment, gymnasia are unnecessary, and all that is required is a thorough understanding between the surgeon and his patient as to the simplest means by which healthy physiological movements may be executed. As a preventive of muscle-wasting the writer knows of no method which even approaches this in its results either as to efficiency, simplicity, or rapidity. Movements and exercises against resistance. No one will gainsay the importance of exercising weak- ened or stiff muscles by means of weight-lifting or other methods in gymnasia, as often without some IN THE TREATMENT OF SPRAINS, ETC. 221 such means cases go from bad to worse ; but it is here contended that these systems will be less and less required as the more rational treatment of sprains becomes more and more universally adopted. A sprain properly treated in the first instance will rarely, if ever, require gymnasium treatment. APPENDIX It has been thought advisable to add an Appendix, for although most of the details are elementary and already well known, there is reason to believe that they may prove useful to some practitioners. Of local applications, the following have been found useful : — The ordinary Soap Liniment (Linimentum Saponis) is convenient for rubbing in almost all cases in which massage is indicated. It provides a suitable lubricant, and prevents chafing of the skin wherever friction is considerable. It may be used in acute as well as chronic cases. Iodine Liniment (Linimentum lodi) is occasionally useful as a counter-irritant, and as being stronger than the tincture of iodine. It has the disadvantage of being rather irritating to some skins. It is most useful for painting chronically inflamed joints, and in teno-synovitis. Terebine Liniment (Linimentum terebinthini Acetici) is a rubrifacient and mild counter-irritant when rubbed in. It is useful in strains of both muscles and joints where there is little or no swelHng. It may also be used in joints that are chronically painful. Vasogen-Iodine is par excellence the most useful applica- tion. It possesses all the advantages of the liniment of iodine without its disadvantages. May be used almost universally for acute as well as chronic cases, and causes little or no irritation. Tincture of Iodine is of little real value ; it is apt to irritate or harden the skin, and is inferior both to the liniment and vasogen-iodine. It is sometimes useful in the mildest cases, and where only a few applications are required. APPENDIX 223 Scott's (mercurial) dressing is useful in sprains complicated by tuberculosis, and in some very chronic forms of relapsing synovitis. BANDAGES AND STRAPPING. Plain rubber bandages are not recommended. They are too powerful, often produce pain, are hot, allowing little or no evaporation, and if long continued or constantly worn, tend to deplete the part of its proper blood-supply, and thereby lowering its nutrition, and producing muscle- was ting and enfeeblement. Elastic Webbing (of from 2 to 2 J inches in width) is more useful as a supporting-bandage, and should be substituted for the plain rubber bandage. Such a bandage is chiefly useful as a support, either in the early convalescence or on the return to athletic exercises. It should never be worn continuously, and should at least be removed during the night. Being elastic, it prevents the natural and proper circulation in the part. Elastic Knee-caps and Anklets are helpful more as a placebo than any definite means of support. The athlete, on his return to sport, is kept ever mindful of its presence as well as of its meaning. They may be employed during active and violent exercises when these are first resumed after an injury, but should be removed as soon as the exer- cises are over. They must not be worn continuously or for any considerable time, and as a rule should be avoided whenever possible. Leather straps to the wrist are not recommended. Instruments for preventing displacement of the semilunar cartilages, and highly recommended by some, should be avoided as much as possible. They eventually lead to atrophy of the thigh muscles, and are only helpful to those who, for some definite reason, are unable to undergo an operation. That they retain the cartilage in position is absurd, since the structure is almost invariably displaced 224 APPENDIX inwards into the inter-condyloid notch and almost never outwards. Their action depends entirely on reducing the knee to a hinge, disallowing all rotation, and the general utility depends upon the accuracy of the fit of the circular bands around the thigh and leg. The hinge of the apparatus readily allows of flexion and extension. The small ' Spring trusses ' for the knee, advertised and recommended in some quarters, are absolutely useless, since they are worn on the assumption that the semilunar cartilage is displaced from the knee. This is a fallacy, readily ex- posed both by pathological data and clinical experience. It may here be stated as a general dictum, that every apparatus or appliance that can be dispensed with should be done away with on the earliest possible occasion when dealing with injured joints. Of Plaster for strapping • several kinds are useful, none are ideal. The essentials of a good plaster are strength, a rubber base to prevent slipping, and perforations to allow of evaporation from the skin. The plaster made by Messrs. Ewen and Sons, and spread upon chamois leather, is an excellent strapping, but it is rather expensive and somewhat irritating unless removed frequently. Johnson and Johnson's * Z ' (Zinc Oxide) plaster is very useful. It causes less irritation than most others, and is sufficiently firm. * Leucoplast ' or White Rubber adhesive plaster (Pilot Brand) is useful. It answers most requirements, and is not expensive. Seabury's Rubber Adhesive Plaster, when perforated, is particularly useful for strapping the muscles of the thigh ; but, even though it is perforated and allows of some evapora- tion, will produce irritation if left on for more than a few days. APPENDIX 225 In applying strapping, certain details must be attended to if success is to be attained. The limb or part of the body to be strapped must be cleanly shaved, then washed with soap and warm water, and subsequently cleansed with ether or benzine, and carefully dried. This is essential if the plaster is to remain in situ for several days. The accompanying plates are illustrative of the writer's plan of strapping some of the commonest sprains in the body. Fig. 63. Photograph of ankle strapped for strain by author's method. In strapping for a sprain of the chest (intercostal muscles). Fig. 56 A, the strips of plaster should be from 1 J to 2 inches wide, and made long enough to encircle the body to at least two-thirds of its circumference. Each horizontal strip, beginning from above and passing downwards, should cover half of the one immediately above it, and must be applied at the end of the act of expiration. The strapping should extend for some inches both above and below the injury. In ' Bowler's side ', Fig. 56 b (strain of the obKque abdominal muscles), the same plan as the above should be adopted, WmXELOCKE n 226 APPENDIX and the strapping should extend from three inches above the level of the twelfth rib to well below the iliac crest. The rectus abdominis (Fig. 55) is best strapped with a wide piece of Ewen's chamois leather plaster extending from the upper thigh, passing by Poupart's ligament, to the front of the chest wall and slightly across the middle line of the body. FiQ. 64. To illustrate plan of strapping the shoulder for contusion or sprain. The axilla should be well padded, and the plaster extend to the middle line of body. Small overlapping strips may, however, be employed with equal efficiency. The muscles of the thigh (extensors, adductors and ham- strings) are conveniently supported by a wide strip of Seabury's perforated plaster, not less than six inches in width, and made to encircle the limb for the greatest part of its circumference. It should not be made to meet, how- ever [vide Fig. 58), or the muscles may be torn during vigorous contractions. APPENDIX 227 The muscles of the calf (soleus and plantaris) are strapped from below upwards, beginning at the smallest part of the leg and extending up to two inches below the knee. The strips of plaster will vary in width according to the size of the limb, and overlap from below upwards. The limb should always be depleted of as much blood as possible, by Fig. 65. effusioiiv An elbow- joint with elastic pressure applied for sprain with elevating it before the strips are laid on. Unless this precaution is taken, the plaster will soon become loosened by reason of the absorption of the blood which was effused. Strapping of the knee, ankle, and feet is done on general principles. The deltoid and shoulder region should be accurately strapped by means of a spica, the ends of the plaster extend- Q2 228 APPENDIX ing to the middle line of the body, both before and behind ; while the axilla must be carefully padded with thick layers of wadding. The other joints of the upper extremity, such as the elbow, wrist, carpo-metacarpal and inter-phalangeal, are dealt with on general lines. The figures show also, in a graphic way, the method of applying elastic pressure to the knee- and elbow-joints ; the details of the process having been described in chapter ii. The application of high degrees of temperature to sprains has, in the hands of some, met with much favour. Radiant- heat baths are extolled by some surgeons ; but the writer's limited experience of the treatment does not fill him with much enthusiasm. The injection of Fihrolysin for the removal of adhesions and as a means of rendering stiff joints more supple and movable is a new departure and seems to promise well. The writer's experience in this field is somewhat limited, but as far as it goes, it leads him to be hopeful. The data at the present time are hardly sufficient to allow of any dog- matic statement. It is possible that a more extensive ex- perience may even diminish present enthusiasm ; time alone will prove the efficacy or otherwise of this our latest nostrum. INDEX Acromio-clavicular joint, sprains of, 75. causes of, 75. symptoms, diagnosis, and treat- ment of, 75. guarded prognosis in, 75. Active voluntary movements, in treatment of sprains, 26, 81, 214. early uses and advantages of, 26, 214, 216. limitations of, 214, 216. physiological action of, 214. method of employment, 214. Acute traumatic sjniovitis of knee, treatment of, 116. prognosis of, 116. Adductor longus muscle, 43, 62. rupture of, 201. causes, symptoms, diagnosis, and treatment of, 201. Adductor magnus tendon, strain of, 202. Albuminuria, as a complication of sprains, 19. Anaesthetics, in treatment of sprains, 14. contra-indications of, 14. for diagnosis, 33. uses of, in aspiration, 33. use of, in synovitis, 45. Anatomy, general, of joints, 2. surgical, of knee-joint, 109, 113. ' Angler's elbow,' 170. Ankle-joint, sprains of, frequency of, 102. surgical anatomy of, 102. causes of, 102. complications in, 102, 106. differential diagnosis of, 103. prognosis and treatment of, 103, 105. sprain-fracture of, 103. symptoms of, 103. Ankle-joint, sprains of, method of strapping in, 103, 223. advantages of elastic pressure in, 105. after-treatment of, 105. Ankylosis, as sequela of sprain- fracture, 41. causes of, 56. treatment of, 56. Annandale, Professor, the late, 163. Anterior annular ligament, 102. Anterior crucial ligament of the knee. 111, 131. Apparatus for preventing displace- ment of semilunar cartilage, 223. Appendix, 222. Arthritis deformans, 67. Arthrotomy, in treatment of joints, 34. and temporary drainage of joints, 34, 48, 162. for digital exploration in recur- rent synovitis, 34. temperature charts in, 47, 158-61. author's operation for, 153. for removal of cartilages and loose bodies, 153. Articular sprains, 8. classification of, 9. individual articular sprains, 74. Articular vessels, 3. Aspiration, in treatment of synovitis and tension in joints, 33. special advantages of, 33. indications for, 33. for large blood extravasations, 79. Aspirin, in treatment of nerve pain, 53. Athletics, as a factor of sprains, 6. Atrophy of muscles, acting on joints, 2,43. as a sequela of articular sprains, 41. 230 INDEX Atrophy of muscles, as the result of nerve injury, 43. from prolonged fixation in splints, 43. means adopted for preventing, 81. treatment of, by active voluntary movements and exercises, 215, 216. Bandages, ' crepe velpeau ', 23, 28. advantages of intermittent re- moval and reapplication of, 24. special, domette, elastic webbing, plain rubber, 23, 223. spica, use of, in sprain of shoulder- joint, 78. Bennett, Professor, of Dublin, 96. Bennett, Sir William, 123, 139. Biceps brachialis, rupture of, 190. Biceps cruris muscle, rupture of, 200. Biceps flexor cubiti muscle, rupture of, 192. diagnosis and treatment of, 192, 193. Bicipital groove, 192. Blistering in treatment of nerve lesions, 37. Bone-setters, treatment of sprains by indiscriminate movements and rubbings, 1, 6, 7, 36, 181. Bones entering into formation of joints, 2. ' Bowler's side ', 170, 183, 189. method of strapping for, 225. Brachial plexus, injuries of, 13. Breaking-down, in treatment of ankylosis, 56. in treatment of stiff shoulder- joint, 80. Brunton, Sir Lauder, Bart., 211. * Calcareous deposition ' in muscles, 63. in detached semilunar cartilage, * 71. possible forerunner of other osteo- arthritic changes, 71. Calico bandage, 23. Callus, in sprain-fracture, increased by movement and friction, 1. Callus-formation at seat of frac- tures, 60. Capsular ligament, structure of, 2. linings of, 2. Capsular ligament, endothelium of, 2. of sterno- clavicular, 74. of shoulder, 76. of knee-joint, 108. Carpal bones, fracture of, 86. cases illustrative of, 89, 90, 91. Carpal joints, 4. Carpo-metacarpal joints, injury of, in sprains of thumb, 95, 96. Cartilage : semilunar cartilages of knee, anatomy of, 131, 132,134. displacement of internal semi- lunar, 70, 125, 126, 129. symptoms and clinical characters of, 135. differential diagnosis of, 137. author's method for reducing displacement, 139-40. displaced semilunar, treatment of recurring or relapsing dis- placement of, 149. operative treatment of, 150. preliminaries to operation, 152. author's operation for, 153. hyaline, growth of, in detached portions within the capsule of a joint, 69, 147. loose in joints {see Loose Bodies), 70. inter-articular, 5. Cases illustrating treatment of — sprains, rheumatism as a com- plication of, 29. ' wobbly joint ', 48. ossifying myositis, 60, 61. loose bodies in joints, 69. fracture of scaphoid bone, 89, 90, 91. fracture of metacarpal bone of thumb, 96. displacement of internal semi- lunar cartilage in football- player, 127. longitudinal splitting of an inter- nal semilunar cartilage, 129-30. displaced internal sejoiilunar car- tilage illustrated by tempera- ture charts, 158-161. displaced peroneal tendons, 175-7. displacement of small tendons at back of neck, 178-80. separation of epiphysis of an- terior inferior spine of ilium, 1 94. INDEX 231 Case illustrating treatment of rup- ture of tendo-Achillis, 206. Charcot's disease, 67, 217. Charts, temperature, in arthro- tomy, 158-61. in chronic relapsing synovitis, 116. Chronic atrophic neuritis, 12. Chronic and relapsing synovitis, treatment of, 116. Clavicular joints, 4. inter-articular cartilage of, 12. Coccygodynia, a symptom in sacro- coccygeal sprain, 108. electrical vibration for relief of, 108. Coccyx, fracture or dislocation of, 108. Cold, in treatment of sprains, 19. contra-indications of , in debilitat- ing diseases, 19. CoUes's fracture, 85. Complications of sprains, 9, 10. with injury to nerves, 12, 35. with tumour, 16. with rheumatism, 29. with gout, 30. with tuberculosis, 31. Constitutional complications of sprains, 30. treatment of rheumatic, gouty, syphilitic, and haemophilia, 30. Contusions, elastic pressure in treat- ment of, 20. Corpora oryzoidea, 66. Crepe velpeau bandages, 23, 28. Crepitus, value as diagnostic sign in sprain, 15. occasional absence in fracture, 15. present in osteo-arthritis occa- sionally, 15. ' Cricket shoulder ', 19, 183. nature of injury, 191. treatment of, 192. ' Cricket thigh ', 194. Crippled or deformed joint as sequela of sprain, 41. etiology of, 53. Crucial ligaments, anatomy of. 111. Crureus muscle, 60. Deferred swelling in joints, 10. Deformed joint as sequela of sprain, etiology of, 54. Deltoid muscle, 56. oversprain of, or partial rupture of, 43. causes of wasting of, 43. rupture of, 190. Deltoid sub-, bursa, enlargement of, 77. Diagnosis, modern methods of, in sprains, 14. Dislocation, 4. with sprain, 12. * by elongation ', symptoms of, 82. injury of wrist in, 83. diagnosis of, 83. treatment of, 83. prognosis of, 83. of semilunar cartilages, 124. anatomical reasons for greater frequency of internal displace- ment, 138. treatment of, 139, 140. of tendons, 173. Displaced external semilunar car- tilage, 163. pathology of, 163-4. cases illustrative of, 163-4. treatment of, 166. diagnosis of, 167. Displaced internal semilunar car- tilage, symptoms and clinical characteristics of, 135. differential diagnosis of, 137. causes of, 138. early treatment of, 139-43. popular devices for reduction of, 139-43. author's special method for re- duction of, 140-3. subsequent treatment of, 144-9. temperature charts in operation for removal of, 158-61. Displacement of tendons, 173. biceps flexor cubiti, 174, 178. peroneus brevis, peroneus longus, 173, 176. short tendons of neck, 173-8. tibialis posticus, 173. peroneal tendons, 177. Distal muscles of a joint, hyper- trophy of, 50. Domette bandage, 23. Drainage, in arthrotomy, 48, 162. for exploration of knee, 48. for chronic synovitis, 49. 232 INDEX Drainage for removal of displaced semilunar cartilage, 157. ' Driver's elbow ', 169. ' Drop-top ', anatomy of, 97. symptoms of, 97. how caused, 97. deformity in consequence of, 97. treatment of, 98-9. author's operation for, 99-100. Dumbbells, uses of, for developing muscles, 81. Elastic anklets, 223. Elastic knee-caps, 223. Elastic pressure, in treatment of sprains, 20, 227. principles for applying, 20, 22. universal application of, in cases of extravasation, 20, 24. special advantages of, 20. in tension of joints, 33. in treatment of fracture-sprains, 38. . in treatment of synovitis, 44. advantage of, in sprains of ankle, 105. compared with massage, 215. Elastic pressure in treatment of contusions, 20. Elastic rubber bandage, contra- indications of, in sprains, 25. Elastic webbing, 223. Elbow- joint, hinge of, 4. sprain of, 81. surgical pathology of, 82. differential diagnosis, treatment, and prognosis of, 82. orbicular ligament of, 82. treatment of sprain of, by elastic compression, 227. Electric vibrating machine in treat- ment of sprains of the ankle- joint, 107. Endothelium,secretingfunctionof,2, Epiphysis for anterior inferior spine of ilium, separation of, 194. cases illustrating, 194. Evaporating lotions in treatment of sprains and contusions, 50. Exercises, indications for, in frac- ture-sprain, 38, 40. against resistance, 81, 220. by means of weights and pulleys, 81. Exploratory arthrotomy, 34. temperature charts for, 47. External lateral ligament of knee, sprains of, 121. symptoms of, 122. prognosis and treatment of, 122. External semilunar cartilage of knee, anatomy of, 131-4. displacement of, 163. Extravasation, elastic pressure as a means of checking, 20, 24. in muscular sprains, 24. in articular sprains, 24. aspiration for, 79. Ewen's plaster, 224. Fatigue, to be avoided while prac- tising movements and exer- cises, 81. Femur, internal and external con- dyles of. 111. Fibrinous loose bodies, 66. Fibrolysin, 228. Fixed apparatus, disadvantages of, in treatment of sprains, 26, 28. ' Floating patella ', as symptom in sprain of knee, 113. value of, 114. Fomentations with anodine lotions for relief of tension, 34. ' Footballer's knee,' 116. Forcible movements of stiff joints under an anaesthetic, 216. limitations of, 216. special advantages of, 216. contra-indications for, 217. indications for, 217. rules governing use of, 217-18. Fracture-sprain, 10. X-rays in diagnosis of, 8. treatment of, 38. causes of imperfect recovery, 38. treatment of, compared with that of simple sprain, 39. of wrist-joint, 84-7. of metacarpal bone of thumb, 96. Gamgee-tissue, 28. as application in elastic com- pression, 23. Gastrocnemius muscle, in case of ossifying myositis, 62. General injuries to muscles and tendons, 169-86. INDEX 233 Genu- valgum or genu- varum, as result of sprained knee, 55. etiology of, 55. Gluteal muscles, 54, 101. Glycosuria as a complication of sprains, 19. Godlee, R. J., Professor, 163. Gout as a complication of sprains, 30. Gymnasium, exercises at, 81, 216, 220. Hsematomata in sprains, 10. as complication, 14, 30. operation for large, 79. Haemophilia as complication of sprains, 28. Haemorrhage, in articular and mus- cular sprains, 9. means of checking, 20. Hamstring muscles, rupture of, 199. usual sites of, 200. causes, symptoms, prognosis, and treatment of, 200. Heat in treatment of sprains, 33. Hernia of muscles, 84, 170. adductor longus, 171. rectus abdominis, 171. rectus femoris, 171. tensor vaginae femoris, 171. tibialis anticus, 171. Hip, contusions of, treatment of, 101. Hip, sprains of, 100. causes of, 100. symptoms of, 100. painful nature of, 100. difficulty of diagnosis in, 101. prognosis and treatment of, 100, 101. osteo- arthritic changes in, 101. wasting of muscles in, 101. Hip- joint, ball-and-socket arrange- ment of, 4. Hot fomentations in treatment of sprains, 34. Hunter, John, 208, 209. Hyaline cartilage, 94. purposes of, in structure of joints, 2. Hypertrophy of synovial fringes, symptoms of, 168. diagnosis of, 168. operative treatment of, 168. Iliacus muscle, 14. Ilio-psoas muscle and tendon, rup- ture of, 190. causes, symptoms, and treatment of, 190. Immediate massage, 213. Improper union of muscles and tendons, as sequela of sprains, 41, 55. Indications for massage, 213. Individual injuries to muscles and tendons, 187-209. Inflammation in joints, etiology of, 32. Infra-patella pad, 46. Injuries, diagnosis and treatment of, 1. Inter-articular fibro-cartilage of knee, 15, 111, 132. surgical anatomy of. 111. special attachments to, 112. anatomical variations in, 113. Inter-articular fibro-cartilage of sterno-clavicular joint, 74. Inter-muscular septa, overstretch- ing and tearing of, in elbow - sprain, 84. Internal derangement of knee-joint, 124. terms synonymous with, 124. causation of, 124. surgical pathology of, 124. common site for laceration of internal cartilage, 125. Internal condyle of femur. 111. Internal lateral ligament of knee, 110. rupture of, 119. causes of, 119. usual sites of laceration in, 119. symptoms of, 119. diagnosis and treatment of, 121. Internal semilunar cartilage, longi- tudinal splitting of, 128. anatomy of, 131. more liable to injury than external, factors concerned in, 132. Iodine, liniment and tincture of, 222. Johnson and Johnson's plaster, 196, 224. Joint, cavity of, 3. 234 INDEX Joint, distension of, from injury or disease, 3. persistent pain in, 51. Joints, adhesions within, 2. total disablement of, 2. capsule of, 2. structure and function of, 2. blood-vessels of, 3. nervous supply of, physiological relation of, 3. stability and strength dependent upon, 3. inter-articular cartilages of, 5. gliding movements as a source of strength of, 5. loose bodies in, 16, 65, 66, 72. tension in, 32. ' weak joint ',48. ' wobbly joint ', 48. causes of neuralgia in, 52. crippled and deformed as sequela to sprain, 53. ' Jumper's (broad) sprain ', 169, 200. Knee-joint, 4, disorganization of, as a result of enforced exercise, 16, 17. treatment of sprain of by elastic pressure, 22, 23. open operation not to be lightly considered, 34. sprains in region of, 109. surgical anatomy of, 109. internal derangements of, 124: pedunculated bodies in, 168. Knee-joint, sprains of, 101, 109. capsular ligament of, 109. patellar ligament of, 110. posterior ligament of, 110. internal lateral ligament of, 110. long external lateral ligament of, 110. crucial ligaments of, 110. quadriceps extensor tendon of inter-articular fibro-cartilage of, 111. coronary ligaments of, 113. differential diagnosis of, 115. usual site of pain in, 115. after-effects of, 116. treatment and prognosis of, 116. Konig, Professor, 68. ' Labourer's back ', 170. Langton, J., Mr., 163. Laparotomy, 157. ' Lawn- tennis leg ', 183. nature of injury, 203. symptoms, diagnosis, prognosis, and treatment of, 204, 205. Leather straps for wrist, 223. Leslie's plaster, 18. Leucoplast, 18, 224. Ligamenta alaria, 46, 155, 168. photograph of specimen removed by operation, 69. conversion of, into fibrous bands, 71. Ligamentum mucosum, 46, 155, 168. Ligaments, inter-articular, 2. ossification of, 3. stretching and elongation of, from distension of joint cavity, 3. injury of, in elbow- joint, 82. of sacro-iliac joints, 107. capsular, of knee-joint, 109. patellar, of knee, 110, 198, 202, 203. posterior, of knee, 110. internal lateral, of knee, 110, 115, 119. long external lateral of knee, 110, 121. crucial ligaments of knee. 111, 112, 131. coronary of knee, 113. external lateral of knee, 121. Lindsey & Sons, Messrs., 150. Liniments in use, 222. Local applications in treatment of sprains and injuries to joints, 222. Local depletion and flushing in treatment, 36. Local heat a symptom of tension in joints, 32. Localized palsy and paresis as sequelae, 57. Long external lateral ligament of knee, 110. Longitudinal splitting of internal semilunar cartilage, 128. Loose bodies in joints, 16, 57, 65, 72. classification of, 65, 66. etiology of, 66, 68, 69, 72. pedunculated loose bodies, 70. INDEX 235 Loose bodies in joints, developing in ligamenta alaria, 71. microscopical appearance of, 71. commoner varieties of, 71. symptoms and treatment of, 72. preliminaries to operative treat- ment of, 73. Lower extremity, rupture of muscles of, 190. * Mallet-finger ', anatomy of, 97. symptoms of, 97. how caused, 97. deformity in consequence of, 97. photographs of, 98. treatment of, 98-9. author's operation for, 99-100. Malleoli, 102, 105, 176. Marsh, Howard, Professor, 175. Massage, for reducing pain, 18. uses of, as an assistant to elastic pressure, 25. supposed disadvantages of, 25. when and how to apply, 26. in treatment of fracture-sprain, 38, 40. in treatment of sprains, 210. physiology of, 210. mechanical action of, 211. limitations of, 212, 213. indications and contra-indica- tions of, 213. immediate massage, 213. Massage movements and exercises in treatment of sprains and bruises, 210. Mead's plaster, 18. Medical practitioner, treatment of sprains by, 1. Mercury, uses of, in constitutional complications, 30. Mesoblast, common ancestor of, 3. structures in joints derived from, 3. Metacarpal bone, Bennett's fracture of, 96. photographs of, 95. linear fracture of metacarpal bone of thumb, 96. Metacarpo- phalangeal joints, injury of, in sprains of thumb, 95, 96. Metatarsal pain, causes of, 106. description of, 106. symptoms and treatment of, 106, 107. Metatarso-phalangeal joints, 106. Minor surgery, ' little things of, 6. importance of, 6. Movements and exercises, in treat- ment of sprains and bruises,. 210-21. against resistance, 220. Mucin, 2. Muscle sprain, 9. 168. examples of, 170. symptoms and treatment of, 170* Muscle strain, 170. Muscle- wasting, as result of treat- ment by splints, 26. as a serious complication of sprains, 26. as a result of lesions of nerves, 37.^ as a sequela of sprains, 41. caused by injury to nerve supply^ 43. and from disuse, 43. following immediately upon in- jury, 43. causes of, 43. author's means of preventing, 218-220. Muscles, atrophy of, acting on. joints, 2, 43. ossification of, 63. regeneration of atrophied, 81, hernia of, 84, causes of, 170. examples of, 171. symptoms, diagnosis, and treat- ment of, 172-3. operation for suturing, 196. of lower extremity, rupture of, 193. of trunk, ruptures of, 187. of calf, mode of strapping, 227. of chest, mode of strapping, 225. of thigh, mode of strapping, 226. Muscles, injured, and in region of injuries — rectus abdominis, 31, 171, 188, 226. psoas, 31. iliacus, 31. adductor longus, 43, 62, 63, 201. deltoid, 43, 56, 77. gluteal, 54, 101. pectineus, 62. sub-deltoid bursa, 77, 79. intra-spinatus, 77. supra-spinatus, 77. 236 INDEX Muscles, injured, and in region of injuries — sacro-lumbalis, 35, 170, 181, 190. . proximal, 50. rectus fern oris, 56, 193, 194. quadratus extensor, 60, 199. crureus, 60. soleus, 61, 62. gastrocnemius, 62. supinator longus, 83. , extensor carpi radiales longiores et breviores, 84. . popliteus, 122. pronator radii teres, 169. tensor vaginae femoris, 171. tibialis anticus, 171. the peronei, 174. plantaris, 183, 203. oblique, of abdomen, 188. triceps, 190. hamstring, 199, 200. adductor magnus, 202. Muscles and tendons, general in- juries to, 170-86. individual injuries to, 187-209. Myositis ossificans as sequela, 60. treatment of, 63-4. Nation, wage-earning capacity of, 6. Nerve, sciatic, injury to, 13. Nerves, lesions of, as complication of sprains, 35. difficulty of early diagnosis of, 35. importance of seeking for, 35. numbness and tingling as symp- toms of, 35. symptoms due to tearing of, 35. massage in treatment of, 36. absolute and complete rest often imperative, 36. treatment of, ^6. local neuritis as result of, 37. static electricity in treatment of, 37. blistering in treatment of, 37. opiates contra-indicated in, 37. wasting of muscles in, 37. pain in, as result of pressure, 51. circumflex, pressure upon cause of pain in sprain of shoulder- joint, 77. Neuralgia, causes of, in painful joints, 52. treatment of, 53. Neuritis, chronic atrophic, 12. Neuritis, local treatment of, 37. as a cause of persistent pain in a joint, 51. as complication of sprain of shoulder- joint, 77. Nutrition of joints, influenced by alternate flushing and deple- tion in treatment by elastic pressure, 24. Oblique muscles of abdomen, rup- ture of, 188. causes, symptoms, prognosis, and treatment of, 188, 189. Open operation, not to be lightly considered, 34. often only means of cure, 34. Operation, for displaced semilunar cartilage, author's method of, 153. for exploratory arthrotomy, 34. for large haematomata, 79. for'droptop' or 'mallet-finger ',99. for suturing muscles, 196. for rupture of quadriceps extensor, 199. for displacement of peroneal ten- dons, 177. for ruptured patellarligament,203. Orbicular ligament, of elbow- joint, 82. Ossifying myositis, 57. usual situations of, 58. etiology of, 58. osteo-blasts in production of, 60. structure of bone in, 60. symptoms of, 63. in quadratus extensor muscle, 60. in crureus muscle, 60. in soleus muscle, 61, 62. in gastrocnemius muscle, 62 in deltoid muscle, 62. in adductor longus muscle, 62. in pectineus muscle, 62. diagnosis of, important, 63. preventive and curative treat- ment of, 64. Ossification of muscle, symptoms of, 62, 63. mistaken for sarcoma of thigh, 63. Osteo-arthritiSjCrepitus occasionally present in, 15. as sequela, 16, 57, 64. as result of injury, 64. INDEX 237 Osteo-arthritis, etiology and path- ology of, 65. treatment of, 65. calcareous deposition a possible forerunner of, 71. Osteo-blasts, in production of ossify- ing myositis, 60. Osteo-chondritis dissecans, 68. Pain, as a symptom of tension in joints, 32. persistent, in joints, 41, 51. metatarsal, 106. Painful and stiff joints, general causes of, 42. Palsy, localized, as sequela of sprain, 57. etiology of, 57. treatment of, 58. Papillae, liypertrophied, of synovial membrane, in chronic synovitis, 70. See Villi. Paralysis, local, as sequela of sprain, 56. Paresis, local, as sequela of sprain, 56, 57. Passive movements, comparison with active, in treatment of sprains, 27. in simple sprain, 27, 214. limitations of, 27. mechanical action of, 27, 214. in sprain-fracture, 38, 214. contra-indications of, 214. special uses, 214. Patella, floating, 113. Patellar ligament, rupture of, 198, 202. symptoms, diagnosis, and treat- ment of, 202, 203. operative treatment of, 203. Pectineus muscle, 62. rupture of, 200. Pectoral muscle, rupture of, 190. Pectoralis major muscle, 191. Pedunculated bodies in knee-joint, 168. Periosteum, injury to, in ossifying myositis, 58, 60, 61, 62. Peroneal tendons, displacement of, symptoms and treatment of, 177. Persistent pain in joints, 41, 51. Physiology of massage, 210. Plantaris muscle, rupture of, 183. Plasters, Mead's, 18. Leslie's, 18. Seabury's, 18. Johnson and Johnson's, 196, 224. various, 224. Poirier, Professor, 133. Popliteus muscle, 122. Popliteus tendon, 132. Posterior crucial ligament of knee, attachments of, 131. Posterior ligament of knee, 1 10. Poupart's ligament, 190, 201. Preventible sequelae of sprains, 41. enumeration of, 41. Prevention of muscle-wasting by gentle, active, muscular exer- cises and training, 218. Prognosis in sprains, importance of, 16. Pronator radii teres muscle, 169. Proximal muscles of a joint, atrophy in, 50. Psoas muscle, 14, 35. ' Pulled elbow ', symptoms of, 82. injury of wrist in, 83. diagnosis, treatment, and prog- nosis of, 83. Quadriceps extensor muscle of thighs 60, 183. operation for rupture of, 199. Quadriceps extensor tendon, rupture of, 198. diagnosis and treatment of, 198, 199. operation for treatment of, 199. Radcliffe Infirmary, 164. Radiant heat in treatment of sprains, 33, 228. Radiocarpal epiphysis, 85. Radiographer, 89. Radiography, 88, 93. Radioscopy, 82. Range of movement in stiff joints, 217. Rawling, L. B., :Mr., 135. Rectus abdominis muscle, 31, 171. rupture of, 188. causes, symptoms, and treatment of, 188. method of strapping, 226. Rectus femoris muscle, 56. rupture of, 194. 238 INDEX Rectus femoris muscle, rupture of, symptoms and treatment of, 194-6. plaster strapping for, 196, 197. Recurrent or relapsing displacement of semilunar cartilage, 137. palliative treatment of, 149. operative treatment of, indica- tions for, 150. preliminaries to operation, 152. author's method for removing, 153. illustrations of, 154-6. after-treatment of, 162. Recurring and relapsing synovitis, 44, 70. arthrotomy for digital explora- tion in, 34. appearance of synovial membrane in, 46. appearance of naked-eye and microscopic, 46. nature of synovial secretion in cases of, 46. method of operation for, 46. relaxed state of ligaments in cases of, 50. temperature charts in, 116. Relapsing sprains, often dependent upon health of individual, 28. Rest, in treatment of sprains, 41-2. Restoration of mobility in injured joints, primary object in treat- ment, 26. Rheumatism as complication of sprains, 29. treatment of, 30. * Rice bodies ' in joints as sequela of sprain, 66, 71. * Rider's sprain ', 43, 168, 183, 201. Rigid splints, uses of, contra-in- dicated in treatment of sprains, 26. Rule-of-thumb methods, disadvan- tages of, 1, 6, 7. Rupture of muscles and tendons, causes of, 182-3. pathology of, 182. clinical symptoms of, 183. treatment of, 183-4. athletic exercises in relation to, 184. circumstances which influence tendency to, 185-6. Rupture of muscles and tendons — influenced by season of year, 185. by temperature of air, 185. by want of training, 186. by age of individual, 186. by kind of game, 186. of the body, 188. of oblique muscles of abdomen, 188. of rectus abdominis, 188, 226. of upper extremity, 190. of ilio-psoas, 190. of sacro-lumbalis, 190. of lower extremity, 193. of rectus femoris, 193. of tendons of forearm, 193. of quadratus extensor, 198. of hamstrings, 199. of adductor longus, 201. of adductor magnus, 202. of patellar ligament, 202. of plantaris, 203. of tendo-Achillis, 206. Sacro-coccygeal sprain, causes of, 107. symptoms of, 107. differential diagnosis of, 108. treatment and prognosis of, 107-8. coccygodynia a symptom in, 108. Sacro-iliac ligaments, 107. Sacro-lumbalis muscle, 35, 170, 181. dislocation and rupture of, 190. symptoms and treatment of, 190. Sankey, R. H., Mr., 89. Scaphoid bone, cases illustrating fracture of, 88-9, 90-1. clinical symptoms of, 90-1. Mr. Elliot Stanford's case, 91. treatment of, 92, 94. prognosis of, 94. Sciatic nerve, injury to, 13. Scott's dressing, 223. Seabury's plaster, 196, 198, 224. Semilunar cartilages of knee, cal- careous deposition in detached, 71. longitudinal splitting of internal, 128. internal more liable to injury than external, 131. factors concerned in, 131-2. INDEX 239 Semilunar cartilages of knee, changes observable in cartilages that have become detached or torn, 135. drainage for, 157. author's method of operation for displacement of, 153. apparatus for preventing displace- ment of, 223. See Displaced semilunar carti- Semi-membranosus muscle, rupture of, 200. Semi-tendinosus muscle, rupture of, 200. Separation of body of an internal semilunar cartilage from deep fibres of internal lateral liga- ment of joint, 122. symptoms and results of, 122. Separation of epiphysis for anterior inferior spinous process of ilium, 194. Sequelae of sprains, 41. preventable, 41. unavoidable, 41, 56-7. Serous effusion in joints, 10. Simple sprain, 9, 17. passive movements in, 27, 214. treatment of, compared with that of fracture-sprain, 39. Simple strains, 18. Shoulder-joint, integrity of, depen- dent upon strength of its liga- ments, &c., 4. weakness of, 4. sprains of, 76. surgical anatomy of, 76. symptoms of, 77. swelling often considerable in, 77. diagnosis of, 78. liability to atrophy of muscles in, 77. causes of pain in, 77, 79. treatment of, 78-9. aspiration in treatment of, 79. complications of, 79. movements in, importance of early, 79. treatment of, 80. permanent ill-effects of, 80. ' Slipped cartilage ', 124. subluxation of, 124. Soleus muscle, ossifying myositis in, 61-2. Special sprains — shoulder- joint, 76. wrist, 84. thumb, 94. hip- joint, 100. ankle-joint, 101. knee-joint, 101, 113. Splenius capitus muscle, 179. Splints, prolonged and constant use of harmful, 42. uses of strictly limited, 42. Sprain-dislocation, 12 ' Sprained elbow ',81. causation of, 83. exercises productive of, 84. symptoms of, 84. Sprain-fracture, 1, 10, 16. pathological significance of, 8. passive movements in, 38, 214. causes of stiffness in, 40. ankylosis as sequela of, 41, 56. Sprain with fracture, 10, 214. Sprain, with immediate swelling, 9, 19. of external lateral ligament of knee, 14, 121. of elbow- joint, 81, 83. of the body, 107. sacro-coccygeal, 107. in region of knee-joint, 108. Sprains, anatomical conditions un- derlying, 1. treatment of, 1. pathological conditions of, 1. general considerations of, 6. definition of, 7. classical conception of, 8. articular, 8. of muscle, 9. complicated with injuries to bone, 10. hsematomata in, 10. complicated with injury to nerve, 12, 35. numbness a symptom of, 12, anaesthetics in treatment of, 14, diagnosis of, 14. complicated with hsematomata, 14. crepitus as a symptom of, 15. warm applications in treatment of, 19, 78. 240 INDEX Sprains, cold in treatment of, 19. elastic pressure in treatment of, 20, 22. treatment of deferred swelling in, 27. with fracture, treatment of, 38. rest in treatment of, 41. ' Rider's sprain ', 43. evaporating lotions in treatment of, 50. treatment of improper union of muscles and tendons as sequela of, 55. paresis and paralysis as sequelae of, 56. unavoidable sequelae of, 56-7. of acromio-clavicular joint, 75. of shoulder- joint, 76. of thumb, 94. of the hip, 100. of tarso -metatarsal joint of great toe, 107. of the knee, 109-16. of internal lateral ligament of knee, 119-20. massage and movements in treat- ment of, 210. Spring-truss for knee, 224. ' Sprinter's thigh ', 183. Stanford, Mr. Elliot, fracture of sca- phoid bone by, 91. description of, 91-3. Static electricity in treatment of nerve lesions, 37. Sterno- clavicular joint, sprain of, 74. anatomy of injury, 74. S3naaptoms and treatment of, 74. Stiffness in joints, 41. causes of, 42. range of movement in stiff- joints, 217. Strain, anatomical conditions under- lying, 1. the simplest form of sprain, 9. treatment of simple, 18. of internal lateral ligament of knee, 119. Strapping, for strains, 18. of injured muscles, advantages of, 197, 198. for muscles of chest, rectus abdo- minis, muscles of thigh, muscles of calf, 225-7. Strapping, for knee, ankle, foot, and shoulder, 227. Strata, fascial and inter-muscular, 3. Styloid processes of radius, fracture of, 85-6. Sub-deltoid bursa muscle, 77. haemorrhage into, in sprains of shoulder- joint, 77. Subluxation, 124. of head of radius, 82. Surgical anatomy, general, of joints, 2-4. of knee-joint, 108. of inter-articular fibro-cartilage of knee. 111. Synovia, function of, 2. Synovial cavity, stomata in con- nexion with, 3. Synovial fringes, 46, 68, 168. Sjrnovial membrane, folding of, 2. villi or papillae of, 2, 3. appearance of, in relapsing syno- vitis, 46. Synovitis, chronic, hypertrophy of papillae in, 70. formation of loose bodies in, 70. drainage for, 49. recurring and relapsing, 44. general relaxation of ligaments as result of, 44. treatment of, 44. presence of adhesions as a cause of, 44. means of preventing, 44. use of anaesthetics in, 45. forcible movements in treatment of, 45. exploratory arthrotomy in treat- ment of, 45. acute traumatic of knee, 116. Tarsal joint, 4. Tarso-metatarsal joint of great toe, 107. Temperature, high degrees of, appli- cation in treatment of sprains, 228. Temperature charts, in operation for displaced semilunar carti- lage, 158-61. for exploratory arthrotomy, 47. Temporo-maxillary joint, 12. inter-articular cartilage of, 12. Tendo-Achillis, rupture of, 206. INDEX 241 Tendo-Achillis, rupture of, S5mip- toms, diagnosis, and treatment of, 206-9. ossification in, 208. Tendons, treatment of improper union of, as sequela of sprains, 55. quadriceps extensor, 110, 113. popliteus, 113, 132. displacement or dislocationof , 173. examples of, 173. the peroneal, 174, 177. long of biceps, 178. small, at back of neck, 178, 181. rupture of, causes of, 182-3. of forearm, rupture of, 193. ilio-psoas, rupture of, 190. ' Tennis elbow ', 169. Tension in joints, local treatment of, 32. local heat as symptom of, 32. aspiration in treatment of, 33. uses of elastic pressure in, 33. Tensor vaginae femoris muscle, 171. Thumb, sprains of, 94. causes of, 95. carpo-metacarpal joints of, in- juries to, 95. metacarpo-phalangeal joints of, injuries of, 95. symptoms of, 95. differential diagnosis of, 96. treatment of simple sprain of, 97. prognosis of, 97. sprain-fracture of, 97. treatment of, 97. Tibialis anticus muscle, 171. Tincture of iodine, 222. Traumatic hydrops, etiology of, 116. Treatment of recurring and relaps- ing displacement of semilunar cartilages, 149-50. Treatment of sprains, 17. Triceps muscles, rupture of, 190. Tuberculosis as sequela and com- plication of sprain, 31. Tumour as sequela and complica- tion of sprain, 16. Tunnicliffe, Dr., 211. Unavoidable sequelas of sprains, 56-7. classification of, 56-7. Unregistered practitioners, 7. Upper extremity, rupture of muscles of, 190. causes, symptoms, and treatment of, 190. Vasogen-iodine, 30, 222. Villi of synovial membranes, dis- eased conditions of, 2. development of cartilage or bone from, 3. hypertrophy in chronic S3movitis, 69. Warm applications in treatment of sprains, 19, 78. 'Weakjoint', 41, 48. Whitelocke, R. H. Anglin, Mr., 139, 194. Wicket-keepers, injuries to fingers of, 55. 'Wobblyjoint', 41, 48. local treatment of, 51. Workmen's Compensation Act, 6, 17. Wrist, 4 leather straps for, 223. Wrist- joint, sprain of, in 'pulled elbow', 83. simple sprain of, 84. etiology of, 85. symptoms of, 85. differential diagnosis of, 85. treatment of, 87. swelling in sprain of, 86. X-rays as an aid to diagnosis, 8, 16 40, 55, 60, 63, 82, 88, 97, 98, 103, 202. OF THE UNIVERSITY OF WHITELOCKE i^iLlFOHTiVi OXFORD : HORACE HART PRINTER TO THE UNIVERSITY \A ■x^ UNIVERSITY OF CALIFORNIA LIBRARY ^3 te. 30rn-7,'12