CHAPTER XXV DIAGNOSIS OF DISEASES OF JOINTS (Part 1)

CHAPTER XXV DIAGNOSIS OF DISEASES OF JOINTS AND BURSiE In this chapter an attempt will be made to enable the reader to examine intelligently and purposively, and then to arrive at a correct diagnosis of, any disease of a joint or of the structures immediately surrounding it. It will be convenient to consider, first, the general principles of diagnosis of articular disease, and then to refer in detail, where that is necessary, to the diagnosis of affections of individual joints. When such a case presents itself to the surgeon the first fact to be ascertained is whether there is any organic disease of the part, for it must be borne in mind that hysteria, or ncuromimesis, often closely imitates gi'ave articular lesion. Hysteria is more common in women, but it is not limited to either sex, or to any age ; in many cases it may be traced to the influence of some strong emotional disturbance. The main fact upon which the diagnosis of hys- teria must rest is the want of correlation of the symptoms. Thus, when a patient complains of pain n a joint of a very severe character, especially if ■,his is accompanied with marked superficial hyper- esthesia, but there is no discoloration or heat or welling about the part, or wasting of the muscles f th". limb, an hysterical joint must be suspect'^d. If 330 SURGICAL DIAGNOSIS [chap. it is found that the johit is held rigid-usually in the position assumed in disease, but sometimes stnk- [n.ly different, as e.g. m the position of extreme extension-and that all attempts to move it excit^ ^asms of the muscles and cries fi.-om the patien^ but that when the attention is diverged passive n'ovem nt can be made without difficulty or pam 01 that the patient herself moves the part, this ispicion becomes converted into a positive diag^ Tiosis A skiagram does not show any of the bone changes always found in organic joint disease of for standing In cases where the surgeon remains rilt he history of some strong emotion or of the witn ssmg of a case of real joint disease just - ■ ore the onset of the illness, or the presence of other hyLrical phenomena, such as exaggerated reflexes will be of assistance ; and it may be useful tc place he patient rmder the influence of --"-f^^^^^ to examine with care the outhne and mobilit} oi tL lou t and particularly to notice when the joint becom s noid, for it is stated that m neuromimesis Z miIy 0 dy reappears when the patient s con- stu uess -turL, while m painful organic diseas joint stiuctuies 'iu smootli- iKrps licraments, and muscles , {-^i ^ . -.nd lages, iipciiui^i , f ,1 CQ^jit movements , ^ The best viethod of cxmmnaiion is first ot XXV] EXAMINATION OF A JOINT 331 look at the joint carefully, next to feel it, then to study its movements, both active and passive, and to supplement this by a study of good comparative skiagrams of the diseased joint and of the corre- sponding healthy one. By inspection of a joint we can learn the relation of the bones to one another, the attitude assumed, and the general form of the part, whether swollen, deformed, or wasted. By palpation we can determine more accurately whether a svyelling corresponds to the outline of the synovial cavity, to one or more of the bones, or to neither of the joint structures; whether the swelling is solid or fluid, and whether any one of the joint struc- tures is tender to pressure through it. Observation of the mobility of a joint tells us not only the range of movement, whether normal, limited, or excessive, but also whether it is smooth or uneven, painless or painful. Skiagrams show chansres in the struc- ture and density of the articular bones, as well as in their outline and relations. They may show changes in the soft parts too, such as effusions, abscesses cysts, and new growths. I. The Structures involved Disease in the neighbourhood of a joint often simulates disease of the joint itself ; it is therefore very important to notice whether any swelling present corresponds in outline with some neighbour- ing structure, such as a bursa or synovial sheath and not with the articular cavity or either of the bones. Movement of a joint is usually attended with movement also m adjacent bursje and synovial sheaths and pain and creaking due to disease of the latter may be mistaken for articular pain and creaking. To avoid this error, notice the eJact seat ot the pam and creaking, and especially whether these 332 SURGICAL DIAGNOSIS [chap. Sims can be elicited by manipulations which cause movement in the bursa or synovial sheath m ques- tion without movement of the joint. For example, the prepatellar bursa can be tested by moving the skin over the front of the knee ; the synovial sheaths of the ankle or wrist can be tested by moving the digits while the ankle- or wrist-joint is held fixed. When a swelling is found which corresponds m outline to some neighbouring structure, as a bursa or synovial sheath, and not to the articular cavity or to any of its bones, and if at the same time there is no alteration in the mobility of the ]oiut,_ or pam produced by it mdess it excites it in the inflamed structure outside, it will be at once known that the disease is extra-articular; such cases are of common occurrence e.g. housemaid's knee, and teno-synovitis o the wrist 'or ankle. On the other hand, when a swelling corresponds in outlme to the synovial caX of a joint or to one of the articular bones, or when the motion of a joint has lost its smooth- ness or is painful, or the articular bones are foimd sensitive to pressure or shocks transmitted through thein, it may be judged that the actual joint struc- tnrps are involved. . , j T Vhen a swelUng is present which corresponds in outUne to the synovial cavity, or -ojem- J the ioint is attended witli soft crealcmg, the disease s ai ectin- the synovial membrane of the jomt. The changes met with in the synovial membrane Ire .Sy three: (i) effusion of blood, serum or nus into the cavity, distending it more oi less ^OinWtratiou of the synovial ^-f^"^^ hickening of the tissue, t^^beixulous, ypluht c^^^^^ sarcomatous; and (hi) hypertrophy of ,ts fim.,e., rendering the surface villous. 2. The signs of disease of hnameut^ aio, XXV] DISEASES OF JOINTS 333 the early and acute stage, tenderness, especially at the attached end of a ligament, pain on any move- ment which stretches the ligament, and later on dis- placement of bones, or an abnormal range of mobility in the joint, from shortening or from lengthening of the ligaments. Ligaments are never the only struc- tures of a joint affected by disease, and these signs therefore are always combined with others. 3. When the movement of the joint has lost its usual smoothness and is accompanied by hard grat- ing or a soft rubbing or a crackling sensation, or, again, when nodular growths can be felt springing from the edge of the articular cartilage, the disease is known to be affecting the cartilage. In the acute diseases of joints the occurrence of severe starting-pains, especially just as the patient is fall- ing asleep, is regarded as evidence that the articular cartilage is involved. Disease very rarely, if indeed ever, begins in articular cartilage. 4. If an articular bone is found swollen, and tender on pressure, and if pain is excited by force transmitted through it, or if the skiagram shows alteration in the outline or in the intimate structure of the bone, it will be known that the articular bone is diseased. 5. If a swelling corresponds in position and out- line to a bursal cavity, or there is soft friction felt on movement of the walls of a bursa over one another while the neighbouring joint is at rest, it will be evident that the disease is in a bursa. 6. And when a swelling corresponds in position or outline to a tendinous synovial sheath, or pain and soft grating are elicited by movement of a particular muscle or muscles while the adjacent joint is kept at rest (where this is possible), the diagnosis of disease of a synovial sheath k obvious. 334 SURGICAL DIAGNOSIS [chap. 7. Lastly, a swelling or other morbid phenomenoii may not correspond with any special structure, but may involve the common connective tissue of the part. Many joint diseases affect more than one of the above structures, either primarily or in succession, and in the latter case it may be impossible to tell where the disease originated ; but wherever it is possible, and certainly in all cases of early disease, a careful attempt to localize the affection will usually be attended with success. II. Nature of the Affection The suro-eon must next determine the nature of the affectioli present. Inflammation in its various forms is the most frequent disease, and its symp- toms are like those observed in other situations. Degenerations and neoplasms are also met with. A. Acute disease. — The acute diseases of joints most" often affect mainly the synovial membrane and are characterized by more or less rapid and abundant effusion of fluid into the cavity. Where the effusion follows immediately upon a severe injury to the joint, especially a fracture of one of the bones into the joint, e.g. the patella, it is an effusion of blood— hsmarthrus. Signs of bruising of the soft parts, or their subsequent staining with blood pigment, would confirm this diagnosis. A sudden effusion into a joint after even moderate use of the part, or some trifling strain, in a patient with the history and evidences of hceiiiopJiilia, is also to be recognized as hajmarthrus. . A rapid effusion of fluid into a joint, cither spon- taneous or quicklv following over-use, or sprain, or an " internal derangement of tlie joint, is in noail} all cases at Hrat a serous synovitis. With this tlicre xxv] ACUTE JOTNT DISEASES ' 335 may be some local heat, slight redness of the skin if the joint is not thickly covered in, pain on and limitation of movement, and some pyrexia. When the pain is severe, and there are acnte local tender- ness, and great pain on movement, and the outline of the joint is blurred by swelling outside the synovial membrane, the ligaments of llie joint are also acutely- inflamed. When the swelling steadily increases and is sup- plemented by superficial oedema, and the local pain, tenderness, heat, and redness become more marked, suppuration is indicated. With the formation of pns in the joint cavity the fever increases, the daily range of temperature becomes greater, and there may be a rigor. In all cases of doubt, and where from the nature of the case suppuration is likely to occur, some fluid should be removed from the joint with an exploring syringe to determine its nature. A bacterial examination of the fluid removed should be made, to determine the causative organism. In pyjBmia suppuration occurs in joints not only very rapidly but without much pain or local cedema. There are many forms of acute synovitis and arthritis which must be distinguished. For this purpose in- quire carefully into the apparent cause of the malady, especially injury, over-use, or sudden slipping or lock- ing of the joint. Notice whether more than one joint is affected, and inquire into the previous history of the patient, immediate and remote, particularly for evidence of rheumatism, gout, gonorrhoea, syphilis, pyorrhoea, or suppuration in any part of the body. 1. When the synovial effusion quickly follows upon an injury such as a sprain, or upon over-use, or any form of " internal derangement " of the joint, it is a case of traumatic synovitis. 2. When the inflammation quickly follows a 336 SURGICAL DIAGNOSIS [chap. wound into the joint cavit)^ is intense and rapidly runs on to suppuration, it is the result of infection of the joint with pyogenic organisms, and the par- ticular organism must be identified. 3. A synovial effusion which has developed rapidly and insidiously, i.e. without acute local pain and bright redness of the skin, in a patient suffering from fever with considerable daily range, possibly interrupted by a rigor or rigors, with sweating, wasting, and general iUuess out of proportion to the joint affection, is pycemic synovitis. The effusion is purulent from the first, and contains streptococci, or, less commonly, staphylococci or one of the specific pus-producing organisms. Several joints may be affected, and the cartilage and bone are liable to be eroded. In almost every case the primary focus of disease is quite obvious. 4. An acute inflammation of a joint coming on during or soon after an attack of pneumonia, typhoid fever, influenza, or scarlet fever is due to infection of the joint with the specific organism of the disease. Wherever possible the organism should be identified. As a rule, the effusion in these cases remains serous, but in the pneumococcal variety it frequently be- comes purulent. Pneumococcal arthritis also occurs apart from any other pneumococcal lesion. Exactly similar joint affections may be caused by pyorrhosa, or by chronic suppuration in the nasal sinuses, a.limentary or genito-urinary canals. 5. An acute swelling of a joint coming on spon- taneously in a patient who has gonorrhoea or gleet is gonorrhceal arthritis. Cases vary much in severity ; there is usually, in addition to synovial effusion, some swelling of the ligaments of the joint, and more pam and tenderness than in a simple synovitis, suppura- tion may occur, and ankylosis often results. The I' XXV] ACUTE JOINT DISEASES 337 disease a<;tacks the large joints, especially the knee, ankle, and wrist ; it may be associated with inflam- mations of fasciae and aponeuroses. The gonococcus can frequently be found in the fluid in the joint. This disease may come on at any time during the course of gonorrhoea, and when the local evidences of this disease are only to be detected by careful examina- tion. 6. If several joints are simultaneously or succes- sively attacked with moderate, general, ill-defined swelling, and the parts are found slightly red, tender, and very painful on any movement, and along with this local condition there are acute pyrexia, profuse sour-smelling perspiration, concentrated acid urine, a coated tongue, and particularly if there is peri- carditis, endocarditis, or pleurisy, or a history of previous attacks, the surgeon will recognize the joint affection as a part 'of acute articular rheumatism. The number of joints affected, the rapid onset and subsidence of the local lesions, the character of the general disturbance, and the history of previous attacks are the main points on which to found a diagnosis. 7. If a patient is seized in the night with a very severe pain in a joint which in a few hours becomes swollen, with a red glossy appearance of the skin over it, and oedema of the subcutaneous tissue, the part being exquisitely tender, and the temperature is only moderately raised, it will be recognized as acute gout. This diagnosis will be confirmed if the affected joint is the metatarso-phalangeal, if previous similar attacks have occurred, and particularly in that joint, and if there are other evidences of gout such as tophi, dyspepsia, cramps, or excess of uric acid in the blood. 8. A slightly painful effusion into a joint arising 338 SURGICAL DIAGNORIS [chap. spontaneously in a patient who is the subject of early secondary syphilis is syphilitic synovitis. The diagnosis is confirmed by a positive Wassermanu reaction and by rapid resolution under anti-syphi- litic treatment." Syphilitic synovitis occurs also in the congenital type of disease and takes tlie form of a i^ainless, rapid efJusion into one of the large joints, unaccompanied by any limitation of move- ment, and with a tendency to recur from time to time. 9. If in an infant or a young child a joint— especi- ally the hip or shoulder— becomes acutely swollen,, with great local tenderness and pain on any move- ment, and the child is very ill with high fever, it is a case of the acute arthritis of infants, due to in- fection of the joint with virulent pyogenic organisms, and quickly resulting in suppuration and more or less destruction of the joint, dislocation, etc. 10. Where a joint becomes suddenly and spon- taneously greatly distended with fluid, and there is neither pain nor tenderness, nor marked limitation of movement, it is Charcot's diseasc^ataxic arthro- fathy, and the reflexes, the pupils, and the sensation in the limbs should be examined for evidence of tabes or of syringo-myelia. [See p. 342.) 11. If there is a fluctuating swelling m the posi- tion of a bursa, with pain, tenderness and redness of the skin, and some pyrexia, it may be diagnosed as acute bursitis : and if the surrounding tissues become oedematous, the pain throbbing in character, and the temperature still more raised and variable during the day, it indicates that suppuration has occurred. This affection is most frequontly seen in the bursse over the patella and the olecranon, or in a bunion, and is often the result of a wound. 12. Jf the patient complains of sharp pricking pain in the silo of a bursa, and it is found tender XXV] CHRONIC JOINT DISEASES 339 on pressure and yields soft crepitus or friction when the part is so pressed or moved as to glide the two surfaces of the bursa over one another, it is to be recognized as subacute plastic or dry bursitis. This is seen most often and is most readily diagnosed in the prepatellar bursa. 13. An acute swelling over a tendon sheath, with creaking on moving the tendon in its sheath, is acute tenosynovitis ; this is most often seen in