CHAPTER XXV DIAGNOSIS OF DISEASES OF JOINTS (Part 3)

349 iudicate dislocation of the femur. A skiagram shows the exact position and outline of the bones. 2. Mobility of the joint.— Test its range, the charac- ter of resistance offered, its smoothness, and whether movement is painful or not. For this the left hand should be placed firmly upon the pelvis, and the right hand, grasping the knee, should first make gentle, and then more forcible, attempts to flex and extend, abduct and adduct, and rotate the thigh. Care should be taken to divert the patient's attention as much as possible while carrying out this manipulation. The surgeon should notice (1) whether the pelvis follows the movements of the thigh closely, or whether there is only a limited range of movement of the joint ; (2) whether the movement is painful, and, if so, whether, when the joint is fully flexed, rotatory and lateral movements are still pain- ful and limited, or painless, free, and smooth ; (3) whether movement is attended with grating or cre- pitus, soft or hard, smooth or rough. Limitation of movement of the joint may be due to ankylosis, to muscular spasm, or to deformity or displacement of tlie bones. It is a very important sign of disease. Limitation of movement in one special direction, or in one position of the joint only, always indicates that it is due to some particular local condition and not to a general disease of the joint. Thus, when extension of the joint is painful and limited, but on full flexion the rigidity and pain in moving the thigh pass off, it indicates that there is spasm of the ilio-psoas muscle only, and careful- examination should be made for abscess in its sheath, or between it and the capsule of the joint. If all rigidity passes off under an aiifesthctic it is entirely muscular. In connexion with this symptom notice the tension of the adductor tendons and of the sartoriiis. 350 SURGICAL DIAGNOSIS [chap. 3. Condition of the bones, their outline, and sensitiveness. — Tlie outline of tlie trochanter should first be com- pared on the two sides, and then, the palm of the hand being placed flat on the trochanter, firm and gradually increasing pressure shoidd be made in the line of the neck of the bone ; if this elicits signs of pain it indicates tenderness to pressure and inflam- mation of the neck or head of the femur. This sign should not be elicited by sudden blows upon the trochanter or upon the heel ; in children the mere blow may cause them to cry, and in all patients alike unnecessary pain may be caused ; when the heel is struck the position of the tender part cannot be precisely localized. The surgeon should next place one hand on the front of each iliac crest and attempt to press these two bones asmider or together, and to compress the pelvis laterally ; by this means some slight movement is occasioned between the ilium and sacrum, and by the occurrence or non- occurrence of pain it may be inferred that that joint is, or is not, diseased. 4. Swelling about the hip. — Any swelling of the part should be carefully investigated ; there may be sim- ply indistinct fullness in the groin, or swelling of the inguinal glands, or a fluctuating collection of fluid. If the latter, care should be taken to notice whether it corresponds in position with the bursa under the psoas muscle, or with the sheath of the iho- psoas, or with the bursa over the great trochanter of the femur, or is occupying the planes of cellular tissue of the pare. A fluctuating swelling bulgmg above Poupart's ligament (ligamentum mgumale). just internal to the iliac crest, not reachmg mto the thigh at all, or only to the outer side of the femoral vessels, is an iliac abscess. A fluctuating swelling pointing above the middle of Poupart s XXV] SACRO-ILIAC DISEASE 351 ligament, and extending into the thigh behind the femoral vessels to their inner side, is a psoas ahscess. An abscess pointing above the brim of the pelvis is probably connected with disease of the acetabulum. 5. Condition of the muscles, whether spasmodically con- tracted or wasted. — Spasm is especially well marked in the adductor muscles ; it is a sign that movement of the joint is painful. Wasting is especially seen in the glutei muscles, leading to flattening of the buttock and lowering of the gluteal fold. It is most often seen in tuberculous disease of the joint, and in osteo-arthriiis. Pain in the knee, especially at the inner side of the joint, may be the chief or the only spontaneous pain in hip-joint disease. The surgeon may diagnose sacro-iliac disease in cases where the limb is apparently lengthened, while the hip-joint can be fully extended, and there is no rigidity of, or pain in moving, this joint, whereas there is tenderness over the sacro-iliac joint, with pain on pressing the two innominate bones together or asunder. This is a disease of adult life ; it comes on insidiously, the patients complaining of lameness, weakness and pain in the back and along either the sciatic or anterior crural nerve. An iliac abscess, which may cause flexion of the hip, but neither rigidity nor pain in moving it, or an abscess in tlie buttock or in the pelvis, possibly bursting into the rectum, may be found. If the liip-joint can be moved in. all directions and to the full extent without pain, and no pam is caused by firm pressure along the neck of the bone and the skiagram shows the bones to be unaltered' the hip-joiut and the articular bones jnay be regarded as free from active disease. " ^ When tlie femur is rotated out, the great tro- 352 SURGICAL DIAGNOSIS [chap. chanter slightly raised on the pelvis, and the hollow of the groin a little fiUed out, and the skiagram shows ths angle of the neck of the femur to be diminished, it is due to coxa vara. Abduction and rotation inwards are limited. This condition is most common in adolescents. (Plate xi., Fig. 1.) If with similar limitation of movement of the hip of a child or adolescent, and a pronounced limp, without pain, there is found slight flexion of the joint, and perhaps some raising of the trochanter, and the skiagram shows a flattening of the head of the femur with increase in width of the epiphysial line, it is a case of pssudo-coxaJgia or Perthes' disease. (Plate XII., Fig. 2.) The absence of pain and the characteristic X-ray appearance enable the con- dition to be distinguished from early tuberculosis. If when a child begins to walk there is found to be considerable lordosis on standing, a peculiar roll- ing gait, and the top of the trochanter is about on a level with the front of the iliac spine instead of well below it, it is due to congenital dislocation of the hip. This may be bilateral and the parts symmetrical, or unilateral with the affected linib much shorter than its fellow, and the limp in walking correspondingly great As a rule, by drawing upon the limb the femur can be made to glide down over the ilium — telescopic movement. This excursion of the femur never occurs in pathological dislocation; it is one of the chief causes of the extensive lameness in this deformity. Tlie skiagram will show the position of the luad of the femur, and the imperfectly developed acetab- ulum. ■ (Plate XI., Fig. 2.) Pathological dislocation is always marked by con- siderable shortening of tlic limb, a hollow ni the groin, and prorainencc of the raised great trochanter. Fi(!. 3. - SclilniiLi 's diseasi.' (p. 211). (p. 352). In I'i^. . n..u: n.uicning of l,<.:ul ami \ucv,:^-cd ^^ia.h of cpi,.ln>i:.' Unc. PL MM Ml. xxvj DISEASES OP HIP-JOINT 353 If the head and neck of the bone are unaltered there is marked adduction and internal rotation of the femur, and the rounded head can be felt in the buttock. This is seen after septic and enteric arthritis. If the head and neck of the bone have undergone much absorption, or the neck has sepa- rated from the epiphysis of the head, which still occupies the acetabulum, there is but little adduc- tion or inversion. This occurs as a late result of tuberculous arthritis. In the early stage of tuberculous disease of the hip the diagnosis rests upon fixation of the joint by muscular spasm, in a position of flexion, abduction, and external rotation, combined with painful limita- tion of movement in all directions, wasting of the glutei muscles with lowering of the gluteal fold. When the disease is confined to the bone there is marked tenderness of the bone to pressure. In late stages the position of the limb is one of adduction and inversion accompanied by real or apparent shortening. Abscess or sinus is also liable to be present. In all cases a skiacjram is of great assistance; it not only shows rarefaction of the affected bone, but assists in eliminating other pos- sible diagnoses. (Plate xii., Fig. 1.) Disease of the pelvic part of the articidation may be suspected when abscess is fomid coming up from the inner surface of the pelvis to the brim, and pointing at the groin; or when a probe passed along a smus strikes necrosed bone which does not move when the thigh is rotated ; this sign may however, be caused by separation of the head of the femur, but m that case the surgeon will notice that the trochanter turns upon its own axis, or round a much smaller circle than on the sound side The skia gram will at once clear up this point in the diagnosis M ' 354 SURGICAL DIAGNOSIS [chap. lu osteo-arthriiis the femur becomes adducted and a little flexed, and the range of movement is gradually reduced. The neck of the femur, too, becomes shortened. (Plate xiii.) Inability to extend the thigh, and pam in at- tempting to do so, together with a fluctuating swell- ing deep in the groin, associated with freedom of flexion of the joint, and, when the 'joint is flexed, absence of all rigidity, and smoothness of motion of the femur in the acetabulum, are the signs whereby we can recognize effusion into the bursa under the fsoas. This may be met with as a complication of disease of the joint. When the skiagram shows the articular bones to be healthy the diagnosis is very easily made. If a fsoas abscess is present the spine, especially the lower dorsal region, must be carefully examined for evidence of caries ; failing that, the pleural cavity and the kidney of the same side should be examined. When an iliac abscess is found, its cause should be sought for in disease of the lumbar spine, of the sacro-iliac joint, or of the ilium, or in inflammation around the cfeciim or descending or pelvic colon. Knee- joint. — This joint should always be examined with the limb extended. The syno\ual membrane extends on each side of the patella and above it ; when distended it gives a smooth, elastic, fluctuating swelling in this position, and it floats the patella forwards away from the femur, upon which it normally rests. Then, when this bone is pressed upon at right angles to its surface, it is felt to yieW, and presently to tap against the femur; this is what is known as " floating of the fateUar It is an extremely iinporliuit sign of efl'usion into the ]om_.., as it may be obtained when (he amount of fl'ud i3 too smail to yield cither fluctuation or decided Osteo-arthrilis ol' hip. Plate XUl. 355 xxv] EXAMINATION OP KNEE swelliug. To teat for this sigu the knee must be extended and the rectus relaxed. The patient should therefore sit up in bed or on a couch, and the surgeon should grasp the thigh just above the knee with his left hand, and gently but firmly draw the soft parts down to relax the rectus, and to make sure of this he should note whether the patella is freely movable from side to side ; he should then with the tips of two or three fingers of the right hand press the bone directly back, and if he feels it yield under the pressure, and then strike against the femur, the patella " float.." Unless there is some- thmg in the joint raising the patella, it always lies on the femur m every position. But if care is not taken, the surgeon may be deceived. Thus if the bone IS pressed obli.juely or laterally it may be so moved on the femur as to simulate the tap of the floatmg patella ; while if the amount of fluid is small or moderate, and the rectus is contracted, the bone may be pressed back on the femur by that eTcitId 'Vf' " '^^^ symptom "Is not S^f 1 f ''S^ «f the knee- jomt, and the only other condition causing it is the presence of a very soft neoplasm in the joint Another reliable test for fluid m the knee-ioint IS made as follows : Grasping the thigh jS^t above the knee with one hand, pressure is made doZ wards towards the patella ; with the finger ™d humb of the other hand, pressure is made" on th ynovial pouches on either side of the patella U uid IS pi^sent a sense of fluctuation is i^ptrted to ! he first hand, the fluid being expelled from the lomt cavity mto the extcnsioS of \ynov al mem brane under the quadriceps tendon. in al acute and subacute inflammations of the jo.nt it assumes a position of n,oderate flcmon 'oith 356 SURGICAL DIAGNOSIS [chap. rulaUon mil wards of the tibia ; if tlie head of the tibia becomes displaced backwards ou the femur it shows that the hamstring muscles are spasmodically con- tracted, and that the crucial and lateral hgaments have yielded to their traction ; this displacement therefore, is an important sign of the extension of the disease to the ligaments. ... Excessive lateral motion m the joint is sometimes seen as the result of stretching of the hgaments m hydrarthrosis and in Charcot's disease. Partial dis- placement of the tibia backwards with externa rotation 13 frequently seen in the later stages of tuberculous disease. It is a sign of more or less destruction of the anterior crucial ligament. Tenderness over the attachments of the internal lateral hgament is not uncommon after acute synovitis. The bones are so superhcial that their condition can be well investigated. It must be remembered that the patella alone may be involved in acute or chrome inflammation endmg in either necrosis or caries. Loose bodies are more frequent and more of en occasion acute and characteristic symptoms ni the knee than in any other joint. The joint is also liable to tearing and displacement of a semiluna, car- tilage (meniscus), givmg rise ^^^/^^^'^ .^^^ an the ioint and severe pam, often followed by an Staci of subacute syiiUs. These symptoms ai-e like those met with in " loose body m ^^^y^^ the diagnosis of the case depends ^^V^l^'f '1'^. tL trouble first occurred as the of a violen rotation of the knee, and recurs ^^^^^ during ro tation, that the seat of pain ,s lime some other semilunar cartilage, that at the t.me projection of the cartilage may be felt, o possib .y i depression if i. is displaced inwards, and th^^ "loose body" can be felt .n fne jomt ; the pam is xxv] BURSiE OF KNEE 357 not so great in displacement of a meniscus as in impaction of a " loose body." {See also p. 207.) There are a number of bursas around the knee- joint, the position of which must be remembered. A swelHng on the front of the knee, obscuring the lower half of the patella and the uj^per -part of the patellar hgament, may be diagnosed as prepatellar bursitis, and is either acute or chronic, serous, sup- purative, villous, or j^lastic ; in the last case it may assume the form of a globular, unyielding tumour, smooth and rounded externally, adherent to the skin, and movable over the patella. If there is a romided, tense, fluctuating swelling above the patella, but that bone does not " float," and there is no swelling on either side of the patella, or fluctuation across the joint from side to side, it is to be diagnosed as effusion into the suprapatellar bursa. If there is no fluid in the knee-joint, but active extension of the joint is painful, and the ligamentum patellse is prominent with a little swelling on either side of it, and fluctuation across from one side to the other, and especially if pressure upon the ligament causes some pain and a lateral bulging on each side of it, effusion into the infrafatellar bursa (or the bursa between the patellar ligament and the upper part of the tubercle of the tibia) may be diagnosed. The fat normally present around this bursa may give a sensation very closely simulating fluctuation, and theTefore a comparison with the sound knee should be made with every care, and this diagnosis arrived at only when the condition is different on the two sides, and fluctuation is miequivocal. If a fluid tumour is found on the inner side of the knee beneath the semimembranosus tendon, 358 SURGICAL DIAaNOSIS [chap. which becomes full and tense and projects back into the ham when the knee is extended, but is much less tense Avhen the joint is bent, it is an effusion into the bursa between the semimembranosus and the gastrocnemius, sometimes called the popliteal or semimembranosus bursa. When the joint is bent the swelling will be plainly felt between the muscles ; if the bursa communicates with the joint it is reducible on