Manual of Surgery - Alexis Thomson (read me a book txt) 📗
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Dislocation of the peronei tendons may occur, for example, from a violent twist of the foot. There is severe pain and considerable swelling on the lateral aspect of the ankle; the peroneus longus by itself, or together with the brevis, can be felt on the lateral aspect or in front of the lateral malleolus; the patient is unable to move the foot. By a little manipulation the tendons are replaced in their grooves, and are retained there by a series of strips of plaster. At the end of three weeks massage and exercises are employed.
In other cases there is no history of injury, but whenever the foot is everted the tendon of the peroneus longus is liable to be jerked forwards out of its groove, sometimes with an audible snap. The patient suffers pain and is disabled until the tendon is replaced. Reduction is easy, but as the displacement tends to recur, an operation is required to fix the tendon in its place. An incision is made over the tendon; if the sheath is slack or torn, it is tightened up or closed with catgut sutures; or an artificial sheath is made by raising up a quadrilateral flap of periosteum from the lateral aspect of the fibula, and stitching it over the tendon.
Similarly the tibialis posterior may be displaced over the medial malleolus as a result of inversion of the foot.
The long tendon of the biceps may be dislocated laterally—or more frequently medially—as a result of violent or repeated rotation movements of the arm, such as are performed in wringing clothes. The patient is aware of the displacement taking place, and is unable to extend the forearm until the displaced tendon has been reduced by abducting the arm. In recurrent cases the patient may be able to dislocate the tendon at will, but the disability is so inconsiderable that there is rarely any occasion for interference.
Wounds of Muscles and Tendons.—When a muscle is cut across in a wound, its ends should be brought together with sutures. If the ends are allowed to retract, and especially if the wound suppurates, they become united by scar tissue and fixed to bone or other adjacent structure. In a limb this interferes with the functions of the muscle; in the abdominal wall the scar tissue may stretch, and so favour the development of a ventral hernia.
Tendons may be cut across accidentally, especially in those wounds so commonly met with above the wrist as a result, for example, of the hand being thrust through a pane of glass. It is essential that the ends should be sutured to each other, and as the proximal end is retracted the original wound may require to be enlarged in an upward direction. When primary suture has been omitted, or has failed in consequence of suppuration, the separated ends of the tendon become adherent to adjacent structures, and the function of the associated muscle is impaired or lost. Under these conditions the operation of secondary suture is indicated.
A free incision is necessary to discover and isolate the ends of the tendon; if the interval is too wide to admit of their being approximated by sutures, means must be taken to lengthen the tendon, or one from some other part may be inserted in the gap. A new sheath may be provided for the tendon by resecting a portion of the great saphenous vein.
Injuries of the tendons of the fingers are comparatively common. One of the best known is the partial or complete rupture of the aponeurosis of the extensor tendon close to its insertion into the terminal phalanx—drop- or mallet-finger. This may result from comparatively slight violence, such as striking the tip of the extended finger against an object, or the violence may be more severe, as in attempting to catch a cricket ball or in falling. The terminal phalanx is flexed towards the palm and the patient is unable to extend it. The treatment consists in putting up the finger with the middle joint strongly flexed. In neglected cases, a perfect functional result can only be obtained by operation; under a local anæsthetic, the ruptured tendon is exposed and is sutured to the base of the phalanx, which may be drilled for the passage of the sutures.
Subcutaneous rupture of one or other of the digital tendons in the hand or at the wrist can be remedied only by operation. When some time has elapsed since the accident, the proximal end may be so retracted that it cannot be brought down into contact with the distal end, in which case a slip may be taken from an adjacent tendon; in the case of one of the extensors of the thumb, the extensor carpi radialis longus may be detached from its insertion and stitched to the distal end of the tendon of the thumb.
Subcutaneous rupture of the tendon of the extensor pollicis longus at the wrist takes place just after its emergence from beneath the annular ligament; the actual rupture may occur painlessly, more frequently a sharp pain is felt over the back of the wrist. The prominence of the tendon, which normally forms the ulnar border of the snuff-box, disappears. This lesion is chiefly met with in drummer-boys and is the cause of drummer's palsy. The only chance of restoring function is in uniting the ruptured tendon by open operation.
Fig. 108.—Avulsion of Tendon with Terminal Phalanx of Thumb.
(Surgical Museum, University of Edinburgh.)
Avulsion of Tendons.—This is a rare injury, in which the tendons of a finger or toe are torn from their attachments along with a portion of the digit concerned. In the hand, it is usually brought about by the fingers being caught in the reins of a runaway horse, or being seized in a horse's teeth, or in machinery. It is usually the terminal phalanx that is separated, and with it the tendon of the deep flexor, which ruptures at its junction with the belly of the muscle (Fig. 108). The treatment consists in disinfecting the wound, closing the tendon-sheath, and trimming the mutilated finger so as to provide a useful stump.
Diseases of Muscles and TendonsCongenital absence of muscles is sometimes met with, usually in association with other deformities. The pectoralis major, for example, may be absent on one or on both sides, without, however, causing any disability, as other muscles enlarge and take on its functions.
Atrophy of Muscle.—Simple atrophy, in which the muscle elements are merely diminished in size without undergoing any structural alteration, is commonly met with as a result of disuse, as when a patient is confined to bed for a long period.
In cases of joint disease, the muscles acting on the joint become atrophied more rapidly than is accounted for by disuse alone, and this is attributed to an interference with the trophic innervation of the muscles reflected from centres in the spinal medulla. It is more marked in the extensor than in the flexor groups of muscles. Those affected become soft and flaccid, exhibit tremors on attempted movement, and their excitability to the faradic current is diminished.
Neuropathic atrophy is associated with lesions of the nervous system. It is most pronounced in lesions of the motor nerve-trunks, probably because vaso-motor and trophic fibres are involved as well as those that are purely motor in function. It is attended with definite structural alterations, the muscle elements first undergoing fatty degeneration, and then being absorbed, and replaced to a large extent by ordinary connective tissue and fat. At a certain stage the muscles exhibit the reaction of degeneration. In the common form of paralysis resulting from poliomyelitis, many fibres undergo fatty degeneration and are replaced by fat, while at the same time there is a regeneration of muscle fibres.
Fibrositis or “Muscular Rheumatism.”—This clinical term is applied to a group of affections of which lumbago is the best-known example. The group includes lumbago, stiff-neck, and pleurodynia—conditions which have this in common, that sudden and severe pain is excited by movement of the affected part. The lesion consists in inflammatory hyperplasia of the connective tissue; the new tissue differs from normal fibrous tissue in its tendency to contract, in being swollen, painful and tender on pressure, and in the fact that it can be massaged away (Stockman). It would appear to involve mainly the fibrous tissue of muscles, although it may extend from this to aponeuroses, ligaments, periosteum, and the sheaths of nerves. The term fibrositis was applied to it by Gowers in 1904.
In lumbago—lumbo-sacral fibrositis—the pain is usually located over the sacrum, the sacro-iliac joint, or the aponeurosis of the lumbar muscles on one or both sides. The amount of tenderness varies, and so long as the patient is still he is free from pain. The slightest attempt to alter his position, however, is attended by pain, which may be so severe as to render him helpless for the moment. The pain is most marked on rising from the stooping or sitting posture, and may extend down the back of the hip, especially if, as is commonly the case, lumbago and gluteal fibrosis coexist. Once a patient has suffered from lumbago, it is liable to recur, and an attack may be determined by errors of diet, changes of weather, exposure to cold or unwonted exertion. It is met with chiefly in male adults, and is most apt to occur in those who are gouty or are the subjects of oxaluric dyspepsia.
Gluteal fibrositis usually follows exposure to wet, and affects the gluteal muscles, particularly the medius, and their aponeurotic coverings. When the condition has lasted for some time, indurated strands or nodules can be detected on palpating the relaxed muscles. The patient complains of persistent aching and stiffness over the buttock, and sometimes extending down the lateral aspect of the thigh. The pain is aggravated by such movements as bring the affected muscles into action. It is not referred to the line of the sciatic nerve, nor is there tenderness on pressing over the nerve, or sensations of tingling or numbness in the leg or foot.
If untreated, the morbid process may implicate the sheath of the sciatic nerve and cause genuine sciatic neuralgia (Llewellyn and Jones). A similar condition may implicate the fascia lata of the thigh, or the calf muscles and their aponeuroses—crural fibrositis.
In painful stiff-neck, or “rheumatic torticollis,” the pain is located in one side of the neck, and is excited by some inadvertent movement. The head is held stiffly on one side as in wry-neck, the patient contracting the sterno-mastoid. There may be tenderness over the vertebral spines or in the lines of the cervical nerves, and the sterno-mastoid may undergo atrophy. This affection is more often met with in children.
In pleurodynia—intercostal fibrositis—the pain is in the line of the intercostal nerves, and is excited by movement of the chest, as in coughing, or by any bodily exertion. There is often marked tenderness.
A similar affection is met with in the shoulder and arm—brachial fibrositis—especially on waking from sleep. There is acute pain on attempting to abduct the arm, and there may be localised tenderness in the region of the axillary nerve.
Treatment.—The general treatment is concerned with the diet, attention to the stomach, bowels, and kidneys and with the correction of any gouty tendencies that may be present. Remedies such as salicylates are given for the relief of pain, and for this purpose drugs of the aspirin type are to be preferred, and these may be followed by large doses of iodide of potassium. Great benefit is derived from massage, and from the induction of hyperæmia by means of heat. Cupping or needling, or, in exceptional cases, hypodermic injections of antipyrin or morphin, may be called for. To prevent relapses of lumbago,
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