Upper limb

“ The position of the upper limb is typical: the arm and forearm hang close to the side, with the forearm extended and pronated; the deltoid, spinati, biceps, brachialis, and supinators are paralysed, and in some cases the radial extensors of the wrist and the pronator teres are also affected. The patient is unable to supinate the forearm or to abduct the arm, and in most cases to flex the forearm. He may, however, regain some power of flexing the forearm when it is fully pronated, the extensors of the wrist becoming feeble flexors of the elbow. ”

“ The limb usually becomes flexed and adducted, and a swelling forms in front of the joint at the upper part of Scarpa's triangle; the upper femoral epiphysis may be separated and furnish a sequestrum.
The flexion and adduction of the limb favour the occurrence of dislocation. A child who has recovered with dislocation on to the dorsum ilii is usually able to walk and run about, but with a limp or waddle which becomes more pronounced as he grows up. ”

“ In children, the most frequent subjects of such disease, excision of the lower limb may, by removing the epiphyses, cause to a very considerable degree disparity in their length, thus rendering them nearly useless, while in the upper such disparity is neither so extensive nor so injurious to the usefulness of the limb, which is not required for purposes of progression. ”

“ If an examination is made when the patient is thus halting, and even though he complains of no pain, the limb is found shrunk, wasted, and lengthened. The elongation of the limb occurs mainly in consequence of the inclination of the pelvis towards that side. When the disease has made progress, it has been supposed that swelling of the apparatus of the joint, and effusion into its cavity, might separate the head of the bone from the acetabulum, when pressure from the trunk was not applied. ”

“ Tenderness is elicited on making pressure over the joint, on pressing together the iliac bones, or on attempting to abduct the limb while the pelvis is fixed. The muscles of the buttock and thigh are wasted. As any attempt to bear weight on the affected limb causes pain, the patient walks with a limp, and to save the joint he assumes an attitude which is characteristic: he throws his weight on the sound limb, leans forward, using a stick for support, tilts the affected side of the pelvis downwards, and flexes the hip and knee-joints of the diseased limb. ”

“ To illustrate, we will take the lower limb, whether there is lameness, soreness, gouty, rheumatic, neuralgic, swollen, shrunken, feverish, cold, smooth and glassy, sores, ulcers, erysipelas, milkleg, varicose veins, or any defect that the patient may complain of, who is the only reliable book or being of symptomatology. For convenience we will divide that lower limb into five parts, the foot, leg, thigh, pelvis and lumbar region. The patient (symptomatologist) tells us he has a pain in front, center and under part of foot. ”

“ If no means are taken to replace the bone, and painful feelings subside along with the swelling, the limb remains long useless, and is the seat of occasional lancinating pains, but at last motion and utility are to a certain extent restored by the formation of a new joint—the head of the bone, and the parts on which it rests, mutually accommodating themselves to each other, by degrees, and permitting a limited extent of motion. ”

“ But the injured limb, in this case, can support the body much better than in dislocation inward, both because the head of the femur and the neck of its articular extremity, being naturally oblique, have formed a bed under a considerable portion of the hip, and because the extremity of the foot is not forcibly turned outward, but is nearly in a line with the body, and is even inclined more inwardly. ”

“ The limb is adducted, its normal range of abduction, and sometimes also of flexion, is restricted, and there is, as a rule, some degree of lateral rotation, so that the toes point outwards. It should be noted that the same picture—shortening with eversion and stiffness at the hip—results from the common fracture of the neck of the bone in old people. The adduction element of the deformity is partly compensated for by upward tilting of the pelvis on the affected side and curvature of the spine with its concavity towards the affected limb. ”

“ The limb is pained, deformed, and unable to support the body, and swelling to a considerable extent soon follows. Reduction is extremely easy; and the parts are retained in site by the application of a wooden splint, to either the outer or the posterior side of the joint, the leg and foot being previously bandaged. The joint remains long weak, and never recovers entirely; a sustaining apparatus, fitted on the outside, retained by straps, and with a joint opposite to the articulation, is required to be constantly worn when the patient wishes to use the limb. ”

“ This is well seen in adults who have suffered from severe disease of the hip in childhood--the entire limb, including the foot, being shorter and smaller than the corresponding parts of the opposite side. ”

“ The other bones of the human body sometimes undergo subluxation, and sometimes complete luxation, but the articulations at the hip and the shoulder are subject only to complete luxation, more especially the hip-joint, because it has a deep and round cavity which is further strengthened by a strong brim. The limb, then, being subject to displacement from its cavity by some great violence, many differences arise according to the greater or less degree of the dislocation. ”

“ This may soon be absorbed and with it the articular ends of the bones wear away and break down into small fragments. The limb becomes atrophied and shrunken, and the joint itself becomes weak, often flail. ”

“ Those who experience a dislocation backwards can neither extend the ham nor the knee, nor can they bend the limb before bending the groin also. The leg appears shorter, the groin looser, and the head of the thigh is to be felt at the buttock. When, then, from infancy, or simply, when for a length of time the limb has been neglected after being dislocated, and allowed to remain so, the cure is impracticable, callus having been already formed. But when the luxation is recent, it may be managed in the way recommended by Hippocrates. ”

“ There may be a feeling of weight in the limb, and in the case of the knee and ankle the patient tires on walking and drags the leg with more or less of a limp. Movements of the joint are permitted, but are limited in range. ”

“ Sometimes the pain is confined to the knee, and if the examination is restricted to that joint the disease at the hip may be overlooked. At this stage the attitude of the limb is not constant; at one time it may be natural, and at another slightly flexed and abducted. Tenderness of the joint may be elicited by pressing either in front or behind the head of the bone, but is of little diagnostic importance. ”

“ Again, and particularly in adults, the limb is easy only in certain positions, and cannot be moved without great suffering; pain is also complained of in the groin, and often immediately behind the trochanter major. ”

“ After a time, flexion can be made to a right angle; and the limb becomes tolerably useful. By unsuccessful attempts to restore the natural position, inflammation is excited; and thus the salutary processes, commenced by nature for reparation of the displacement, are interrupted and delayed; in young persons such disease of the joint may be produced as might lead to loss of the extremity.
Luxation of the Radius alone, backwards on the outer condyle, is sometimes met with; but this bone is seldom singly displaced far from its original site. ”

“ These points must all be considered, but as a general rule, I would say that such attempts at preservation of the limb are much more justifiable, and longer justifiable in the hip and knee-joints than in the elbow or shoulder; for the results in the lower limb will probably be as good, if the patient survive, if not better, than those obtained by excision, while the danger of the operation is greater ”

“ The limb is often enormously swollen and indurated. The gelatinous effusion beneath the periosteum speedily becomes organised, nodules of osseous matter project into it, and adhere to the surface of the bone frequently by a narrow neck; these increase in number, gradually assume a solid appearance: the bone is thus thickened, often to a very great extent. ”

“ The fracture is exposed, the joint cavity opened up and cleared of clots, and silver-wire sutures passed through the fragments without encroaching upon the articular cartilage. The limb is fixed with the elbow-joint in the position of almost complete extension. Movement may be commenced at the end of a week, the angle at which the joint is fixed being changed morning and evening. During the day the flexed position should be maintained and the arm carried in a sling; during the night the limb is fixed to a pillow in the extended position. ”

“ For if the accident be recent and the patient young, we may sometimes succeed in reducing the limb by grasping and rotating the thigh this way and that. When the dislocation is inwards we may sometimes accomplish our purpose by bending the limb at the groin inwards frequently and strongly. If the dislocation does not yield to these means we must have recourse to extension, first with the hands, certain assistants grasping the thigh and leg and pulling the limb downwards, while others grasp the body at the armpits and pull upwards. ”

“ Complicated cases occasionally occur—as when a patient who has been labouring under hip-joint disease, perhaps not in an aggravated form, falls heavily, and on being lifted up is found to be incapable of moving the joint, the limb at the same time being elongated, and having a distorted appearance. ”

“ If any osseous deposit has taken place, it is absorbed; the ends of the bone are diminished in size by interstitial absorption; ligamentous or fibro-cartilaginous tissue is formed round the wasted extremities; and the surrounding cellular tissue being thickened and condensed, a sort of synovial pouch is formed, in which the ends, by this time smooth and rounded off, move freely. The limb is shortened in some degree, and its actions are very much diminished in force, there being no sufficient support for the muscles. ”

“ Further to simplify our study, we will, at first, consider the mechanism of one limb only. As [102] one foot swings forward and reaches a certain place, it seems to hesitate for an instant and then come down, heel first, on the ground. As the heel strikes, the body is slightly jarred and the oblique line of the limb, its axis, moves and approaches the vertical. In a moment, the limb is vertical as it supports the trunk and the sole of the foot bears on the ground. ”

“ B. Age of Patient.—It must be remembered that excision in a child removes the epiphyses by which in great measure the growth of the bone is to be managed, and the stunted limb, especially in the leg, will eventually be of little advantage, though after the operation it looked excellently well, if a few years later it be found to be seven or eight inches shorter than its neighbour. ”

“ The cartilages enjoy a limited range of movement within the joint, passing backwards during flexion, and forwards again when the limb is extended; under normal conditions the lateral moves more freely than the medial. While the limb is partly flexed, a slight degree of rotation of the leg at the knee is possible, and during this movement the cartilages glide from side to side, and the tibia rotates below them. ”

“ In rest when the relaxed muscles offer but little resistance, the effort for support is nothing. A paralyzed limb can be195 luxated much more easily than another, by external violence.
The order of moveable articulations with contiguous surfaces, has as a means of union, a substance, the nature of which is between that of the ligaments and that of the cartilages. ”

“ The circumstances attending the first stage of the disease in childhood, in which the limb is lengthened, and there is no decrease, but rather an enlargement of the parts composing the joint, have been already described and illustrated. When, however, absorption occurs, and the articulation begins to be destroyed, the second stage of the disease commences, and the limb becomes then sensibly shortened; the toes are turned inwards or outwards; in many cases there is every appearance of dislocation of the thigh upward and backward ”