CHAPTER X.

SPRAINS OF JOINTS.

By a sprain is understood an injury produced in a joint when its movements are carried beyond their normal physiological limits or when the bones entering into its formation are deflected in some unnatural direction without undergoing actual dislocation. The most common injuries are falls with the limb in an abnormal position, or twists when the lower part of the limb is fixed. Sprains may also be caused by violent muscular action, but this is a much less frequent cause than those already mentioned.

Various conditions predispose to sprains. Amongst the most common are a previous injury of a similar nature which leaves a weak joint behind it, or anything, such as a deformity-for example, knock-knee, or club foot-which places the joint at a mechanical disadvantage and alters the normal line of transmission of the body-weight.

The actual lesion which occurs when a joint is sprained varies in different cases and is often difficult to determine. Probably the chief effect of the injury falls on the ligaments of the joint, and they are damaged to a more serious extent than any other structure entering into the articulation. In the mildest forms the ligaments are merely over-stretched. In the more severe cases a portion of the capsule of the joint is ruptured, and some of the ligaments are torn wholly or in part from their attachments to the bones. The amount of damage to the ligaments depends largely upon their form, strength, and structure; broad, thin, flattened ligaments are more often damaged than comparatively thick and strong ones. Very severe injury is required to tear the latter, and it is more common to find them detached from their insertion into the bone. In joints furnished with an inter-articular fibro-cartilage this structure may be partially or entirely detacheda condition which gives rise to the series of symptoms referred to in connection with displacement of the semilunar cartilages of the knee. In the most serious cases of all, the sprain may be combined with a

fracture, small portions of the bone being detached along with the ligament. Bony injuries varying from a split to actual detachment of a fragment are very common. For example, many so-called 'sprains of the wrist' are really fissured fractures of the radius or one of the carpal bones, especially the scaphoid. These fractures are not very obvious: a radiogram should, therefore, always be taken in so-called sprains. In some of these bad forms of sprain the injury may involve the muscles surrounding and strengthening the joint, and these may be torn from their attachments.

The immediate effect of these injuries is pain, followed by swelling of the joint. Unless efficiently treated, a feeling of weakness and pain in the joint may last for a long time or may even be permanent.

When the ligaments are stretched rather than torn, there is comparatively slight swelling immediately after the accident, but an obstinate synovitis may subsequently occur. In the more severe cases there is effusion of blood at the time of the injury, and this produces immediate swelling of the joint which is increased later on by the occurrence of synovitis. When there is much hæmorrhage, the blood is only slowly absorbed from the articular cavity and it may remain fluid for a long time. When a large area of the joint capsule or a broad flat ligament has been ruptured, the torn portion may project into the joint, and become nipped during movement and thus give rise to serious disability.

The remote effects of sprains are due partly to the synovitis and partly to imperfect union of the torn fibres of the capsule. The latter condition. is especially troublesome and gives rise to that feeling of weakness which is so common a result of neglected sprains. The synovitis also is apt to be followed by adhesions in the joint, or even to obliteration of a portion of the joint cavity.

It is thus evident that a sprain of a joint should not be lightly treated, as the serious trouble that so frequently follows the injury is largely due to imperfect appreciation of the ill-results that follow neglect. The common saying that a sprain of a joint is worse than a fracture is explained by the fact that the care devoted to a fracture is seldom bestowed upon a sprain, with the result that fluid blood remains in the joint for a long time, that the union of the torn ligaments is defective, that there is a tender cicatrix in the capsule, and that fibrous adhesions form between the opposed synovial surfaces.

TREATMENT.-The treatment of a sprain depends largely upon the severity of the injury and the joint affected, but there are certain principles common to all cases. The first indication is to check the extravasation of blood into the joint, while the second is to promote absorption of the blood already poured out; a third and equally important indication is to obtain satisfactory healing of the injured ligaments, and to restore the movements of the joint to their full degree.

In every instance the treatment for a sprain should commence with full movement of the joint in all directions, so as to make sure that no portion of torn capsule or synovial membrane is left between the articular surfaces. Should this be the case, suitable movements of the joint will probably cause them to become disengaged.

1. Slight sprains.-After having moved the joint and ascertained that the movements are free, the surgeon should strap the part firmly with rubber strapping, and for the first twelve hours it is well to apply an icebag so as to diminish any bleeding or effusion which may take place. On the following day the patient may be allowed to move the joint, and walk about. If the strapping is put on properly, the movements of the muscles and joint have practically the same result as external massage: they promote the lymph flow and lead to rapid absorption of the effusion. Further, the pressure diminishes the effusion, and the movement prevents the formation of adhesions. The strapping should be kept on for about a week, being renewed if necessary, and as a rule, no further treatment will be required, or at most a little external massage, for about another week. The strapping must not be limited to the joint, however, but should extend well above and below it. For example, in the case of a sprain of the ankle-joint, the strapping must be applied from the toes nearly to the knee; it must not be limited to the ankle-joint (see Fig. 42). When, however, the sprain affects a joint, such as the hip, in which this treatment is not applicable, external massage, at first gentle, but soon becoming more vigorous should be employed, combined with active and passive movements.

OF

FIG. 42. METHOD STRAPPING THE LIMB FOR A SPRAIN OF THE ANKLE.

2. Severe sprains.-When actual rupture of ligaments has taken place, the patient may not be able to bear passive movements, or to use the joint in the early stage, and the treatment consists in massage and elastic pressure. At first the massage should be used once, and subsequently twice a day; in the early stage it should be quite gentle. At the same time it should be combined with such passive movements as the patient can bear, care being taken that the movements employed are not such as would stretch the sprained ligaments and prevent their union. After the massage the joint should be wrapped up in a mass of wool and a firm elastic bandage applied outside it; this should not only surround the joint itself, but should also extend for some distance above and below it. After about ten days, when the joint has become less tender, it may be strapped, and active movements permitted, as in the case of slight sprains. When massage is necessary, however (and

in the more severe forms it may be required for two or three weeks longer), it is more convenient to continue the elastic bandage; indeed, in bad cases, it is as well to wear the elastic bandage or strapping for some six weeks or more. If treated in this way the majority of sprains, without extensive rupture of ligaments, recover without any trouble.

Should a feeling of weakness still persist in the joint (and this is not uncommon), benefit will be derived from douching it for about three minutes at a time with a jet of water as cold as can be borne, with as much force as the patient can stand. This should be followed by massage, and the application of a firm bandage.

3. When a ligament is ruptured, there is considerable risk of imperfect union and a permanently weak joint, unless great care be taken in the early treatment. This is especially the case in the ankle-joint, where a portion of one of the lateral ligaments is not infrequently ruptured. In these cases the limb should be fixed on a splint, so designed as to obviate all possibility of movement in directions that would separate the torn ends. Massage should also be employed, special care being taken not to pull on or strain the ruptured ligament. It is desirable that the person who performs the massage should be acquainted with the anatomical structure of the joint, and it should be done by the medical man himself in the first instance. Something like six weeks' complete rest is required for the union of a ruptured ligament, and during that time care must be taken to prevent the formation of adhesions by practising passive movements almost from the commencement. If care is taken not to stretch the torn ligaments the passive movement will permit union, and at the same time leave the joint free from adhesions; but if the joint is simply placed on a splint and left for six weeks without massage or passive movement, severe and possibly intractable adhesions are very likely to form.

When portions of bone have been detached along with the ligament, the limb should be put on a splint and massage and careful movements employed after the first two or three weeks. Should the detached piece of bone be large or should there be any difficulty in getting it into position, a better result will be obtained by cutting down upon it and fastening it in place (see Vol. II. p. 304) or by removing it altogether.

CHAPTER XI.

WOUNDS OF JOINTS.

IN speaking of wounds of joints, we shall confine ourselves to wounds. which actually penetrate the articulation-a condition recognised in. most cases by the escape of synovial fluid or, when the wound is of large size, by actual inspection. Non-penetrating wounds of joints are not, strictly speaking, wounds of the articulation at all, their only importance being that they may be accompanied by sepsis, which may ultimately lead to suppuration within the joint.

VARIETIES.-Wounds of joints may be divided into punctured wounds, and large wounds which freely expose the interior; the latter may be subdivided according as they are clean-cut or contused. The subsequent course may differ in each case. In a punctured wound there is often no introduction of septic material into the joint cavity; in the other forms, especially in contused wounds, septic contamination of the joint will almost certainly occur.

Distinction should also be made between wounds that are quite recent and those in which some hours have elapsed since their infliction. The importance of this lies in the fact that, in the former group, microorganisms that have gained access to the joint will not have had time to multiply and become diffused throughout the joint and the surrounding tissues before the surgeon sees the case, whereas in the latter this will have taken place.

TREATMENT OF RECENT WOUNDS.

PUNCTURED WOUNDS.-It is generally safe in these cases to regard the articular cavity as free from infection; punctured wounds are inflicted by a slender pointed instrument, and the probability is that any organisms present upon it will be removed during its passage through the skin and subcutaneous tissues. This is a point of great practical importance, because it will not be necessary to open up the