Manual of Surgery Volume First: General Surgery. Sixth Edition.

by Alexis Thomson; Alexander Miles

A contused muscle should be placed at rest and supported by cotton wool and a bandage; after an interval, massage and appropriate exercises are employed.

Sprain and Partial Rupture of Muscle.—This lesion consists in overstretching and partial rupture of the fibres of a muscle or its aponeurosis. It is of common occurrence in athletes and in those who follow laborious occupations. It may follow upon a single or repeated effort—especially in those who are out of training. Familiar examples of muscular sprain are the “labourer's” or “golfer's back,” affecting the latissimus dorsi or the sacrospinalis (erector spinæ); the “tennis-player's elbow,” and the “sculler's sprain,” affecting the muscles and ligaments about the elbow; the “angler's elbow,” affecting the common origin of the extensors and supinators; the “sprinter's sprain,” affecting the flexors of the hip; and the “jumper's and dancer's sprain,” affecting the muscles of the calf. The patient complains of pain, often sudden in onset, of tenderness on pressure, and of inability to carry out the particular movement by which the sprain was produced. The disability varies in different cases, and it may incapacitate the patient from following his occupation or sport for weeks or, if imperfectly treated, even for months.

The treatment consists in resting the muscle from the particular effort concerned in the production of the sprain, in gently exercising it in other directions, in the use of massage, and the induction of hyperæmia by means of heat. In neglected cases, that is, where the muscle has not been exercised, the patient shrinks from using it and the disablement threatens to be permanent; it is sometimes said that adhesions have formed and that these interfere with the recovery of function. The condition may be overcome by graduated movements or by a sudden forcible movement under an anæsthetic. These cases afford a fruitful field for the bone-setter.

Rupture of Muscle or Tendon.—A muscle or a tendon may be ruptured in its continuity or torn from its attachment to bone. The site of rupture in individual muscles is remarkably constant, and is usually at the junction of the muscular and tendinous portions. When rupture takes place through the belly of a muscle, the ends retract, the amount of retraction depending on the length of the muscle, and the extent of its attachment to adjacent aponeurosis or bone. The biceps in the arm, and the sartorius in the thigh, furnish examples of muscles in which the separation between the ends may be considerable.

The gap in the muscle becomes filled with blood, and this in time is replaced by connective tissue, which forms a bond of union between the ends. When the space is considerable the connecting medium consists of fibrous tissue, but when the ends are in contact it contains a number of newly formed muscle fibres. In the process of repair, one or both ends of the muscle or tendon may become fixed by adhesions to adjacent structures, and if the distal portion of a muscle is deprived of its nerve supply it may undergo degeneration and so have its function impaired.

Rupture of a muscle or tendon is usually the result of a sudden, and often involuntary, movement. As examples may be cited the rupture of the quadriceps extensor in attempting to regain the balance when falling backwards; of the gastrocnemius, plantaris, or tendo-calcaneus in jumping or dancing; of the adductors of the thigh in gripping a horse when it swerves—“rider's sprain”; of the abdominal muscles in vomiting, and of the biceps in sudden movements of the arm. Sometimes the effort is one that would scarcely be thought likely to rupture a muscle, as in the case recorded by Pagenstecher, where a professional athlete, while sitting at table, ruptured his biceps in a sudden effort to catch a falling glass. It would appear that the rupture is brought about not so much by the contraction of the muscle concerned, as by the contraction of the antagonistic muscles taking place before that of the muscle which undergoes rupture is completed. The violent muscular contractions of epilepsy, tetanus, or delirium rarely cause rupture.

The clinical features are usually characteristic. The patient experiences a sudden pain, with the sensation of being struck with a whip, and of something giving way; sometimes a distant snap is heard. The limb becomes powerless. At the seat of rupture there is tenderness and swelling, and there may be ecchymosis. As the swelling subsides, a gap may be felt between the retracted ends, and this becomes wider when the muscle is thrown into contraction. If untreated, a hard, fibrous cord remains at the seat of rupture.

Treatment.—The ends are approximated by placing the limb in an attitude which relaxes the muscle, and the position is maintained by bandages, splints, or special apparatus. When it is impossible thus to approximate the ends satisfactorily, the muscle or tendon is exposed by incision, and the ends brought into accurate contact by catgut sutures. This operation of primary suture yields the most satisfactory results, and is most successful when it is done within five or six days of the accident. Secondary suture after an interval of months is rendered difficult by the retraction of the ends and by their adhesion to adjacent structures.

Rupture of the biceps of the arm may involve the long or the short head, or the belly of the muscle. Most interest attaches to rupture of the long tendon of origin. There is pain and tenderness in front of the upper end of the humerus, the patient is unable to abduct or to elevate the arm, and he may be unable to flex the elbow when the forearm is supinated. The long axis of the muscle, instead of being parallel with the humerus, inclines downwards and outwards. When the patient is asked to contract the muscle, its belly is seen to be drawn towards the elbow.

The adductor longus may be ruptured, or torn from the pubes, by a violent effort to adduct the limb. A swelling forms in the upper and medial part of the thigh, which becomes smaller and harder when the muscle is thrown into contraction.