A chasseur, 22, received a bullet wound in the anatomical snuffbox, the bullet emerging under the styloid process of the radius, having traversed the back of the hand without striking bone. Healing was rapid, but the hand assumed a peculiar position. The second and third phalanges of the fingers were extended, whereas the first phalanx was flexed. The four fingers were as if glued together. Both phalanges of the thumb were flexed, the wrist was in extension, and the tendon of the palmaris seemed contractured. The fingers could not be moved and the wrist was very mobile. There was pain on attempts to move the hand passively, and small clonic contractions were made by the fingers. There were no sensory disorders, but there was a maceration of the interdigital spaces.
Mechanotherapy accelerated the contracture, and massage, motor reëducation, bromides, and sedative drugs, had no effect. Under kelene-anesthesia the contracture would disappear. In January, 1915, the hand was put up in plaster in a position opposite to the contracture. The intense pain of the first days was treated by opium. The patient was sent on leave, and, at the end of two months, the plaster was removed; but the hand at once resumed its faulty position, and attempts to alter its position again provoked pain. Elastic traction was then tried for six weeks, and the bad position was somewhat modified but not improved by hyperextending the second phalanx on the first, and putting the third in slight flexion on the second. Hot compresses were unsuccessful also. May 14, 1915, the position was still irreducible; there was no R. D. or electrical hyperexcitability. This was not a question of radial paralysis, since finger extension was distinct; nor a paralysis of the median, since the thumb was flexed. The contracture, in fact, does not affect a special nerve territory, and the disorder is in the ulnar, radial, and median territories.
Orthopedic case.
Case 487. (Sollier, November, 1916.)
A patient suffered from a rupture of the peroneal nerve in its lower part, September, 1915, and had operation scars before and behind the external malleolus. He was immobilized for 45 days at first, and then for 30 days, with the foot in extension on account of the pain produced in the endeavor to put it into normal position. A 6 cm. atrophy was then found to affect the calf, and there was a fibrous retraction of the tendo Achillis and of the calf muscles. There was no anesthesia, the toes moved easily, the foot was fixed in equinus, with about 7 cm. of the heel above the ground. He was placed in various orthopedic institutions and was treated with mechanotherapy, but without result.
At the neurological center, however, in six weeks, he was got to walk, with his heel on the ground, by means of massage and manual mobilization. The atrophy diminished a centimeter and the foot became mobile in all directions.
According to Sollier, mechanotherapy by means of apparatus is apt to be ineffective, especially in contractures, because its action ceases the moment it ought to commence, namely, when the patient is beginning to react a little painfully after recovery from anesthesia. In cases of retraction, mechanotherapy with apparatus does not allow the proper combination of massage with progressive mobilization.
Re orthopedic cases, Jones classes the conditions that create an orthopedic case under four heads (note especially the fourth):
1. Mechanical injury to bone, joint, muscle, or nerve.