Treatment.
—Every appearance of this kind calls for early incision, by which not only the skin but the tendon sheath as well should be freely incised. An incision at either end of the involved sheath, with flushing and drainage, may save a tendon and preserve function. Incision should not be delayed, as destruction may have occurred and deformity be the result. When the common palmar sheath is involved a long incision from the base of the index finger, around the base of the thumb and up the wrist to a point considerably above the annular ligament, will afford considerable relief. It will, moreover, shorten the time of ultimate restoration of function.
Chronic Tendosynovitis.
—Chronic tendosynovitis may be the result of rheumatism, in which case it assumes the plastic form, or of gonorrhea; the same being true of a tuberculous invasion, which may vary much in intensity. In the subacute forms the deposition of tubercles may lead to a plastic outpour which, being detached by constant motion of the parts, is broken into masses whose minute portions become rounded off by friction and condensed by time, and appear as the so-called “melon-seed or rice-grain bodies.” Some of the same material may be found adherent to the walls of such a cavity. In slower forms there is less tendency to plastic outpour, but much more to the formation of granulation tissue, such as is seen in tuberculous lesions in all parts of the body. When, therefore, a case of this general character presents we have the signs of local tuberculosis, or of dropsy of the tendon sheaths, with the fluctuation somewhat modified by the presence in the fluid of rice-grain or melon-seed bodies. Should, in such a case, an acute infection be added we will have the chronic symptoms merged suddenly into acute. A tendovaginitis of this type appears as a ridge or swelling along the course of one or more tendons. It will be elastic and fluctuate in proportion to the distention of the sheath. When the palmar bursa is involved there is usually, in the palm of the hand, a bag of fluid which may be forced above the wrist by pressure, while frequently the little bodies above described are recognizable by the sensations (crepitus) which they produce. The plastic type rarely proceeds to suppuration or ulceration unless secondarily infected. The granulation type proceeds to ulceration and destruction.
Treatment.
—Treatment of the rheumatic and gonorrheal forms is at first rest, with later passive and forced motion, in order to break up adhesions and prevent their re-formation. If one wait too long he meets with great difficulty in these efforts and the cases become exceedingly tedious. Forcible motion should be practised under nitrous oxide anesthesia and should be repeated every two or three days. Meanwhile massage should be employed. If pain or reaction be extreme ice-cold applications should be applied. Extreme swelling may be combated by the use of a rubber glove. If this be worn, ichthyol-mercurial ointment should be used beneath it, in order to promote absorption.
Treatment of the tuberculous cases is often disappointing. Non-operative measures afford but temporary benefit, while operation to be effective should be thorough. It should consist of free incision, with exposure in whole or in part of the affected channel or cavity, thorough cleaning out of its contents, removal of all edematous or tuberculous tissue or granulations, and the use of an antiseptic as strong as it can be employed.
The new opsonic serum treatment, now being placed on trial as this work goes to press, promises much in the treatment of all these septic affections, though detailed statements would be premature.
TENDOPLASTY.
It was a step in advance in surgical technique when Stromeyer and Dieffenbach, in 1842, introduced the method of subcutaneous division of tendons and aponeuroses, and showed how easily contracted tendons could be lengthened by tenotomy. From their time until somewhat recently tenotomy has held its place in the treatment of various deformities, and until Anger, Gluck, Hoffa, and others have taught the surgical profession what can be done by various plastic and suture methods in overcoming defects and atoning for loss of function in paralyzed muscles. To the surgery of tendons and muscle terminations have been added the further resources of tendon suture, i. e., tenorrhaphy, and tendoplasty, by which latter something more than the mere suture is meant, i. e., the plastic rearrangement and grafting of tendons one upon another.[20]