MYOTOMY AND TENOTOMY.
Myotomy is a measure seldom practised. It is performed either subcutaneously or by open incision. Tenotomy is indicated whenever contracted tendons need simply to be divided, either in chronic orthopedic cases or after injuries or operations when it is desired to put muscles temporarily at rest. The tendo Achillis has thus been divided to prevent the consequences of muscle spasm when dealing with certain fractures, especially compound fractures of the leg. There are obvious advantages obtaining in subcutaneous tenotomy when properly performed; the freedom from hemorrhage, the minuteness of the opening, the rapidity of healing, are all in its favor. It is performed with a small-bladed knife, known as the tenotome, with either sharp or blunt point, the cutting portion being from 1 to 2 Cm. in length. The sharp-pointed tenotome suffices for its own insertion, the blunt one being used after an opening has been made with a sharp one. The puncture is made obliquely through the skin, which should be drawn a little aside from the site of the deeper opening in order that it may be hermetically closed as it slips back into place. Whether the cutting blade should be turned outward or inward will depend largely on the preference of the operator and the location of the tendon. In some locations, as about the hamstring tendons, the puncture should be made with the sharp instrument and the deeper tenotomy with the blunt one. If the tendons alone have been divided there will be trifling hemorrhage and the puncture can be occluded without entrance of air. Similarly an aponeurotomy may be performed. Not only may the tendons be divided by the open method, but everything else which resists. This is practised more in contracted knee-joint and in club-foot, when operated on by Phelps’ method, than anywhere else. Special indications for the operation will be given in other parts of this work.
GANGLION.
This term is applied to a cyst of new-formation, which occurs in connection with the sheath of a tendon, having a lining membrane continuous with the sheath and containing thick, gelatinous, mucoid fluid. It is termed “weeping sinew.” It is often seen on the back of the wrist in connection with the extensor tendons, but may occur in various parts of the body. It probably begins as a hernia of the synovial membrane through a weak spot in the tendon sheath, which tends to increase in size, weakening surrounding structures by pressure, and interfering more or less with the function of the tendon whose sheath is involved. These cysts sometimes connect with joint cavities, especially those occurring behind the knee-joint; as a rule, however, they do not. At first they constitute merely a disfigurement; later they produce natural impairment of function. In the majority of cases the sac becomes finally shut off from the tube with which it originally connected.
When these lesions are new they may be successfully dealt with by forcible rupture, such as can be made by firm pressure. When old, or when rupture has failed, they should be treated by incision, practised the same as a tenotomy, by moving the skin to one side, pricking the sac, turning the blade of the tenotome so as to permit the fluid to be emptied by pressure, and then, by manipulating the point, irritate and do some damage to the sac lining. Such provocation as this will be followed by a hemorrhage, and the resulting clot may obliterate the sac by organization and cicatricial contraction. This failing, excision is the only expedient which promises success. The slightest operation upon a ganglion should be done under aseptic precautions.
FELON, OR WHITLOW.
Felon, or whitlow, was discussed in the previous chapter, especially the form which has its origin around the root of the nail. It often originates in tendon sheaths and even in bone or close to it. It is so often accompanied by a suppurative thecitis, i. e., tendosynovitis of destructive form, especially when not primarily incised, that the necessity for early treatment needs to be emphasized. It gives rise to excessive pain, with throbbing, and to swelling of livid hue and intense degree. The parts involved are too essentially fibrous and resisting to yield, hence the intensity of the pain. Deep incision at the earliest moment, for the purpose of relieving tension, is the only proper treatment. To temporize with hot poultices, etc., is to invite necrosis and sepsis. This incision may be made with local anesthesia. Even though little pus be obtained the relief of tension will afford the greatest comfort ([Figs. 130], [131] and [132]).
Fig. 130
Felon of thumb. (Burrell.)