Symptoms.
—The symptoms of sprain are loss of function, swelling, pain, and later ecchymosis. The first is usually immediate, the swelling takes place rapidly, and ecchymosis occurs after two or three days, unless the joint be near the surface. The degree of tenderness will afford a measure of the amount of damage done. The swelling may be produced either by serous outpour or by hemorrhage, or by both. Ecchymosis is usually due to minute lacerations, and may spread to a considerable distance. Where there has been much outpour of blood into a joint it sometimes produces a reactional hydrarthrosis, which appears only after a week or more. Such hemorrhage is serious, and is frequently the cause of more or less pseudo-ankylosis by organization of clot.
Sprain may then be of all degrees of severity. From the mildest of these one may expect perfect functional recovery in short time, while in the more severe cases chronic thickening, with hydrarthrosis, tender areas, and muscle atrophies, often persist for a long time or even permanently.
Treatment.
—The ordinary treatment of a sprain consists, first, in physiological rest. If the swelling be already pronounced when seen by the surgeon he will endeavor to promote absorption by elevation, gentle compression, perhaps with an elastic bandage, and by cold wet compresses. If seen early and before much swelling has occurred it will often give great relief, especially in certain joints (e. g., the ankle), to partially immobilize the part by strapping it with a series of adhesive strips, 2 Cm. in width, cut sufficiently long to encircle the foot, ankle, and lower part of the leg. The strapping should be begun at the base of the toes, and each strap as thus applied should be made to slightly overlie the preceding one. It is possible by neatly compressing the involved region in this way to almost prevent swelling, and to give such support that function is but slightly impaired, and pain reduced to a minimum. The objection to plaster of Paris or the more fixed dressings is that they are usually allowed to remain too long. Far better in most of these cases is either a splint or a dressing which permits of daily examination. With the subsidence of acute symptoms, massage and passive movement should be practised. There are cases in which swelling will be so extreme that aspiration or even incision may be advisable for the purpose of emptying the joint.
The surgeon sees many a case of this kind after it has become chronic and after domestic or simple applications have failed. Most of these cases require massage, practised skilfully, and with intelligence, by which absorption is much promoted. The same result, as well as relief of soreness or pain, follows the constant use of cold wet compresses, perhaps combined with the use of ice-bags. If the material used for these compresses be dipped in solution of sodium or ammonium chloride, say 5 per cent., the effect is much enhanced, while laudanum can also be used upon them. Tenderness and localized pain in old cases may be treated by a succession of blisters, but can be better treated by the application of the flying cautery, i. e., by the light touch of a glowing cautery point swept rapidly over the surface involved. This is one of the most powerful agents for the relief of pain. Occasionally the cautery point may be applied more deeply, i. e., ignipuncture. If localized collections of fluid form they may be incised.
The statements and advice given in regard to sprain will apply equally well to the ordinary contusions of joints.
PENETRATING WOUNDS OF THE JOINTS.
These are inflicted as are wounds elsewhere, and, while always serious, have an importance proportionate to the infection which may have occurred with the injury or afterward. In practise it may be assumed that the skin, like the clothing outside, is always dirty and infected, and that every penetrating wound should be regarded as an infected wound. Not every wound in the vicinity of a joint is penetrating, and it is advisable to ascertain whether a joint cavity be actually open, as much of the method of treatment will depend upon this fact. The majority of these injuries are of the punctured or small incised variety. The actual joint opening is usually smaller than that in the skin. It may be so small as to escape observation. Outflow of blood is not pathognomonic, but escape of synovial fluid always indicates that some serous cavity, possibly a bursa or tendon sheath, has been opened. Immediate accumulation of fluid within a joint after probable wounding of the synovial membrane is quite suggestive, as it is likely to imply that the joint is filling with blood. After any injury which may loosen them the epiphyses should be carefully examined, in order to determine if they have been loosened, while it should be estimated, so far as possible, whether the epiphyseal junction has been disturbed or is probably infected. The student should remember that punctured wounds of joints are not necessarily made from without inward. A spicule or fragment of bone may, by protruding, produce exactly the same condition, only in this case there may be a compound fracture to complicate it. Infection does not invariably follow these injuries. Their gravity is in large degree measured by the presence or absence of a suppurative synovitis. This does not necessarily instantly follow the injury, but develops within the ensuing two or three days. Therefore the fate of such a joint is not necessarily determined by inspection within the first few hours. Esmarch’s dictum regarding gunshot wounds may here be paraphrased. The fate of every punctured joint depends upon the man who first takes care of it. If the proper thing be done promptly a good result may usually be obtained.
The first indication in every such case is sterilization of the parts, including the area of the wound. If by a small elliptical incision the wounded skin can be excised, it may perhaps very much improve the prospect. A small punctured wound may be watched for a day or two, especially if it be believed that the first attention were prompt and antiseptic. Should no unpleasant features appear little need be done except to apply ice externally and maintain rest. On the first appearance of sepsis or of increasing trouble in the joint it should be promptly incised, irrigated, and drained.