In the larger openings of joints it should be assumed from the outset that infection has occurred. In such a case the wound margins should be trimmed, the joint cavity thoroughly irrigated, and explored for foreign bodies, by enlarging the existing opening. After thorough irrigation a drain should be inserted for at least a few hours. For this purpose a catgut strand or a drainage tube may be employed.
As soon as the presence of pus (acute pyarthrosis) is made clear the case takes on a larger aspect, in that drainage not alone at one point is indicated, but probably at two or three. Nothing is so disastrous to an involved joint as pus retained within its hidden recesses. Almost every other consideration is sacrificed to its discovery and to affording a means for its escape. Counteropenings in numbers sufficient for the purpose are, therefore, indicated, and it will often be best to draw through the affected joint a drainage tube, of a size sufficient to prevent its occlusion by thick pus or debris. Daily and continuous irrigation may be practised to great advantage, or, as is possible with the ankle, the wrist, or elbow, continuous immersion may be substituted as a still better measure. Wherever infection and destruction to this degree have taken place it may be presumed that the future of the joint is seriously compromised. There will, therefore, be room for display of judgment as to when to begin passive and when active motion; moreover, a guarded prognosis concerning restoration of function should be given.
Gunshot fractures of joints constitute almost a category by themselves. Under the old regime, and in the pre-antiseptic era, gunshot wounds of joints condemned one to amputation and loss of at least the part below. The mortality attending injuries of this kind, with the resulting amputations, during our Civil War, and all others previous to it, was extreme. The Continental surgeons first appreciated the value of antiseptic occlusion, and taught the rest of the world that this wholesale sacrifice of limb, and often of life, was unnecessary and could be avoided. Reyher’s first papers on this subject revolutionized previous views and practises, and established on a firm basis the general principle of primary antiseptic occlusion of those injured joints. The accumulated experience of military surgeons since his time, as well as of civil surgeons all over the world, has demonstrated that if a gunshot wound of a joint be afforded prompt antiseptic occlusion and rest the chances are in favor of restoration of function, with a minimum of disturbance and a maximum of result. It was because of these results that soldiers were provided with the “first aid to the injured” packets, so that a punctured wound might be protected immediately after its reception. Even the complete tunnelling of a joint, which the Mauser bullets so often accomplish, does not seem to be so serious an injury today as was the puncture of a needle or an awl in the pre-antiseptic era. Therefore the best thing to do with a gunshot wound is to practise antiseptic occlusion. If it become troublesome it should be treated in accordance with the advice given above.
This relegates the matter of amputation or of primary excision of an injured joint to those cases of extensive and mutilating injury where not only the soft structures are widely opened and infected, but the joint ends of the bones also are seriously involved. When it comes to the treatment of compound dislocations it is difficult to lay down principles which shall be universally applicable. As a general rule primary excision will usually be indicated, and prove not only life-saving but limb-saving. In compound dislocations of the astragalus its removal will be nearly always indicated. Only in cases of extensive damage will amputation be necessary.
Inasmuch as it is infection, leading to suppurative synovitis or arthritis, which gives to all serious cases their greatest dangers, it will be sufficient at this point to remind the reader to this effect and to describe the condition itself a little later.
SYNOVITIS AND ARTHRITIS.
The various surgical affections of a joint may be of primary or secondary origin, and of rapid or chronic type. The acute are usually expressions of serious infection, while the chronic are frequently of toxemic origin, including under this heading manifestations of a particular diathesis or defective metabolism. Others are so exceedingly slow in their course and are so intimately connected with other indications of disease of the central nervous system as to be called neuropathic. (See below.)
Nearly all the acute affections begin in the synovial sac proper. From this they may spread and involve the adjoining parts. The acute toxic lesions also arise within the synovial cavity, such as those which follow gonorrhea, typhoid, scarlatina, pneumonia, influenza, etc. Tuberculosis may primarily affect either the synovia, in which case we have a condition corresponding to tuberculous peritonitis, or it may take its origin in the expanded bone ends or in the epiphyseal cartilages. Syphilitic affections of the joints are rarely acute. They lead rather to chronic disintegrations or hypertrophy. No matter how the lesion may have arisen it will nearly always extend to and involve other parts; thus in acute suppurations the articular cartilages are soon attacked, while in the more chronic forms, which have their origin in the bone, the joint cavity is slowly encroached upon and its integrity impaired or destroyed.
So long as the type of joint disease be not destructive a complete or nearly complete restoration of function can be expected, provided suitable treatment be given early. If, however, a case occur only after fibrinous outpour has organized into adhesions, muscles have withered from disuse, and the entire joint become distorted or disarranged, then it may be too late to cure, and it is a question then of how much improvement can be effected. Even after acute suppuration, if the case be properly managed from the outset, very useful joints can be regained.