The principles and practice of modern surgery

by Roswell Park

When the disease has involved the articular side of an epiphyseal line, and when there is complete epiphyseal separation with consequent pyarthrosis, the probable consequence will be necessity for a complete or partial resection of the joint and the probability of subsequent ankylosis. Patients may find later that a modern artificial limb with its possibilities will be preferable to such a condition, and may readily consent later to an amputation which they would at first refuse.

Acute Infectious Periostitis.

—This is an infection of the same general character and type as the osteomyelitis just described, but refers to those cases where the disease apparently is confined to the periosteum and the outermost layer of the bone. In its possibilities for harm it is scarcely less serious, although in its tendency to spontaneous perforation and escape of pus it is less likely to prove fatal.

Causes.

—The causes and the general clinical manifestations are practically identical. The disease is perhaps less grave in its acute manifestations, the localization of pain more exact, with ordinarily less tendency to joint complications. Local tenderness is exquisite, and particularly in those bones which lie near the surface—e. g., the tibia—and early recognition of fluctuating areas is easy. It may be localized over a small area, or the entire periosteum of the shaft may be involved; in which case, so soon as pus forms and the periosteum is separated from the bone, there is probability of acute necrosis of the shaft. Here, again, there may be a tendency to mistake at least the first signs of the disease for acute rheumatism, from which it must necessarily be early differentiated as above.

Treatment.

—Here also there is the same necessity for immediate intervention, if possible before pus be formed, in order that there may be little or no periosteal separation and encouragement to necrosis. Anesthesia is necessary, with prompt incision, the use of the sharp spoon, and disinfecting agents: no attempt should be made to close the wound, but drainage should be favored in every way. The intensity of the pain is promptly relieved and the whole clinical picture immediately changed by such a procedure.

The ordinary bone felon upon a terminal phalanx is practically an expression of this type of disease, and experience corroborates the wisdom of deep and early incision, even in the case of so small a bone entity as a phalanx.

Acute Epiphysitis.

—This is a term applied rather indiscriminately to a form of acute osteomyelitis involving primarily and especially the epiphyseal lines, or to a condition of hyperemia and neurovascular excitement at epiphyseal junctions stopping short of suppuration, but giving rise to intense pain, muscle contraction, joint tenderness, etc. It is often seen at the upper end of the tibia. Sympathetic disturbance may extend even to serous effusion into a joint, although this is not necessarily the case. The limbs are early drawn up, and every attempt to extend them simply aggravates the distress. So long as there are no evidences of suppuration, it is sufficient in these cases to apply a sufficient degree of traction to overcome muscular contracture and to straighten the limbs. This should be applied first under anesthesia, and the patient kept under anodynes for a few hours thereafter. So soon, however, as the muscles are tired out by the steady traction, pain subsides, and the intensity of the condition may be thus relieved within forty-eight hours or less. It would be well to continue physiological rest and traction as long as there remains the slightest tenderness. Should evidences of suppuration at any time supervene, incision and evacuation of pus and exudate should be practised. Should epiphysitis occur in one of two parallel bones, there may result such failure of growth of that bone as shall cause marked deformity in the attacked hand or foot. In some of these cases, should operation be required on one bone, the other may be shortened at the time, or later, by exsection of a portion of the shaft, or even of the epiphyseal junction.