Alexis Thomson and Alexander Miles - Manual of Surgery

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AFFECTION OF THE NAILS

_Injuries._--When a nail is contused or crushed, blood is extravasated
beneath it, and the nail is usually shed, a new one growing in its
place. A splinter driven underneath the nail causes great pain, and if
organisms are carried in along with it, may give rise to infective
complications. The free edge of the nail should be clipped away to allow
of the removal of the foreign body and the necessary disinfection.

_Trophic Changes._--The growth of the nails may be interfered with in
any disturbance of the general health. In nerve lesions, such as a
divided nerve-trunk, the nails are apt to suffer, becoming curved,
brittle, or furrowed, or they may be shed.

_Onychia_ is the term applied to an infection of the soft parts around
the nail or of the matrix beneath it. The commonest form of onychia has
already been referred to with whitlow. There is a superficial variety
resulting from the extension of a purulent blister beneath the nail
lifting it up from its bed, the pus being visible through the nail. The
nail as well as the raised horny layer of the epidermis should be
removed. A deeper and more troublesome onychia results from infection at
the nail-fold; the infection spreads slowly beneath the fold until it
reaches the matrix, and a drop or two of pus forms beneath the nail,
usually in the region of the lunule. This affection entails a
disability of the finger which may last for weeks unless it is properly
treated. Treatment by hyperaemia, using a suction bell, should first be
tried, and, failing improvement, the nail-fold and lunule should be
frozen, and a considerable portion removed with the knife; if only a
small portion of the nail is removed, the opening is blocked by
granulations springing from the matrix. A new nail is formed, but it is
liable to be misshapen.

_Tuberculous onychia_ is met with in children and adolescents. It
appears as a livid or red swelling at the root of the nail and spreading
around its margins. The epidermis, which is thin and shiny, gives way,
and the nail is usually shed.

[Illustration: FIG. 107.--Subungual Exostosis growing from Distal
Phalanx of Great Toe, showing Ulceration of Skin and Displacement of
Nail.

_a._ Surface view. _b._ On section.]

_Syphilitic_ affections of the nails assume various aspects. A primary
chancre at the edge of the nail may be mistaken for a whitlow,
especially if it is attended with much pain. Other forms of onychia
occur during secondary syphilis simultaneously with the skin eruptions,
and may prove obstinate and lead to shedding of the nails. They also
occur in inherited syphilis. In addition to general treatment, an
ointment containing 5 per cent. of oleate of mercury should be applied
locally.

_Ingrowing Toe-nail._--This is more accurately described as an
overgrowth of the soft tissues along the edge of the nail. It is most
frequently met with in the great toe in young adults with flat-foot
whose feet perspire freely, who wear ill-fitting shoes, and who cut
their toe-nails carelessly or tear them with their fingers. Where the
soft tissues are pressed against the edge of the nail, the skin gives
way and there is the formation of exuberant granulations and of
discharge which is sometimes foetid. The affection is a painful one and
may unfit the patient for work. In mild cases the condition may be
remedied by getting rid of contributing causes and by disinfecting the
skin and nail; the nail is cut evenly, and the groove between it and the
skin packed with an antiseptic dusting-powder, such as boracic acid. In
more severe cases it may be necessary to remove an ellipse of tissue
consisting of the edge of the nail, together with the subjacent matrix
and the redundant nail-fold.

_Subungual exostosis_ is an osteoma growing from the terminal phalanx of
the great toe (Fig. 107). It raises the nail and may be accompanied by
ulceration of the skin over the most prominent part of the growth. The
soft parts, including the nail, should be reflected towards the dorsum
in the form of a flap, the base of the exostosis divided with the
chisel, and the exostosis removed.

_Malignant disease_ in relation to the nails is rare. Squamous
epithelioma and melanotic cancer are the forms met with. Treatment
consists in amputating the digit concerned, and in removing the
associated lymph glands.

CHAPTER XVIII

THE MUSCLES, TENDONS, AND TENDON SHEATHS

INJURIES: _Contusion_; _Sprain_; _Rupture_--Hernia of
muscle--Dislocation of tendons--Wounds--Avulsion of tendon.
DISEASES OF MUSCLE AND OF TENDONS: _Atrophy_; _"Muscular
rheumatism"_--_Fibrositis_; _Contracture_; _Myositis_;
_Calcification and Ossification_; _Tumours_. DISEASES OF TENDON
SHEATHS: _Teno-synovitis_.

INJURIES

#Contusion of Muscle.#--Contusion of muscle, which consists in bruising
of its fibres and blood vessels, may be due to violence acting from
without, as in a blow, a kick, or a fall; or from within, as by the
displacement of bone in a fracture or dislocation.

The symptoms are those common to all contusions, and the patient
complains of severe pain on attempting to use the muscle, and maintains
an attitude which relaxes it. If the sheath of the muscle also is torn,
there is subcutaneous ecchymosis, and the accumulation of blood may
result in the formation of a haematoma.

Restoration of function is usually complete; but when the nerve
supplying the muscle is bruised at the same time, as may occur in the
deltoid, wasting and loss of function may be persistent. In exceptional
cases the process of repair may be attended with the formation of bone
in the substance of the muscle, and this may likewise impair its
function.

A contused muscle should be placed at rest and supported by cotton wool
and a bandage; after an interval, massage and appropriate exercises are
employed.

#Sprain and Partial Rupture of Muscle.#--This lesion consists in
overstretching and partial rupture of the fibres of a muscle or its
aponeurosis. It is of common occurrence in athletes and in those who
follow laborious occupations. It may follow upon a single or repeated
effort--especially in those who are out of training. Familiar examples
of muscular sprain are the "labourer's" or "golfer's back," affecting
the latissimus dorsi or the sacrospinalis (erector spinae); the
"tennis-player's elbow," and the "sculler's sprain," affecting the
muscles and ligaments about the elbow; the "angler's elbow," affecting
the common origin of the extensors and supinators; the "sprinter's
sprain," affecting the flexors of the hip; and the "jumper's and
dancer's sprain," affecting the muscles of the calf. The patient
complains of pain, often sudden in onset, of tenderness on pressure, and
of inability to carry out the particular movement by which the sprain
was produced. The disability varies in different cases, and it may
incapacitate the patient from following his occupation or sport for
weeks or, if imperfectly treated, even for months.

The _treatment_ consists in resting the muscle from the particular
effort concerned in the production of the sprain, in gently exercising
it in other directions, in the use of massage, and the induction of
hyperaemia by means of heat. In neglected cases, that is, where the
muscle has not been exercised, the patient shrinks from using it and the
disablement threatens to be permanent; it is sometimes said that
adhesions have formed and that these interfere with the recovery of
function. The condition may be overcome by graduated movements or by a
sudden forcible movement under an anaesthetic. These cases afford a
fruitful field for the bone-setter.

#Rupture of Muscle or Tendon.#--A muscle or a tendon may be ruptured in
its continuity or torn from its attachment to bone. The site of rupture
in individual muscles is remarkably constant, and is usually at the
junction of the muscular and tendinous portions. When rupture takes
place through the belly of a muscle, the ends retract, the amount of
retraction depending on the length of the muscle, and the extent of its
attachment to adjacent aponeurosis or bone. The biceps in the arm, and
the sartorius in the thigh, furnish examples of muscles in which the
separation between the ends may be considerable.

The gap in the muscle becomes filled with blood, and this in time is
replaced by connective tissue, which forms a bond of union between the
ends. When the space is considerable the connecting medium consists of
fibrous tissue, but when the ends are in contact it contains a number of
newly formed muscle fibres. In the process of repair, one or both ends
of the muscle or tendon may become fixed by adhesions to adjacent
structures, and if the distal portion of a muscle is deprived of its
nerve supply it may undergo degeneration and so have its function
impaired.

Rupture of a muscle or tendon is usually the result of a sudden, and
often involuntary, movement. As examples may be cited the rupture of
the quadriceps extensor in attempting to regain the balance when falling
backwards; of the gastrocnemius, plantaris, or tendo-calcaneus in
jumping or dancing; of the adductors of the thigh in gripping a horse
when it swerves--"rider's sprain"; of the abdominal muscles in vomiting,
and of the biceps in sudden movements of the arm. Sometimes the effort
is one that would scarcely be thought likely to rupture a muscle, as in
the case recorded by Pagenstecher, where a professional athlete, while
sitting at table, ruptured his biceps in a sudden effort to catch a
falling glass. It would appear that the rupture is brought about not so
much by the contraction of the muscle concerned, as by the contraction
of the antagonistic muscles taking place before that of the muscle which
undergoes rupture is completed. The violent muscular contractions of
epilepsy, tetanus, or delirium rarely cause rupture.

The _clinical features_ are usually characteristic. The patient
experiences a sudden pain, with the sensation of being struck with a
whip, and of something giving way; sometimes a distant snap is heard.
The limb becomes powerless. At the seat of rupture there is tenderness
and swelling, and there may be ecchymosis. As the swelling subsides, a
gap may be felt between the retracted ends, and this becomes wider when
the muscle is thrown into contraction. If untreated, a hard, fibrous
cord remains at the seat of rupture.

_Treatment._--The ends are approximated by placing the limb in an
attitude which relaxes the muscle, and the position is maintained by
bandages, splints, or special apparatus. When it is impossible thus to
approximate the ends satisfactorily, the muscle or tendon is exposed by
incision, and the ends brought into accurate contact by catgut sutures.
This operation of primary suture yields the most satisfactory results,
and is most successful when it is done within five or six days of the
accident. Secondary suture after an interval of months is rendered
difficult by the retraction of the ends and by their adhesion to
adjacent structures.

_Rupture of the biceps of the arm_ may involve the long or the short
head, or the belly of the muscle. Most interest attaches to rupture of
the long tendon of origin. There is pain and tenderness in front of the
upper end of the humerus, the patient is unable to abduct or to elevate
the arm, and he may be unable to flex the elbow when the forearm is
supinated. The long axis of the muscle, instead of being parallel with
the humerus, inclines downwards and outwards. When the patient is asked
to contract the muscle, its belly is seen to be drawn towards the
elbow.

The _adductor longus_ may be ruptured, or torn from the pubes, by a
violent effort to adduct the limb. A swelling forms in the upper and
medial part of the thigh, which becomes smaller and harder when the
muscle is thrown into contraction.

The _quadriceps femoris_ is usually ruptured close to its insertion into
the patella, in the attempt to avoid falling backwards. The injury is
sometimes bilateral. The injured limb is rendered useless for
progression, as it suddenly gives way whenever the knee is flexed.
Treatment is conducted on the same lines as in transverse fracture of
the patella; in the majority of cases the continuity of the quadriceps
should be re-established by suture within five or six days of the
accident.

The _tendo calcaneus_ (Achillis) is comparatively easily ruptured, and
the symptoms are sometimes so slight that the nature of the injury may
be overlooked. The limb should be put up with the knee flexed and the
toes pointed. This may be effected by attaching one end of an elastic
band to the heel of a slipper, and securing the other to the lower third
of the thigh. If this is not sufficient to bring the ends into
apposition they should be approximated by an open operation.

The _plantaris_ is not infrequently ruptured from trivial causes, such
as a sudden movement in boxing, tennis, or hockey. A sharp stinging pain
like the stroke of a whip is felt in the calf; there is marked
tenderness at the seat of rupture, and the patient is unable to raise
the heel without pain. The injury is of little importance, and if the
patient does not raise the heel from the ground in walking, it is
recovered from in a couple of weeks or so, without it being necessary to
lay him up.

#Hernia of Muscle.#--This is a rare condition, in which, owing to the
fascia covering a muscle becoming stretched or torn, the muscular
substance is protruded through the rent. It has been observed chiefly in
the adductor longus. An oval swelling forms in the upper part of the
thigh, is soft and prominent when the muscle is relaxed, less prominent
when it is passively extended, and disappears when the muscle is thrown
into contraction. It is liable to be mistaken, according to its
situation, for a tumour, a cyst, a pouched vein, or a femoral or
obturator hernia. Treatment is only called for when it is causing
inconvenience, the muscle being exposed by a suitable incision, the
herniated portion excised, and the rent in the sheath closed by sutures.

#Dislocation of Tendons.#--Tendons which run in grooves may be displaced
as a result of rupture of the confining sheath. This injury is met with
chiefly in the tendons at the ankle and in the long tendon of the
biceps.

Dislocation of the _peronei tendons_ may occur, for example, from a
violent twist of the foot. There is severe pain and considerable
swelling on the lateral aspect of the ankle; the peroneus longus by
itself, or together with the brevis, can be felt on the lateral aspect
or in front of the lateral malleolus; the patient is unable to move the
foot. By a little manipulation the tendons are replaced in their
grooves, and are retained there by a series of strips of plaster. At the
end of three weeks massage and exercises are employed.

In other cases there is no history of injury, but whenever the foot is
everted the tendon of the peroneus longus is liable to be jerked
forwards out of its groove, sometimes with an audible snap. The patient
suffers pain and is disabled until the tendon is replaced. Reduction is
easy, but as the displacement tends to recur, an operation is required
to fix the tendon in its place. An incision is made over the tendon; if
the sheath is slack or torn, it is tightened up or closed with catgut
sutures; or an artificial sheath is made by raising up a quadrilateral
flap of periosteum from the lateral aspect of the fibula, and stitching
it over the tendon.

Similarly the _tibialis posterior_ may be displaced over the medial
malleolus as a result of inversion of the foot.

The _long tendon of the biceps_ may be dislocated laterally--or more
frequently medially--as a result of violent or repeated rotation
movements of the arm, such as are performed in wringing clothes. The
patient is aware of the displacement taking place, and is unable to
extend the forearm until the displaced tendon has been reduced by
abducting the arm. In recurrent cases the patient may be able to
dislocate the tendon at will, but the disability is so inconsiderable
that there is rarely any occasion for interference.

#Wounds of Muscles and Tendons.#--When a muscle is cut across in a
wound, its ends should be brought together with sutures. If the ends are
allowed to retract, and especially if the wound suppurates, they become
united by scar tissue and fixed to bone or other adjacent structure. In
a limb this interferes with the functions of the muscle; in the
abdominal wall the scar tissue may stretch, and so favour the
development of a ventral hernia.

Tendons may be cut across accidentally, especially in those wounds so
commonly met with above the wrist as a result, for example, of the hand
being thrust through a pane of glass. It is essential that the ends
should be sutured to each other, and as the proximal end is retracted
the original wound may require to be enlarged in an upward direction.
When primary suture has been omitted, or has failed in consequence of
suppuration, the separated ends of the tendon become adherent to
adjacent structures, and the function of the associated muscle is
impaired or lost. Under these conditions the operation of secondary
suture is indicated.

A free incision is necessary to discover and isolate the ends of the
tendon; if the interval is too wide to admit of their being approximated
by sutures, means must be taken to lengthen the tendon, or one from some
other part may be inserted in the gap. A new sheath may be provided for
the tendon by resecting a portion of the great saphenous vein.

_Injuries of the tendons of the fingers_ are comparatively common. One
of the best known is the partial or complete rupture of the aponeurosis
of the extensor tendon close to its insertion into the terminal
phalanx--_drop-_ or _mallet-finger_. This may result from comparatively
slight violence, such as striking the tip of the extended finger against
an object, or the violence may be more severe, as in attempting to catch
a cricket ball or in falling. The terminal phalanx is flexed towards the
palm and the patient is unable to extend it. The treatment consists in
putting up the finger with the middle joint strongly flexed. In
neglected cases, a perfect functional result can only be obtained by
operation; under a local anaesthetic, the ruptured tendon is exposed and
is sutured to the base of the phalanx, which may be drilled for the
passage of the sutures.

_Subcutaneous rupture_ of one or other _of the digital tendons_ in the
hand or at the wrist can be remedied only by operation. When some time
has elapsed since the accident, the proximal end may be so retracted
that it cannot be brought down into contact with the distal end, in
which case a slip may be taken from an adjacent tendon; in the case of
one of the extensors of the thumb, the extensor carpi radialis longus
may be detached from its insertion and stitched to the distal end of the
tendon of the thumb.

Subcutaneous _rupture of the tendon of the extensor pollicis longus_ at
the wrist takes place just after its emergence from beneath the annular
ligament; the actual rupture may occur painlessly, more frequently a
sharp pain is felt over the back of the wrist. The prominence of the
tendon, which normally forms the ulnar border of the snuff-box,
disappears. This lesion is chiefly met with in drummer-boys and is the
cause of drummer's palsy. The only chance of restoring function is in
uniting the ruptured tendon by open operation.

[Illustration: FIG. 108.--Avulsion of Tendon with Terminal Phalanx of
Thumb.

(Surgical Museum, University of Edinburgh.)]

_Avulsion of Tendons._--This is a rare injury, in which the tendons of a
finger or toe are torn from their attachments along with a portion of
the digit concerned. In the hand, it is usually brought about by the
fingers being caught in the reins of a runaway horse, or being seized in
a horse's teeth, or in machinery. It is usually the terminal phalanx
that is separated, and with it the tendon of the deep flexor, which
ruptures at its junction with the belly of the muscle (Fig. 108). The
treatment consists in disinfecting the wound, closing the tendon-sheath,
and trimming the mutilated finger so as to provide a useful stump.

DISEASES OF MUSCLES AND TENDONS

_Congenital absence_ of muscles is sometimes met with, usually in
association with other deformities. The pectoralis major, for example,
may be absent on one or on both sides, without, however, causing any
disability, as other muscles enlarge and take on its functions.

_Atrophy of Muscle._--Simple atrophy, in which the muscle elements are
merely diminished in size without undergoing any structural alteration,
is commonly met with as a result of disuse, as when a patient is
confined to bed for a long period.

In cases of joint disease, the muscles acting on the joint become
atrophied more rapidly than is accounted for by disuse alone, and this
is attributed to an interference with the trophic innervation of the
muscles reflected from centres in the spinal medulla. It is more marked
in the extensor than in the flexor groups of muscles. Those affected
become soft and flaccid, exhibit tremors on attempted movement, and
their excitability to the faradic current is diminished.

_Neuropathic atrophy_ is associated with lesions of the nervous system.
It is most pronounced in lesions of the motor nerve-trunks, probably
because vaso-motor and trophic fibres are involved as well as those that
are purely motor in function. It is attended with definite structural
alterations, the muscle elements first undergoing fatty degeneration,
and then being absorbed, and replaced to a large extent by ordinary
connective tissue and fat. At a certain stage the muscles exhibit the
reaction of degeneration. In the common form of paralysis resulting from
poliomyelitis, many fibres undergo fatty degeneration and are replaced
by fat, while at the same time there is a regeneration of muscle fibres.

#Fibrositis# or "#Muscular Rheumatism#."--This clinical term is applied
to a group of affections of which lumbago is the best-known example. The
group includes lumbago, stiff-neck, and pleurodynia--conditions which
have this in common, that sudden and severe pain is excited by movement
of the affected part. The lesion consists in inflammatory hyperplasia of
the connective tissue; the new tissue differs from normal fibrous tissue
in its tendency to contract, in being swollen, painful and tender on
pressure, and in the fact that it can be massaged away (Stockman). It
would appear to involve mainly the fibrous tissue of muscles, although
it may extend from this to aponeuroses, ligaments, periosteum, and the
sheaths of nerves. The term _fibrositis_ was applied to it by Gowers in
1904.

In _lumbago_--_lumbo-sacral fibrositis_--the pain is usually located
over the sacrum, the sacro-iliac joint, or the aponeurosis of the lumbar
muscles on one or both sides. The amount of tenderness varies, and so
long as the patient is still he is free from pain. The slightest
attempt to alter his position, however, is attended by pain, which may
be so severe as to render him helpless for the moment. The pain is most
marked on rising from the stooping or sitting posture, and may extend
down the back of the hip, especially if, as is commonly the case,
lumbago and gluteal fibrosis coexist. Once a patient has suffered from
lumbago, it is liable to recur, and an attack may be determined by
errors of diet, changes of weather, exposure to cold or unwonted
exertion. It is met with chiefly in male adults, and is most apt to
occur in those who are gouty or are the subjects of oxaluric dyspepsia.

_Gluteal fibrositis_ usually follows exposure to wet, and affects the
gluteal muscles, particularly the medius, and their aponeurotic
coverings. When the condition has lasted for some time, indurated
strands or nodules can be detected on palpating the relaxed muscles. The
patient complains of persistent aching and stiffness over the buttock,
and sometimes extending down the lateral aspect of the thigh. The pain
is aggravated by such movements as bring the affected muscles into
action. It is not referred to the line of the sciatic nerve, nor is
there tenderness on pressing over the nerve, or sensations of tingling
or numbness in the leg or foot.

If untreated, the morbid process may implicate the sheath of the sciatic
nerve and cause genuine sciatic neuralgia (Llewellyn and Jones). A
similar condition may implicate the fascia lata of the thigh, or the
calf muscles and their aponeuroses--_crural fibrositis_.

In _painful stiff-neck_, or "rheumatic torticollis," the pain is located
in one side of the neck, and is excited by some inadvertent movement.
The head is held stiffly on one side as in wry-neck, the patient
contracting the sterno-mastoid. There may be tenderness over the
vertebral spines or in the lines of the cervical nerves, and the
sterno-mastoid may undergo atrophy. This affection is more often met
with in children.