Diagnosis.—This is easy, only a traumatic exudate from one of the frequent unobserved falls of children may make some difficulty. In these latter cases, especially in small children, the negative result of von Pirquet's cutaneous reaction has been very helpful to the author. For the other diseases which set in similarly see Coxitis.
Treatment.—In gonitis in children, our treatment must be as con servative as possible. "The greater our patience, the better our results" (Schanz).
The superficial position of the joint makes removal of the diseased joint within the healthy tissues quite easy (see Elbow-joint). But later examination of these resected cases—this operation having been a favorite one some years ago—shows that this joint, the solidity of which is continuously tested, is usually deformed after the wounds have healed, so that we were wont to speak of a deformity from resection (Konig, Kirmisson). This deformity is usually of the yarns type; but we may observe all other forms of malposition, which is not in the least astonish ing when we consider that atrophic bone has been united by the resec tion, and especially when we remember that the growth in the epiphyses was disturbed.
In adults the results of these operations are much better, and in these the stiffened leg after a resection will be quite solid.
These are the reasons why, nowadays, surgeons generally prefer a conservative therapy in children.
Gradual straightening by extension with weights is desirable, in which special attention must be paid to the subluxation. We combine the extension in the long axis of the leg with a backward pressure upon the condyles and a forward leverage of the upper end of the tibia.
When the knee is nearly straight, then it is fixed in a snug plaster cast which must reach from the ankles to the tuber ischii; a stirru is fastened in the lower end to bear the weight.
This treatment of taking off the weight is persisted in as long as stepping upon the leg causes pain; then we leave off the stirrup.
By combining the plaster cast with elastic traction and steel rods we can get the extension while the patient is walking around in the cast, but this makes the casts heavier, less durable, and it takes a much longer time to make these, which latter fact is of great importance in poli clinic work (Fig. 130). We prefer, therefore, preliminary extension with
weights, followed by simple solid plaster casts. Later on, towards the end of treatment, either a removable plaster cast or a celluloid or leather brace is given.
A fixation splint has to be worn for years to prevent the return of the contracture in flexion in eases of fibroid union.
For the wealthier classes of patients we have a choice among a number of braces, from the simple Thomas splint, which consists of a ring as a support for the tuberositas iseldi and a long stirrup, to the exact but complicated braces of Messing, the same as for coxitis except for the hip support (Fig. 126), in which by applying all the principles of technic we attempt to get fixation and at the same time prevention of deformity, in which we succeed if they are made carefully and applied patiently.
The treatment with apparatus should be combined with Bier's passive congestion. Should abscesses appear these have to be punctured (injection of iodoform-glyeerine). Absolute cleanliness in treating the fistuhe, protection from secondary infection by the application of tinc ture of iodine or balsam of Peru, avoiding all probing and scraping out, are especially recommended.
We are justified and forced to open and remove a focus in the bone, when we can thus prevent infection of the joint by making a para-artic ular opening.
Old and healed gonitic deformities, which do not yield to extension with weights, may be removed by wearing for some time a portable apparatus (Braatz, Hoffa, Hessing), but in all these procedures we must consider especially the subluxation.
Fibrous unions will yield to this. When the bones are ankylosed and the patella is in solid bony fixation we will not succeed without oper ative measures, but these should not be attempted until the disease is surely healed (not earlier than after four years), especially when we have to open the joint for a cuneiform osteotomy (circular resection according to ITelferich) (Fig. 13114.