A subperiosteal resection without opening the joint means a capital operation which leaves considerable shortening (Flint, Wolkowitsch).
The para-erticular supracondyloid osteotomy according to Oilier, which corrects the deformity outside the diseased joint by a counter deformity, seems better pathologically, and might also be clone in the upper end of the tibia.
(g) Tuberculosis of the Joints in the Fool Pathology and Symptomatology.---The joints of the foot are much oftener affected by tuberculosis in children than the joints in the hand. The disease is usually of osteal origin. The focus is in the eaput tali, in the calcaneus or in tarsal or metatarsal bones, more rarely in the lower end of the tibia.
The course is similar to that in other joints, especially to that of the wrist; here also the communications between the joint-cavities and the tendon-sheaths favor a spreading of the process.
In the beginning we observe a swelling in the joint which is most pronounced at both sides of the tondo Achillis (upper astragalus joint). This increases, the gait becomes limping, and again we notice the easing position in abduction of the leg with outward rotation of the foot; the opposite position, when a localization of the disease causes a varus position of the foot in fixation from pain (Hofmann). When the foot is not used we observe an equinus position.
There are fixation of the affected joints, loss of respective motions, formation of abscesses and fistuhe (sec Gonitis, eoxitis).
The diagnosis is made uncertain only by rheumatic and traumatic affections (history, skiagram, course, von Pirquet's test); a painful flat foot may at times make the diagnosis difficult, though painful flat-foot in children is rare and a one-sided one still rarer.
Tuberculosis of the different bones—calcaneus, talus, or the small bones and their joints—is recognized by the swelling over the respective site and tenderness on pressure on these bones, also especially by the skiagram (Fig. 119, Plate 11).
Treatment. — This in children is at first conservative. Rest is obtained by a plaster cast which must be well moulded to the tuberositas below the knee and which, if motion should be painful, takes up the weight through a walking stirrup; we may also succeed with a brace similar to the one used in coxitis.
Should the foci be easily diagnosed and accessible in the tarsus, then these must he opened to avoid perforation into the joints. Espe cially in the calcaneus will we frequently find isolated foci which can easily be reached from without before they break through into the articulatio pedis (Fig. 119, Plate 11). Should the infection spread, then larger resections will be of little use, and we will try to succeed with the above-mentioned measures combined with congestion and injections of iodoform.
Total resection or amputation is only justified when life is in danger (Codivilla).
(h) Tuberenlar Disease of the Bones and Joints of the Spinal Column (Spondylitis, Spondylarthritis tuberenlosa) form of tubercular infection is very frequent in childhood, especially in the first few years, and is most frequent in the second year of life (Wullstein). The weight then carried by the spine and intercurrent infectious diseases which weaken the system, as well as frequent injuries, are all of great importance in the etiology.
The vertebra most frequently affected depends upon the age of the child, as those vertebrae are the most frequently affected which are most used and injured at the respective age. Thus we will find in young children a preference for the lower dorsal spine, which ap pears to be most compressed and protruding in kyphasis from sitting. In adults the lumbar spine is more employed to carry the weight and is therefore the most frequently affected (Hoffa). The cervical spine is rarely affected, and the disease of the uppermost cervical yertebrm, which we know under the name of malum suboccipitale, is very rare in children.
The focus is as a rule found in the body of the vertebra, the loose network of the tissues of which offers les resistance to the entrance and the progress of the disease than the solid structure of the arches (skia gram, Fig. 132, Plate .12).