Prognosis is bad owing to the nearness of the lungs. Healing always leaves a loss of function of the joint, unless the effusion is promptly evacuated.
The destruction from suppuration and the consequent formation of scars leave not only a stiff joint but also a shortened limb owing to the destruction of the epiphyseal line.
Differential diagnosis is not difficult. A collection of fluid in the shoulder-joint in a child should always arouse our suspicion, because traumatic omarthritis in childhood is very rare. Pyxmic infection of the joint or the periartieular tissues is characterized by its rapid course. Syphilitic separation of the epiphysis in small children is shown by the negative Pirquet test, by serodiagnosis, and skiagraphy (see Hochsinger, Syphilis, bone diseases). Fractures near the joint in the humerus, clavicle, or acromion are detected by careful examination and with the aid of the X-ray.
In paralyses we have passive motil ity while rheumatic affections are gen erally multiple.
Treatment must be conservative in children. It consists in proper position, in passive congestion of the shoulder (Bier), and general systemic treatment. Abscesses must be punctured where the capsule protrudes the most and may be injected with a few c.c. of a 5 per cent. iodoform-glycerinc emulsion.
Cleaning out the synovia (syno vectomy) and resection of the joints, recommended by some surgeons, are not permissible in children. Extra-articular foci in the metaphysis may be opened to prevent their breaking through into the joint.
Resection may be considered only to correct malposition long after the process has healed, but even then it is better to leave it alone, as the focus may be only encapsulated, and we eau make use of the motility of other parts to make the arm more useful.
In the normal joint any elevation of the arm above is not done with the shoulder-joint but with the whole shoulder-girdle, i.e., by rota tion of the scapula around its sagittal axis. We must therefore bring the arm in that position to the shoulder-blade so that elevation may be accomplished by moving the scapula. The inward rotation of the arm must also be done away with, because this interferes with the motility of the elbow-joint.
From these observations we may also learn something of the posi tion of the arm in those inflammatory processes in the shoulder in which we might have to expect a fixation. Instead of putting the arm in a Velpeau or DessauIt bandage in adduction, we attempt an elevated posi tion by weight extension and thus fix it with plaster splints. When the affection in the joint is healed we will then have a useful arm even if the shoulder-joint should have been entirely destroyed (Fig. 121).
lobilizing manipulations and brisement force in narcosis are danger ous procedures because they may reawaken the slumbering process.
Intra-artieu]ar subperiosteal resection of the shoulder-joint should never be considered in children.
(b) Tuberculosis of the Elbow-joint This is much more frequent in children than that of the shoulder joint and is usually ()steal. The foci are found in the humerus:, frequently in the olecranom and very rarely only on the caput radii. In the humerus the external condyle is often affected, whence the disease breaks through to the outside without infecting the joint, or the granulating and suppurating type of tuberculosis of the elbow-joint may follow the disease in the bone (Fig. 122 and Fig. 11S, Plate 11).
The symptoms consist in gradual swelling and filling up of the joint, with increasing fixation and tenderness. The joint loses its normal contour and be Comes fusiform; the joint is fixed in slight flexion and proration (biologic po sition). All motions from this position and pressure on the joint are painful.
The fistula; usually break through near the joint at either side of the triceps tendon where the capsule is closest to the skin.
Caries of the elbow may heal spon taneously, but this will always leave the arm in a fixed position in which it is of little use, as the hand can reach neither head nor mouth.
In the diagnosis only a trauma may make some difficulty, especially a haanatoma after an overlooked injury (see Tuberculosis of shoulder and fractures of the elbow).