Treatment has to be systemic and prophylactic in this affection especially. The frequent extra-articular origin of the process offers a chance in some cases, after studying the skiagram, of opening the bone abscess externally, and we can thus prevent rupture into the joint.
Once the joint becomes tuberettlous we must fix the arm on a plaster splint in such an extreme position of flexion and supination that the palm of the hand can easily reach the mouth. Furthermore, we employ conservative treatment, constriction, and injections of iodoforin.
Of the operative measures, the early extra-articular resection of Bardenheuer is the one to be recommended. In this operation the joint is rcsected subperiosteally and removed as far as the healthy tissues without its being opened and with the avoidance of any injury of the muscles, blood-vessels, and The results are splendid as to mo tility, nor is the interference with growth as considerable as it is in the shoulder-joint.
This method is especially adapted to mobilize stiff elbows after the caries has healed for some time (interposition of muscles and fat).
The other operations, arthrectomies and resections (Langenheek, Miter, Konig, Kocher), can be considered in children only in extreme conditions when a life is at stake.
(c) Taberculo:5is of the Wrist and Finger-joints Tuberculosis of the carpus is rarely an isolated condition in children and is mostly seen in extensive tuberculosis of the bones. On account of their close intercommunication, the disease crawls from one joint and from one bone to another.
The hand is slightly flexed, the wrist is swollen, and the fold between the hand and forearm is filled out (frog-hand). Pains and disturbances of motion appear later, when the process has attacked the tendon sheaths and the syno•ial sacs. Soon abscesses and fistulae leading down to the foci in the bones will show on the surface.
The prognosis is unfavorable as far as the function of the hand is concerned, and the anatomic conditions favor a spreading of the process. Healing is accompanied by loss of function.
The diagnosis must exclude other kinds of chronic arthritic affec tions. In this we are aided by the course, the multiple involvement in
arthritis and by the lack of bone foci in the skiagram.
Treatment must consia of careful position and rest of the wrist, constriction or suction, and other conservative measures. Hardly any body would nowadays clean out the carpal sac in a child through the incision of Langenbeck and Kocher, since this would mean working inside the diseased area and it would be impossible to reach every synovial pocket.
Tuberculosis of the metacarpus and phalanges is identical with spina ventosa (Fig. 117). This type of tuberculosis of the bones is extremely frequent in childhood. It affects the short tubular bones of the hand and foot and leads, as described above, to the swelling of one or more bones, which become fusiform and are painful to pressure. The skin over them remains normal for a long time, then it becomes slightly livid, and the abscess soon breaks through to the outside. Should it rupture into is joint, this will usually be destroyed and the tendon will be fixed when the tendon-sheaths are attacked. The skiagram shows slight distention of the bone, rarefaction, and a new periosteal shadow, also frequently a cavity inside the bone and at times a sequestrum.
This form is relatively benign, and after the general condition is improved, the swellings gradually disappear as the child grows, and the fistulte close after the small sequestra have been dissolved and elimi nated. These facts should guide us in the treatment of this affection, which is usually multiple.
We should avoid any considerable interference, which would not only be superfluous anyhow, since all we arc allowed to do is to aspirate the pus and to remove the sequestra, but, moreover, it might give us the unpleasant surprise of seeing the fingers that healed spontaneously show less loss in growth and function than those of the hand on which we have operated. We should place the fingers in the most favorable position, apply passive congestion, cup the fistulae, and make only punetate incisions with the careful injection of 5 per cent. iodoform emulsion.