In cases in which one of the short tubular hones has been entirely destroyed we may remove this as far as the healthy tissues, and when the wound has healed we may try the free transplantation of bone (Muller, Schmieden, Streissler). A splinter of bone with its periosteum attached is removed from the tibia, placed between the freshened ends of the epiphyses and allowed to heal in.
We amputate a finger only when it is entirely destroyed or is second arily infected.
(d) Tuberculosis of the Hip-joint (Cozitis tuberculosa) is the most frequent tuberculous joint disease in children and usually attacks those under ten years of age (rarely infants); according to Dollinger the majority of those attacked are between four and six years old.
The disease may start from the synovia through hiematogenous infection or from the bone itself and from thence spread to the joint. The primary synovial form is rarer in children and is found in 20 to 30 per cent. of all cases. The course of the synovial type is the same as in other joints: formation of tubercles and granulations, caseation, destruction of the hone.
In the osteal type the diseased focus is found in the bony structure of the head of the femur, the trochanter, or the acetabulum (Konig), whence the infection advances to the joint, where it destroys the liga ments and bony parts.
When the head of the femur and the sect abulum are both being destroyed, the latter will resist longer, owing to its firmer structure. The whole head and neck may be involved, and when any weight is put on the friable bone this will sometimes break at the neck and the head will be found loose in the acetabulum like a sequestrum (see hip lux:I lion, Fig. 50, Plate 8).
When the aeetabulum is destroyed, any weight will cause the head to move upward, thus extending the soft acetabulum upward (wander ing acetabulum).
In advanced eases we may find a position of complete lunation, though the loosening of the caput mentioned above may simulate this.
The abscesses perforate the capsule and appear under the fascia lata, either near the trochanter or at the lower border of the gluteal muscles, in rare cases on the inside of the thigh.
Repair may set in at any stage of the disease, but only in the serous and light fungous type do we observe total restitution of function; in all other cases there will remain more or less stiffness of the joint in the position it occupied during the disease. This is caused either by scars
or by osseous or fibrous ankylosis of the eroded joint.
The interference with the nutrition of the bones surrounding the joint is quite apparent; the femur itself is much thinner and more deli cate in structure than that of the healthy side; this atrophy is caused by diminished growth at the epiphyses, but still more by the inactivity of the affected limb (see Paralyses) (Fig. 125c).
Symptomatology and Course.—A child otherwise healthy begins to limp more and more (voluntary limp). The mother notices that the child favors one leg, "it always stands on the sound leg." The gait changes, since it leaves its weight for a shorter time on the diseased leg.
To minimize the pain when putting the weight upon this side, the leg is held in abduction so as to get it as much as possible out of the axis of gravity. This "position from pain," which can also be observed in other painful affections of the log, is the cause for the position in abduc tion which is apparent in the beginning of this disease (Fig. 123).
This side position of the leg will naturally increase the limp and the uneven gait will make it appear somewhat like a jump. Fixation in the abducted position makes the diseased leg appear longer. This is most pronounced when the patient is lying flat on his back and the sound log is placed alongside of the diseased one (Fig. 123a).
Slight pains are usually referred to the knee by the little patient. After a few days of rest all these symptoms may disappear entirely (hydrops), though in some cases they will return More intensely. Should a considerable exudate set in suddenly, then these initial symptoms will be more pronounced ipain on walking and fever).
Even in this early stage swelling and pain in the joint are present. If we feel for the place where the pulsating femoral artery appears under Poupart's ligament, we will find the hip-joint directly under the examin ing finger. On pressing deeper we will feel the increased boggy resistance, and this will cause pain t'alot).