Orthopedic Diseases

Suppuration connected with a bone is usually presented to us under three forms: 

First, between the surface of the bone and the periosteum by far the most common. When it occurs at some part of a long bone, as a result of osteitis and periostitis, if the abscess is left to itself, after having caused much suffering, it will break, and generally after some exfoliation of bone, slowly heal, with a white, shining cicatrix adherent to the bone. [...] The pain is worse at night [...]. The swelling is most prominent about its centre, extending to the tubercle above [...] the swelling is hard, except at its centre, where it is soft, fluctuating, and tender. The integuments about this situation are of a yellowish red colour, and edematous. [...] Skin hot; sweats at night; pulse 92; headache. [...] Pus, mixed with blood, was discharged.

Secondly, diffuse suppuration in bone is a most formidable affection: the bone itself is often destroyed, the periosteum stripped from the surface of the bone [...] the bone full of pus [...] pain and swelling of the limb, which is usually edematous. [...] At other times the matter unhappily makes an entrance into a joint, which then becomes intensely inflamed, necessitating the loss of the limb, or causing a stiff and anchylosed joint. [...] It is, happily, not a very common affection; it is most frequently observed in the young [...].

Thirdly, [...] the acute, circumscribed abscess beings with severe pain, [...] swelling, redness, and exquisite tenderness. [...] A free incision let out a quantity of thick, yellow matter, with great relief. The surface of the bone, stripped of periosteum, was rough and hard, the matter having been situated between it and the periosteum. A rugged opening in the tibia led down into a cavity: when the point of the probe touched the bottom or sides, it gave exquisite pain.

Smith, W.G. (1856). Art. II - Abscess of Bone by John Hamilton. In Dublin Quarterly Journal of Medical Science (Vol. 21) Pg. 9-12.

Entered by: Ayushi Chintakayala, 7/2/2020

The sternal extremity of the clavicle is sometimes dislocated forwards, in consequence of falls on the shoulder and arm. The displacement is readily recognized by the swelling arising from the projecting end of the bone and superjacent portion of the sterno-mastoid muscle, and by the mobility of the clavicle and depression of the shoulder that proceed from it.

Syme, J. (1856). The Principles of Surgery. (pp.213-214). London: J. Murray.

Created by: Bernardo Galvan, 11/01/2021

Entered by: Rachel Johnson, 11/30/2021

In such cases the muscles are sound and the child moves the foot freely, but there is a variable degree of fixed dorsal flexion, and on attempting forcible plantar flexion the extensor tendons become prominent and prevent the movement being carried out to its full extent. […] Although the sole may look inwards, still the foot is, as a rule, quite flat, and the inner edge is more pronounced than normal, or even in some cases convex, especially in the region of the medio-tarsal joint. Here we not infrequently meet with a distinct prominence due to the projecting scaphoid. This condition of the inner edge of the foot may have given rise to the generally accepted dictum that valgus is the common, if not universal, accompaniment of congenital calcaneus. But the inner edge is on a higher level than the outer, and although the scaphoid and astragalus are more prominent, they are elevated and not depressed, as in valgus.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

In severe cases the foot is rigidly fixed in the abnormal position which cannot be overcome by manual force; in medium cases the deformity is well marked, but the rigidity is not so great and the malposition can be greatly diminished by manual force: in slight cases there is but little rigidity, and the foot can be easily brought to its normal shape. […] In infants who have not walked, the inner border of the foot is shortened, the outer shows signs of pressure, i.e. thinning of the skin over the outer malleolus and the prominent cuboid bone. The sole of the foot shows a transverse crease opposite the transverse tarsal joint, showing that there is some flexion at this joint; in other words, some pes cavus is present. In older patients who have walked, callosities with underlying bursa? form over the outer border of the foot and a longitudinal crease develops in the sole.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

Pain — During the initial period of the deformity this symptom is usually present and is often marked. It may simulate early hip-disease. The duration of the painful period is usually some weeks or months. It is often overlooked or passed over as " growing pains."

Lameness —This symptom varies with the degree of the deformity, and according to whether the affection is unilateral or bilateral. In bilateral cases there is a rolling gait, somewhat akin to that seen in cases of double congenital hip dislocation; in unilateral cases the lameness consists in a sudden dip and lurch of the body towards the affected side

Attitude —In unilateral cases the pelvis is tilted downwards towards the affected side. In infants a marked eversion of the limb is often the first sign of the deformity. In advanced cases, the adduction of the limb leads to crossing of the legs and scissor-legged progression.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

The instep is sunken, the hollow that should be found beneath the inner border of the foot when the patient stands up is diminished or lost, and the inner border of the foot may be convex inwards, presenting prominences corresponding to (1) the displaced head of the astragalus and (2) the tuberosity of the scaphoid bone. The skin is often thickened over this projection of the inner border. In most cases the internal malleolus is seen to be unduly prominent, and it appears to be displaced inwards, and below it the foot is bent outwards, i.e.. everted. […] The sole of the foot loses its hollow on the inner side, and its fore part deviates outwards so that a line drawn from the posterior border of the foot forwards through the middle of the heel (Meyer's line) would pass to the inner side of the great toe instead of along its center. In severe cases the weight of the patient in walking is borne entirely by the inner edge of the feet, the outer edge being so far everted that it does not touch the ground. By the sinking of the longitudinal arches the foot is elongated. The sole of the foot has an ungraceful, flattened appearance. The gait of one suffering from flat-foot is characteristic. The toes are directed outwards more than is normal; in walking the foot is placed on the ground in a flat, inelastic manner.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

On looking at a person affected with knock knee of marked degree the straddling carriage and gait are striking; in slight cases a closer inspection is required. In standing, the patient's knees are unduly prominent at the inner side. In cases of genu valgum the patient, in order to avoid the knees coming together, abducts the thighs alternately in walking, giving at each forward step of the advancing limb an outward swing which is very conspicuous. If the deformity is very severe the knees form a lozenge-shaped interval, one knee being crossed behind the other, and then walking is extremely difficult. In some cases, besides the alteration in the direction of the legs, there is an outward (more rarely an inward) rotation of the tibia.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

When the patient stands erect with the internal malleoli close together the knees are separated by a greater or less interval. In extreme cases the legs describe a circle.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

Suppuration connected with a bone is usually presented to us under three forms: 

There may be direct symptoms of the presence of the growth- pain in the spine, sometimes severe, sometimes absent; local tenderness, and occasional interference with movement apart from pain. A palpable tumor is never an early symptom, but ultimately a deep-seated, hard swelling may be felt on one side of the spine, most readily and earliest when the disease is in the cervical region, where it is occasionally perceptible in the posterior triangle of the neck . The nerves give rise to radiating pain, felt along the course of the nerves that emerge from the diseased portion of the spine, and due to their irritation by pressure or inflammation. Such pains are far more prominent symptoms in this disease than in caries [Pott’s disease]. At first light, they gradually increase to extreme intensity.

The pains are paroxysmal; in the intervals the patient is at first free from pain, but subsequently pain is constant. It is usually sharp, lancinating pain, and its special characteristic is the degree in which it is increased by movement. The distribution depends on the seat of the disease. It is extremely rare for these pains to be absent, but they are now and then a late, instead of an early, symptom. Cutaneous hyperaesthesia usually accompanies them, and spots of anaesthesia often develop after time in the hyperaesthetic area. Corresponding damage to the motor roots may cause painful muscular contracture, paralysis, and wasting.

Displacement of the bone has also been known to cause rapid paralysis. Other symptoms are the same as in compression from any cause. The course of the disease is, from its nature, usually progressive. Occasionally, however, some improvement occurs. An inflamed cord may partially recover if life is prolonged for a sufficient length of time.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 187-188.

Entered by: Sonia Y. Khan, 6/11/2020

The great toe is slightly flexed at the metatarsophalangeal joint and attempts at passive extension cause pain to the patient. […] The normal extent to which the great toe can be bent back varies in different individuals; in hallux rigidus this range is diminished. In many cases the toe cannot be brought into a straight line. The condition interferes greatly with walking, the patient limps on the outer border of the foot.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

It will be noticed that in the right foot the displaced great toe has passed beneath, whilst in the left it has passed above the second toe. In other cases, again, the second toe is doubled back in the peculiar form known as hammertoe; or, again, the second toe may remain parallel with its displaced companion, being simply flattened against it. In this last instance either the outer, or more rarely the inner edge of the nail of the great toe may be forced into the soft tissues. […] In the more severe grades of hallux valgus the great toe may be almost at a right angle with the metatarsal bone, and much discomfort or pain is usually complained of. Indeed, the complicating bursa and other sequels of the deformity often render it a very serious affliction.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

The deformity consists in a permanent flexion at one of or both the inter-phalangeal joints. The second toe is by far the most commonly affected. […] In the early stages of the affection the deformity is readily overcome by manipulation, whilst in the later stages it is fixed by the rigidity of the parts concerned.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

This condition is observed after an injury, which is usually a slight one, such as suddenly catching the finger in some part of the dress when dressing, or some similar act. The patient is incapable of extending the terminal joint of one or other of the fingers. Sometimes the last phalanx hangs helplessly at a right angle to the second.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

The first sign of the affection is a subcutaneous nodule which appears most commonly over the metacarpophalangeal articulation of the ring finger. The nodule is periodically the seat of slight tenderness, and during these periods the skin covering it may be red. Sometimes the patient first notices a "stiffness " of the finger, owing to an inability to extend it fully. At this stage there is usually but little pain. On examining the palm, besides the simple nodule, rigid bands can be felt or seen, pro longed to one or more of the fingers. In course of time fresh nodules may appear, and several fingers become affected. In the later stages the bands stand out as rigid cords. […] At last several fingers may be drawn down so firmly that callosities or even ulcers form in the palm of the hand.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

This condition is frequently hereditary. Cases may be arranged in various groups. Thus, (1) the extra digit may be rudimentary; in such cases it is usually attached to the outer or inner border of the hand, and is attached by a short pedicle ; (2) the extra digit may possess all its complement of bones, etc., and it may either (a) be coherent with a neighboring digit, or (b) free and functional. Both hands and feet may be affected in the same case, or only one member may be affected.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

There are seen the large head, beaded ribs, narrow chest, prominent abdomen, symmetrical swelling of the epiphyses of the wrists and ankles, and curvature of the extremities. […] The most constant early symptoms are sweating of the head, extreme restlessness at night, constipation, beading of the ribs, and cranio-tabes. The head-sweating is rarely absent and may continue for several months. It is especially profuse during sleep, the perspiration standing out in large drops on the forehead, often being sufficient to wet the pillow. […] There is marked restlessness during sleep: the children tossing about the crib, kicking off the clothes, and never having a quiet, natural slumber of healthy infants. […] Constipation is frequently seen as an early symptom, although it is more marked in the later stages of the disease. The beading of the ribs is almost invariably the first appreciable change in the bones, and it is well-nigh constant. […] It may be slight, or there may be a row of knobs as large as small marbles. […] The principal deformities of the lower extremity are bow-leg and knock-knee. […] The muscles are small, very flabby, and poorly developed; hence rachitic children are unable to sit erect, or stand or walk at the proper age. […] As a rule, dentition is late and apt to be difficult—i.e., it is associated with attacks of indigestion or other disturbances which may be serious. […] There may be laryngismus stridulus, tetany, or general convulsions.

Holt, L Emmett. The Diseases of Infancy and Childhood: for the Use of Students and Practitioners of Medicine. Appleton and Co, 1897. Pg. 222-232.

Entered by: Erin Choi, 6/23/20

The degree of arching of the foot varies within normal limits, so that what constitutes talipes cavus, i.e. a pathological increase in the arching of the foot, in one may be normal in another individual. In the more marked degrees, the footprint is altered; in such cases the outer border of the foot between the ball of the toes does not touch the ground, and so the middle part of the normal footprint is wanting. Pain in the instep and painful corns usually cause the patient to seek advice.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021

Clinically it is characterized by an impediment in either of or both the movements of flexion and extension. The movement of extension is more often at fault. On the patient closing the hand and then attempting to extend all the fingers, one of them remains flexed, and it can only be extended by using the other hand, when it becomes straightened out by a sharp movement resembling that of the blade of a clasp-knife. In many cases this " claspknife " action is repeated when the finger is bent.

Clarke, J. J. (1899). Orthopædic surgery: A textbook of the pathology and treatment of deformities. New York: William Wood & Company.

Entered by: Bernardo Galvan 02/28/2021