In complete paralysis, the joints of the affected limb with the exception of the shoulder are usually flexed when the horse is resting. In consequence of loss of power in the triceps and anterior brachial muscles, the arm is extended and straightened on the shoulder, the scapulohumeral angle is open, and the elbow depressed. The forearm is flexed on the arm by the contraction of the coracoradialis (biceps brachii), while the metacarpus and phalanges are bent by the action of the posterior antibrachial muscles. The knee is carried in advance, level with, or in front of, a vertical line dropped from the point of the shoulder. The hoof is usually rested on the toe, but when advanced beyond the above mentioned vertical line, it may be placed flat on the ground, the joints then being less markedly bent. When the limb as a whole is flexed, it may be brought into normal position by thrusting back the knee with sufficient force to counteract the action of the flexor muscles.
Fig. 9—Merillat's method of fixing carpus in radial paralysis. Courtesy, Alex. Eger.
When made to walk, the animal being unable to exert muscular action with the paralyzed structures, limply carries the member as a whole, and there is shortening of the anterior portion of the stride. There being loss of function of the triceps brachii, it is impossible for the subject to straighten the leg in the normal position for supporting weight; therefore, any attempt to bear weight results in further flexion of the affected member and the animal will fall if the body is not suddenly caught up with the sound leg.
Differential Diagnosis.—In making examination of these cases, one can exclude fracture by absence of crepitation and usually, also, swelling is absent in radial paralysis. In a typical case of radial paralysis, the affected leg can sustain its normal share of weight if placed in position, that is, if the carpal joint is extended in such manner that the leg is positioned as in its normal weight-bearing attitude. In brachial paralysis, whether due to fracture of the first rib or to other serious injury, it is impossible for the subject to support weight with the affected member even when it is passively placed in position.
No difficulty is ordinarily experienced in differentiating radial paralysis from muscular injuries to the triceps; yet, in some cases of "dropped elbow," it is necessary to observe the progress of the case for ten days or two weeks before one can positively establish a diagnosis.
Quoting Merillat[12]: "When, after four weeks, there is no amelioration of the paralysis, the muscles have atrophied, and the patient has become emaciated from pain and discomfort, the diagnosis of brachial paralysis with fracture of the first rib may then be announced."
Prognosis.—When no complete paralysis of the brachial plexus or no fracture of the first rib exists, the majority of cases recover completely in from ten days to six weeks. Some writers claim that recoveries occur in ninety per cent of cases when conditions are favorable.
Treatment.—When incomplete radial paralysis exists, little needs be done except to allow the subject moderate exercise and to provide for its comfort. Local applications, stimulative in character, are beneficial, and the internal administration of strychnin is indicated.
In the cases where weight is not supported without the affected leg being passively placed in position, it is necessary to provide for the subject's comfort in several ways.
Mechanical appliances such as braces of some kind in order to keep the affected leg in a position of carpal extension, constitute the essential part of treatment. The leg is supported in such a manner that flexion of the carpus is impossible. Due regard is given to prevent chafing or pressure necrosis by contact of the skin with the braces—this may be done by bandaging with cotton. The supportive appliance is kept in position for ten days or two weeks. At the end of this time the brace may be removed and the subject given a chance to walk, and improvement, if any exists, will be evident. When there is manifested an amelioration of the condition, moderate daily exercise and massage of the affected parts are helpful.
Should the subject be seriously inconvenienced by the application of a brace or other supportive appliances, it is necessary to employ slings. Further, if weight is supported entirely by the unaffected member, laminitis may supervene if a sling is not used.
Thrombosis of the Brachial Artery.
Thrombosis of the brachial artery or of its principal branches is of very rare occurrence in horses.
Etiology.—Partial or complete obstruction of arteries (brachial or others) occurs as the result of direct injury to the vessel wall from compression and tension of muscles and resultant arteritis; lodging of emboli; and parasitic invasion of vessel walls causing internal arteritis.
Symptomatology.—If sufficient collateral circulation exists to supply the parts with blood, no inconvenience is manifested while the subject is at rest. Where the lumen of the affected vessel is not completely occluded, there may be no manifestation of lameness when the ailing animal is moderately exercised. Consequently, the degree of lameness depends upon the extent of the obstruction to circulation; and, likewise, the course and prognosis depend upon the character and extent of such obstruction.
In severe cases, lameness is markedly increased by causing the animal to travel at a fast pace for only a short distance. There are evinced symptoms of pain, muscular tremors and sudation, but the affected member remains dry and there is a marked difference of temperature between the normal areas and the cool anemic parts. When the subject is allowed to rest, circulation is not taxed, and there is a return to the original and apparently normal condition, only to recur again with exertion. This condition characterizes thrombosis.
Treatment.—In these cases, little if any good directly results from any sort of treatment in the way of medication. Absolute rest is thought to be helpful. Potassium iodid, alkaline agents such as ammonium carbonate and potassium carbonate, have been administered. Circulatory stimulants also have been given, but it is doubtful if any good has come from medication.
Fracture of Humerus.
The shaft of the humerus, protected as it is by heavy muscles, is not frequently fractured; and fractures of its less protected parts, as for example, the head, are complicated in such manner that resultant arthritis soon constitutes the more serious condition.
As a result of falls on frozen ground, kicks or any other form of heavy contusion, the humerus is occasionally broken. It is rarely fractured otherwise. Because of the force of contusions usually required to effect humeral fracture, the manner in which the bone is broken, with respect to direction, is variable. Often oblique fractures exist and occasionally there occurs multiple fracture. In addition to the ordinarily serious nature of the fracture itself, there is always much injury done the adjoining structures.
Symptomatology.—Mixed lameness and manifestation of severe pain characterize this affection. Considerable swelling which increases, in some cases for a week or more, is to be observed. Crepitation is readily detected, if pain and swelling is not too great to prevent passive movement of the member. Where intense pain is not manifested, because of manipulation, one may abduct the extremity and thereby occasion distinct crepitation; but when it is possible to recognize crepitation by holding the hand in contact with the olecranon while the animal is made to walk, this method is to be preferred, if the subject can move without serious difficulty. The pathognomonic symptom here is recognition of crepitation, but this may be very difficult to recognize in fracture of condyles, and in such instances, a careful examination is necessary. Gentle manipulation in a manner that pain is not aggravated will tend to inspire confidence on the part of the subject and relaxation of muscles will enable the operator to detect crepitation.
Course and Prognosis.—Because of the direction of the long axis of the humerus, with relation to the bony column of the extremity, it is obvious that any lateral movement of the leg tends to rotate the shaft of this bone. In fractures of the shaft of the humerus, then, it is apparent that immobilization is very difficult if at all possible.
The proximity to the axillary lymph glands makes for easy dissemination of infection when the contused musculature becomes infected. The adjacent brachial nerve plexus is so very apt to become involved, if not actually injured at the time fracture occurs, that paralysis is a probable complication. Consequently, it is logical to reason that because of the many possible serious complications, such as shock, occasioned by the injury and the distress and pain which this accident produces, recovery must be the exception in fracture of the humerus. However, recoveries do take place and in addition to the reported recoveries by Liautard, Moller, Stockfleth, Lafosse, Frohner and others, we have instances cited by American practitioners where cases resulted in recovery. Thompson[13] reports a good recovery in a 1600-pound mare where there existed an oblique fracture of the humerus. This mare was kept in slings for eight weeks. Walters[14] reports complete recovery in humeral fracture in a foal three days old. The only treatment given was the application of a pitch plaster from the top of the scapula to the radius. The colt was kept in a comfortable box stall and in about four weeks regained use of the leg. Complete recovery eventually resulted. In the experience of the author, recovery has not occurred in humeral fractures.
Treatment.—When animals are not aged and of sufficient value to justify treatment, they are best supported in a sling, if halter broken. If subjects are nervous, wild and unbroken, it is possible to employ the sling, if care is given to train the animal to this manner of restraint. The presence of an attendant for a day or two will reassure such subjects so that even in these cases it may be practicable to employ the sling.
Braces and other mechanical appliances intended to immobilize the parts are not of practical benefit in the horse. Unlike the dog, the horse as yet has not been successfully subjected to tolerating rigid braces for the shoulder and hip.
Everything possible must be done that will make for the patient's comfort. If the subject turns out to be a good self nurse, and the nature of the fracture is such that practical apposition of the broken ends of bone may be maintained, recovery will occur in some cases.
Inflammation of the Elbow.
(Arthritis.)
Affections of this articulation other than those which are produced by traumatism are rare. This joint has wide articular surfaces, and securely joined as they are by the heavy medial and lateral ligaments (internal and external lateral ligaments), luxation is practically impossible. When luxation does occur, irreparable injury is usually done. Castagné as quoted by Liautard[15], reports a case of true luxation of the elbow joint in a horse where reduction was effected and complete recovery took place at the end of twenty-five days. This is an unusual case. The average practitioner does not meet with such instances.
Anatomy.—The condyles of the humerus articulate with the glenoid cavities of the radius and a portion of the ulna. Two strong collateral ligaments pass from the distal end of the humerus to the head of the radius. The capsular ligament is a large, loose membrane which encloses the articular portion of the humerus with the radius and ulna and also the radioulnar articulation. It is attached anteriorly to the tendon of the biceps brachii (flexor brachii). The capsule extends downward beneath the origin of these digital flexors. This fact should be remembered in dealing with puncture wounds in the region, lest an error be made in estimating their extent and an open joint be overlooked at the initial examination.
Etiology and Occurrence.—Exclusive of specific or metastatic arthritis, which is seldom observed except in young animals, inflammation of the elbow joint is usually caused by injury. This articulation is not subject to pathologic changes due to concussion or sprains as occasioned by ordinary service, but is frequently injured by contusion from falls, blows from the wagon-pole and kicks. Wounds which affect the elbow joint, then, may be thought of in most cases, as resultant from external violence. They may be contused wounds or penetrant wounds. Sharp shoe-calks afford a means of infliction of penetrant wounds which may occasion open joint and infectious arthritis.
Classification.—A practical manner of classifying inflammation of the elbow is on an etiological basis. Eliminating the forms of elbow inflammation, such as are caused by metastatic infection and other conditions which properly belong to the domain of theory of practice, we may consider this affection under the classification of contusive wounds and penetrative wounds.
Symptomatology.—Any injury which is of sufficient violence to occasion inflammation of the elbow causes marked lameness and manifestation of pain. The degree of lameness and distress manifested by the subject, depends upon the nature and extent of the involvement. A contusion suffered as the result of a fall, which occasions a circumscribed inflammation of the structures covering this joint and where little inflammation of the articulating parts exists, marked evidence of pain and lameness might be absent. On the other hand, if a true arthritis is incited, there will be evident distress manifested, such as hurried respiration, accelerated pulse, inappetence, mixed lameness, local evidence of inflammation and particularly marked supersensitiveness of the affected parts. Considering these two extremes of manifested distress and injury, one may readily conclude that in the frequently seen case, wherein contusion has occasioned a moderate degree of injury, prognosis is favorable and recovery ordinarily follows in the course of a few weeks' treatment.
In cases of arthritis due to penetrative wounds (because of the important function of this joint and its large capsule, which when inflamed discharges synovia in a manner that closure of such an open joint is seldom possible) a very grave condition results.
Treatment.—Inflammation of the elbow, such as is frequently seen in general practice where horses are turned out together and exposed to kicks and other injuries, yields to treatment readily, if an open joint does not exist.
Hot packs supported in contact with the elbow and kept around the inflamed articulation for a few days, materially decrease pain and tend to reduce inflammation. The subject must be kept quiet in a comfortable stall and, if necessary, a sling used. Where it is impossible for the animal to support much weight with the injured member the sling should be employed.
As inflammation abates, which it does in the course of from one to three weeks in uncomplicated cases, the subject may be allowed the freedom of a comfortable box stall. Vesication of the parts is in order, and this may be repeated in the course of two weeks, if it is deemed necessary.
Penetrative wounds resulting in open joint are not treated with success as a rule, and because of the handicap under which veterinarians labor, methods of handling such cases, where large, important articulations are affected, are not being rapidly improved. Prognosis is usually unfavorable, and for humane and economic reasons, animals so affected should be destroyed.
Ordinary wounds of the region of the elbow are treated along general lines usually employed. They merit no special consideration, except that it may be mentioned that with such injuries concomitant contusion of the parts occasions injury that does not recover quickly.
Fracture of the Ulna.
Etiology and Occurrence.—Fractures of the ulna in the horse are not common in spite of the exposed position of the olecranon. This bone when broken, is usually fractured by heavy blows and any form of ulnar fracture is serious because of its function and position in relation to the joint capsule. Transverse fractures do not readily unite because of the tension of the triceps muscles, which prevent close approximation of the broken ends of the bone.
Thompson[16], however, reports a case of transverse simple fracture of the ulna in a mare, the result of a kick, in which complete recovery took place. He kept the subject in a sling for six weeks and then allowed six months rest.
Symptomatology.—The position assumed by a horse suffering from a transverse fracture of the ulna, is similar to that in radial paralysis. Crepitation may be detected by manipulating the parts, and in some instances of fracture of the olecranon, there occurs marked displacement of the broken portions of the bone. Lameness is intense and the parts are swollen and supersensitive. The capsular ligament of the elbow joint is usually involved in the injury because fracture of the ulna may directly extend within the capsular ligament. In such cases, there is synovitis, and later arthritis causes a fatal termination.
Treatment.—The impossibility of applying a bandage in any way to practically immobilize these parts in fracture of the ulna, prevents our employing bandages and splints. Therefore, one can do little else than to put the patient in a sling and try to keep it quiet and as nearly comfortable as circumstances allow.
Fracture of the Radius.
Etiology and Occurrence.—From heavy blows received such as kicks, collision with trees or in falls in runaway accidents, the radius is occasionally fractured. In very young foals, fracture of the radius, as well as of the tibia and other bones, results from their being trampled upon by the mother.
Symptomatology.—Excepting in some cases of radial fracture of foals where considerable swelling has taken place, there is no difficulty in readily recognizing this condition. The heavy brachial fascia materially contributes to the support of the radius, and in cases where swelling is marked, crepitation may not be readily detected. In fact, a sub-periosteal fracture may exist for several days or a week or more and then, with subsequent fracture of the periosteum, crepitation and abnormal mobility of the member are to be recognized. In such cases, the subject will bear some weight upon the affected member, but this causes much distress. In one instance the author observed a transverse fracture of the lower third of the radius which was not positively diagnosed until about ten days after injury was inflicted. In this case, without doubt, the subject originally suffered a sub-periosteal fracture of the bone and because the animal was a good self nurse, the brachial fascia supported the radius until the periosteum gave way and the leg dangled. In this instance infection took place and suppuration resulted. It was deemed advisable to destroy this animal.
Prognosis.—In adult animals, radial fracture constitutes a grave condition; generally speaking, prognosis, in such cases, is unfavorable. Because of the leverage afforded by the extremity, immobilization of the radius is difficult. Any sort of mechanical appliance, which will immobilize these parts, is likely to produce pressure-necrosis of the soft structures so contacted. There is occasioned thereby much pain and the subject becomes restive, unmanageable and sometimes the splints are completely deranged because of the animal's struggles, and much additional injury to the leg is done. Occasionally, an otherwise favorable case is thus rendered hopelessly impossible to handle, and the subject must be destroyed several days after treatment has been instituted.
Consequently, unless all conditions are good, and the affected animal a favorable subject, young, of good disposition, and the fracture a simple transverse one, complete recovery is not likely to result from any practical means of handling.
Treatment.—Mature subjects ought to be put in slings and kept so restrained throughout the entire time of treatment. Immobilization of the broken parts of the bone is the object sought. This is attempted by practitioners who employ various methods, and each method has its advocates.
Casts are used by some and serve very well in many cases; but because of their bulk and unyielding and rigid nature, they are not well adapted to use on fractures of bones proximal to the carpus and tarsus. This is in reference to plaster-of-paris casts or those of any similar material.
Appliances which depend on glue or other adhesive substances combined with leather, wood or fiber for their support, are efficacious but not comfortable.
The use of heavy leather when the member has been suitably padded with cotton and bandages, constitutes a very good manner of reducing fracture of the radius or of the tibia. Leather when cut to fit both the medial and lateral sides of a leg, and firmly held with bandages, will form a firm support that yields slightly to changes of position, thus making for comfort of the subject.
Such a splint or support should extend from the fetlock region to the elbow, but the cotton and bandages are to reach to the foot. When one considers that, with the supportive appliance placed on each side of the affected member, rigidity is accomplished as much from tensile strain put upon the leather as from its own stiffness, it is seen that the leather need not be of the heaviest—sole leather is unnecessary. Because of the more comfortable immobilizing appliance, the subject is less restive, and chances for a successful outcome are materially increased thereby.
In the mature subject, six or eight weeks' time is required for union of the parts to occur sufficiently so that splints may be dispensed with. Rearrangement of the supportive apparatus, however, is possible and usually necessary during the first few weeks of treatment. By employing care in handling the parts, the subject will be unlikely to do itself injury at the time readjustment of splints is being effected.
In foals, it is best to give them the run of a box stall with the mother. Being agile, they get up and lie at will without doing injury to the fractured member. The splints (leather is preferable in these cases also) are looked after and readjusted as necessity demands.
Three or four weeks time is all that is required for the average young colt to be kept in splints when suffering from simple transverse fracture of the radius.
Compound fractures are necessarily more difficult to treat than are the simple variety, but even in such cases recovery results sometimes, and the practitioner is justified in attempting treatment after having explained the situation to his client.
Oblique fractures, even when simple, do not completely recover. Muscular and tendinous contraction, together with the natural tendency for the beveled contacting parts of the broken bone to pass one another in oblique fracture, results in shortening of the leg and, if union results, a large callus usually forms. Where shortening of bones occur, necessarily, permanent lameness follows.
Wounds of the Anterior Brachial Region.
Etiology and Occurrence.—Contusions and lacerations of the forearm are of frequent occurrence in horses and are troublesome cases to handle; particularly is this noticeable where extensive laceration of the parts occurs. These injuries are caused by animals being kicked; by striking the forearm against bars in jumping; and in sections of the country where barbed wire is used to enclose pastures, extensive lacerated wounds are met with when horses jump into such fences.
Symptomatology.—Any wound which causes inflammation of the structures of the anterior half of the forearm, is characterized by swinging-leg-lameness. Depending upon the nature and extent of the injury, manifestation varies. In cases where laceration has practically divided all of the substance of the extensor tendons, it is, of course, impossible for the subject to advance the leg; but where lacerated wounds involve only a part of the extensor apparatus of the foreleg, not so much inconvenience is evident, unless the wound is seriously infected and inflammation involves contiguous structures. Therefore, in many instances, lameness is more pronounced in contusions of the anterior brachial region than where tissues have been divided more or less keenly.
In every instance diagnosis is easily established. The injury is quite evident, and the manner of locomotion is not in itself an essential feature to be considered in a discussion of symptoms. Where a contusion of the anterior brachial structures occurs, there is, in addition to lameness, swelling which is painful because of the pressure occasioned by the heavy non-yielding brachial fascia. And where suppuration occurs, there is then an intensely painful condition which is not relieved until pus has been evacuated. Rather frequently, drainage for wound secretions is a difficult problem, and approximation of the divided ends of muscles is always difficult to maintain.
Treatment.—Contused wounds of the anterior brachial region are treated along usual lines; that is, attempt is made to stimulate prompt resolution. Hot or cold applications are employed throughout the acute stage of the affection. Complete rest is provided for until all pain has subsided. Later, stimulating liniments are beneficial.
Where no injury is done the periosteum or bone, complete resorption of all products of inflammation usually occurs, though in many instances, this is tardy—six weeks or more are sometimes required for recovery to take place.
If suppuration occurs, it is necessary to provide for drainage as soon as it is possible to distinguish the presence of pus. Due regard is given the manner of establishing drainage because of the usual existence of sub-fascial fistulae. In these cases, one avoids injecting solutions of aqueous antiseptics. By gently compressing the parts, pus is caused to drain out and in enforcing a moderate amount of exercise at a walk, when lameness is not intense, drainage is maintained. Cotton packs, moistened with hot antiseptic solutions, and kept around the forearm for several hours daily, are helpful because drainage is facilitated, and resolution is stimulated by the increase of blood thus attracted to the parts, and pain materially diminishes.
In lacerated wounds of the anterior brachial region, after having controlled hemorrhage, an area around the wound margin is freed of hair by clipping or shaving. The wound is carefully examined, and the best site for drainage is selected and a suitable opening for wound discharge is provided for. Where the extensor carpiradialis (metacarpi magnus) with other structures, is divided and the distal portion is torn downward, as frequently is the case in barbed wire cuts, it is necessary to make careful provision for drainage. The wound is thoroughly cleansed by means of ablutions if necessary; but preferably by swabbing with pledgets of cotton or gauze which are moistened in antiseptic solutions. All shreds of macerated tissue are clipped with scissors and finally the whole wound surface is painted with tincture of iodin.
If drainage is made by cutting through the tissues in the median portion of the structures that have been displaced, the opening should be packed with gauze so that it may remain patent after swelling has occurred. Such packing is left in situ for twenty-four hours.
The pendant muscular portions of tissues are sutured up by means of tapes and, while perfect apposition is not ordinarily possible, it is very essential to train the pendant tissues in their normal position even if they require resuturing within a week. This minimizes granulation of tissue, and there results less scar if the detached portions are kept near, even if not in contact with the proximal wound margins. The skin together with subcutaneous fascia is sutured on either side unless drainage is to be provided for on one side, and the lowermost part of that side is left unsutured.
After-care.—Where extensive suturing of tissues has been necessary, subjects must be kept quiet. They are best confined in box stalls and not taken out for several weeks. Particularly is this true where transverse division of extensors has taken place. Sutures are removed at the end of from ten days to three weeks as cases permit. Drainage of wound secretions, which usually become infected, is necessary, because with obstructed drainage in an infected wound of this kind, there will result an early destruction of tissue at some point sutured. Daily irrigation done in a manner that practical asepsis is carried out, is necessary for about a week. All irrigation is done by way of the drainage opening, and this with warm aqueous solutions of suitable antiseptics. After a week or ten days' time, the wound should not be dressed more frequently than twice weekly.
If it is necessary to leave a portion of the wound uncovered, as in cases where skin is destroyed, the frequent (three or four daily) application of a suitable antiseptic powder is necessary to check exuberant granulation. This may be directly effected by the use of an astringent or desiccant preparation, and such dressing serves as a mechanical protection as well.
When such wounds are kept clean, where drainage is properly maintained, and the subject kept quiet, no particular attention other than the local application of an astringent lotion (such as the zinc and lead lotion) is necessary after the first three or four weeks. Usually, if the animal gnaws at the parts or otherwise manifests evidence of discomfort, it is an indication that new areas of infection are being established because of obstructed drainage or retained eschars. A thorough cleansing of the wound with a two per cent solution of Liquor Cresolis Compositus and this followed by moistening every part of the wound with tincture of iodin, will check all such disturbance if done promptly.
Where practically all of the anterior surface of the radius has been denuded, recovery is tardy and there is in some cases imperfect extension of the leg for months after the wound has healed. But in such instances, animals gradually regain complete use of the affected member and in the course of a year function is fully restored.
Inflammation and Contraction of the Carpal Flexors.
Anatomy.—The structures which are usually considered as true flexors of the carpus are a group of three muscles, which have separate heads of origin and different points of tendinous insertion.
The flexor carpiradialis (flexor metacarpi internus) originates from the medial epicondyle of the humerus. It is inserted to the proximal end of the medial metacarpal (inner metacarpal or splint) bone. This muscle is the smaller of the three and is not usually divided in doing carpal tenotomy.
The flexor carpiulnaris (flexor metacarpi medius) has two heads of origin; one, the larger, originates from the epicondyle of the humerus and the other from the posterior surface of the olecranon. The two heads unite at the upper third of the radius and the muscle, becoming tendinous, as is the case with the other carpal flexors, is attached by one point of insertion to the accessory carpal bone (trapezum). The other blends with the posterior annular ligament of the carpus.
The ulnaris lateralis (flexor metacarpi externus) has its origin from the lateral epicondyle of the humerus and inserts to the proximal extremity of the fourth metacarpal (outer splint) bone and by another attachment to the accessory carpal bone (trapezium) with the tendon of the flexor carpiulnaris (flexor metacarpi medius).
Acting together, these muscles flex the carpus or extend the elbow and this action is antagonized by the biceps brachii (flexor brachii) and extensors of the carpus and phalanges.
Etiology and Occurrence.—Inflammation of the muscular or tendinous parts of the carpal flexors, does not occur as frequently as does inflammation of the flexors of the extremity. They are subject to injury such as is occasioned by hard work and concussion and contract as a result; but, more frequently a congenital malformation of the leg is responsible for undue strain upon these parts. Horses that are "knee sprung" or that have a congenital condition where in the anterior line, as formed by the radius, carpal and metacarpal bones, is bent forward at the carpus, are subject to inflammation and contraction of the carpal flexors. When these flexors are contracted, the condition is commonly known among horsemen as "buck knee." In itself, inflammation of the carpal flexors is not a condition which is likely to prove troublesome, but because of carpal involvement (which is often present) the cause of the trouble remains, and inflammation of the carpal flexors recurs or becomes chronic and contraction of tendons results.
Symptomatology.—Inflammation of the carpal flexors, when acute and uncomplicated, is characterized by a painfully swollen condition of the affected tendons. No weight is borne upon the affected leg and the carpal joint is flexed. Mixed lameness is present. There is no difficulty encountered in arriving at a diagnosis because of the very noticeably inflamed parts.
Many fully developed cases of contraction of the tendons of the carpal flexors are observed where the condition has become established gradually and no lameness has resulted from tendinitis or carpitis. In some of these cases, subjects are stumblers and when they are carelessly handled or kept at fast work over irregular or hard roads, chronic carpitis with hyperplasia of the structures of the anterior carpal region results, owing to frequent bruising from falls.
Fig. 10—Contraction of carpal flexors, "knee sprung."
Where inflammation is caused by a puncture wound and subfascial infection occurs, there is evident manifestation of pain. No weight is supported by the affected member and because of the pressure, occasioned by the swollen muscles confined within the non-yielding brachial fascia, there exists marked supersensitiveness of the affected parts. Flexion of the elbow is avoided because contraction of the biceps brachii (flexor brachii) or the extensors, which are antagonists of the flexors of the carpus, tenses the carpal flexors and pain is thereby increased.
However, in most instances, the practitioner's attention is not directed to typical and uncomplicated cases, but to subacute or chronic inflammations which are often attended with contraction of the tendinous parts of the carpal flexors, and in such cases carpitis is present. Animals so affected have lost the rigidity which characterizes the normal carpal joint when the leg is a weight bearing member, and because of its sprung condition, the leg trembles when supporting weight.
Treatment.—Acute inflammation is treated by means of local application of cold or hot packs until the pain and acute stage of inflammation has subsided and later stimulating liniments are indicated. Absolute quiet must be enforced. Especially where the carpus is involved must the subject be kept quiet until all evidence of inflammation has subsided.
The application of vesicants or line-firing is beneficial in subacute inflammation of the tendons of the carpal flexors. Where contraction of tendons exists and no osseous or ligamentous change prevents correction of the condition, tenotomy is necessary. The reader is referred to Merillat's "Veterinary Surgery"[17] for a good description of the technic of this operation.
In all serious cases of inflammation of the carpal flexors, whether tenotomy has been performed or not, the subject needs a long period of rest subsequent to treatment. In fact, three or four months at pasture is necessary to permit of recovery and this where no congenital deformity has predisposed the subject to such affection of the flexors. Return to work must be gradual and the character of the work such as to enable the animal to become inured to service without a recurrence of the trouble if possible.
It follows then, that tenotomy, here as in other cases, is not practical from an economic viewpoint, unless the animal be of sufficient value to justify the long period of rest for recovery. Tenotomy is not of practical benefit unless ample time is allowed for regeneration of divided tendinous tissue.
Fracture and Luxation of the Carpal Bones.
Etiology and Occurrence.—Fracture of the carpal bones is of infrequent occurrence in horses and, when it does occur, it is usually due to injuries, and because of their nature (resulting as they generally do from heavy falls or in being run over by street cars or wagons), a comminuted fracture of one or more bones exists. The accessory carpal bone (trapezium) is said to be fractured at times without being subjected to blows or like injuries, but this is exceptional.
Luxations of the carpal joint are of rare occurrence, and very few cases of this kind are on record. Walters[18] reports a case of carpometacarpal luxation in a pony wherein reduction was spontaneous and an uneventful recovery followed. His reason for reporting the case, as he states, is its rarity.
Symptomatology.—Fractures of the carpal bones as they usually take place are diagnosed without difficulty. Because of their usually being comminuted, abnormal movement of the joint is possible. Such movement is not restricted and flexion of the leg at the carpus in any direction is possible. Crepitation is readily detected and frequently these fractures are of the compound-comminuted variety.
In fracture of the accessory carpal bone (trapezium) or in fracture of any other single bone when such exists, there is no increase in the movement of the joint. The accessory carpal bone may be readily manipulated and when fractured, its parts are more or less displaced. Recognition of fracture of any other single carpal bone must be done by detecting crepitation unless it be a compound fracture, whereupon probing is of aid in establishing a diagnosis.
Carpal luxation when present is to be recognized by finding the apposing carpal bones joined in an abnormal manner—that is, out of position. There is restricted or suspended function of the joint, and in the cases recorded, no difficulty has been experienced in making a diagnosis. The carpometacarpal portion of the articulation is the part which is usually affected.
Prognosis and Treatment.—There is no chance for complete recovery in the usual case of carpal fracture because of the fact that there results sufficient arthritis to destroy articular cartilage beyond repair. In the average instance, because of arthritis which persists for a considerable length of time, more or less ankylosis results. At best, one can only hope for partial recovery, that is to say, the member may regain its usefulness as a weight-supporting part, but because of restricted or abolished joint function, locomotion is more or less difficult. Exostoses, articular and periarticular, occur and the carpus usually becomes a large immobile articulation. There is danger of infection resulting in simple carpal fractures and, needless to say, in a compound-comminuted fracture of the carpus, infection usually occurs and a fatal outcome is probable.
When treatment is instituted, antiseptic precautions are taken in handling the compound fractures, and in any case immobilization of the parts is sought. Here, as has been previously pointed out, it is best to employ leather splints, so that a maximum degree of rigidity with a minimum of distress and inconvenience to the patient will result. The leg must be bandaged from the hoof upward, making use of a sufficient amount of cotton to ensure against pressure-necrosis. The leather splints are placed mesially and laterally and, of course, need to extend as high as the proximal end of the radius. Subjects must be kept in slings until union of bones has become established, and as a rule there will then exist marked ankylosis.
There is no particular difference in the handling of carpal luxation and dislocation of other bones. Where ligaments have not been destroyed to the extent that reduction is of no practical use, the parts are kept immobilized, if thought necessary. Later, vesication of the whole pericarpal region is done and the subject allowed exercise at will.
Carpitis.
Etiology and Occurrence.—Inflammation of the carpus is caused by contusions, such as are occasioned in falling, by kicks by striking the carpus against objects in jumping and sometimes by striking it against the manger in pawing. The condition is of rather frequent occurrence.
Symptomatology.—Evident symptoms of inflammation in carpitis are always present—hyperthermia, supersensitiveness and swelling. Also, there exists lameness which is characterized by an apparent inability to flex the leg, and there is circumduction of the leg as it is advanced because in this way little if any flexion of the carpus (which increases pain) is necessary.
Depending upon the nature of the cause, there occurs a marked difference in the character and amount of swelling.
Fig. 11—Pericarpal inflammation and enlargement due to injury.
Naturally, when much extravasation of serum and blood takes place, there is occasioned a fluctuating swelling which is usually less painful to the subject upon manipulation than is a dense inflammatory change without marked extravasation.
In acute carpitis, there is present, then, a very painful condition which involves the articulation, causing marked lameness, disturbance of appetite and some elevation of temperature.
Chronic cases do not occasion serious pain or constitutional disturbances, but do interfere with locomotion in direct proportion to the existing articular inflammation and periarticular hypertrophy of ligamentous and tendinous structures.
Treatment.—If possible, keep the subject absolutely quiet, employing the sling if necessary. During the first stages of inflammation, the application of ice packs to the affected parts, is of marked benefit. At the end of forty-eight hours, hot applications may be used and this treatment continued throughout several days. Anodyne liniments are of service and should be employed throughout the acute stage of inflammation during intervals between the hydrotherapeutic treatments.
As inflammation subsides, a counterirritating application such as a suitable liniment and later blistering or line-firing is helpful in stimulating resolution.
Fig. 12—Hygromatous condition of the right carpus, also distension of sheaths of extensor tendons of both fore legs.
Open Carpal Joint.
Anatomy.—The carpal bones as they articulate with one another and with the radius and metacarpal bones, as classed by anatomists, form three distinct articular parts of the joint as a whole and are known as radiocarpal, intercarpal and carpometacarpal. These three pairs of articulating surfaces are all enclosed within one capsular ligament. On the anterior face of the bones, the capsular ligament is attached to the carpal bones in such manner that an imperfect partitioning of the three joint compartments is formed. Posteriorly, the capsule is very heavy and forms a sort of padding over the irregular surfaces of the bones, and also its reflexions constitute the sheaths of the flexor tendons. The anterior portion of the capsular ligament forms sheaths for the extensor tendons, and both portions of the joint have an attachment around the distal end of the radius and another at the proximal end of the metacarpal bones.
Fig. 13—Carpal exostosis in aged horse.
Etiology and Occurrence.—Puncture wounds of any kind may serve to perforate the joint capsule and such traumatisms are occasioned by falls, kicks and in various ways in runaway accidents, and open carpal joint may follow.
Symptomatology.—The pathognomonic symptoms of the existence of an open joint is the exposure to view of articular surfaces of bones or noting the escape of synovia from the joint capsule. As has been previously referred to, there always exists a peculiar suspension of carpal flexion in all cases of carpitis.
Non-infective wounds which may cause open joint are not necessarily productive of an active carpitis—a synovitis may be the extent of the disturbance. Unlike synovitis, which may characterize a non-infectious penetrative wound of the capsular ligament, septic arthritis which may supervene is a very painful inflammatory disturbance. It is characterized by all of the symptoms which attend the case of open joint and synovitis plus the obvious manifestation of great pain. There is an elevation of temperature of from two to five degrees above normal; circulation is accelerated; the pulse is bounding; respiration is hurried; there is an expression of pain as indicated by the physiognomy; and because of rapid erosive changes of cartilages which take place, there is soon so much of the articulation destroyed that death is inevitable. Death is usually due to generalization of the arthritic infection.
| Fig. 14—Exostosis of carpus resultant from carpitis. |
Fig. 15—Distal end of radius. Illustrating the effects of chronic carpitis. |
In the meanwhile, if the character of the infectious material is not so virulent, the disease will take on a slower course and the subject may experience laminitis from supporting weight upon the sound member, or because of continued recumbency, decubital gangrene and emaciation sometimes cause death. If the subject does not soon succumb, it is compelled to undergo days or even weeks of unnecessary suffering, and too often in such cases, it is later deemed advisable to destroy the animal because of the cost of continuing treatment until the horse is serviceable. Therefore, it is evident that when such joints as the carpus or tarsus are open and infection exists, if they are not promptly treated and the infectious process checked, it is neither humane nor practical to prolong treatment.
Distinction must be made between the different joints when infected as the condition is much more serious in some cases than in others. All things considered, perhaps open joints rank, with respect to being serious cases as follows: elbow, navicular, stifle, tarsus, carpus, fetlock and pastern. This, of course, is restricted to articulations of the locomotory apparatus.
Treatment.—Preliminary care in the treatment of an open carpal joint, is the same as has been described in this condition as it affects the scapulohumeral articulation described on page 65. Likewise the further treatment of such cases is along the same lines except that where it is possible, the parts are kept covered with cotton and bandages. However, in some cases, animals have been successfully treated without bandaging and by keeping the patient in a standing position and on pillar reins until recovery resulted. Such cases were of the non-infectious type and recovery was possible within three or four weeks. Further, the condition is not sufficiently painful in such instances as to prevent the subjects bearing weight with the affected member; hence, no danger of resulting laminitis is incurred. And finally, where bandages are not employed, the frequent use of antiseptic dusting powders is substituted for cotton as a protector.
When bandaged, such wounds need dressing more or less frequently, as individual instances demand. The purulent infective inflammation of a carpal joint will require daily dressing; whereas, in other cases (non-infective), semi-weekly change of bandages is sufficient. Equal parts of boric acid and exsiccated alum constitute a suitable combination for the treatment of these cases, and this powder should be liberally employed. Tincture of iodin may be injected into the joint capsule where there is provision for its ready evacuation, as conditions seem to require. Daily injections for three, four or five days, are not harmful and will control infection in many instances.
Thecitis and Bursitis.
Etiology and Occurrence.—The thecae and bursae of the leg are several in number. In the carpal region, the flexors of the phalanges are contained together in the carpal sheath, and this is the principal theca in the carpal region. Each of the tendons is provided with synovial sheaths which are subject to inflammation and occasionally synovitis and distension of these synovial sheaths occur.
Because of faulty conformation, some animals are subject to inflammation of these sheaths, and all forms of strenuous work which taxes the tendons greatly is apt to result in synovitis. Direct injury such as blows may be the cause of synovial distension of thecae and the affection is to be seen in all horses that have done much fast work on hard road surfaces or pavements.
The usual case as it occurs in practice is a non-infective synovitis, but where puncture wounds cause the trouble, an infectious inflammation obtains.
Symptomatology.—No trouble is experienced in diagnosing distension of tendon sheaths, for the affection is very palpable. During acute inflammatory stages of this affection, some lameness is present—in infectious inflammation lameness is intense. Local heat and pain upon manipulation are readily discernible in all acute cases. And finally, where there is reason for doubt, an aseptic exploratory puncture of the wall of the fluctuating enlargement may be made with a suitable trocar, and the discharging synovia will be proof of the existence of synovial distension.
After the affection becomes subacute or chronic, no lameness or inconvenience is manifested, and the condition is undesirable only because of its being a blemish.
Treatment.—Acute non-infectious synovial distension of tendon sheaths is treated by aspirating as much synovia as possible from the affected theca (this is, of course, done under strict asepsis) and by means of bandages, a uniform degree of pressure is kept over the parts for ten days or two weeks. The patient is kept quiet and in the course of two weeks an active blistering agent is employed over the region affected. Usually, at the end of a month's time, complete recovery has taken place and the subject may be gradually returned to work.
When synovial distensions are of long standing, it is necessary to take special precautions to check excessive secretion of synovial fluid, and, also because of the atonic condition of the tissues affected, resolution is tardy. In addition to aspirating synovia, the introduction of equal parts of alcohol and tincture of iodin into the theca is necessary. The quantity of this combination injected, depends upon the size of the sheath affected and the amount of synovia retained at the time injection is made. Experience is necessary to judge as to this part of the work, but one may consider that a quantity between three and ten cubic centimeters of equal parts of tincture of iodin and alcohol constitutes the proper amount to employ. Where much synovia is contained within the sheath at the time of injection, there occurs great dilution of the agent injected and consequently less irritation results.
The object of such injections is to check synovial secretion, and this is sought by the local effect of iodin in contact with the secreting cells together with the reactionary swelling which occasions pressure. An increase in the local blood supply also follows. In all cases where it is possible to employ suitable bandages, this should be done. The ordinary derby bandages serve well and if their use is continued for a sufficient length of time, good results follow.
There are other methods of treating these affections, and each has its advantages and disadvantages. Line-firing, instead of the vesicant is made use of by some, but the object desired is the same and results obtained are similar.
Sheaths may be opened surgically by means of a knife, and the removal of a portion of the wall of distended and atonic tendon sheaths is possible. These operations belong to the realm of surgery and are not properly a part of this treatise. However, in passing, it may be said that if a perfect technic is possible in doing the last named operation, a permanent recovery is the outcome.
Fracture of the Metacarpus.
Etiology and Occurrence.—As the result of all sorts of violence, such as falls and injuries in accidents of various kinds wherein the metacarpals are subjected to contusions, fractures may result. In the horse it is unusual for fracture of one of the small metacarpal bones to take place without there being at the same time a fracture of the third (large) metacarpal bone.
Classification.—Fractures of the metacarpal bones as they occur, are as likely to be compound as simple, and the multiple and comminuted varieties are occasionally observed. The manner in which the third (large) metacarpus is fractured, largely determines the outcome in any given case.
Symptomatology.—Abnormal mobility of the broken parts of bone and crepitation mark fracture of the metacarpus, and the condition is easily diagnosed. In many instances, when compound fracture exists, broken ends of bone are protruding through the skin. No weight is borne upon the fractured member ordinarily, although during the excitement occasioned by runaways, horses are sometimes seen to support weight with a broken leg even when the protruding bone is sunk into the ground in so doing.
Prognosis.—Generally speaking, fractures other than the simple-transverse in young animals, are considered unfavorable cases. With the metacarpus, however, there are instances where compound fracture occurs in colts that justify treatment. But in all cases of compound fracture, the element of infection in addition to the increased difficulty in maintaining immobility of the broken bone, creates almost insuperable difficulties in the average instance. And unless the practitioner distinctly explains to his client the various reasons which make treatment an economic impracticability, dissatisfaction is likely to follow if treatment is instituted without such an understanding.
Treatment.—Perfect apposition of the broken ends of bone is easily effected and less difficulty is encountered in maintaining such relations in metacarpal fractures than in fractures of the radius. However, reduction and immobilization of this as in all fractures, must be done without delay. In simple fracture, the metacarpus is covered with enough cotton to pad the parts, and this is retained in position by bandages. Splints of heavy leather or of thin pieces of tough flexible wood are placed on each side of the leg and firmly held in position with bandages. Bandages may be put on in layers and a coating of glue applied over each layer if this is thought necessary. The advantage gained in using glue or other adhesive materials is that the cast thus formed is more rigid than where such material is not employed. On the other hand, all elasticity is lost as soon as the cast adapts itself to the contour of the extremity, and because of this rigidity, it is doubtful if anything is gained by the incorporation of glue, except in the way of added strength of the cast. Since the animal does not walk upon the broken leg, it is possible to employ splints of suitable materials which are retained in position without glue and frequent readjustment of a part of the immobilizing apparatus is possible. This is impossible with casts.
In compound fractures, provision ought to be made for dressing the wound of the soft structures. This entails adjusting the splints in such manner that one splint may be retained and others removed for dressing the wound and readjusted as often as wound dressing is necessary.
Splints.
By this term is meant a condition where there exists an exostosis which involves usually the second (inner small) and third (large) metacarpal bones. While an exostosis involving any one of the splint bones, even when directly caused by an injury, is called a "splint," the term is employed here, in reference to exostoses not due to direct injury such as in contusions.
Etiology and Occurrence.—This condition is one wherein there is osseous formation following a periostitis and the region of the upper portion of the second (inner small) metacarpal bone is the usual site of the exostosis. There is incited an inflammation of the periosteum at the site of the interosseous ligament which attaches the small to the large metacarpal bone. This ligament is involved in the inflammatory process, and according to Havemann, whose view is supported by Moller, this inflammation is the origin of the trouble.
Various theories attempting an explanation of the frequent affection of this one certain part so regularly involved have been offered, but no proof of the correctness of any exists. It follows, however, that splints occur in young animals; that the affection seldom starts in subjects that are ten years of age or older, and that when the exostosis has formed, lameness usually subsides. Anything which will cause undue strain or irritation of the metacarpal bones in young animals, is quite apt to result in a splint being formed. Concussion such as is caused by fast work on hard roads, or work on rough or irregular road surfaces which cause unequal distribution of weight, will cause splint lameness and exostosis follows.
Fig. 16—Posterior view of radius (right) illustrative of
effects of splint. Note the extent of exostosis.
Course.—Because of the peculiar manner in which the second and third metacarpal bones articulate in young animals, until the bones become ossified and permanently joined, the inflammation which attends the acute stage of this affection, causes lameness. Later, unless an unusually large exostosis is formed, which may cause a constant irritation due to its size and juxtaposition to the carpus, lameness is discontinued.
Symptomatology.—Lameness is usually the first manifestation of this disorder, and the thing which characterizes splint lameness is its peculiar intermittence. There is a mixed form of lameness which may not be in evidence when an affected animal is started on a drive, but which is marked after the subject has gone some distance. The animal may, however, go lame throughout the whole of a drive and continue to be lame for several days or weeks in some cases. It is noticeable that lameness is augmented or produced when the subject travels on rough road surfaces and that little or no difficulty is encountered when roads are smooth.
The heavy brachial fascia is inserted in part to the head of the second metacarpal (inner small) bone together with the oblique digital extensor (extensor metacarpi obliquus) and this explains the reason for pain being manifested during extension of the member.
Before there is a visible exostosis, supersensitiveness is readily recognized upon palpation of the parts, if careful comparison is made between the sound and unsound members. However, frequently splints occur on both forelegs at the same time and in some instances exostoses are several in number upon each member affected. In some instances, the affection involves the outer splint bone and no evident involvement of the inner one exists.
Treatment.—At the onset complete rest should be provided and the local application of some good cataplasm is in order. A stimulating liniment is beneficial when employed several times daily and massage is also quite helpful. Later, the application of a blistering ointment is good treatment. The use of the actual cautery stimulates prompt resolution, but there is seldom any resorption of products of inflammation following firing. Whereas, in cases where other treatment is begun early, there usually follows considerable diminution in the size of the exostosis. A rest of four or five weeks is necessary and very young animals should not be put to work too soon, if the character of the work is such as to induce a recurrence of the trouble.
Many cases are treated successfully in draft types of animals (where the subjects are not kept at work that occasions serious irritation to the affected parts) by blistering the exostosis repeatedly and allowing the animals to continue in service. In such cases, it is unreasonable to expect to check the size of the exostosis and, of course, such methods are not employed where lameness causes distress to the subject.
Firing usually causes prompt recovery from lameness and is a dependable manner of treating such cases but there remains more blemish following cauterization than where vesication is done.
OPEN FETLOCK JOINT.
This condition, because of the frequency with which it occurs may be taken as typal, from the standpoint of treatment and results obtained therefrom. While it serves to constitute a basis from which other joints, when open, are to be considered, due allowance must be made for the fact that, as has been previously mentioned, some articulations when open constitute cause for grave consequences; while with others an open capsule, even when infected, does not cause disturbance enough to be classed as difficult to handle. Moreover, the fetlock joint is admirably suited, anatomically, to bandaging; and when wounded, is easily kept protected by means of surgical dressings. This fact is of great importance in influencing the course and termination in any given case of open fetlock joint and should not be forgotten.
There is no logical reason for comparing the pedal joint with the pastern on the basis that it may also be completely and securely bandaged. Open navicular joint does not occur, as a rule, except by way of the solar surface of the foot, and the introduction of active and virulent contagium is certain to happen; consequently, an acute synovitis quickly resulting in an intensely septic and progressively destructive arthritis soon follows in perforation of the capsule of the distal interphalangeal articulation.
Etiology and Occurrence.—Wounds of the fetlock region resulting in perforation or destruction of a part of the capsular ligament are caused by all sorts of accidents, such as wire cuts, incised wounds occasioned by plowshares, disc harrows, stalk cutters and other farming implements. In runaways the joint capsule is sometimes punctured by sharp pieces of wood or other objects. In horses driven on unpaved country roads the fetlock is occasionally wounded by being struck against the sharp end of some object, the other end of which is firmly embedded in the ground. In one instance the author treated a case wherein the fetlock joint was perforated by the sickle-guard of a self-binder. In this case there occurred complete perforation causing two openings through the cul-de-sac of the joint. Such wounds are produced by implements which are, to say the least, non-sterile, and this perforation of the uncleansed skin conveys infectious material into the joint capsule. Yet in many instances, especially in country practice, no infectious arthritis results where cases are promptly cared for.
Symptomatology.—A difference in the character of symptoms is evidenced when dissimilar causes exist. Small penetrant wounds which infect the synovial membranes cause infectious arthritis in some cases, whereas a wound of sufficient size to produce evacuation of all synovia will, in many instances, cause no serious distress to the subject, even when not treated for several days. If it is not evident that an open joint exists and the articular cavity is not exposed to view a positive diagnosis may be early established by carefully probing the wound. In some cases where a small wound has perforated the joint capsule, swelling and slight change of relation of the overlying tissues may preclude all successful exploratory probing. In such instances it is necessary to await development of symptoms. Twenty-four hours after injury has been inflicted, there is noticeable discharge of synovia which coagulates about the margin of the orifice, where synovial discharge is possible. Particularly evident is this accumulation of coagulated synovia where wounds have been bandaged—there is no mistaking the characteristic straw-colored coagulum which, in such cases, is somewhat tenacious.
No difference exists between other symptoms in infectious arthritis caused by punctures, and non-infectious arthritis, excepting the intensity of the pain occasioned, the rise in temperature, circulatory disturbances, etc.; all of which have been previously mentioned.
Treatment.—Just as has been stated in discussions on the subject of open joint, probing or other instrumentation is to be avoided until the exterior of the wound and a liberal area surrounding has been thoroughly cleansed—too much importance can not be placed on this preliminary measure. In cases of open joint where ragged wound margins exist and the interior of the joint capsule is contaminated, much time is required to thoroughly cleanse all soiled parts. In some instances an hour's time is required for this cleansing process after the subject has been restrained and prepared. In order to thoroughly cleanse these delicate structures without doing them serious injury, one ought to be skillful and careful in all manipulations of the exposed parts of the joint capsule.
The general plan of treatment, after preliminary cleansing has been accomplished, has been outlined on page 66 in the consideration of scapulohumeral joint affections. The injection of undiluted tincture of iodin in ounce quantities, it must be remembered, is not to be done unless there is provision for its free exit. Where good drainage from the joint cavity exists all infected wounds should be thus treated, and this treatment may be repeated as conditions seem to require—until infection is checked.
If daily injections are necessary, dilution of the tincture of iodin with an equal amount of alcohol is advisable in order to avoid doing irreparable damage to the articular cartilages and synovial membranes.
An antiseptic powder composed of equal parts of boric acid and exsiccated alum is employed to protect the wound surfaces and the margins, and the parts are then bandaged. In bandaging wounds of this kind a liberal amount of cotton should be employed, and after a large surface surrounding the wound has been thoroughly cleansed, it must be so kept thereafter. This is impossible, if one uses a small amount of cotton, particularly if such meager quantity of dressing material is carelessly wrapped in position with an insufficient amount of bandage material. Mention, without description of the elemental problem of applying cotton and bandages to a wound, would be sufficient, were it not that this is a very important part of the handling of such cases, and many practitioners are not only thoughtless in this part of their work, but also apparently careless. What does it profit to prepare a part and cleanse a wound with painstaking care and then neglect to take every possible precaution to prevent its subsequent contamination?
In the handling of open joint capsules where the perforation of the capsular ligament is small and discharge of synovia does not immediately follow, there is presented a problem which is difficult to decide upon and that is the manner in which such wounds are to be handled. One hesitates to enlarge such openings to drain or irrigate the capsule when there is no proof that serious trouble will follow because of infectious material which has probably been introduced at the time the wound was inflicted. It is especially difficult to decide upon the manner of handling such cases where the tarsal joint is wounded, although one hesitates to invade any joint to the extent of incising its capsule, unless there is urgent need of so doing.
Frost[19] offers the following suggestion in such instances: