Surgical diseases of the skeletal system

Inflammations of the skeletal system

The skeletal system may be the site of in­flammatory disease in any of its parts. The proper prefix with the suffix -itis designates the part involved.

Osteitis is inflammation of bone. Myelitis means inflammation of the bone marrow. Chondritis is inflammation of cartilage. Arthri­tis is inflammation of a joint or joints. Synovitis is inflammation of a synovial membrane of a joint. Bursitis means inflammation of a bursa. Epiphysitis is inflammation of an epiphysis. In many cases the inflammation involves more than one part, such as osteochondritis or osteo­myelitis.

Any of the inflammatory diseases of the skeletal system may be acute or chronic. They may be initiated by any of several causes; namely, infection, injury, toxins or chemicals, mechanical, or those of unknown cause.

Acute osteomyelitis is an acute infection of the bone marrow and bone. It may develop any place in the body but occurs most com­monly in the long bones, appearing most com­monly in childhood and adolescence. The in­fecting germ is usually a specific type. The process generally begins in the marrow, gain­ing entrance to the marrow cavity by the blood stream from infections in other parts of the body; it then extends to the cortex. In other in­stances it may follow slight injury to a bone, or may be a complication of a compound frac­ture wherein the bone is exposed.

In essence, acute osteomyelitis is an abscess forming within a bone. In the natural course of events the abscess would erode through the bone and surrounding soft parts to open and drain to the surface. More often, however, in­cision for drainage must be done by the surgeon. The infected cavity contains dead bone tissue which does not readily liquefy for drainage.

The dead bone is called sequestrum. In this type abscess healing does not take place as readily because the cavity cannot collapse and scar to­gether. Nature’s attempt at repair is by new bone formation to fill the cavity. This may be a rather slow process and the new bone may surround a sequestrum so that the disease proc­ess recurs. This then is called chronic osteo­myelitis.

Treatment of the acute form of osteomyelitis is by the use of the recently discovered drugs which kill germs. Since the advent of sulfa drugs and penicillin, the disease is far less com­mon. In cases refractory to these drugs, and in neglected cases, surgical incision and drain­age of the abscess may be required. In the chronic form of the disease all of the infected dead bone fragments must be removed before healing can take place. In this operation, called sequestrectomy, a shell of bone is removed over the abscess cavity and by chiseling and curetting (scraping) the cavity is hollowed out into a broad shallow concavity; this is called saucerization. Muscle may be used to help fill the space of the cavity. The skin may or may not be closed; if not it may be grafted later. When osteomyelitis develops from a compound fracture, treatment is essentially the same ex­cept that the fracture must be treated in addi­tion.

Tuberculosis is a chronic infectious disease most often of the lung, but it may spread to al­most any other tissue of the body. Tuberculosis of the bones and joints is not uncommon. The disease process is similar to other bone infec­tions except that here many small abscesses may form. Tuberculosis of the spine is known as Pott’s disease; another common site is tuber­culosis of the hip joint. As with all forms of this chronic disease, rest is essential along with other supportive measures. The bone must be maintained in optimal functional position. In the case of spinal tuberculosis, operation to fuse the spinal column in one position is frequently used; this may be done by a bone graft, fre­quently taken from the tibia. Postoperative care must be precise and may be over a long period of time.

Bursitis is an inflammation of the small fluid- filled sacs between bones, tendons, and muscles. The inflammation may be due to injury or in­fection or constant irritation. It may be acute or chronic. Excessive fluid is formed in the bursa. A typical example is “housemaid’s knee” (patellar bursitis). When bursitis is prolonged, calcium deposits may occur within the sac or bone spurs may form. Treatment is by several means. In some forms x-ray treatment will be curative. Aspiration of the fluid with inject­ing mcdication will bring relief in others. In still others, especially those associated with bone spur, operation with removal of the bursa sac will be necessary. Rest and elimination of irri­tation are essential in all cases.

Most other forms of inflammation of the skeletal system are treated by medical measures.

Tumors of the skeletal system

The skeletal system may be involved with a variety of tumors. These may be benign or malignant and may develop at any site. The term osteoma literally means bone-tumor and usually designates the benign type; chondroma is tumor of cartilage; osteochondroma is a tu­mor composed of both bone and cartilage; osteo­sarcoma is a malignant bone tumor.

In the diagnosis of bone tumors, x-ray studies are a most important tool.

Benign tumors of bone are rather common, but usually are not of import unless they de­velop symptoms, interfere with joint motion, are painful, impair weight-bearing, or are pro­gressively enlarging. Benign tumors, therefore, sometimes may require removal by operation. Often biopsy to determine benignancy or ma­lignancy will be necessary.

Malignant tumors of bone may develop pri­marily from the bone or they may be spread from malignancy in other parts of the body. Many of the primary tumors will necessitate amputa­tions. All require wide excision. Tumors of bones which are metastases from cancers of other organs are often multiple. Any bone may be involved; the ribs, pelvis, and spinal column are common sites. Spread may be from cancer primary in any organ; the breast, prostate, thy­roid, and kidney are common parent organs. Rarely is surgical removal of these secondary cancers indicated. X-ray therapy and hormonal treatment may help to control the symptoms of spread of the tumor.

Joint mice are loose bodies found in joints. They are actually small bone particles which most often have developed during chronic in­flammation. They may be attached at first, but then break off to lie free in the joint. They cause symptoms when they slip between the bones. There may be locking of the joint; manipula­tion for reduction may be necessary. The knee is commonly involved. Arthrotomy (operation on joint) may be necessary for permanent relief.

Metabolic diseases of the skeletal system 

Diseases due to hormonal disturbances, such as of the parathyroid glands, have been men­tioned in other posts.

During the complex processes of development of the skeletal system in the embryo and fetus, certain malformations may ensue. A great variety arc known; the commoner ones are presented here.

Congenital dislocation of the hip is one of the most frequent deformities. In this malforma­tion the head of the femur does not rest within the socket (acetabulum) of the pelvis. It may in­volve both hips but more often just one. When detected early, treatment is simpler, but often it is not apparent until the child starts to walk. Un­less the dislocation is reduced there is a limp, and other deformities, such as curvature of the spine, develop as the child grows. Treatment in the early stages is by reduction without open operation and maintaining the correction by any of several type casts, slings, dressings, and frames. In older children (usually five or over) open operation is most often necessary. The femur is replaced into its socket if possible, or a new socket is devised; a cast is necessary post- operatively. In any method of treatment the position must be retained for long periods of time with gradual return of the lower extremity to its normal attitude, and gradual rehabilitation in walking.

Clubfoot may be a deformity of one foot or both. It is thought to be due to malposition in the womb or arrested growth of the bones, liga­ments, and tendons. Clubfoot is scientifically called talipes. Four specific abnormal attitudes of the foot occur. These are designated by nomenclature which describes the exact posi­tion:

• Talipes equinovarus—sole turns inward with heel elevated.
• Talipes equinovalgus—sole turns outward with heel elevated.
• Talipes calcaneovarus—sole turns inward with ankle turned upward.
• Talipes calcaneovalgus—sole turns outward with ankle turned upward.

Any degree of any type clubfoot may occur. The deformity may be recognized soon after birth, and when treatment is instigated at this early age there usually results a complete cure. At later ages treatment is much more formidable.

Treatment at an early age entails manipula­tion, strapping, and casting. Often a series of casts is used, or casts may be modified by cutting and wedging to change their position. In gen­eral, the foot is maintained in an overcorrected position for a definite period of time dependent on the degree of deformity and the age of the child. Other very minor deformities may be treated by massage and tendon-stretching ex­ercises.

If a minor clubfoot is recognized when the child begins to walk, exercises in the form of “games” played with the child, or corrective shoes, may be all that is necessary. In other cases the correction of position may be done forcibly under anesthesia with application of cast; a walking cast may be used.

Open operation may be necessary in those late cases where the above methods are not cor­rective. Various procedures are used in which ligaments and tendons are severed and bone structures altered; tendon lengthening techniques are often used. Casts are employed after opera­tion.

No matter what the method of treatment, continued re-examination and x-ray treatment are necessary. Exercises, physiotherapy, and/or corrective shoes may be utilized for complete restoration of the foot to normal position and function.

Spina bifida is the condition of incomplete formation of the spinal column’s canal for the spinal cord. Frequently it is associated with meningocele or meningomyelocele.

Other congenital defects of the skeletal sys­tem occur in numerous forms, none of which, fortunately, is common. Various parts may be completely missing (aplasia), such as the skull, clavicles, extremities, or digits of extremities. Other organs or parts may be formed in marked disproportion to the size of the rest of the body, either excessively large (hyperplasia) or small (hypoplasia). In some instances excessive parts are formed, such as supernumerary (above­number) fingers and toes. Other parts may be abnormally joined, such as web-fingers. Many such abnormalities are correctable or improved by operative methods, especially those where there are excessive parts or enlarged parts.

Acquired defects of the skeletal system 

As the result of certain diseases of the skeletal system and related systems, various deformities may be acquired. Some of these will be im­proved by operative techniques in conjunction with supportive measures. Of primary concern are function of the parts and comfort, second­arily esthetic or cosmetic aims.

Poliomyelitis, or infantile paralysis, fre­quently results in paralytic deformities. This dis­ease can destroy nerve cells of the spinal cord, which produces paralysis of the muscle groups supplied by the cells. It affects children of all ages as well as adults. Most commonly involved are the arm and leg muscles, but any part may be involved to any degree. A flaccid type of paralysis can occur, producing a frail limb.

Initial treatment of polio is by repeated ap­plication of hot packs and other means to reduce painful muscle spasm, followed by untiring and diligent re-education of the involved muscles as soon as the patient’s condition allows. In the early stages of the disease, when paralysis be­comes evident, attempts are made to prevent deformity development by splints, braces, and casts which protect weak muscles and hold the involved part in optimal position. After the acute stage, many of the physical therapy methods may also be employed with beneficial results. These therapy methods may be continued as long as there are signs of im­provement, in many cases up to two years, after which time little improvement is to be expected.

In many cases of deformities acquired through polio, operative methods may be utilized to eliminate or minimize the necessity for support­ing apparatus, and for maximal function. Many different operative procedures are used; in effect, each case dictates specific and different require­ments according to the deformity and its degree. In frail and unsupported joints better function is often obtained by producing an artificial fixa­tion of the joint, called ankylosis, by the opera­tion arthrodesis. Tendons may be transposed or transplanted to other areas so that normal mus­cles may be utilized to act in place of paralyzed ones. Casts, slings, braces, and splints may be used in the postoperative period, and again physical therapy techniques in rehabilitation.

Torticollis or wryneck is a condition where the head is inclined to one side with limited movement due to shortening of the neck muscles on a side. This is frequently due to injury at the time of childbirth, with bleeding into the muscle; this causes scarring of the muscle with loss of normal elasticity and loss of ability to contract. This deformity may lead to distortion of the face as well as the neck.

If the condition is recognized early, conserva­tive measures of massage and heat and carefully supervised passive exercises to stretch the in­volved muscles may obviate permanent deform­ity; other physical methods may be prescribed. In later stages, little benefit is derived from these methods. Surgery will be corrective to various degrees in the late case. This entails sectioning of the involved tight muscle (sterno- cleido-mastoideus) at its scarred portion, most often the lowermost attachments. Corrective casts and physical therapy may be employed postoperatively.

Spinal curvatures may be the result of many different skeletal and muscular abnormalities. Such deformity may be of three types to any degree. Kyphosis, or hunchback, is an exaggera­tion of the thoracic curvature of the spinal column; always associated is “stoop shoulders,” often progressive with age. This abnormal spinal curvaturc is most often caused by faulty posture in early childhood and youth which may be due to excessive fatigue, self-conscious attitudes, faulty school chairs, and malnutrition. Disease may also produce this deformity.

An exaggeration of the lumbar curvature of the vertebral column is called lordosis, or hol- lowback. This is often associated with other skeletal diseases as well as with visceral diseases.

Curvature of the spine in a sideward manner is known as scoliosis. This may take place at any level to any degree and to either side. Most often there is acquired an associated second curvature at a different level to a similar degree to compensate for the initial side curvature so that the individual may balance himself for walking and maintaining the upright position. The initial spinal deviation in alignment may be from any of several causes: shortening of one of the legs from any cause, tilted pelvis, spinal arthritis, fractures, spinal tuberculosis, infantile paralysis, chest diseases, and malignant disease.

Frequently spinal curvatures and rotations are improved by postural instructions and exercises. Others may require more active measures as body casts and braces. In most cases improve­ment may follow correction of a primary de­formity. Advanced spinal curvatures, particu­larly those which are progressive and those of younger persons, may be corrected by operation, usually spinal fusion; casts and braces and phys­ical therapy may be necessary in the postopera­tive care.

Rickets, or rachitis, is primarily a medical disease but may require orthopedic measures. It is a deficiency disease with failure of normal growth and development of the bones. The de­ficient element is vitamin D. Not only may there be this dietary lack but lack of sunshine can lead to rickets, since exposure to ultraviolet light forms vitamin D in the pigment layers of the skin. Various deformities result. Common are “bowlegs,” “knock-knees,” and kyphosis.

In the early stages of the disease the deficiency must be corrected by proper diet and supple­mentary vitamin D and ultraviolet light. Casts and splints may be employed to overcome mild deformities. In advanced cases, seen most often in children 3 to 5 years of age, operation may be indicated. This entails dividing the bones of the limbs at their deformed site and placing them in casts in a corrected position, usually for several weeks. Fortunately rickets is not now so common in the United States as formerly, but it is prevalent in indigent and malnourished peoples.

Other acquired deformities arc numerous in variety, many of which are secondary to other diseases. Angulation or shortening may result from fractures, as well as stiff joints from pro­longed immobilization. Various paralyses may result in deformed or frail or stiff joints. Infec­tions may destroy bone with resultant deformity. Other deficiency diseases can affect the skeletal system. Treatment of any deformity, of course, is best directed at the underlying cause. Some, however, will require operative procedures for permanent correction. Re-fracture and re-setting of a fracture united in a deformed position, or arthrodesis of a deformed joint, are typical ex­amples. Corrective casts and braces and physio­therapy employed vary with each individual case.