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Fig. 113.—Hydrops of Prepatellar Bursa in a housemaid.
The treatment varies according to the variety and stage of the affection. In recent cases the symptoms subside under rest and the application of fomentations. Hydrops may be got rid of by blistering, by tapping, or by incision and drainage. When the wall is thickened, the most satisfactory treatment is to excise the bursa; the overlying skin being reflected in the shape of a horse-shoe flap or being removed along with the bursa.
Other Diseases of Bursæ are associated with gonorrhœal infection, and with rheumatism, especially that following scarlet fever, and are apt to be persistent or to relapse after apparent cure. In the gouty form, urate of soda is deposited in the wall of the bursa, and may result in the formation of chalky tumours, sometimes of considerable size (Fig. 114).
Fig. 114.—Section through Bursa over external malleolus, showing deposit of urate of soda. (Cf. Fig. 117.)
Tuberculous disease of bursæ closely resembles that of tendon sheaths. It may occur as an independent affection, or may be associated with disease in an adjacent bone or joint. It is met with chiefly in the prepatellar and subdeltoid bursæ, or in one of the bursæ over the great trochanter. The clinical features are those of an indolent hydrops, with or without melon-seed bodies, or of uniform thickening of the wall of the bursa; the tuberculous granulation tissue may break down into a cold abscess, and give rise to sinuses. The best treatment is to excise the affected bursa, or, when this is impracticable, to lay it freely open, remove the tuberculous tissue with the sharp spoon or knife, and treat the cavity by the open method.
Syphilitic disease is rarely recognised except in the form of bursal and peri-bursal gummata in front of the knee-joint.
New growths include the fibroma, the myxoma, the myeloma or giant-celled tumour, and various forms of sarcoma.
Diseases of Individual Bursæ.—The olecranon bursa is frequently the seat of pyogenic infection and of traumatic or trade bursitis, the latter being known as “miner's” or “student's elbow.”
Fig. 115.—Tuberculous Disease of Sub-deltoid Bursa.
(From a photograph lent by Sir George T. Beatson.)
The sub-deltoid or sub-acromial bursa, which usually presents a single cavity and does not normally communicate with the shoulder-joint, is indispensable in abduction and rotation of the humerus. When the arm is abducted, the fixed lower part or floor of the bursa is carried under the acromion, and the upper part or roof is rolled up in the same direction, hence tenderness over the inflamed bursa may disappear when the arm is abducted (Dawbarn's sign). It is liable to traumatic affections from a fall on the shoulder, pressure, or over-use of the limb. Pain, located commonly at the insertion of the deltoid, is a constant symptom and is especially annoying at night, the patient being unable to get into a comfortable position. Tenderness may be elicited over the anatomical limits of the bursa, and is usually most marked over the great tuberosity, just external to the inter-tubercular (bicipital) groove. When adhesions are present, abduction beyond 10 degrees is impossible. Demonstrable effusion is not uncommon, but is disguised by the overlying tissues. If left to himself, the patient tends to maintain the limb in the “sling position,” and resists movements in the direction of abduction and rotation. In the treatment of this affection the arm should be maintained at a right angle to the body, the arm being rotated medially (Codman). When pain does not prevent it, movements of the arm and massage are persevered with. In neglected cases, when adhesions have formed and the shoulder is fixed, it may be necessary to break down the adhesions under an anæsthetic.
The bursa is also liable to infective conditions, such as acute rheumatism, gonorrhœa, suppuration, or tubercle. In tuberculous disease a large fluctuating swelling may form and acquire the characters of a cold abscess (Fig. 115).
The bursa underneath the tendon of the subscapularis muscle when inflamed causes alteration in the attitude of the shoulder and impairment of its movements.
An adventitious bursa forms over the acromion process in porters and others who carry weights on the shoulder, and may be the seat of traumatic bursitis.
The bursa under the tendon of insertion of the biceps, when the seat of disease, is attended with pain and swelling about a finger's breadth below the bend of the elbow; there is pain and difficulty in effecting the combined movement of flexion and supination, slight limitation of extension, and restriction of pronation.
In the lower extremity, a large number of normal and adventitious bursæ are met with and may be the seat of bursitis. That over the tuberosity of the ischium, when enlarged as a trade disease, is known as “weaver's” or “tailor's bottom.” It may form a fluctuating swelling of great size, projecting on the buttock and extending down the thigh, and causing great inconvenience in sitting (Fig. 116). It sometimes contains a number of loose bodies.
There are two bursæ over the great trochanter, one superficial to, the other beneath the aponeurosis of the gluteus maximus; the latter is not infrequently infected by tuberculous disease that has spread from the trochanter.
The bursa between the psoas muscle and the capsule of the hip-joint may be the seat of tuberculous disease, and give rise to clinical features not unlike those of disease of the hip-joint. The limb is flexed, abducted and rotated out; there is a swelling in the upper part of Scarpa's triangle, but the movements are not restricted in directions which do not entail putting the ilio-psoas muscle on the stretch.
Cartilaginous and partly ossified loose bodies may accumulate in the ilio-psoas bursa and distend it, both in a downward direction towards the hip-joint, with which it communicates, and upwards, projecting towards the abdomen.
The bursa beneath the quadriceps extensor—subcrural bursa—usually communicates with the knee-joint and shares in its diseases. When shut off from the joint it may suffer independently, and when distended with fluid forms a horse-shoe swelling above the patella.
In front of the patella and its ligament is the prepatellar bursa, which may have one, two, or three compartments, usually communicating with one another. It is the seat of the affection known as “housemaid's knee,” which is very common and is sometimes bilateral, and, less frequently, of tuberculous disease which usually originates in the patella.
Fig. 116.—Great Enlargement of the Ischial Bursa.
(Mr. Scot-Skirving's case.)
The bursa between the ligamentum patellæ and the tibia is rarely the seat of disease. When it is, there is pain and tenderness referred to the ligament, the patient is unable to extend the limb completely, the tuberosity of the tibia is apparently enlarged, and there is a fluctuating swelling on either side of the ligament, most marked in the extended position of the limb.
Of the numerous bursæ in the popliteal space, that between the semi-membranosus and the medial head of the gastrocnemius is most frequently the seat of disease, which is usually of the nature of a simple hydrops, forming a fluctuating egg-or sausage-shaped swelling at the medial side of the popliteal space. It is flaccid in the flexed, and tense in the extended position. As a rule it causes little inconvenience, and may be left alone. Otherwise it should be dissected out, and if, as is frequently the case, there is a communication with the knee-joint, this should be closed with sutures.
Fig. 117.—Gouty Disease of Bursæ in a tailor. The bursal tumours were almost entirely composed of urate of soda. (Cf. Fig. 114.)
An adventitious bursa may form over the lateral malleolus, especially in tailors, giving rise to the condition known as “tailor's ankle” (Fig. 117).
The bursa between the tendo-calcaneus (Achillis) and the upper part of the calcaneus may become inflamed—especially as a result of post-scarlatinal rheumatism or gonorrhœa. The affection is known as Achillo-bursitis. There is severe pain in the region of the insertion of the tendo-calcaneus, the movements at the ankle-joint are restricted, and the patient may be unable to walk. There is a tender swelling on either side of the tendon. When, in spite of palliative treatment, the affection persists or relapses, it is best to excise the bursa. The tendo-calcaneus is detached from the calcaneus, the bursa dissected out, and the tendon replaced. If there is a bony projection from the calcaneus, it should be shaved off with the chisel.
The bursa that is sometimes met with on the under aspect of the calcaneus—the subcalcanean bursa—when inflamed, gives rise to pain and tenderness in the sole of the foot. This affection may be associated with a spinous projection from the bone, which is capable of being recognised in a skiagram. The soft parts of the heel are turned forwards as a flap, the bursa is dissected out, and the projection of bone, if present, is removed.
The enlargement of adventitious bursæ over the head of the first metatarsal in hallux valgus; over the tarsus, metatarsus, and digits in the different forms of club-foot; over the angular projection in Pott's disease of the spine; over the end of the bone in amputation stumps, and over hard tumours such as chondroma and osteoma, are described elsewhere.
CHAPTER XXDISEASES OF BONE Anatomy and physiology —Regeneration of bone —Transplantation of bone. Diseases of Bone —Definition of terms —Pyogenic diseases: Acute osteomyelitis and periostitis; Chronic and relapsing osteomyelitis; Abscess of bone —Tuberculous disease —Syphilitic disease —Hydatids; Rickets; Osteomalacia —Ostitis deformans of Paget —Osteomyelitis fibrosa —Affections of bones in diseases of the nervous system —Fragilitas ossium —Tumours and cysts of bone.
Surgical Anatomy.—During the period of growth, a long bone such as the tibia consists of a shaft or diaphysis, and two extremities or epiphyses. So long as growth continues there intervenes between the shaft and each of the epiphyses a disc of actively growing cartilage—the epiphysial cartilage; and at the junction of this cartilage with the shaft is a zone of young, vascular, spongy bone known as the metaphysis or epiphysial junction. The shaft is a cylinder of compact bone enclosing the medullary canal, which is filled with yellow marrow. The extremities, which include the ossifying junctions, consist of spongy bone, the spaces of which are filled with red marrow. The articular aspect of the epiphysis is invested with a thick layer of hyaline cartilage, known as the articular cartilage, which would appear to be mainly nourished from the synovia.
The external investment—the periosteum—is thick and vascular during the period of growth, but becomes thin and less vascular when the skeleton has attained maturity. Except where muscles are attached it is easily separated from the bone; at the extremities it is intimately connected with the epiphysial cartilage and with the epiphysis, and at the margin of the latter it becomes continuous with the capsule of the adjacent
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