Page Four P H Y S I O T H E R A P Y September, 1948 It is, however, the private practitioner of physiotherapy w ho will be m ost concerned. It seems obvious that h e/sh e will suffer con ­ siderable financial hardship. The loss suffered w ill be in direct proportion to the speed with which hospitals expand their physiotherapy services. W ith ou t some com pensatory plan, h e/sh e m ay have to give up the unequal struggle and seek a Provincial appointment. A t present the F.H.S. is confined to the Transvaal and affects m embers in that P ro­ vince only. If it is successful, the possibility exists that it will be extended through­ out the Union. (Free hospitalisation has already been approved in principle by the Orange Free State Provincial Executive Com ­ mittee, and the Central G overnm ent has sought inform ation regarding the Transvaal scheme w ith a view to its w ider application) . Physiotherapists therefore— in com m on with other m edical auxiliaries— feel that they are entitled to a responsible statement from the Provincial authorities on how the Free H os­ pitalisation Scheme will affect members of their respective Societies. The follow ing suggestion, w hich is based on the same principles as those involved in over­ com ing the question o f insufficient accom m o­ dation, m ay provide food for thought to all concerned. W here insufficient physiotherapy services are provided in Provincial hospitals, private practitioners could make their services avail­ able to the Province. Fees could conform to the Standard Rate as laid down by the South A frican Society o f Physiotherapists in June, 1948. The Province would be responsible for payment, provided that the patient passed through the recognised channels. This suggestion, which could be enlarged upon, offers several advantages: (1 ) The Patient would receive the treatm ent which he re­ quired with the m inim um delay. (2 ) The Physiotherapist Hospital employees w ould not be m ore overworked than at present. Private practitioners would not suffer the severe financial hardship w hich w ould be other­ wise inevitable. (3 ) The Hospital Department w ould be able to cater for hospital and outpatient requirements only and would not be congested w ith patients who take a perfectly correct advantage o f the Free H ospitalisation Scheme. (4 ) The Province would not require to embark on a large expansion programme. (5 ) The Suggestion could be extended, with m inor m odifica­ tions, to other professions. M edical auxiliaries in general and physio­ therapists in particular will await w ith keen interest an authoritative statement o f policy from Provincial sources. Treatm ent of Elbow Joint Injuries By L. M A C E D A V ID , M .B., F.R.C.S. (Ed.) Clinical Assistan t, Department of Su rgery, T ran svaal Mem orial Hospital for Children. M o r e than so y e a r s ag o H u g h O w e n T h o m a s ta ug ht his stude nts the d a n g e r s of s t r e t c h i n g and fo rc i b ly m a n ip u la t in g an elbo w joint w h ic h is. stif f as the result o f trau ma. S u c h t re a t m e n t is still bei ng pursued and is h a v i n g th e opposite e ff e ct o f that fo r w hi ch it w a s intended. T h e elbow jo in t is v e r y su sceptib le to injury. Im p a ir e d function, so obvi ous in mos t cas es, m a y be cau sed not o n ly b y a lesion w ith in the jo in t (i nt ra - art ic u la r) but b y so m e condition eithe r o f the soft tissues in the v i c i n it y o f the jo in t o r withi n the mus cle s w h ic h a cti vat e it (e x t r a - a r t ic u la r ) . I t can also be cau sed b y m in or s tra in s if t h e y ar e re pe at ed fr eq uen tly . T h e co m m on es t cause o f st if fne ss of the join t is adhes ion form at ion , e ith er in t ra - or e xt ra - ar t ic u la r. A n adhe sion is a pa th ological ba nd re s ul t in g fr om ex ud a t e br ou gh t about b y tr a u m a or in flammation (')• T h u s , a f t e r the in jur y, join t st if fne ss occurs because of adhe sion s of the c a p s u la r plication w hic h is the result of or ga n i sa t i o n of the e x ud at e in the p e ri art er ial tissues. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) September, F ig . 1.— L a t e r a l V i e w .— B e f o r e M a n i p u l a t i o n . S h o w i n g p o s t e r i o r d i s p l a c e m e n t p l u s a n g u l a t i o n o f d i s t a l f r a g m e n t . F i g . l a . — A . P . V i e w . — B e f o r e M a n ip u la t io n . S h o w i n g medial displa cem en t with inter con dy lo r fract ur e. i Page Five F ig . 2.— L a t e r a l V i e w . — A f t e r M a n ip u la t io n . F r a g m e n t s n o w i n Rood a l i g n m e n t . W a t s o n - J o n e s p o i n t s o u t t h a t t h e r e a r e s e v e r a l i m p o r t a n t f a c t o r s w h i c h c o n t r i b u t e t o t h e c o n t i n u e d o r r e c u r r e n t e x u d a t e . 1. Functional inactivity and d i s u s e : — C ir c u la t o r y and lymphatic stasis and w a t e r lo g g in g of the tissues with sero-fibrinous fluid. 2. Join t i n j u r y : — T r a u m a t ic se ro -fi b ri no us exudation from the torn caps ule or from a nei gh bo u ri ng fr acture— a source of re cu rr ent exud ation if the injured joint is fr e q u e n t ly or fo rc ib ly moved in the early stages. 3. Recurrent o e d e m a : — R e a c t i o n a r y tra um at ic oedema especially in the lower limbs in the later stages. F ig . 2a.— A . P . V i e w .— A f t e r M a n ip u la t io n . F r a g m e n t s in good alignment. 4. In fe cti on near the j o i n t : — I n f la m m a t o ry s e r o ­ fibrinous exud ation s p re a d i n g from a ne i ghb ou ri ng focus o f infection. 5. F o r e i g n bodies, espec ial ly ske letal traction pins close to j o i n t s : — R e a c t i o n a r y and low gr a de in­ fl a m m a t o r y sero -fi b ri no us exud ation s p re a di ng fr om the pin track. 6. R e pe a t e d p as siv e s t r e t c h i n g and fo rcible m a n i ­ pulation of a st iffened j o i n t : —T r a u m a t i c s e r o ­ fibrinous exud ation from the st retched and torn adhe sion s ('). One can discard cau ses 3. 4 and 5, and co n ce nt rat e on num ber s I, 2 and 6 for the pur poses of this article. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Six P H Y S I O T H E R A P Y September, 1948 Functional inactivity and disuse.— Im m obi li sat io n in its elf is not a m a j o r fa c t or in the de velopmen t of adhesions, w h en un complicated b y ot he r fac tors. A n y adh e s io ns so fo rm e d a r e due to ven ous and lymphati c stasis, and once the patient re su m e s acti ve use o f the part, re c o v e r y of nor mal function occurs. B u t if the injured joint is treated by e a r l y p as siv e mov em ent s, there is repea te d exudation and it is this w hic h cau ses dense adhesions. Joint injury.— A simple joint in ju ry such as dislo ­ cation or uncomplicated f r a c t u r e does not cause serio us or la st in g disability. T h e practice of tre at in g dislocations and f r a c t u r e s b y imme di ate move me nts, re p ea te d daily,, d e fe a t s its own object. In s te a d of p re v e n t in g stiffness, it a g g r a v a t e s it. T h e correct ap pr oa c h is co m p le te ly to immobilise the joint until all the tissues have healed, and then to start e x e r ­ cises by m a k i n g the p atient c a r r y out act iv e m o v e ­ m en ts only. It must not be fo rg ot t e n that the pr o xim al and distal jo ints should be ac t i v e ly ex ercised while the inju red join t is immobilised. Repeated passive stretching and forcible manipula­ tion of a stiffened joint.— M a s s a g e and m ov em en ts , so com m on ly p res cr ib ed b y the p ra c t is in g medical a t t e n d ­ ant as the co rr ect tr e a t m e nt for a stiff joint are, in fact, one of the comm on est ca u se s of a stiff joint. W h e n an adhesion is form ed and is stretc he d or torn by passi ve s t r e t c h i n g or manipulation, reactionarx exudati on follows, p ro duc in g fresh adhesions. Traumatic myositis ossificans.— T h i s complication resul ts from te a ri n g o f the periosteum. It is e n ­ cou ntered most ofte n in children and adolescents because the perio steu m of the y o u n g stri ps more easily. A s a result of dislocation o f the joint, muscle and capsule in sertions into the pe riosteum must n e ce s s ar il y be torn ; the condition is thus more common a f t e r dislocations than a f t e r fractures. It must be em phasised that a f t e r reduction it is p as siv e s t re t ch in g and not act iv e e x e rc is e s which ag ai n displaces the periosteum. T h e ossification is th e re f o re seen in front of the joint, in some cases because of avulsion o f the bra chi alis muscle from the ulna, and the first sign o f this complication is rad iogr ap hic evidence of a shadow, w hich gr ad ua lly becomes more dense as the mass becomes co ns ol i­ dated. It is u n n e c e s s a r y in these cas es to completely immobilise the joint, but all p assive m ov e m e nt s must be avoided, and the patient should be allowed to ca r ry out active m ove m ent s only. R e c o v e r y is fa i r l y rapid, and ab sorption of the ossified ma te ri al takes place. Fig. 3.— 3 months after injury— Full extension recovered. If this trea tm ent is continued, it b r e a k s and s tre tch es some adhe sion s, but fre sh a dh es ion s will still be formed, r e t a r d in g and d e la y i n g r e c o v e r y of movement. E n t h u si a s t ic p h ys io t h e r ap is t s seem unable to resist the temptation to fo rcc a stiff elbow joint. W a t s o n - J o n e s e m pha sis es not o n ly the se rious di sab ili ty that follows such action, but also denou nce s a n y attempt at passi ve s t re t c h i n g and e x e rc i s e ( z). M a n y other fo rm s of passive s t r e t c h i n g are pr ac tis ed b y p h y s i o ­ therapists. P a t i e n t s wit h stiff elbows ar e e nco ur ag ed to c a r r y h e a vy w e ig h t s or to hang from ov erh ea d beams, while children ar e made to c a r r y a h ea vy school case. I n c r e a s i n g s tif fn e s s is inevitable. F r o m this it will be g a t h e r e d tha t passive st re tc hi ng of the joint a l w a y s d e fe a t s its own object. Inste ad of in cr e as in g the r a n ge of mov em ent , it ac tu a lly a g g r a v a t e s the st iffness. T h i s is not the o n ly sequel. It is ofte n resp onsi ble for the form at ion of new bone arou nd the joint, a condition kn ow n as myos iti s ossificans traumatica. Fig. 3a.— 3 months after injury— Full flexion recovered. S U M M A R Y . T h i s short pap er is published wit h the plea that all elb ow-joint injuries should be approac hed with respect. T h e treatm ent, once the in jur y is refe rr ed from the medical prac titioner, is one of active m o v e ­ m ents and active m ov e m e nt s only. M a s s a g e , passive st re t c h i n g and m ani pulation should be avoided at all costs. In the v e r y you ng, active m ove m ent s can be e nc ou rag ed by the use o f suitable toys. T h e a c c o m ­ p an yi n g p h ot og r a ph s and X - r a y s show that even in a b a dl y injured and displaced joint, full r an ge of flexion and ex tension can be obtained by active movements. T h e p hy s io th e r a pi s t must ex e rc is e a g r e a t deal of patience, for it tak es 14 d a y s at least to accomplish 5 d e gr ee s of ex tension (3). T h e temptation to hur ry this on by m ani pulation and passiv e st re tc h in g must be co n st a n t ly avoided. T h u s a thorough kn owle dg e of the cau ses of a stiff elbow join t will help to avoid the t r a g e d y of complete stiffness, which one comes a cr os s so often to-day. References : 1. W a t s o n - J o n e s “ A d h e s io n s of J o i n t s and I n j u r y , ” B . M . J . . M a y 1936, 92s. 2. W a t s o n - J o n e s “ F r a c t u r e s and J o in t In ju ri e s," Vol. r. 1944. 3. W a l t e r M e rc e r , "O rt h o p a e d ic S u r g e r y , ” 1945. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )