TUBERCULOSIS

OF THE

By JAMES

WRIST

E. MOORE,

AND

CARPUS.

M.D.,

MINNEAPOLIS.

Tiirs subject was chosen because it has not been before this Asso
ciation for discussion yet, and because the writer hopes to bring out
the experience of those present in the discussion.
As compared with other joints, this is a rare seat of disease, and
one man's experience is necessarily limited.
Of 919 cases of tuber
cular arthritis collected by Cheyne, only six were of the wrist and
hands.
Most writers state that wrist-joint disease constitutes from
4 to 5 per cent. of all cases of joint disease.
A peculiarity of this disease is that it occurs most frequently be
tween the ages of fifty and sixty.
Chieyne says that he believes the
synovial type prevails here, but says that it is difficult to prove.
Senn says that the synovial type is most common.
Every case
operated upon by the writer has been of bony origin.
The radius
is the most frequent seat of disease, and the proximal ends of the
metacarpal bone next.
The causes of tuberculosis here are the same as in other joints,
save that in a majority of cases of tuberculosis of the wrist it begins
in matured tissues instead of growing tissues.
It would also seem
that tuberculosis of the wrist is more closely connected with a gen
eral tubercular condition than the same disease in other joints.
Although this joint is so situated that it is very sub,ject to trau
matism, this disease is rarely the result of an injury.
The only
case under the writer's care due to an injury was one in which the
patient was already suffering from a tubercular empyema, and who
finally died from pulmonary tuberculosis.
The pathology of tuberculosis of the wrist and carpus does not
differ in any way from the same disease in other joints. The sheaths

JAMES

E.

MOORE.

101

of the tendons are very liable to become affected secondarily, and

add very materially to the gravity of the disease.
They sometimes
become primarily affected, a fact that should be remembered in
making a diagnosis.
This disease comes on insidiously, usually without the pain and
muscular spasm so characteristic in most joint diseases.
Swelling
withl tenderness and weakness of the joint are usually the first symp
tonis noticed.
The swelling is on all sides of the joint, but is most
marked on the dorsal surface.
When the tendon sheaths are in
volved the swelling extends further up and down the arm. Local
heat and atrophy of the arm are well marked.
Slight flexion usu
ally occurs and the digits soon assume a straight position, the thumb
being parallel with the others and close to the index finger.
While
the pain is seldom severe, the joint is apt to be quite sensitive to the
touch.
Owing to the absence of pain and the insidious manner in which
the disease comes on, it is seldom brought to the surgeon until it is
so well developed that tile diagnosis presents no difficulty.
It can
usually be made at sight when the above symptoms are present, for
the appearance is quite characteristic.
A tenosynovitis occurring independently of the joint affection re
sembles the joint affection somewhat.
In tenosynovitis the swelling
is not so evenly distributed, and may be confined to one or two
tendons.
It extends up and down the arm and can be felt in the
course of the tendon.
The tenderness is elicited by direct pressure
and not by pressing the joint surfaces together.
Ligamentous
crepitus may be present.
Atrophy is not so marked as in wrist
joint disease.
The prognosis in wrist-joint disease is always gravemuch more
so than in most other jointsbecause of the decided tendency to
the development of pulmonary tuberculosis.
In adults it almost
always ends this way. In children the immediate prospect of re
covery is very much better, but they rarely live to maturity.
When
the tendon sheaths are involved the prognosis is very grave indeed.
The functional results after treatment in children are good, but in
adults they are bad.
The treatment of this disease involves much responsibility, be
cause of the gravity of the prognosis.
Many times the surgeon is

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TUBERCULOSIS

OF THE WRIST

AND CARPUS

called upon to advise what would be considered very heroic treat

ment in any other joint, because of the imminent danger of pul
monary complications.
In children extensive suppuration rarely occurs, and tile proper
treatment is rest. This is easily secured by plaster-of-Paris extend
ing from the elbow to the knuckles, the arm being carried in a sling,
and held half-way between pronation and supination.
Six or nine
months of this treatment will often yield a satisfactory result.
Operative measures are rarely indicated in a child for this disease.
Excision in a child is never advisable, because the results both as to
function and life are bad.
In adults, the line of treatment is very different.
The outlook
from rest-treatment
is anything but encouraging, and operative
treatment is often indicated.
Wilen the case is not too far advanced, when there are no sinuses
and no pulnionary complications, the treatment is the same as in
childhood, and can be carried out in the same manner.
When suppuration and sinuses are present in an adult operative
measures are indicated, because of the danger of phthisis.
Un
fortunately, the outlook is grave in such a case with any treatment,
but experience has taught us that it is less grave when operative
measures are judiciously resorted to. The choice of operation lies
between extensive excision and amputation, for arthrectomy, owing
to the anatomical structure of the joint, is out of the question, and
scraping and gouging are worse than useless; they are dangerous.
Early excision, as recommended by Langenbeck and others at
one time, has not become popular, because the functional results are
bad, and as a life-saving measure it does not compare favorably with
amputation.
When the disease is well-marked and progressing rapidly, or when
the tendon-sheaths are involved, amputation is the best treatment.
When there is well-marked
wrist-joint disease with beginning
phthisis, amputation should be performed.
When there is well
marked phthisis with wrist-joint disease, which is causing the patient
much suffering, amputation is the best treatment, because the wrist
joint will never recover, and will be a constant source of suffering
and annoyance to the patient as long as he lives.

JAMES

E. MOORE.

103

On the other hand, when amputation is performed under such

circumstances, the lung trouble often shows marked improvement.
These problems are frequently brought before the surgeon, because
tuberculosis of the wrist rarely continues any length of time in an
adult without the presence of pulmonary tuberculosis, and not in
frequently the two diseases are present when the case first comes to
the surgeon.
The fact cannot be too forcibly stated that amputa
tion in such cases is often truly conservative.
When the disease is not too extensive, when the tendon-sheaths
are not involved, and the patient is in good health, excision may be
considered.
The operation, when undertaken,
should be very
radical.
The extremities of the radius and the metacarpal bones
should he removed with the whole of the carpus.
Anything short
of this is disappointing and dangerous.
The double posterior incision of Lister is the best operation in
common use, since it affords the readiest access to the diseased
structures.
The Esmarch bandage should be applied so that the
operator can see just what he is doing.
It is absolutely necessary that every particle of diseased tissue
should be removed.
The wound should be thoroughly iodoformized
and closed, without drainage, if possible.
The part can be very con
veniently kept at rest by means of a plaster-of-Paris dressing applied
over the surgical dressing.
The writer believes that any interference with the part, with the
hope of securing a movable joint, is unwise, because after so radical
an operation any such effort is likely to fail, and may result in a
relapse.
The patient has every reason to be congratulated if he
secures a sound arm without movement at the wrist.
The writer has been greatly pleased with the suggestion of Studs
gaard, of Copenhagen, that the diseased tissues in tuberculosis of
the wrist and carpus be reached by splitting the hand between the
metacarpal bones. There is no anatomical reason why this cannot
be done, and it would certainly admit of much freer access to the
diseased part than any other operation with which we are familiar.
Di-. Mynter reported a case to this Association, two years ago, in
which he split the hand between the second and third metacarpal
bones and found very ready access to the joint.
Everyone who has performed an excision of the wrist by any of

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TUBERCULOSIS

OF THE

WRIST

AND CARPUS.

the recognized methods will bear me out in the statement that it is

a difficult matter to remove all diseased tissues without injury to
surrounding healthy tissues.
The writer has had no experience with iodofornl injections in
wrist-joint disease, but believes that it is worthy of trial in adult
cases that are not severe enough to demand operative interference.
Senn reports very satisfactory results. The needle can be introduced
at almost any part, and the emulsion forced in. This treatment
certainly has the great virtue of being perfectly harmless when pro
perly performed.

DISCUSSION.
DR. MCKENZIE

said that

he had

seen

a case of very extensive

wrist-joint disease in a man of nineteen years.

He had advised in
this a very free use of injections of a ten per cent. solution of iodo
form in glycerin with the very best results, so far as the recovery
from the disease was concerned.
There was a fair restoration of
the function of the hand, although, of course, the motions of the
fingers were very much restricted. He had advised massage for this.
He had had equally good results with iodoform injections in other
cases, although his records had not been so carefully kept as in Dr.
Sherman's cases. His temperature records showed no great reaction
after these injections; indeed, he had observed a reduction of the
pyrexia following the injections.
DR. SHERMAN said that his experience with wrist-joint disease
was very limited.
He wished to commend the classification given
in the paper.
He had had a few cases in children recover in a few
months.
If a wrist-joint were bad, it was better to amputate.
In
the last case of the kind he had seen he had performed excision in
stead of amputation, the object of the operation being simply to
make the patient more comfortable for the brief remainder of his
life.
DR. WIRT said

that he had just

in a man, thirty-three

years of age.

seen a case of wrist-joint

disease

He had had it for ten years,

DISCUSSION.

105

He thought now after hearing Dr. McKenzie's

would try the iodoform injections.
DR. GILLETTE

said that he had been

surprised

remarks

that he

to hear the state

ments made regarding the amount of pain from this condition, for
he had been under the impression that there was but little pain as
sociated with wrist-joint disease.
DR. MOORE, in closing

the discussion,

said

that

he had

simply

advised amputation in those cases in which pain was one of the

reasons. Exceptionally this was the case. He had done amputation
in one case simply because of the intense pain. The patient's life
was certainly considerably prolonged by the amputation, and during
this time his general condition was greatly improved.