Sprains
A sprain results from a stretching or twisting form of violence which causes the joint to move beyond its physiological limits, or in some direction for which it is not structurally adapted. The main incidence of the force therefore falls upon the ligaments, which are suddenly stretched or torn. The synovial layer also is torn, and the joint becomes filled with blood and synovial fluid. Muscles and tendons passing over the joi36nt are stretched or torn, and their sheaths filled with serous effusion. It is not uncommon for portions of bone to be torn off at the site of attachment of strong ligamentous bands or tendons, constituting a “sprain fracture”; or for intra-articular cartilages to be torn and displaced, as in the knee. Clinical Features.—The injury is accompanied by intense sickening pain, and this may persist for a considerable time. At first it is aggravated by moving the joint, but if the movement is continued it tends to pass off. The particular ligaments involved may be recognised by the tenderness which is elicited on making pressure over them, or by putting them on the stretch. In this way a sprain may often be diagnosed from a fracture in which the maximum tenderness is over the injury to the bone. The effusion of blood and synovia into the joint and into the tissues around gives rise to swelling and discoloration, and the fluid effused into tendon sheaths often produces a peculiar creaking sensation, which may be mistaken for the crepitus of fracture. In sprains, the bony points about the joint retain their normal relations to one another, and this usually enables these injuries to be diagnosed from dislocations. When the swelling is great, it is often necessary to have recourse to the Röntgen rays to make certain that there is no fracture or dislocation. The special features and complications of sprains of the knee are discussed with other injuries of that joint. Repair of Sprains.—Blood and synovia are absorbed and torn structures become reunited, but in this process adhesions may form inside the joint and in the surrounding tendon sheaths and interfere with the movement of the joint. Prognosis.—Stiffness, lasting for a longer or shorter time, follows most sprains, but may be largely prevented by proper treatment. In old and rheumatic persons, changes of the nature of arthritis deformans are liable to supervene, interfering greatly with movement. While suppuration is rare, tuberculous disease is alleged to have resulted from a sprain. Treatment.—If seen immediately after the accident, firm pressure should be applied by means of an elastic bandage over a thick layer of cotton wool, to prevent bleeding and effusion of synovia. Later the best treatment is by massage and movement. In the ankle, for example, massage should be commenced at once, the part being gently stroked upwards. If the massage is light enough there is no pain, it is actually soothing. The rubbing is continued for from fifteen to twenty minutes, and the patient is encouraged to move the toes and ankle; a moderately firm elastic bandage is then applied. The massage is repeated once or twice a day, the sittings lasting for about fifteen minutes. The patient should be encouraged to move the joint from the first, beginning with the movements that put least strain upon the damaged ligaments, and gradually increasing the range. In the course of a few days he is encouraged to walk or cycle, or otherwise to use the joint without subjecting it to strain, or to a repetition of the movement that caused the accident. Alternate hot and cold douching, or hot-air baths, followed by massage, are also useful. Complete rest and prolonged immobilisation are to be condemned.
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